We are concerned that the recent paper by Bernard et al published in BMJ Global Health 2016 fails to provide a scientific basis to support the stated conclusion that within Western countries the proportion of Catholics in the population influences the breastfeeding initiation rates.
The paper does not include a literature review on the role of religion in relation to infant feeding and there is no convincing scientific rationale presented to support the hypothesis being tested. There then follows a description of the study’s methods and results which reveals a series of methodological and reporting problems which, in our view, renders the work wide open to biases, confounders and incorrect deductions.There is evidence of selection bias in the five countries selected for within-country analyses, all limited to specific Western countries, with no explanation as why these particular countries were selected for inclusion. It is noteworthy that of these selected five, the dominant languages for each is either English or French which suggests language bias may also be a factor.
A further problem with the methods is the unexplained differences in the selection of the Protestant populations for each of the five countries. For the US the researchers included two categories of Protestants in their analysis (Evangelical Protestants and Mainline Protestants), for Canada and France the category of Protestants was used but then for the U...
We are concerned that the recent paper by Bernard et al published in BMJ Global Health 2016 fails to provide a scientific basis to support the stated conclusion that within Western countries the proportion of Catholics in the population influences the breastfeeding initiation rates.
The paper does not include a literature review on the role of religion in relation to infant feeding and there is no convincing scientific rationale presented to support the hypothesis being tested. There then follows a description of the study’s methods and results which reveals a series of methodological and reporting problems which, in our view, renders the work wide open to biases, confounders and incorrect deductions.There is evidence of selection bias in the five countries selected for within-country analyses, all limited to specific Western countries, with no explanation as why these particular countries were selected for inclusion. It is noteworthy that of these selected five, the dominant languages for each is either English or French which suggests language bias may also be a factor.
A further problem with the methods is the unexplained differences in the selection of the Protestant populations for each of the five countries. For the US the researchers included two categories of Protestants in their analysis (Evangelical Protestants and Mainline Protestants), for Canada and France the category of Protestants was used but then for the UK and Ireland they select only Protestants of Anglican religion – specifically, for the UK regions, the category Anglicans was used and then for Ireland Anglicans (Church of Ireland) is used. The rationale for confining the analysis to Anglican Protestants alone is not explained and the exclusion of data on the other Protestant religions such as Presbyterians, Methodists etc. strikes us as an important omission. For example, in Ireland the percentage of Anglicans is 2.9% (Ref 1). If other Protestant religions were included, this proportion would increase by a quarter to 3.6%. Similarly for the UK, the exclusion of non-Anglican Protestants in the four UK regions is also likely to have impacted on the results. Not being consistent and complete in the manner in which the Protestant groups were determined and enumerated undermines the scientific credibility of this work.
The presentation of results is of concern. The authors fail to clarify that each dot in Figure 2 represents findings from population groups that vary in size from the largest at a population of 53 million population for England to just under 32,000 for the smallest county In Ireland. Presenting results from such disparate population sizes can mislead reader’s interpretation of the scatter plot. Also, it is odd that the US data is presented separately from the other four countries included in the within-country analysis. Of note is the fact that the US was the outlier in that it differed from the others in having breast feeding rates that actually positively correlated with state-level proportions of Catholics. However, the authors subjected these data to a different analysis and presented the results separately. Of concern to us is that, unlike what had been done for the other four countries as displayed in Figure 2 and Table 3, the results by US state is not presented. Rather, the US data analysis included additional stratification by ethnicity (Non-Hispanic white, Hispanic white and Black) and presented separately in Table 4. As a result of this further analysis, the finding of the positive correlation with proportion of Catholics in US states is somewhat diluted.
There are a number of political factors and economic factors that impact on breastfeeding initiation rates and yet the authors have not included or considered these in this paper. It would have been particularly helpful if they had considered important potential confounders that may be associated with historical religious affiliations and infant feeding practices such as the economic importance of the dairy industry, including formula milk production, as well as demographic factors such as urban/rural population ratios.
