I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
It should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced di...
I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
It should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced differences between multidisciplinary surgery and the solitary surgeon are not only of importance in relation to credibly building effective alliances. Those who control national, regional and local budgets do not understand the differences and view surgery and surgeon as the same. Stories are already emerging where health ministries have cut funding to anaesthesia and nursing so as to fund the training of more surgeons. More surgeons unable to perform surgery because of the absence of the others needed for the team is not a goal we should aspire to. It behooves all of us in this enterprise to speak carefully, accurately, and consistently.
References:
Ng-Kamstra JS et al. BMJ Global Health. Global Surgery 2030: a roadmap for high income country actors. DOI: 10.1136/bmjgh-2015-000011 Published 6 April 2016
To the Editor
The article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a mu...
To the Editor
The article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a must for being qualified as DP. Mere presence of a Sub-center, Primary Health Center or Community Health Center (three levels of health care facilities in India) does not ensure existence of a DP. In brief, the strategy stresses on presence functional health facilities, rather than increasing number of hospital buildings. Consideration of these facts would help the readers understand the challenges better.
References
1. Iyer V, Sidney K, Mehta R, et al. Availability and provision of emergency obstetric care under a public– private partnership in three districts of Gujarat, India: lessons for Universal Health Coverage. BMJ Global Health 2016;1:e000019. doi:10.1136/bmjgh-2015-000019
2. Government of India. Maternal and newborn health toolkit. Ministry of health and family welfare. New Delhi. 2013.
3. WHO, UNICEF, UNFPA and AMDD. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organisation, 2009.
Mishra and colleagues1, discussed a fairly discouraging trend of smoking over decades in India. But in India, tobacco chewing is also associated with the risk of cancer among those who never smoked bidis or cigarettes.2 Smokeless tobacco products like Gutkha (crushed areca nut, tobacco) and pan masala (mixture of tobacco, essence and other ingredients) are available in attractive colorful small sachets for as low as half a rupee, and have become increasingly popular with aggressive marketing and advertisements.
In addition, many Indians smoke the much cheaper, unfiltered crude tobacco product called Bidi, which is made of 0.15-0.25g of sun-dried flaked tobacco rolled in a dried rectangular piece of Tendu or Temburni leaf (Diospyrosmelanoxylon) and a thread securing the roll. Bidis have lower tobacco content than cigarettes, but more nicotine, tar and carbon monoxide. Stick for stick, they are deadlier. Unregulated, Bidi is a major form of tobacco use, with a predicted sale of 1031 billion bidis in 2007.3
There are however two sides of the tobacco coin in India: One side allows for the production of tobacco in the country. In 2012, India was the 2nd largest producer of tobacco in the world.4 On the other side, there are increasing taxes on the sale of tobacco product, which is a way of generating revenue and restricting its use. Although it is thought that higher taxes would make cigarettes unaffordable to poor Indians, these taxes have had the effect of promoti...
Mishra and colleagues1, discussed a fairly discouraging trend of smoking over decades in India. But in India, tobacco chewing is also associated with the risk of cancer among those who never smoked bidis or cigarettes.2 Smokeless tobacco products like Gutkha (crushed areca nut, tobacco) and pan masala (mixture of tobacco, essence and other ingredients) are available in attractive colorful small sachets for as low as half a rupee, and have become increasingly popular with aggressive marketing and advertisements.
In addition, many Indians smoke the much cheaper, unfiltered crude tobacco product called Bidi, which is made of 0.15-0.25g of sun-dried flaked tobacco rolled in a dried rectangular piece of Tendu or Temburni leaf (Diospyrosmelanoxylon) and a thread securing the roll. Bidis have lower tobacco content than cigarettes, but more nicotine, tar and carbon monoxide. Stick for stick, they are deadlier. Unregulated, Bidi is a major form of tobacco use, with a predicted sale of 1031 billion bidis in 2007.3
There are however two sides of the tobacco coin in India: One side allows for the production of tobacco in the country. In 2012, India was the 2nd largest producer of tobacco in the world.4 On the other side, there are increasing taxes on the sale of tobacco product, which is a way of generating revenue and restricting its use. Although it is thought that higher taxes would make cigarettes unaffordable to poor Indians, these taxes have had the effect of promoting the use of the unregulated Bidi.5 On the one hand, India is leading in tobacco production, exporting tobacco to generate revenue. On the other hand, India is increasing tax on tobacco.
It remains to be seen how increasing taxes on tobacco production without curtailing and regulating its production would benefit public health in India.
References
1. Mishra S, Joseph RA, Gupta PC, et al. Trends in bidi and cigarette smoking in India from 1998 to 2015, by age, gender and education. BMJ Global Health 2016;1:e000005.doi:10.1136/bmjgh-2015-000005
2. Sapkota A, Gajalakshmi V, Jetly DH, Roychowdhury S, Dikshit RP et al. (2007) Smokeless tobacco and increased risk of hypopharyngeal and laryngeal cancers: a multicentric case-control study from India. Int J Cancer 121: 1793-1798
3. Shimkhada R, Peabody JW. Tobacco control in India. Bull World Health Organ. 2003;81:48–52.
4. Food and agriculture organization of the United Nations. FAO. [Last accessed on 2016 April 17]. available from: http://faostat.fao.org/site/339/default.aspx .
5. Kyaing NN, Islam MA, Sinha DN, Rinchen S. Social, economic and legal dimensions of tobacco and its control in South-East Asia region. Indian J Public Health. 2011;55(3):161-8.
I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
Show MoreIt should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced di...
To the Editor
Show MoreThe article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a mu...
Mishra and colleagues1, discussed a fairly discouraging trend of smoking over decades in India. But in India, tobacco chewing is also associated with the risk of cancer among those who never smoked bidis or cigarettes.2 Smokeless tobacco products like Gutkha (crushed areca nut, tobacco) and pan masala (mixture of tobacco, essence and other ingredients) are available in attractive colorful small sachets for as low as half a rupee, and have become increasingly popular with aggressive marketing and advertisements.
Show MoreIn addition, many Indians smoke the much cheaper, unfiltered crude tobacco product called Bidi, which is made of 0.15-0.25g of sun-dried flaked tobacco rolled in a dried rectangular piece of Tendu or Temburni leaf (Diospyrosmelanoxylon) and a thread securing the roll. Bidis have lower tobacco content than cigarettes, but more nicotine, tar and carbon monoxide. Stick for stick, they are deadlier. Unregulated, Bidi is a major form of tobacco use, with a predicted sale of 1031 billion bidis in 2007.3
There are however two sides of the tobacco coin in India: One side allows for the production of tobacco in the country. In 2012, India was the 2nd largest producer of tobacco in the world.4 On the other side, there are increasing taxes on the sale of tobacco product, which is a way of generating revenue and restricting its use. Although it is thought that higher taxes would make cigarettes unaffordable to poor Indians, these taxes have had the effect of promoti...
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