The Lancet Digest October 27 - November 2 2007
This week The Lancet is one of the 235 journals from 37 countries, covering every region of the world, which participated in the Council of Science Editors’ global theme issue on global poverty and human development. Collectively, nearly 750 articles were published representing 110 countries, and The Lancet’s contribution is published in this week’s issue. You can also hear more about them in this week’s Lancet podacst
A Lancet editorial says, “The statistics on global poverty are appalling: over 1 billion people throughout the world still live on less than US$1 a day. And despite the fact that the world is generally richer and there is enough food in the world to feed the global population twice over, the number of people living in absolute poverty has actually increased by 200 000 over the past 10 years. Such figures are shocking. They are a shameful indictment on the international community. But as highlighted by 20 years of the UN International Day for the Eradication of Poverty-on Oct 17 every year-drawing attention to global poverty is not enough.”
It continues, “During the past 4 years, since our first child survival series in 2003, The Lancet’s focus on global health issues, such as maternal survival, sexual and reproductive health, and global mental health, has sought to act as an advocacy tool-to make science the catalyst for political change. The global partnerships and initiatives that have been formed after each series aim to enhance evidence-based policymaking and bring about lasting improvements in human health.”
The editorial concludes, “But there is no room for complacency. By the end of today, 30 000 more people will have died from poverty-related illnesses. We should never let the familiarity of the statistics dull the outrageousness of this situation. There is much to celebrate in the astounding feat of cross-journal partnership. We can, and should, do a great deal more.”
In a Comment, Marion Birch from the charity Medact looks Beyond the Surgery at the role of health professionals in fighting global poverty, arguing that “the fact that health professionals have to patch up the end result of global policies adds weight to statements they make about the causes of human suffering. Good co-operation between health professionals at local, regional and national levels means they can emphasise links between disease, inequality and power. Together, health workers can draw attention to global policies that limit the abilities of national and regional governments to make policy choices that are good for health.”
Another Comment looks at Central Asia and Eastern Europe- two neglected parts of the world. The Authors, Martin McKee and colleagues say, “Similarly to sub-Saharan Africa, eastern Europe and central Asia include many countries with declining life-expectancy. However, their economies are different from sub-Saharan Africa, because many countries have substantial industrial sectors and generally a more developed infrastructure. Eastern Europe and central Asia’s pattern of health is also different: a far greater share of disease burden is accounted for by complex non-communicable diseases and injuries, and thus findings from Africa might not apply directly. Countries in eastern Europe and central Asia are also largely overlooked in the global-health arena, receiving much less development assistance for health than might be expected, in view of the extent of their health and economic development.”
The issue also features a Special Report on Global health governance and the World Bank. Global financial investments in health doubled from $6 billion to nearly $14 billion between 2000 and 2005, but closer scrutiny suggests much of this money is spent on consultants in donor countries, on debt relief, or on bilateral aid to specific countries to achieve donor foreign policy objectives. The Bank has been a prime target for global health advocates since the structural adjustment programs of the 1970s which cut spending on health and social care in many developing countries. Jennifer Prah Ruger looks at how the Bank has rethought its strategy on global health, and at how it could better address the social production of disease through a stronger focus on the political economy of health.
She concludes, “The Bank must make better use of its role in providing policy advice and technical assistance to aid countries not only in building health systems, but also in eliminating their need for bank assistance. After all, the ultimate goal of the bank should be to put itself out of business, to shape a world whose health sectors are sustainable and can function effectively without assistance from the World Bank.”
Another Comment looks at the health impact of the recent uprising in Burma. Chris Beyrer from the Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, says, “Burma’s “Saffron Revolution”, and the brutal military crackdown which followed it, brought the world’s attention to this closed and troubled country. The Buddhist monks and nuns who led the movement have called for dialogue, democracy, and human rights. But they also called on the junta to address the initial spark of the uprising: the five-fold increase in the cost of gas, the doubling of diesel prices, and the two-thirds increases in petrol costs imposed by the junta on Aug 19, 2007. Burma’s people were already in desperate straights before these price hikes. In 2000, Burma’s health-care system was ranked 190th out of 191 nations by WHO.UNICEF estimates that close to a third of children nationwide were malnourished in 2006, real wages were being devoured by inflation, and HIV/AIDS, tuberculosis, malaria, and a range of other health threats were taking terrible tolls on ordinary Burmese.”
