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...
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 et al., 2018). As Walter Rodney demonstrates (Rodney and Recorded Books, 2012), the profits from British colonial endeavours were directed back to Britain, developing British society and infrastructure at the cost of underdeveloping colonial countries. The global North, built as it is on theft of the world’s wealth, is a creation of the global South (Fanon, 1963; Vergès, 2021). Therefore, to be anti-colonial one must be anti-capitalist.
The alternative I would suggest in this article is to name these relations as capitalism, not feudalism. To understand the persistence of colonial and neo-colonial relationships in global health, it’s necessary to understand how these relationships are related to our current system of production, oppression and exploitation: capitalism. For example, the well-documented phenomenon of “brain drain” where doctors are being lost to their global South contexts can be understood, in part, as an expression of the contradictions of capitalism. The structures that enable imperialist exploitation of the global South for the benefit of the global North, including through the global health ecosystem are capitalist, not feudal.
Imperialism, to which the authors allude, is not called the highest stage of capitalism for nothing (Lenin, 1916). The financial leverage that imperial countries hold over colonial and neo-colonial countries cannot be broken only by considering the positionality of individual actors but rather by dismantling and reforming the existing relations of production, returning genuine autonomy to the global South. I hope that through this, global health is truly transformed.
Bibliography
Alavi, H. (1980) India: Transition from feudalism to colonial capitalism. Journal of Contemporary Asia 10, (4) 359–399. https://doi.org/10.1080/00472338085390251
Blaut, J. M. (1989) Colonialism and the Rise of Capitalism. Science & Society 53, (3) 260–296
Bryan, B., Dadzie, S., Scafe, S., and Okolosie, L. (2018) The heart of the race: Black women’s lives in Britain. London ; New York: Verso
Fanon, F. (1963) The wretched of the earth. New York: Grove
Lenin, V. (1916) Imperialism, the Highest Stage of Capitalism. https://www.marxists.org/archive/lenin/works/1916/imp-hsc/
Marx, K., Fowkes, B., and Fernbach, D. (1981) Capital: a critique of political economy. London ; New York, N.Y: Penguin Books in association with New Left Review
Robinson, C. J. (2000) Black marxism: The making of the Black radical tradition. Chapel Hill, N.C: University of North Carolina Press
Rodney, W., and Recorded Books, I. (2012) How Europe Underdeveloped Africa. Baltimore, MD: Black Classic Press
Vergès, F. (2021) A decolonial feminism. Trans. by Bohrer, A. J. London: Pluto Press
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...
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. Lancet Infectious Diseases, May 2022) suggests that there was no significant guidance void in England; in fact, that experience meant specialist hospitals in England were better prepared to care for hospitalised patients when the unprecedented outbreak began in May 2022, and various guidance documents - public facing and 'internal' were rapidly updated or produced to support clinicians working in a new outbreak context. Most importantly, and perhaps more useful that any written guidance, was the information sharing network for hospital physicians, which continues to meet to this day.
Guidance takes many different forms. Without understanding the scope, aims and target audience of publicly available guidance, it is inevitable that a systematic review will assign a low quality score when a piece of guidance never set out to be the comprehensive clinical guidance that the review is assessing; thus, one is effectively scoring the wrong thing.
While I welcome and am part of efforts to produce national and international clinical management guidelines for monkeypox, it is also clear that there is a not a single approach to managing patients, even hospitalised patients; clinical manifestations and the required and available treatment approaches will differ between countries and outbreaks. If a systematic review of clinical management guidelines for monkeypox is to be repeated, this is an important point to consider, along with ensuring the scope and aims of published guidance are fully appreciated in systematic reviews. For low-incidence emerging infections, it it also important to recognise that some countries may not publish all of their detailed guidance in a single document online.
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.
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...
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 the global epidemiology of Lyme disease. Caution should be exercised here since Lyme disease as a clinical entity is only reliably described from temperate areas of the northern hemisphere, mirroring the distribution of its tick vectors (2). At least 20 species of bacteria belong to the Bbsl complex (2, 3) and could be transmitted to humans through a tick bite, but only a handful are pathogenic and cause Lyme disease (3). The serology assays used internationally to estimate borrelia exposure may recognise antibodies generated against non-pathogenic Bbsl species. Consequently, the Bbsl global seroprevalence estimate overestimates those who have experienced clinical Lyme disease (or asymptomatic infection) and may explain why Dong et al give Bbsl seroprevalence estimates for countries where no Lyme disease cases have been confirmed.
