- Email: [email protected]
Response to medical students' letter of solidarity with Gaza
Correspondence
In a Correspondence letter (published online Jan 12),1 medical students in Boston, MA, USA implicate Israel in perpetrating a “disproportionate assault” that underlies the humanitarian disaster in Gaza. Although these doubtlessly well intended individuals seek the moral high ground in calling for “an immediate cessation of hostilities”, they unfortunately ignore the realities of the situation. As fellow medical students, we would be remiss if we did not attempt to provide a clearer picture of the reality in Gaza and address some of the troubling points of our colleagues. We believe that the invocation of an alleged “moral voice” in the face of a complex political situation without a full understanding of the facts is irresponsible and unprofessional. A brief chronology of the latest saga of the Israeli-Palestinian conflict is crucial to a proper appreciation of the issues involved in the current war. In August, 2005, after 5 years of fighting in the Second Intifada with no resolution in sight, Israel unilaterally withdrew all of its soldiers and citizens from the Gaza strip in hopes of fostering a lasting peace. Since the Israeli withdrawal, however, Hamas, an internationally recognised terrorist organisation funded by Iran, has fired more than 6000 deadly rockets from Gaza, targeting Israeli civilians. It is against these war crimes, the indiscriminate targeting of innocent civilians, that the Israeli military has been forced to respond. As US President-elect Barack Obama asserted in a campaign visit to Israel in July, 2008, “If somebody was sending rockets into my house where my two daughters sleep at night, I would do everything to stop that, and would expect Israel to do the same thing.” After years of restraint and after exhausting all diplomatic avenues, it www.thelancet.com Vol 373 January 31, 2009
is this very principle of defending its civilians, one of the founding tenets of democracy, which has driven Israel to take up arms against Hamas. There is no question that the loss of Palestinian life in Gaza is terribly tragic and that every effort should be made to avoid civilian casualties and to provide medical aid and supplies to those suffering. Although no party is blameless for the Palestinian death toll, the stark contrast between Israel’s and Hamas’ treatment of the people in Gaza must be asserted. Israel’s defence of its own citizens has gone hand in hand with extraordinary efforts to protect the civilians of Gaza. Israel distributes leaflets, sends voicemails and text messages, and uses radio and television announcements to warn Gazan civilians to clear areas of imminent attacks. Israel seeks to minimise civilian casualties through surgical strikes on military objectives, and frequently aborts key missions due to concerns for civilian casualties. Moreover, since the beginning of the war, Israel has transported thousands of kilograms of food and medical supplies to ease the Gazans’ plight. Israel’s efforts to minimise harm to the civilians of Gaza have been confounded by Hamas who consistently place civilians in the line of fire. Hamas, in clear violation of international law, gathers women and children around military targets to use them as human shields. This terrorist regime endangers the people of Gaza by using civilian homes, schools, mosques, and hospitals as launching grounds for rockets fired at Israeli civilians and prides itself on the number of its own people martyred to the destruction of Israel. It preys on the moral conscience of the democratic world, which places a premium on innocent lives, knowing that Israel seeks to avoid killing the same Palestinian civilians whom Hamas militants hide behind and deem dispensable. It is these abominable tactics of Hamas that lead to the “disproportionate” number
of Palestinian civilian casualties and which should evoke international condemnation and outrage. We recognise the hardships and losses incurred by both sides of this conflict, but we also know that simplistic solutions based on distorted facts are not the answer. Calls for an “immediate cessation of hostilities” outside the context of viable and sustainable security are shortsighted. Although it might seem to be an attractive and “humanitarian” solution in the short term, it will not alleviate the plight of Palestinians who suffer under the policies of the Hamas regime nor bring safety to the civilians of Israel who live in terror of rockets. Every person should rightly be pained by the death and suffering of innocent people wherever they might be. Nonetheless, espousing moral indignation in the face of a skewed and one-sided picture of an immensely complex situation simply delays finding appropriate solutions. How can a letter that calls for humanitarianism and civilian protection point to Israel’s “brutal attacks” while ignoring the countless Israeli efforts to protect Gazan civilians? Why was it deemed irrelevant to mention the significant role of Hamas in the number of Palestinian civilian deaths? It pains us that some would attempt to value the lives and security of one people over the lives and security of another, and to express solidarity with some innocents while ignoring others. As medical students committed to the sanctity and preservation of human life, we too express our grave concern for the protection of innocents and hope for a speedy but viable resolution so that both Palestinians and Israelis can live in peace and safety.