Low levels of breastfeeding is a serious public health problem in many countries. In Ireland, we have one of the lowest breastfeeding rates in the world and, significantly, Ireland currently holds 10% of the global market share of infant formula production (Ref 2). Those of us working at improving breastfeeding rates seek to use the best evidence to inform the range of necessary interventions. We feel that it is therefore very important to highlight our concerns about the limited scope, flawed methods and difficulties in the presentation of the results of this study. In the interests of policy, practice and research, we argue that this paper fails to present convincing evidence to support the stated conclusion.
1.The Central Statistics Office Ireland, Census 2011, accessed 22nd Mar 2017 at: http://www.cso.ie/en/census/
2.Performance and Prospects 2014-2015 Bord Bia, Irish Food Board, accessed 22nd Mar 2017 at: http://www.bordbia.ie/industry/manufacturers/insight/publications/MarketReviews/Documents/Export-Performance-and-Prospects-2015.pdf
Pai et al put up a timely assessment of India’s ambition of achieving tuberculosis elimination by 2025.1 However, the authors seemed to have overlooked the major developments that have been introduced recently in the country. Inclusion of the updated facts could have enriched the discussion, I believe.
In January 2017, a door to door campaign for active case finding for tuberculosis has been started by the Central TB Division (CTD).2 The scheme, if proved successful, has the capacity to effectively reduce the mean delay of two months between appearance of symptoms and initiation of treatment. This, along with introduction of bedaquiline at six referral sites and enhancing the use of cartridge based nucleic acid amplification test across the country, is expected to boost the performance of Revised National TB Control Programme in near future. In fact, CTD has already decided to start daily regimen in 104 districts, spread over five states.3
Now, apart from the budget, the future would also depend on successful vigilance on the dispensing pattern of anti tubercular drugs from private and informal sectors. A study earlier has demonstrated the use of steroids and fluoroquinolones by the pharmacists for probable cases of tuberculosis.5 With the warning against the silent rise of drug resistant tuberculosis and a projected 275% increase in the risk of multi-drug resistant tuberculosis in India over next 20 years, the...
Pai et al put up a timely assessment of India’s ambition of achieving tuberculosis elimination by 2025.1 However, the authors seemed to have overlooked the major developments that have been introduced recently in the country. Inclusion of the updated facts could have enriched the discussion, I believe.
In January 2017, a door to door campaign for active case finding for tuberculosis has been started by the Central TB Division (CTD).2 The scheme, if proved successful, has the capacity to effectively reduce the mean delay of two months between appearance of symptoms and initiation of treatment. This, along with introduction of bedaquiline at six referral sites and enhancing the use of cartridge based nucleic acid amplification test across the country, is expected to boost the performance of Revised National TB Control Programme in near future. In fact, CTD has already decided to start daily regimen in 104 districts, spread over five states.3
Now, apart from the budget, the future would also depend on successful vigilance on the dispensing pattern of anti tubercular drugs from private and informal sectors. A study earlier has demonstrated the use of steroids and fluoroquinolones by the pharmacists for probable cases of tuberculosis.5 With the warning against the silent rise of drug resistant tuberculosis and a projected 275% increase in the risk of multi-drug resistant tuberculosis in India over next 20 years, the surveillance system for detecting cases and ensuring completion of treatment would have to play the major roles in coming days.6
References
1.Pai M, Bhaumik S, Bhuyan SS. India's plan to eliminate tuberculosis by 2025: converting rhetoric into reality. BMJ Global Health 2017;2:e000326. doi:10.1136/bmjgh-2017- 000326
2.Aditi Tandon. Soon, TB services on doorstep: Polio-like campaign to address TB burden from Jan 16. The Tribune, Jan 4, 2017. (Available from
http://www.tribuneindia.com/news/nation/soon-tb-services-on-doorstep/345735.html, last accessed on 22nd March, 2017)
3.Revised National Tuberculosis Control Programme. TB India 2016 annual status report. 2016. (Available from http://www.tbcindia.nic.in/index1.php?lang=1&level=2&sublinkid=4569&lid=3174, last accessed on 22nd March, 2017)
4.Anandhi CL, Nagaraj VK, Kumar R. Knowledge and practice pattern of non-allopathic indigenous medical practitioners regarding tuberculosis in a rural area of India. Indian J Tuberc 2002;6:553–55.
