eLetters

125 e-Letters

  • Protecting Postnatal Care in the Pandemic

    We read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).

    However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interv...

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  • Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

    It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
    This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
    It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...

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  • Involving All for Covid-19 Prevention and Control

    Dear Editor,
    Gilmore. B., et al have highlighted that the community involvement is pivotal to improving on prevention and control of Covid-19. We believed that governments should implement strict policies, to foster a culture of compliance and trust, not infringing on human rights (B., 2009). Take Taiwan for example, who learned from their experiences with SARS in 2003, developed and implemented policies and infrastructure in 2004 to combat any similar outbreaks in future. In 2004, the year after the SARS outbreak, the Taiwan government established the National Health Command Center (NHCC). The NHCC is part of a disaster management center that focuses on large-outbreak response and acts as the operational command point for direct communications among central, regional, and local authorities (C. Jason Wang, Chun Y. Ng, & Robert H. Brook, 2020). Such a policy is able to encourage the dissemination of pertinent information to the people, increase transparency and build trust in the framework. Furthermore, the use of Info dynamics should take precedence to minimize the spread of misinformation among communities. In a 2020 issue, Tangcharoensathien V et al (Tangcharoensathien. V., 2020), the WHO presented a framework for managing the Covid-19 infodemic (G., 2020) which can continue strengthening on a trusting relationship among people and healthcare personnel. Therefore, rallying community members for various roles in disease prevention and control will be widely ac...

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  • Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.

    It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
    This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
    It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...

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  • Under-5 mortality in sub-Saharan Africa has decreased, not increased, from 1990-2018

    I write a quick note to correct what is probably an editing error. Both the abstract and the text state that under-five mortality has increased in sub-Saharan Africa 1990-2018, while decreasing in the rest of the world. In fact, the Unicef data referenced in the paper (https://data.unicef.org/topic/child-survival/under-five-mortality/) indicate that under five mortality has decreased from 178 per 1000 live births in 1990 to 78 per 1000 in 2018, a reduction of 100 per 1000 or 56%. The UN inter-agency group for child mortality estimation (IGME) has similar estimates (https://childmortality.org/data/SDG%20Regions%20%3E%20Sub-Saharan%20Africa).

  • Need to generate data to make health politically relevant

    Arnab and colleagues reported the findings from their research study in India, UK, and the USA that politicians are unlikely to be punished or rewarded for their failures or successes in managing COVID-19 in the next election. (1) By early September, India came only next to the US in terms of COVID 19 burden. Officially, India collects and reports data in terms of geographical variations, disaggregated by age and sex. India also reports the count of deaths among patients with and without comorbidities. However, none of the States report COVID 19 data disaggregated by social determinants, primarily castes and wealth quintiles, which are the most important determinants from an Indian perspective.

    The caste system in India is a ‘disabling myth’ which contributes to preventable and inequitable mortality in women and children.(2) Globally, COVID 19 has once again exposed the vulnerability of disadvantaged groups due to ongoing social discrimination and economic deprivation.(3) Emerging data shows that the racial minorities in the US are disproportionately affected by the pandemic. Data shows that Non-Hispanic Blacks have five times the risk of hospitalization compared to non-Hispanic Whites (age-adjusted) and Hispanic and Latinos have 4 times the risk compared to non-Hispanic Whites.(4,5) However, realizing the importance of having more accurate data to understand the impact of COVID 19, foundations and agencies came forward to support and set-up mechanisms to track rac...

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  • Tranexamic acid in patients with moderate or severe traumatic brain injury

    Williams et al. examined the cost-effectiveness of tranexamic acid treatment for traumatic brain injury (TBI) (1). Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI. In addition, tranexamic acid was even more cost-effective with earlier treatment administration. In contrast, the cost-effectiveness for those with severe TBI could not be clarified. I feel that cost-effectiveness viewpoint is very important for distributing medial resources effectively, and I present recent inconsistent results for the safety and effectiveness of tranexamic acid in TBI patients with special reference to disease severity.

    Rowell et al. conducted a double-blinded, randomized clinical trial to determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI (2). They concluded that tranexamic acid administration did not improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. A large effectiveness trial with optimized dosing protocols, a mortality end point, and specific focus on the TBI severity cohorts might be needed to verify the existence of benefits (3).

    There have been some meta-analyses on the efficacy of tranexamic acid for TBI, and I recently presented a comment regarding inconsistent results of the association (4). Based on the report by Williams et al., the...

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  • Human rights based approach for addressing structural violence

    To the editor
    We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
    global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
    bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.

    The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportio...

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  • A need for better understanding old-age mortality dynamics

    A need for better understanding old-age mortality dynamics
    Sergi Trias-Llimós* & Iñaki Permanyer
    Centre d’Estudis Demogràfics, Carrer de Ca n’Altayó, Edifici E2, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
    * Corresponding author. Email: strias@ced.uab.cat

    Correspondence letter in response to:
    Bergeron-Boucher M-P, Aburto JM, Raalte A van. Diversification in causes of death in low-mortality countries: emerging patterns and implications. BMJ Glob Health. 2020;5(7):e002414.

    Word count: 492

    The recent paper by Bergeron-Boucher et al. published in this journal reports an increasing diversity of cause-of-death mortality in low-mortality populations during the last 20 years [1]. Bergeron-Boucher et al. found that the preponderance of mortality from cardiovascular diseases in the countries under analysis has gradually declined in favour of a wide range of causes of death, including mental and behavioural disorders, nervous system or ill-defined causes. The increasing variability of causes of death is an important matter of potential concern because (a) fragmentation in cause of death might hinder further improvements in life expectancy, (b) preventive health policies have to cope with a more variegated set of causes, which imply more costly and less efficient health policies.
    Despite their enormous interest, these findings should be interpreted with caution. As the authors...

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  • MITIGATION MEASURES TO PREVENT THE NEXT PANDEMIC

    We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1

    COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2

    Airborne or droplet borne. The infectious...

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