Published Online January 19, 2009 DOI:10.1016/S01406736(09)60075-1
Getty Images
Response to medical students’ letter of solidarity with Gaza
We declare that we have no conflict of interest.
Rebecca Braunstein, David Faleck, *David Stern, on behalf of 805 medical students, 503 doctors, 236 health professionals, and 275 other concerned individuals [email protected]
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
377
Correspondence
Albert Einstein College of Medicine of Yeshiva University, Bronx, NY 10461, USA 1
Abdou R, Romm I, Schiff D, et al, on behalf of 753 other medical students. In solidarity with Gaza. Lancet 2009; published online Jan 12. DOI: 10.1016/S0140-6736(09)60042-8.
Science Photo Library
N-3 polyunsaturated fatty acids and statins in heart failure
See Department of Error page 382
378
The cover of The Lancet Oct 4 issue confidently declares that “Supplementation with N-3 polyunsaturated fatty acids should join the short list of evidence-based life-prolonging therapies for heart failure”. However, the GISSI-HF trial, on which this statement is based (p 1223),1 does not support such a strong conclusion. In unadjusted analyses (the “main” analyses according to the trial protocol2) there was only modest evidence of beneficial effects on the primary outcomes of all-cause mortality (hazard ratio 0·93, 95% CI 0·85–1·02; p=0·12) and death or admission for cardiovascular reasons (0·94, 0·87–1·02; p=0·06). These estimates exclude the 20% reduction in risk that was specified as the minimal clinically beneficial effect.2 However, the results highlighted in the Summary and featured in the associated Comment3 were adjusted for prognostic factors (“subsequent analyses” according to the protocol2). Although the size of estimates was barely changed by adjustment, the p values declined to 0·04 and 0·01—ie, below the much-over-interpreted significance threshold of 0·05.4 The protocol states that “any unbalance for baseline characteristics thought to be of prognostic importance will be considered for multivariate adjustment.”2 As noted by the CONSORT investigators,5 multiple analyses of the same data create a risk of false-positive findings. The chosen adjustments were for three (presumably adverse) prognostic indicators, all of which were
more prevalent in the fish oil group. Adjustment therefore increases the apparently beneficial intervention effect. We would be interested to see further analyses adjusting for characteristics such as the presence of chronic obstructive pulmonary disease and having had a coronary artery bypass graft. These were more prevalent in the placebo group so that adjustment would reduce the beneficial effect of fish oil. A reasonable interpretation of the GISSI-HF trial would be that the modest estimated effect of fish oil requires replication. It is disappointing that The Lancet seems to have succumbed to the lure of the significant p value.
could have affected the findings. Whether or not they did, however, is impossible to tell because these data were not recorded. Dietary n-3 PUFA are associated with beneficial cardiovascular effects including reduced incidence of heart failure and lower systolic blood pressure,3 but the effects of dietary n-3 PUFA on the prognosis of heart failure are not known. The GISSI-HF trial addressed an important clinical question, but further research should take into account dietary intake of n-3 PUFA before concluding that supplements clinically benefit patients with heart failure.
We declare that we have no conflict of interest.
