94 e-Letters

  • RE: Concerns about a recent study on the influence of religion on breastfeeding rates
    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...
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  • Recent efforts to boost India’s plan of tuberculosis elimination
    Dear Editor,
    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...
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  • RE: Is it prudent to recommend RUTF in India based on the results of this trial?
    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...
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  • re

    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.


  • RE: Reading Between the Lines of the RUTF trial, India

        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...

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  • Researching the Syrian tragedy: The need for evidence and moral reflexivity

    ‘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...

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  • Essential Medicines List: a good start, but just a start

    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,...

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  • RE: Women's health and men's health - let's move forward together

    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.


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  • Contextual factors influencing village health sanitation and nutrition committees in India

    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 chairm...

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  • How much do LMICs need HICs?

    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...

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