Dong et al derived a seroprevalence estimate for the UK in the 11-20% range based on two Scottish studies, with calculated seroprevalence estimates of 4.17% and 36.48% (4, 5). One (4) used Scottish blood donors. The other (5) utilised sera from individuals with suspected Lyme disease; it was not a study on either seroprevalence or incidence, was not representative of the general population and its inclusion introduces bias into the results. The true seroprevalence figure for Scotland is likely closer to the 4.2% estimate but importantly, there is regional variation (0 - 8.6%) within Scotland (4). Dong et al have used the biased Scottish estimate to extrapolate from one UK nation to others (England, Wales and Northern Ireland). This is misleading since published data on lab-confirmed Lyme disease cases show a higher incidence for Scotland than the other UK nations (6), although published seroprevalence data for the general populations in the other UK nations is lacking (6).
The study by Dong et al has been widely reported by media outlets leading to headlines claiming 1 in 7 people globally have been exposed to B. burgdorferi at some time (7). As described above, the interpretation of the ‘global’ seroprevalence estimate is flawed as are media releases based on it and may mislead and alarm the public unnecessarily. What is most important is that the public understand where high risk areas are locally and when travelling overseas, so that they can take appropriate measures to limit their exposure to ticks and to prevent Lyme and other tick-borne diseases.
References
1. Dong Y, Zhou G, Cao W, Xu X, Zhang Y, Ji Z, et al. Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ Glob Health. 2022;7(6).
2. Mead PS. Epidemiology of Lyme disease. Infect Dis Clin North Am. 2015;29(2):187-210.
3. Bobe JR, Jutras BL, Horn EJ, Embers ME, Bailey A, Moritz RL, et al. Recent Progress in Lyme Disease and Remaining Challenges. Front Med (Lausanne). 2021;8:666554.
4. Munro H, Mavin S, Duffy K, Evans R, Jarvis LM. Seroprevalence of lyme borreliosis in Scottish blood donors. Transfus Med. 2015;25(4):284-6.
5. Mavin S, Evans R, Milner RM, Chatterton JM, Ho-Yen DO. Local Borrelia burgdorferi sensu stricto and Borrelia afzelii strains in a single mixed antigen improves western blot sensitivity. J Clin Pathol. 2009;62(6):552-4.
6. Lorenc T, Jones-Diette J, Blanchard L, et al. Incidence and surveillance of Lyme disease: systematic review and policy mapping. London: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London; 2017.
7. Wetzel C. More than 1 in 7 people worldwide have had Lyme disease. New Scientist. 2022.
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...
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 "emerging infectious diseases", 70% of which would originate, in turn, from one or more animal reservoirs, as definitely proven with the two betacoronaviruses SARS-CoV and MERS-CoV, while being largely plausible and highly suspect also in the case of the pandemic SARS-CoV-2 betacoronavirus (2).
The seven years between 2015 and 2021 have been the hottest ones ever recorded on Earth within the last 140 years, with this significantly impacting also the vectorial efficiency of arthropods toward their respective pathogens. Indeed, under the present meteo-climatological conditions insects and ticks are now being increasingly reported to overcome the autumn and winter seasons ("overwintering") far more easily than in past decades. These progressively higher and higher average temperatures are responsible, in fact, for a (more or less) consistent reduction of the life cycle and replication ("extrinsic incubation period") of the infectious pathogens carried inside insects' and ticks' bodies. Based upon the above, a progressive "transfer to northern latitudes" of arthropod-borne infections, of either viral or non-viral aetiology, has been documented in more or less recent years, as clearly shown by the emergence of bluetongue virus - carried by Culicoides spp. - among ruminants from northern European Countries (3), as well as by the detection of Leishmania spp. - carried by Phlebotomus spp. - in dogs from UK (4).