5.Satyanarayana S, Kwan A, Daniels B, et al. Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study. Lancet Infect Dis 2016;16:1261–68.
6.Law S, Piatek AS, Vincent C, Oxlade O, Menzies D. Emergence of drug resistance in patients with tuberculosis cared for by the Indian health-care system: a dynamic modelling study. Lancet Public Health 2017:2:e47-55.
This RUTF trial from India has compared the efficacy of RUTF (centrally produced and locally produced) with augmented energy-dense home-prepared foods (comparison group) for home based management of uncomplicated severe acute malnutrition (SAM).
I would like to draw attention of the authors on following issues.
1.The study reports that 40% children affected with SAM in the study did not recover even with a prolonged (16 weeks), supervised treatment with RUTF and other supportive measures like deworming, antibiotics at the initiation of treatment and increased access to healthcare for morbidity. The recovery rate was 17.3% with the use of locally produced RUTF and 12.1% with centrally produced RUTF at 16 weeks after the end of treatment phase. With such low recovery rates, is it prudent to make a recommendation for the policy that “Children with uncomplicated SAM can be managed at home with RUTF instead of through inpatient hospitalization”?
2.In this trial, researchers aimed to achieve an intake of 175 kcal/kg body weight/ day for the enrolled children and collected consumption data for both the RUTF groups which were largely comparable. But they fail to do so for the comparison group stating greater difficulty in capturing valid information. Authors need to explain if this has led to a less th...
This RUTF trial from India has compared the efficacy of RUTF (centrally produced and locally produced) with augmented energy-dense home-prepared foods (comparison group) for home based management of uncomplicated severe acute malnutrition (SAM).
I would like to draw attention of the authors on following issues.
1.The study reports that 40% children affected with SAM in the study did not recover even with a prolonged (16 weeks), supervised treatment with RUTF and other supportive measures like deworming, antibiotics at the initiation of treatment and increased access to healthcare for morbidity. The recovery rate was 17.3% with the use of locally produced RUTF and 12.1% with centrally produced RUTF at 16 weeks after the end of treatment phase. With such low recovery rates, is it prudent to make a recommendation for the policy that “Children with uncomplicated SAM can be managed at home with RUTF instead of through inpatient hospitalization”?
2.In this trial, researchers aimed to achieve an intake of 175 kcal/kg body weight/ day for the enrolled children and collected consumption data for both the RUTF groups which were largely comparable. But they fail to do so for the comparison group stating greater difficulty in capturing valid information. Authors need to explain if this has led to a less than robust comparison of outcomes between the two RUTF groups and the augmented energy-dense home-prepared foods group as energy intake in the comparison group is not known.
3.It will be useful if the authors provide opinion about efficacy of centrally produced RUTF in comparison to locally produced RUTF in treating SAM as adequate data in this regard are available to them in the study to do so. This information will be relevant from programmatic point of view as programmes for treatment of SAM in some states of India are using centrally produced RUTF.1
4.The study has reported that centrally produced RUTF was not efficacious in comparison to nutrient-rich homemade foods to treat SAM. It will be useful if authors can provide some underlying factors for this finding, just like they have explained many other findings in the discussion.
Reference:
1. National Health Mission – Government of Rajasthan. Poshan. Available at: http://nrhmrajasthan.nic.in/POSHAN.asp
Abdur Sarker et al have highlighted an incredibly important aspect of Bangladeshi society that acts as a pivotal part of achieving Universal Health Coveage (UHC). They have clearly highlighted aspects such as the promotion of health equity and access within cooperatives, however, two aspects of such societies have not been discussed, namely technology and education.
Reading Between the Lines of the RUTF trial, India
Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...
Reading Between the Lines of the RUTF trial, India
Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied in the augmented home foods category, but had to be cooked, also underplays this issue and complicates the results, as does the fact that peer support was different in each arm (though statistically insignificant) and this was adjusted for in the results, without offering details on these differences and adjustments.
Nonetheless, results show that the differences between A- HPF and RUTF-C were not significant. RUTF-L (being different from RUTF-C only in texture) was found to be inexplicably better than A-HPF, achieving a 57% recovery rate compared to 43% in 16 weeks. However, 16 weeks after the intervention, the overall numbers of children cured had dwindled to 15%.
