139 e-Letters

  • 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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  • COVID-19: Considerations of domestic violence amongst low- and middle-income countries.

    Dear Editor,

    We read with great interest the original research by Coll CVN, Ewerling F, García-Moreno C, et al which found that domestic violence in low- and middle-income countries was more prevalent amongst certain groups of women.

    The ongoing COVID-19 pandemic has already ravaged countries within Asia, Europe and the United States, defined as high-income by the World Bank Group. [1] Actions taken to prevent the spread of the virus has meant a large proportion of the population in these countries is currently under some degree of confinement, and consequently, an alarming increase in domestic violence has been reported by the news. [2]

    Coll CVN, Ewerling F, García-Moreno C, et al recognises Africa and SouthEast Asia to have a higher prevalence of domestic violence. At the time of writing (29/03/2020), the WHO has already reported 3005 cases and 51 deaths in Africa and 3709 cases and 139 deaths in SouthEast Asia, with no doubt that these numbers will continue to grow. [3]

    Resources to fight the COVID-19 epidemics in these regions are limited and thus, efforts aiming to curb the transmission will soon undoubtedly follow other countries’ mitigation plans; police enforcing a lockdown, healthcare workers treating COVID-19 patients and government officials attempting to gather the necessary equipment for the care of its citizens. This means an extensive proportion of the workforce needed to help women undergoing domestic violence will already be si...

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  • Defining global health as public health everywhere else

    While liking the idea, I find two main problems with the suggested definition of global health as "public health somewhere else": 1) it is too narrow and 2) it sounds dismissive. In "global health", the word "global" is inclusive and suggests a health agenda embracing all the communities of the rest of the world. This is lost in the definition. Then there is the dismissive sound of "somewhere else" ("You can join our club or go somewhere else", "This could be Paradise or it could be somewhere else", etc.). I may be thin-skinned, but disdaining to specify a location sounds to me like a slur. For these reasons, and for all the other good reasons offered in the original Commentary, I suggest amending the definition to "public health everywhere else". This follows the original in asserting "elseness", while being inclusive and positive.

  • Trust and culture

    Why the first sentence of this article with its exaggerated claim about the health outcomes of Aboriginal and Torres Strait Islander Australians? The reference cited, 1 does not support the comparison with other populations globally, and the article itself seeks to move beyond negative images of Aboriginal and Torres Strait Islander people. Beginning with this negative statement – regardless of its veracity - continues the long history of deficit discourse used in discussing Aboriginal and Torres Strait Islander people. Rather than contribute to improved outcomes deficit discourse can actually reinforce and perpetuate approaches and behaviours such as those the article seeks to address. 2

    Overall the article presents important new research moving beyond negative stereotypes of Aboriginal and Torres Strait Islander people, highlighting their perspectives and insights, and encouraging a more culturally driven approach. This makes the opening even more inappropriate and unnecessary.


    1. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374:65-74.
    2. Fogarty W, Bulloch H, McDonnell S et al. Deficit Discourse and Indigenous Health: How narrative framings of Aboriginal and Torres Strait Islander people are reproduced in policy. Melbourne: The Lowitja Institute; 2018 [cited 20 Jan 2020]. Available from:...

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  • Research Under pressure in Iran from both sides of sanctions and domestic political crisis

    United States withdrawal from the Iran nuclear deal in May 2018 has led to increasing pressure on all members of society (1). Economic sanctions against Iran have not formally targeted health care or access to drugs and ordinary people, but they have indirectly serious impact on health services and consequently on research programs. Economic sanctions resulted in decline in the value of Iran's currency and government faced big budget deficit. Therefore, the cost of research programs and initial equipments for conducting any projects will increase too much. In this case they are unaffordable by institutions (1-3). Based the on Kokabisaghi et al. paper published in BMJ Global Health in 2019, the economic sanctions imposed more problems on Iran’s research and publishing. Also they claimed that academic boycotts violate researchers’ freedom and curtail progress (2). Free exchange of ideas irrespective of creed is needed to optimize global scientific progress (2). But it seems that another factor can indirectly effects on research programs in Iran. Economic sanctions and scientific boycotts are among the most important problems for researchers on Iran. In the meantime importance of domestic political crisis due to economic sanctions has been ignored. This is not mentioned in this study. With decreased national budget and GDP (gross domestic product) per capita, the government was forced to raise prices of energy and oil carriers; as a result, it created a major political c...