He concludes his Comment by saying, “There will doubtless be calls for increasing health and humanitarian assistance efforts in Burma in the aftermath of the Saffron Revolution. Some people might call for a depoliticising of aid efforts and for increased direct collaboration with the junta, its Ministries, and its affiliates. It would be heartless to deny the people of Burma any assistance the international community can provide. But it would be equally heartless to allow aid to be manipulated so as to prolong the junta’s rule or provide preferential relief for the junta’s supporters. Burma’s people have shown again that they want freedom and they have been willing, again, to die for their beliefs. All due diligence must be paid, as health and humanitarian efforts are ramped up, that such efforts do not prolong the cause of the very suffering they seek to alleviate: the military regime, which has proven such a threat to health, wellbeing, and prosperity.”
Another editorial examines malaria eradication. More than half the world’s population are at risk of malaria infection. Each year a million people die from malaria, 80% of them African children under 5. Last week the Gates Foundation called for a new global eradication campaign. The editorial revisits the previous eradication campaign launched by WHO in 1995, noting that “the mosquito and the parasite have proved themselves time and again to be resilient foes. New tools will be needed, and, short of a highly effective vaccine, a successful malaria eradication campaign will require strong health-care systems in regions that often lack even the most basic services. Unless well thought-out and executed, an eradication campaign could divert scarce resources, disrupt other important initiatives, and, should it flounder, undermine support for global health initiatives in general.
But if well-conceived and thoughtfully implemented with close co-ordination, particularly with the nations most afflicted by this disease, an eradication campaign could complement and even strengthen other initiatives, including the building of national health systems.”
Extensively drug-resistant (XDR) strains of tuberculosis, resistant to first and second line therapy, have been reported in 37 different countries across the globe. The largest cluster of cases is in South Africa, where a study by Sanjay Basu of the Yale University School of Medicine found that a combination of existing strategies for controlling nosocomial infection could prevent nearly half of new cases of XDR-TB, even in resource poor settings.
Using a modelling technique, the authors found that use of masks alone would prevent fewer than 10% of cases in the general epidemic, but could, vitally, prevent a large proportion of cases in hospital staff. Combined use of masks, reduced hospitalisation time and a shift to outpatient therapy could prevent nearly a third of cases; and combining this approach with improved ventilation, rapid drug resistance testing, HIV treatment, and tuberculosis isolation facilities could avert nearly half (48%) of cases.
However, the authors add that lengthy hospitalisation or involuntary detention in the absence of sufficient isolation facilities could actually increase the incidence of XDR tuberculosis, since the increased risk of nosocomial transmission outweighed the impact of decreased community-based transmission resulting from these policies.
They conclude by saying their current projections highlight the need for immediate action in addressing the XDR tuberculosis epidemic. The burden of XDR tuberculosis on the health system is already high in this area, and is expected to rise substantially over the next few years.
The authors of an accompanying Comment say, “Multidrug and extensive drug resistance are monsters of our own creation. They might be with us longer than we think and might need us to spend more than governments or institutions are willing or able to pay. Although scientific warnings are often ignored until too late, effective interventions for the control of XDR tuberculosis in Africa are national and international responsibilities, and the world community ignores this message at great peril.”
Clinical articles
Hysterectomy more than doubles risk of requiring stress-urinary-incontinence surgery
Hysterectomy for benign indications, irrespective of surgical technique, more than doubles the risk of requiring subsequent stress-urinary-incontinence surgery (SUIS). As such, women should be counselled on risks associated with hysterectomy, and other treatment options should be considered before surgery concludes an Article.
However, an accompanying Comment examines how the Article contradicts previous studies, including by the same authors, and concludes there could be other reasons why the risk increases.
Many women choose hysterectomy because it offers definite cures to, among other conditions, irregular heavy menstrual bleeding, uterine prolapse, and postmenopausal bleeding. Incidence of hysterectomy-related illness post-operation is also low. By age 55, around one five British Women will have undergone hysterectomy.