Thus, the data clearly shows that the overall impact across all three arms is low, with over 40% children remaining in SAM even after a prolonged period of intervention in the strongest arm. Even these gains are unacceptably temporary. In addition, the element of supervised feeding ‘several times a day’ by a paid peer counselor seems quintessential to the results across the arms. Far from encouraging the use of RUTF in India, all these facts seem to suggest that, given a certain equivalence of quality, the choice of product is largely irrelevant for the community management of malnutrition.
The question this paper should rather be discussing is, whether it is logical, practical, acceptable and cost- effective to have individualized paid workers offering supervised feeding of RUTF-L several times a day at sparsely scattered households, to be able to achieve only moderate and highly unsustained gains in treating SAM.
Instead, the existing alternative hypothesis for SAM prevention and managementiii ; supporting families through comprehensive childcare programmes that organize care, health and nutrition using local resources, needs to be taken seriously and tested if required.
Word count: 498
i Sachdeva HPS, Kapil U, Gupta A, Prasad V. “Sustainable developmental solutions or product- based illusions for addressing severe acute malnutrition?” Paper submitted to the World Nutrition Conference2016, held in Cape Town, South Africa from 30th August to 2nd September 2016. Available http://www2.tulane.edu/publichealth/internut/magic-bullets-workshop.cfm
ii Prasad V, Holla R, Gupta A. Should India use commercially produced ready to use therapeutic foods (RUTF) for severe acute malnutrition (SAM)? Social Medicine 2009; 4(1): 52-5.
iii Prasad V, Sinha D. Potentials, Experiences and Outcomes of a Comprehensive Community Based Programme to Address Malnutrition in Tribal India. International Journal of Child Health and Nutrition, 2015, 4, 151-162

‘The nationalist not only does not disapprove of atrocities committed by his own side, but he has a remarkable capacity for not even hearing about them’ (George Orwell, Notes on Nationalism 1945).
We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.
Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russ...
‘The nationalist not only does not disapprove of atrocities committed by his own side, but he has a remarkable capacity for not even hearing about them’ (George Orwell, Notes on Nationalism 1945).
We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.
Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russian army’s air force in addition to other allies leading to the accelerated destruction of physical infrastructure particularly healthcare facilities.
Despite their insistence that research on Syria is politically one-sided and relies heavily on social media reports, Sen et al do not appear to have properly scrutinised the many reports that document the targeting and destruction of health facilities by all sides. This research particularly that of Physicians for Human Rights has painstakingly made efforts to utilise multiple sources regardless of their political affiliations – government and opposition eyewitnesses in order to corroborate events on the ground. It is clear from this research that SAA forces and their allies are responsible for the bulk of civilian mortality and injuries. This mainly stems from the fact that the official opposition and other rebel groups do not possess air force capabilities which have inflicted the largest amount of damage.
In their previous work Sen et al have continually cited economic sanctions as being the primary cause of the detrimental health impacts on civilians in Syria and a driver of the refugee crisis. It is factually and statistically incorrect to claim that sanctions have had a greater health impact on the Syrian population than almost six years of direct military attacks on civilians, healthcare and systematic destruction of public infrastructure including water plants and sewage farms in opposition-held areas by three major armies (Syrian, Russian and Iranian).
We acknowledge the difficulties of collecting verifiable data in conflict zones and welcome further research on the health and social situation of those living in Government Controlled Areas. This is an issue which has been lacking in the coverage of the Syrian crisis and has often been filled by journalistic sources. However, obtaining reliable data and information from the Syrian government such as the Ministries of Health and Social Affairs in Damascus has proved almost impossible for researchers, multi-lateral and donor agencies. Indeed, accurate mortality statistics for SAA soldiers are impossible to access and yet could provide a more balanced understanding of losses on all sides.