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  • A partnership approach to strengthening IHR compliance

    Dear Editor,

    We read with interest the recent analysis of Joint External Evaluations (JEE) to assess International Health Regulations (IHR) compliance in the WHO African region. It is fantastic to see the engagement in the African region with this voluntary process, with 40 of 47 countries having been evaluated to date and 41 published mission reports (including Zanzibar), the highest proportion of completed JEEs for any WHO region. We congratulate the WHO Regional Office for Africa (WHO AFRO) for its leadership of this critical process. We would like to add our perspective as a technical agency engaged with and supportive of the JEE process.

    As part of Public Health England’s (PHE) IHR Strengthening Project we have been engaging with National Public Health Institutes (NPHIs) in four African countries namely: Ethiopia, Nigeria, Sierra Leone and Zambia. In addition, we work with regional public health institutions such as the Africa Centres for Disease Control and Prevention (Africa CDC), and WHO AFRO to extend our reach beyond the bilateral engagement countries listed. The JEE process, with the subsequent development of a National Action Plan for Health Security (NAPHS), has been instrumental in informing and shaping our areas of engagement. In each of our partner countries, we have worked closely with the leadership of the NPHI and the relevant government ministries to develop workplans that address the gaps and needs highlighted in the JEE and prioritised...

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  • Unpacking the imbalances in authorship in global health.

    DISCLAIMER: Views expressed in this letter are those of the authors only, and do not represent the views or interests of the Bill & Melinda Gates Foundation.

    We enthusiastically agree with the Editor's observation that what underlies the growing concerns about imbalances in authorship are the questions of power asymmetries in the production and benefits of knowledge in global health.

    Critical and open self-reflections and reflexivity on "gaze" (who we write for) and "pose" (position from which we write) are much needed steps towards moving beyond representation on the list of authors.

    However, if what underlies the imbalances in authorship is in fact power asymmetries, solving the problem of imbalances in authors requires directly interrogating the relations of power. Indeed, in our recent article, we identified marginalization the scholarship that interrogates the relations of power represents one of the persistent manifestations of the dominant norms of global health along with democratic deficit and depoliticization of the discourse (Kim et al. 2019). These manifestations may overlap or confound the relation between country/community of origin. We further argue that these manifestations are ideological in character in that they are not merely tendencies but functional in naturalizing and universalizing the implicit assumptions and norms of the dominant narrative.

    The editorial raises an extremely important poin...

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  • Should a paper published by a 'local' researcher about a local country be more valuable?

    Thank you for this extraordinary piece! It provides a more nuanced picture of the concern regarding unequal authorship in global health publishing. In the spirit of your argument, I would like to share my experience and thoughts on this with an example. I have recently received a reviewers comments on an article I submitted for publication that stated that the author is encouraged to review the article, especially if Cameroonian because more research on the topic from Cameroonians is necessary. The article needed more work, I am new to publishing and I am not arguing with that. However, I felt a lot of frustration with the comment about the piece being worth more if written by a Cameroonian as opposed to me a ‘foreigner’/’northerner’. To add to your wonderful piece, I have two reflections on my example: First, I echo your argument that sometimes ‘foreign’ researchers are better placed to conduct ‘local’ research. I conducted research on a very controversial global health project whereby millions of dollars disappeared. If a Cameroonian would ask the questions I asked, they would risk their life. My research took place in an authoritarian state, Cameroonian researchers select very carefully what they say and what they can’t say because of a simple well-founded fear of persecution. They also worry about how critiquing a health programme could affect their future job opportunities with these actors. Second, some Cameroonians don’t want to do the write up because they have sev...

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