104 e-Letters

published between 2019 and 2022

  • On Warlord Discourses – an Inclusive Storytelling is Needed for COVID-19 Response.

    I thank both Rajan et al. and Bali et al. for highlighting a lack of inclusivity in the governance of the coronavirus disease 2019 (COVID-19) response.1,2 While the pandemic raises societal concerns, decision-making bodies remain unrepresentative of civil society and suffer from a dearth of diversity – with, for instance, an underrepresentation of women’s perspectives.1,2 I would add that inclusivity may have been thus far derogated by the popular discourse of some traditional, paternalistic leadership – namely, that which is conveyed through wordings worthy of warlords.

    “We are at war”, as declared the Director-General of the World Health Organization, before exhorting G20 leaders to “fight like hell” and calling for “aggressive action” to combat the COVID-19 pandemic.3 This rhetoric of war echoes that of some men country leaders and scientists, pressing authorities for immediate action. Yet, as metaphors frame the way people act,4 triggering civil and societal responsiveness should instead begin with wordings of compassion, cooperation and emancipation.

    First, the rhetoric of war may monopolize the public attention to a unique, imminent goal: mustering all forces to defeat and annihilate an enemy (here, the severe acute respiratory syndrome coronavirus, SARS-CoV-2) – any other objectives being put aside as under war economy. This imposed monopoly may contrast with population concerns: Do we – civil society – strive merely to exterminate SARS-CoV-2, or rathe...

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  • Institutional misinformation in the time of Covid-19: the case of Italy

    Li et al.[1] analyzed misinformation about the Covid-19 pandemic generated by social media, as well as that from traditional means of communication.[2] We focus here on a further, more insidious form of misinformation: that generated by institutions, by paradigmatically analyzing the case of Italy.
    It was well known on January 31, 2020 that Covid-19 had the potential to become pandemic and detailed measures for adoption by health authorities to combat the disease had already been indicated.[3] On the same day, the Italian government declared a state of emergency.[4] However, while neglecting scientific data [3] and in contrast to the seriousness of the decision,[4] institutional figures (government officials and health authorities), reassured the population through statements in the media that the situation was under control even when the virus had demonstrated its contagiousness and lethality. For weeks prior to the outbreak in Lombardy, the population was told that COVID-19 was little more than a flu. Authorities reassured the population that the measures being adopted to prevent/limit the epidemic were the most stringent in Europe. On February 26th, with 330 infected individuals and 11 dead, the Italian Prime Minister declared that the number of infections should not cause alarm. In the coming days, citizens became aware of the magnitude of the outbreak and found themselves psychologically/materially unprepared, in a stupor in the face of the collapse of the Lomb...

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  • YouTube as a source of information

    This research would be more useful if we were given the raw data containing each misleading publication with precise references to why each misleads. Instead, we obtain a summary of the most inflammatory and outlying presentations, as if those represent the majority. Some of the videos are merely observations by professionals practicing in the field. One of the inflammatory examples about the Italian and Iranian strains stands out. Only last week Governor Cuomo said New York was afflicted by a European strain. Where were the critics calling him out?

  • Healthcare evidence from conflict settings

    To the Editor;
    Three articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
    We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
    The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
    The t...

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  • Socioeconomic Inequalities in Neglected Tropical Diseases

    Dear Editor,

    It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).

    Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.

    There are major ineq...

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  • Simple to use App guides antimicrobial prescribing decisions in LMICS and UK

    Responding to https://gh.bmj.com/content/5/4/e002094
    ‘The Commonwealth Pharmacists Association (CPA) https://commonwealthpharmacy.org/welcomes the publication of this systematic review which confirms the views held by the CPA that usable, point of prescribing decision information in low and middle income countries, is often not readily available where it is most needed. This of particular concern when we consider the prescribing and appropriate use of antimicrobials.
    The UK DHSC Fleming Fund (https://www.flemingfund.org/) Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS) Project has for the last 6 months been piloting an App for use in Ghana, Tanzania, Uganda and Zambia. This is part of the wider CwPAMS programme which is a collaboration between CPA and The Tropical Health and Education Trust (THET) https://www.thet.org/our-work/grants/cwpams/
    The App guides prescribers as per national guidelines, and contains links to WHO resources and other training materials. It is explained clearly in this short u-tube video https://www.youtube.com/watch?v=MJ7fa_aLgCI It is free, to download to a smart phone or device anywhere in the world where there is access to the internet and then...