Academics have a moral obligation to engage widely and with neutrality in information gathering, taking data provided by different sides of highly politicised debates into account. However, the facts-on-the-ground and weight of evidence in the Syrian crisis shows that parties on one side of the conflict – Syrian government forces and their allies in the air and on the ground – are committing the vast majority of violations. Failure to acknowledge this imbalance is academically, ethically and philosophically bad practice. The conclusion by Sen and colleagues that ‘the Syrian conflict urgently needs a reassessment of research ethics’ is out of touch with the urgent need for the Syrian government and its allies to cease targeting civilians, stop attacking healthcare facilities and lift the siege on over one million civilians.
The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.
However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML,...
The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.
However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML, while the safer antithyroid medication, methimazole, is not.
The Pediatric Endocrinology Education Program for Haiti, supported by the Pediatric Endocrine Society and the European Society for Pediatric Endocrinology, aims to introduce pediatric endocrine care to a country where no pediatric endocrinologist currently practices. Unpublished data from teleconsultations as part of this program demonstrate that the majority of children diagnosed with endocrine disorders do not have access to the medications they need – even if these are listed on the national EML. For example, hydrocortisone and fludrocortisone, essential medications for children with adrenal insufficiency, are on Haiti’s EML but were unavailable despite extensive searches. Even inexpensive medications such as levothyroxine and routine supplements such as calcium carbonate and vitamin D2/D3 are often difficult to find and calcitriol is entirely unavailable. The list of inaccessible medications is long, including vital medications such as growth hormone and diazoxide for neonatal hypoglycemia.
Maybe most reflective of the alarming situation is access to insulin. While listed on all EMLs, the reality of children who are diagnosed with diabetes is different. The Kay Mackenson Clinic, a center for children with chronic diseases in Haiti, recently assessed the availability of insulin in Haiti and showed that close to one third of patients do not have access to insulin at the time of diagnosis and close to half lack access to insulin after they are discharged from the hospital following initial diagnosis (5). Further, long-acting and ultra-short acting insulin analogs, mainstay of therapy for intensive diabetes control, are virtually inaccessible.
Inequities in access to essential medications in pediatric endocrinology remain unacceptable. The comparison of EMLs by Rowlands et al should stimulate further research into actual accessibility, including its predictors and barriers.
References:
1. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19:127–140.
2. van Mourik MS, Cameron A, Ewen M, Laing RO. Availability, price and affordability of cardiovascular medicines: a comparison across 36 countries using WHO/HAI data
3. http://www.worldbank.org/en/country/haiti/overview
4. http://www.fda.gov/Drugs/DrugSafety/ucm209023.htm
5. von Oettingen J, Carolan E, Jean-Baptise E, Larco N, Larco P, Ogle G, Lorgeat V, Mascary M, Bonnell R, Carpenter C. (2016). Health care delivery gaps affect children with new onset diabetes in
Dr Peters et al's call for action to reduce the global burden of disease more efficiently in women and men is very well made.
Their article focuses on women's health but many similar points could be made about men's. WHO data shows that, globally in 2012, 52% of all deaths from NCDs were male. Males were more likely than females to die prematurely (under 70 years) from NCDs in almost every country. The major risk factors for NCDs include unhealthy diets, tobacco use and the harmful use of alcohol and men do worse than women in respect of all of these. Data from the Global Burden of Disease Study 2010 shows that, in that year, 55% of deaths from dietary risk factors were male as were 72% of deaths from tobacco smoking and 65% of deaths from alcohol.
Life expectancy data also highlights the health burden borne by men. Globally, male life expectancy at birth, at 68 years, lags five years behind female life expectancy and the global ‘gap’ is predicted to increase over the next 15 years: by 2030, male life expectancy could well be seven years shorter than female life expectancy.
Global as well as the almost all national health policies have largely ignored men. The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-30) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men.
Dr Peters et al's call for action to reduce the global burden of disease more efficiently in women and men is very well made.
Their article focuses on women's health but many similar points could be made about men's. WHO data shows that, globally in 2012, 52% of all deaths from NCDs were male. Males were more likely than females to die prematurely (under 70 years) from NCDs in almost every country. The major risk factors for NCDs include unhealthy diets, tobacco use and the harmful use of alcohol and men do worse than women in respect of all of these. Data from the Global Burden of Disease Study 2010 shows that, in that year, 55% of deaths from dietary risk factors were male as were 72% of deaths from tobacco smoking and 65% of deaths from alcohol.