Dr Daniel Altman, Danderyd University Hospital, Stockholm, Sweden, and colleagues did a 30-year study between 1973 and 2003 of 165 260 Swedish women who had undergone hysterectomy (exposed group), and 479 506 women who had not (unexposed group), matched by year of birth and area of residence. Occurrence of SUIS in both cohorts was established from the Swedish Inpatient Registry.
The researchers found that the risk of undergoing SUIS was 2·4 times higher in the exposed group compared with the unexposed group, irrespective of surgical technique. They found that the highest overall risk was within five years of hysterectomy, when patients in the exposed group were 2·7 times more likely than those in the unexposed group to require SUIS. The lowest risk was seen in patients more than 10 years after hysterectomy, when the risk was 2·1 times higher for exposed patients.
The authors say: “The most biologically plausible rationale for this association is surgical trauma caused when the uterus and cervix are severed from pelvic-floor supportive tissues at the time of hysterectomy. Hysterectomy could interfere with the intricate urethral sphincter mechanism…it might also result in changes of urethral and bladder neck support.”
“We conclude that hysterectomy, irrespective of surgical technique, increases the risk for stress-urinary-incontinence surgery later in life, with multiparous women at particular risk. Our findings have important public-health and clinical applications, in view of the many women undergoing hysterectomy for benign indications.”
In the accompanying Comment, Dr Adam Magos, Royal Free Hospital, London, UK, looks at the contradictory results of Altman and colleagues’ findings compared with previous studies. He says: “So, what is the truth? It seems likely that a simple hysterectomy does not adversely affect bladder function, at least initially, and indeed pre-existing symptoms may improve. If hysterectomy-induced urinary stress incontinence is a reality, it only becomes so several years after the surgery, as already suggested. Or perhaps it has nothing to do with hysterectomy, and women who agree to hysterectomy are just different in ways that we do not yet understand.”
ANP reduces infarct size and reperfusion injury and increases ejection fraction post myocardial infarction
Patients given human atrial natriuretic peptide (ANP) post myocardial infarction have lower infarct size, fewer reperfusion injuries, and better outcomes than those in a control group concludes an Article.
Professor Masafumi Kitakaze, National Cardiovascular Centre Suita, Osaka, Japan, and colleagues, did two randomised trials (the J-WIND studies), one of which assessed the effect of ANP and the other the effect of nicroandil on infarct size and cardiovascular outcome.
In the ANP trial, 277 acute heart-attack patients were randomised to receive intravenous ANP at a dose of 0·025μg/ kg per min for three days, and 292 patients the same dose of placebo. In the nicroandil trial, 276 patients were randomised to receive intravenous nicroandil (0·067 mg/kg as a bolus, followed by 1·67 μg/kg as a 24-hour continuous infusion), and 269 patients the same dose of placebo. Median follow-up was 2·7 years in the ANP trial and 2·5 years for the nicroandil trial.
The researchers found that in the ANP trial, infarct size was reduced by around 15% and left-ventricular ejection fraction (LVEF) increased by an average of 5% in patients given ANP compared with placebo. In the nicroandil trial, nicroandil administration did not decrease infarct size, however oral administration of nicroandil during follow-up did increase the LVEF between the chronic and acute phases.
On the ANP results, the authors hypothesise: “The reduction of infarct size and the improvement of LVEF might decrease mechanical stress on the non-infarcted myocardium, which might decrease hypertrophy and dilation of the non-infarcted myocardium. Since cardiac hypertrophy and dilation cause diastolic and systolic heart failure, a reduction of infarct size and an increase of LVEF could mediate beneficial clinical outcomes. However, we need to do another large-scale clinical trial to target clinical outcomes such as cardiovascular death, because our primary aim here was to test the reduction of infarct size.”
They conclude: “Our finding that treatment with ANP in the acute phase reduced the incidence or readmission to hospital for chronic heart failure, could help to reduce the physical, medical, and economic burdens on people around the world.”
In an accompanying Comment, Dr Richard Bogle and Dr Martin Wilkins, Imperial College London and Hammersmith Hospital, London, UK say: “Use of ANP as a treatment for acute myocardial infarction needs further investigation in a double-blind study, to assess the dose-response association, to test the robustness of the findings, and to further evaluate the mechanism of action before exposing many patients to this treatment.”
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