In consideration of the above and, most importantly, in view of the documented zoonotic potential of many viral and non-viral, arthropod-borne pathogens (including WNV), a "One Health"-based and multidisciplinary approach would be absolutely needed for an "ad hoc" management of the complex ecology and epidemiology of the infections caused by such agents, with this reminding us (once again!) that human, animal and environmental health are mutually and inextricably linked to each other.
References
1) Cantile C, Di Guardo G, Eleni C, Arispici M. (2000). Clinical and neuropathological features of West Nile virus equine encephalomyelitis in Italy. Equine Veterinary Journal 32:31-35. doi: 10.2746/042516400777612080.
3) Carpenter S., Wilson A., Mellor P.S. (2009). Culicoides and the emergence of bluetongue virus in northern Europe. Trends in Microbiology 17:172-178. doi: 10.1016/j.tim.2009.01.001.
4) McKenna M., Attipa C., Tasker S., Augusto M. (2019). Leishmaniosis in a dog with no travel history outside of the UK. Veterinary Record 184:441. doi: 10.1136/vr.105157.
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...
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 received ethical approval, which were typically met with shared concern. Whilst the editorial board had numerous scientific experts examining the study designs and methodologies, they did not have a dedicated ‘ethics expert’ responsible for appraising the ethical appropriateness of the submitted studies. The experience left me with doubt that the editorial team had the interest or capacity to proficiently identify ethical issues in the papers submitted for publication.
Doherty et al.’s commentary together with similar published concerns and my own experiences have left me wondering: is it time to explore the pros and cons of appointing ‘ethics experts’ to the editorial boards of peer-reviewed journals?
Yours sincerely,
Dr Robert Torrance
References:
1. Attarwala, H. TGN1412: From Discovery to Disaster. JYP 2010;2:332.
2. Doshi, P. WHO’s malaria vaccine study represents a “serious breach of international ethical standards.” BMJ 2020.368.
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...
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 case of heat-stable carbetocin (HSC), even when policy updates are accomplished, the regulatory approval that is essential for the drug to enter the country can take time.
In 2021, we expanded our collaboration to include the International Federation of Gynecology and Obstetrics (FIGO) and International Confederation of Midwives (ICM) and their national counterparts to support the transition from policy updates to the development of clinical management protocols and job aids. FIGO and ICM developed a generic protocol on PPH prevention and treatment [3] and engagements with key national stakeholders were held to discuss its usability and adaptability to the country context, and how it could support existing country practices. So far, Ethiopia, Ghana, Rwanda, and Uganda have developed a national PPH clinical protocol that has been approved by the Ministry of Health, and these countries will develop supporting job aids. This work is planned to be completed in 4 other countries – Burkina Faso, Liberia, Sierra Leone, and South Sudan.
The main determinant of choosing which drug(s) to use should be the presence of a skilled birth attendant and reliable cold chain and storage. The more established injectable uterotonics must be kept in cold chain and storage, and quality-assured products must be prioritized for procurement. Implementation considerations must include ensuring that staff know and adhere to the fact that HSC is contraindicated for labour induction and augmentation. HSC is often used for PPH treatment, but this is off-label and the benefits and potential harms are uncertain. Both HSC and tranexamic acid (TXA) should be considered for implementation in peripheral and referral levels of the health care system since at peripheral level the cold chain issues are likely to be more prevalent and the lifesaving role of a quality-assured uterotonic and timely administered TXA in cases of haemorrhage is likely to be crucial. The fact that there seems to be support for intramuscular administration for TXA will make implementation at the periphery easier [4]. In referral settings with surgical capacity, it is essential that TXA is kept in a place where accidental mix-up with local anesthetics that are used in intrathecal anesthesia is avoided, since there have been case reports of deaths due to accidental TXA administration into the intrathecal space [5,6].
We also agree that HSC and TXA should be carefully integrated into the health system in an enabling environment and considering the context perspectives mentioned above. Concept Foundation will conduct implementation pilots in Burkina Faso, Ethiopia, Ghana, Sierra Leone, and Uganda to assess appropriate use following training of healthcare providers, and integration of the two medicines into routine PPH care management. The results of this research will be useful in better understanding the enablers and barriers for successful introduction of essential PPH medicines into clinical practice.