Life expectancy data also highlights the health burden borne by men. Globally, male life expectancy at birth, at 68 years, lags five years behind female life expectancy and the global ‘gap’ is predicted to increase over the next 15 years: by 2030, male life expectancy could well be seven years shorter than female life expectancy.
Global as well as the almost all national health policies have largely ignored men. The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-30) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men.
There should not be a competition between the advocates of men's health and those of women's health to demonstrate which sex is worse off or to grab resources from each other. This must not be a zero sum game. We need action, gendered as and when appropriate, to improve the health of both sexes. Without such an approach, the SDG targets, amongst others, will be far harder to achieve.
I read with interest the abstract on contextual factors influencing village health sanitation and nutrition committee (VHSNC)[1]. The authors mention that none of the 50 VHSNCs in their study received the “untied funds” (Rs.10,000/- per annum) during 18 months of study period. These funds are provided to empower the VHSNCs to address immediate health needs of the community, and to stimulate local action towards raising health awareness and organising village level meetings, sanitation drives and other identified health need. As VHSNCs are expected to leverage funds from other sources, it would have been useful to know how much additional amount these VHSNCs under study were able to generate on their own?
From my personal experience I can say that two contextual factors play key role in success of any such schemes in rural India: a) local village politics, and b) corruption. Authors have mentioned that many VHSNCs were unable to engage crucial elected representatives (Sarpanchs) and instead had to work with the lowest level elected representative (Ward-Panchayat), thereby having little influence. One of the possible reasons for this could be that Sarpanchs despite knowing that VHSNC is a subcommittee of Panchayat, might have viewed it as a parallel authority diluting their role especially as the chairperson of VHSNC has to be a female ward-Panchayat preferably from underprivileged sections of society.
I read with interest the abstract on contextual factors influencing village health sanitation and nutrition committee (VHSNC)[1]. The authors mention that none of the 50 VHSNCs in their study received the “untied funds” (Rs.10,000/- per annum) during 18 months of study period. These funds are provided to empower the VHSNCs to address immediate health needs of the community, and to stimulate local action towards raising health awareness and organising village level meetings, sanitation drives and other identified health need. As VHSNCs are expected to leverage funds from other sources, it would have been useful to know how much additional amount these VHSNCs under study were able to generate on their own?
From my personal experience I can say that two contextual factors play key role in success of any such schemes in rural India: a) local village politics, and b) corruption. Authors have mentioned that many VHSNCs were unable to engage crucial elected representatives (Sarpanchs) and instead had to work with the lowest level elected representative (Ward-Panchayat), thereby having little influence. One of the possible reasons for this could be that Sarpanchs despite knowing that VHSNC is a subcommittee of Panchayat, might have viewed it as a parallel authority diluting their role especially as the chairperson of VHSNC has to be a female ward-Panchayat preferably from underprivileged sections of society.
This becomes more evident if the chairman of the VHSNC and tha Sarapanch have different political affiliations. Although VHSNCs are formed through a consultative process within the village, any favouritism and impartial selection of members of VHSNC (e.g. from a particular political party only) can generate mistrust and decrease its acceptability at large. Keeping such local dynamics in view, it is paramount that the selection of members of VHSNC is transparent and fair, and any grievance related to selection of members is promptly addressed.
Though the untied fund of ₹10,000 per annum is very little, the potential of corruption and bias in spending even such a meagre amount cannot be excluded in Indian context. The vague guidelines to spend this amount also leave lacunae for same. For example, untied funds can be used to help destitute women or poor households to meet their healthcare needs [2]. Understandably these guidelines provide overarching guidance only and give freedom to VHSNCs. However in the absence of clear guidelines to identify such population, it is possible that VHSNC members might spend untied funds on destitute women and poor household of their own ward/locality only. Hence it is important that VHSNCs frame criteria in advance to identify such population and spend money in a transparent manner.
Better management of village politics and corruption risk could help in successful implementation of VHSNCs.
Reference
1. Scott K, Sheikh K, George A, et al. Understanding the contextual factors that influence village health sanitation and nutrition committees in northern India. BMJ Glob Health 2016;1(Suppl 1):A15-A16.
