eLetters

186 e-Letters

  • 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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  • Commentary on how to use heat stable carbetocin and tranexamic acid for postpartum haemorrhage in practice

    How to use heat stable carbetocin and tranexamic acid for postpartum haemorrhage in practice

    A. Metin Gülmezoglu1, Sara Rushwan1
    1 Concept Foundation, Geneva, Switzerland
    We welcome the paper by Tran et al [1]. There are increasing number of options for postpartum haemorrhage (PPH) prevention and management as recommended by WHO and the context is important. We agree that at the national level the first step is to update the national policies including the guidelines and essential medicine lists (EMLs). Since 2019, Concept Foundation and its partners have been working in 14 East and West African sub-Saharan countries to facilitate those updates [2]. We are pleased to report that in 10 out of the 14 countries – Burkina Faso, DRC, Ethiopia, Ghana, Ivory Coast, Liberia, Rwanda, Sierra Leone, South Sudan, and Uganda – the national guideline and/or EML were updated during this period.
    The strength of the project lies in the engagement with policy makers, Ministry of Health officials, clinicians, professional associations, and civil society organizations concurrently. However, competing national policy priorities such as COVID-19, timing of the previous updates, political instability and national capacity and leadership (or lack of) can make the updating process long and challenging even when there is an agreement to update. Secondly, even when the updates happen, proactive dissemination and training within the country can also take time. Thirdly, in the...

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  • Implementation and engineering science and the costs of revising and rolling out hand hygiene programmes

    Dear Editor
    Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)

    The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.

    However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.

    When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.

    Thus, a new implementation strategy...

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  • Biased analysis, a dangerous precedent

    Dear Editor

    The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.

    In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationa...

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  • Risk of bias

    Hi,
    Its more of a doubt. I would like to know what risk of bias tool was used by the team? What were the findings on risk of bias, since I couldn't find anywhere in the article reporting the same.

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