Our experience demonstrates that there are several barriers to access essential, heat-stable PPH medicines that require operationalization of end-to-end thinking at the national level. By end-to-end thinking, we mean addressing the challenges from the highest national policy level right down to the practicing care provider in the most peripheral level of health care where childbirth takes place. To date, most existing programs have focused either on policy level change or health care provider behavior change. Our project adopts a holistic approach, that seeks to align normative change, clinical protocol development, pilot implementation, procurement, and product introduction.
Progress in our project presents a great opportunity to allow the objectives and approach to be achieved in most high-burden countries with modest resources. However, there is undoubtedly a greater need for investment in advocacy, training, and dissemination tools to support the implementation of national guidelines in a locally appropriate way, while ensuring the WHO recommendations are reflected accurately.
References:
[1] Tran NT, Schulte-Hillen C, et al. How to use heat-stable carbetocin and tranexamic acid for the prevention and treatment of postpartum haemorrhage in low-resource settings. BMJ Global Health. 2022; 7:e008913.
[2] Concept Foundation, Country Support page. Geneva; 2021. https://www.conceptfoundation.org/what-we-do/country-support/. Accessed April 28, 2022.
[3] International Federation of Gynecology and Obstetrics (FIGO), Current FIGO projects, IAP page, Project Resources. London; 2022. https://www.figo.org/improving-access-essential-medicines-reduce-postpar.... Accessed April 29, 2022.
[4] Arribas M, Roberts I, et al. WOMAN-PharmacoTXA trial: Study
protocol for a randomised controlled trial to assess the pharmacokinetics and
pharmacodynamics of intramuscular, intravenous and oral administration of
tranexamic acid in women giving birth by caesarean section. Wellcome Open Res. 2021; 6:157.
[5] Patel S, Robertson B, et al. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019; 74: 904-914.
[6] Palanisamy A, Kinsella SM. Spinal tranexamic acid – a new killer in town. Anaesthesia. 2019; 74: 831-833.
The activities in this narrative were supported by funding from MSD, through its MSD for Mothers initiative and are the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co., Inc., Rahway, NJ, USA
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.
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 could be significantly more costly than the previous one.
Yours Sincerely
Thomas Walsh
References
1. Ross I, Esteves Mills J, Slaymaker T, et al. Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries. BMJ Global Health 2021;6:e007361.
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...
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 internationally accepted methodologies and standards to conduct independent investigations that lasted several months and concluded the conflict could not be labeled as ethnic cleansing or genocide; and that acts of sexual violence were committed by individual soldiers and militia from all warring factions including those operating under the TPLF umbrella (3).
In describing humanitarian efforts in the region, the analysis fails to mention that food aid was systematically diverted to combatants rather than civilians and has been used by TPLF leadership in what could be fairly labeled “food as weapons for military recruitment”. Further, the analysis focuses on the assistance of multilateral organizations but fails to describe the extensive assistance provided by the Federal Ministry of Health of Ethiopia in the form of healthcare equipment (worth billions of Ethiopian Birr), medicines, salaries and other benefit packages for over 20,000 healthcare workers in the region, and to analyze the impact of the deployment of over 400 Ethiopian healthcare professionals to the Tigray region to support the Health Care Restoration Plan between November 2020 and June 2021.
This protracted war has indeed ravaged health infrastructure – not only in Tigray, but also in vast regions of Amhara and Afar. It has cost too many lives, devastated the economy, broken families, torn friendships apart, and set back global health and economic initiatives aiming to improve the health and well-being of all Ethiopians. The main victims of this war are ordinary Ethiopians: farmers, drivers, clerks, storekeepers, healthcare workers, mothers and children. We owe it to them to respect the basic tenets of academic integrity, and base our analyses on an even-handed look at the evidence and clearly reasoned arguments, rather than faulty premises and distorted narratives.
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.
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...
Show MoreAs 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...
Show MoreComing 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.
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...
Show MoreDear 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.
Show MoreAs 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...
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...
Show MoreHow to use heat stable carbetocin and tranexamic acid for postpartum haemorrhage in practice
A. Metin Gülmezoglu1, Sara Rushwan1
Show More1 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...
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...
Show MoreDear 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...
Show MoreHi,
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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