2. Ministry of Health and Family Welfare, Government of India. Handbook for members of village health sanitation and nutrition committee. Available from http://nrhm.gov.in/images/pdf/communitisation/vhsnc/Resources/Handbook_for_Members_of_VHSNC-English.pdf
We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
There are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonial...
We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
There are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonialism’ throughout this roadmap. Admittedly, this language is emotive in the context of historic and current relationships between some LMICs and Europe. However, it is not a concept universally understood or experienced by all LMICs globally. It further feeds into the narrative that all people in LMICs are subalterns, subject to decisions and control by Western nations. We ask the authors to be mindful of surgical imperialism, which assumes answers to problems of surgical delivery are held by Western academics and not by those who work in LMICs.
Whilst we are supportive of a call to arms for actors in HIC to work in collaboration with those from other settings, as budding surgeons of the future and an international coalition of students, we are disappointed by the representation of the papers authors; 75% from the USA, and just 12% from LMICs. Whilst HIC actors have an important and continuing role in the delivery of surgical care to the world’s most vulnerable, it is those of us in LMICs who will bear the brunt of this task and ought to be better represented and empowered to dictate the future of our health systems.
1. http://www.smartglobalhealth.org/pages/kenya-mission/kenya-health
http://blogs.worldbank.org/africacan/three-myths-about-aid-to-kenya
Abdur Sarker et al have highlighted an incredibly important aspect of Bangladeshi society that acts as a pivotal part of achieving Universal Health Coveage (UHC). They have clearly highlighted aspects such as the promotion of health equity and access within cooperatives, however, two aspects of such societies have not been discussed, namely technology and education.
Reading Between the Lines of the RUTF trial, India
Show MoreNita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...
‘The nationalist not only does not disapprove of atrocities committed by his own side, but he has a remarkable capacity for not even hearing about them’ (George Orwell, Notes on Nationalism 1945).
We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.
Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russ...
Show MoreThe comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.
However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML,...
Show MoreDr Peters et al's call for action to reduce the global burden of disease more efficiently in women and men is very well made.
Their article focuses on women's health but many similar points could be made about men's. WHO data shows that, globally in 2012, 52% of all deaths from NCDs were male. Males were more likely than females to die prematurely (under 70 years) from NCDs in almost every country. The major risk factors for NCDs include unhealthy diets, tobacco use and the harmful use of alcohol and men do worse than women in respect of all of these. Data from the Global Burden of Disease Study 2010 shows that, in that year, 55% of deaths from dietary risk factors were male as were 72% of deaths from tobacco smoking and 65% of deaths from alcohol.
Life expectancy data also highlights the health burden borne by men. Globally, male life expectancy at birth, at 68 years, lags five years behind female life expectancy and the global ‘gap’ is predicted to increase over the next 15 years: by 2030, male life expectancy could well be seven years shorter than female life expectancy.
Global as well as the almost all national health policies have largely ignored men. The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-30) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men.
The...
Show MoreI read with interest the abstract on contextual factors influencing village health sanitation and nutrition committee (VHSNC)[1]. The authors mention that none of the 50 VHSNCs in their study received the “untied funds” (Rs.10,000/- per annum) during 18 months of study period. These funds are provided to empower the VHSNCs to address immediate health needs of the community, and to stimulate local action towards raising health awareness and organising village level meetings, sanitation drives and other identified health need. As VHSNCs are expected to leverage funds from other sources, it would have been useful to know how much additional amount these VHSNCs under study were able to generate on their own?
From my personal experience I can say that two contextual factors play key role in success of any such schemes in rural India: a) local village politics, and b) corruption. Authors have mentioned that many VHSNCs were unable to engage crucial elected representatives (Sarpanchs) and instead had to work with the lowest level elected representative (Ward-Panchayat), thereby having little influence. One of the possible reasons for this could be that Sarpanchs despite knowing that VHSNC is a subcommittee of Panchayat, might have viewed it as a parallel authority diluting their role especially as the chairperson of VHSNC has to be a female ward-Panchayat preferably from underprivileged sections of society.
This becomes more evident if the chairm...
Show MoreWe congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
Show MoreThere are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonial...
Pages