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  • Ethics in Implementation Research

    Implementation research is crucial to determining effectiveness and appropriateness of interventions that are urgently needed in many contexts, constituting "global health". There is, however, an ongoing surprising relative lack of discussion on the need for appropriate understand of the ethical implications of Implementation research. Ethics committees and researchers are often not well versed in the ethics implications, and how these differ form traditional clinical research. the potential for unintended harm is great in the vulnerable circumstances wheer implementation research is often conducted. It is vital that if implementation research is conducted, ethical implications are considered throughout the process (i.e. continuing throughout the implementation itself and post-research). These issues have been laid out in an online teaching tool (by TDR/Global health Ethics Unit at WHO) and in the following publications:

  • Health and Disease - Just Two States of the Same System

    Paul et al [1] argue for a systemic approach to global health policy. This shift is long overdue, and as they pointed out systems thinking has long been suppressed by the all-powerful reductionist research industry.

    Part of the problem is understanding of health and disease as distinctly dichotomous. However, the experience of health and dis-ease are dynamic as much in the presence as absence of identifiable disease [2]. In addition, health, illness dis-ease and disease occur on a continuum in the same person over time. It entails a continuous change in the physiological dynamics within the person that ultimately leads to changes that we recognise as one or the other disease. The process can lead to multiple expressions of disease, nevertheless, they are nothing more than the result of the overall physiological dysfunction within the same person [3].

    As is well known health and disease disparities follow the socioeconomic gradient [4]. The question arises – how? There is increasing evidence from psychoneuroimmunology research that shows the longterm effects of psychosocial stress on the physiological stress response pathways resulting in chronic inflammatory dysregulation and its link to disease burden [5, 6].

    Taken together, these findings provide a complex adaptive system explanation of the nature of health and disease arising through the network interaction between our environmental, socio-cultural and economic-political contexts and our biological...

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  • Model Hazard?

    Richardson (1) argues three substantive points:
    1. Models are merely fables dressed in formal language.
    2. Fables are unscientific.
    3. Models serve as epistemic confines to our understanding.

    We argue that 2., a premise he makes implicitly, is wrong. Formal language in fables cannot produce an ‘illusion’ of scientific-ness, because there is no division between ‘fables’ and ‘science’. We suggest that scientific models are stories (2) in some real sense, and therefore it does not make sense to say that models are unscientific because they are fables. Science is composed of a complex web of interacting models (stories) whose aims are to explain and understand the world. This would be consistent with Sugden’s (3) view of economic models as credible worlds.
    Richardson cites Rubinstein (4) to buttress his argument that models are merely fictions. This misuses Rubinstein, who argues ‘The models presented… are nothing but fables. Neither of them describes reality, but both of them still describe something from reality… studying both of them together helps to some extent in understanding economic mechanisms.’ (p.182). It does not seem fair to brand models as ‘merely’ fables on this reading, and nor does this give us licence to dismiss fables as unscientific.
    Epidemiologists often make significant assumptions in order to model disease progression. Many parameters are unknown, and there are often practical constraints to modelling significant hete...

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  • India: air pollution and CKD

    As highlighted by Bowe and colleagues, air pollution is closely linked to burden of Chronic Kidney Disease (CKD). (1) A recent article on cardio-pulmonary mortality also highlighted similar issue, with a focus on provision of ventilation. (2)
    India faces similar issues due to air pollution attributable to wide spread traditional habit of cooking with biomass. The contribution of CKD to Disability Adjusted Life Years (DALY) in the country has increased from 0.8% in 1990 to 1.6% in 2016 and it is the 9th common cause of mortality. (3)
    With focus on prevention, CKD has been included under National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, the flagship program for Non-Communicable Diseases (NCD). Through NCD Clinics, diabetes and hypertension, two common risk factors for CKD, are being addressed. Population based screening is also underway for prevention, awareness and early diagnosis of these two morbidities. (4) Pradhan Mantri National Dialysis Program has been put in place to meet the need of dialysis services by the poor people at free of cost. (5) Ujjwala scheme has recently been introduced, under which more than 80 million families have been provided clean fuel. The scheme specifically targets rural areas where biomass is considered as one of the major mean for cooking. (6)
    With so many initiatives, researches are warranted from India to estimate their effects in mitigating CKD burden and to tailor hea...

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