Lorna M Gibson
George Davey Smith, Marie-Jo Brion, *Jonathan A C Sterne
[email protected]
[email protected] University of Bristol, Department of Social Medicine, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK 1
2
3
4
5
GISSI-HF Investigators. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double blind, placebocontrolled trial. Lancet 2008; 372: 1223–30. Tavazzi L, Tognoni G, Franzosi MG, et al. Rationale and design of the GISSI heart failure trial: a large trial to assess the effects of n-3 polyunsaturated fatty acids and rosuvastatin in symptomatic congestive heart failure. Eur J Heart Failure 2004; 6: 635–41. Fonarow GC. Statins and n-3 fatty acid supplementation in heart failure. Lancet 2008; 372: 1195–96. Sterne JA, Davey Smith G. Sifting the evidence—what’s wrong with significance tests? BMJ 2001; 322: 226–31. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001; 134: 663–94.
The GISSI-HF investigators provide evidence that n-3 polyunsaturated fatty acid (PUFA) supplements are safe in patients with heart failure,1 but their conclusions about the supplements’ benefits on survival and admission to hospital might be limited because the trial could be confounded by dietary n-3 PUFA intake. Although daily intake of n-3 PUFA can be as low as 0·2–0·3 g,2 differences between the treatment groups
I declare that I have no conflict of interest.
College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH16 4SB, UK 1
2
3
GISSI-HF Investigators. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebocontrolled trial. Lancet 2008; 372: 1223–30. Kris-Etherton PM, Harris WS, Appel LJ. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 2002; 106: 2747–57. Mozaffarian D, Bryson CL, Lemaitre RN, Burke GL, Siscovick DS. Fish intake and risk of incident heart failure. J Am Coll Cardiol 2005; 45: 2015–21.
In the GISSI-HF study,1 there were fewer first hospital admissions for ventricular arrhythmia in patients treated with n-3 polyunsaturated fatty acids (PUFA) than in the placebo group. A major risk underlying arrhythmias is cardiac dilatation. Dilatation was the cause of heart failure in 30·1% of patients taking n-3 PUFA versus 27·9% of those on placebo. We have shown that, in patients with heart failure, dilatation per se reduced the concentration of antiarrhythmic docosahexaenoic acid in patients with a wide range of leftventricular end-diastolic diameters and dysfunction; for diameters of 68–90 mm (upper tertile) versus 48–61 mm (lower tertile) or ejection fraction 9–25% (lower tertile) versus 35–50% (upper tertile), serum docowww.thelancet.com Vol 373 January 31, 2009
In a Correspondence letter (published online Jan 12),1 medical students in Boston, MA, USA implicate Israel in perpetrating a “disproportionate assault” that underlies the humanitarian disaster in Gaza. Although these doubtlessly well intended individuals seek the moral high ground in calling for “an immediate cessation of hostilities”, they unfortunately ignore the realities of the situation. As fellow medical students, we would be remiss if we did not attempt to provide a clearer picture of the reality in Gaza and address some of the troubling points of our colleagues. We believe that the invocation of an alleged “moral voice” in the face of a complex political situation without a full understanding of the facts is irresponsible and unprofessional. A brief chronology of the latest saga of the Israeli-Palestinian conflict is crucial to a proper appreciation of the issues involved in the current war. In August, 2005, after 5 years of fighting in the Second Intifada with no resolution in sight, Israel unilaterally withdrew all of its soldiers and citizens from the Gaza strip in hopes of fostering a lasting peace. Since the Israeli withdrawal, however, Hamas, an internationally recognised terrorist organisation funded by Iran, has fired more than 6000 deadly rockets from Gaza, targeting Israeli civilians. It is against these war crimes, the indiscriminate targeting of innocent civilians, that the Israeli military has been forced to respond. As US President-elect Barack Obama asserted in a campaign visit to Israel in July, 2008, “If somebody was sending rockets into my house where my two daughters sleep at night, I would do everything to stop that, and would expect Israel to do the same thing.” After years of restraint and after exhausting all diplomatic avenues, it www.thelancet.com Vol 373 January 31, 2009
is this very principle of defending its civilians, one of the founding tenets of democracy, which has driven Israel to take up arms against Hamas. There is no question that the loss of Palestinian life in Gaza is terribly tragic and that every effort should be made to avoid civilian casualties and to provide medical aid and supplies to those suffering. Although no party is blameless for the Palestinian death toll, the stark contrast between Israel’s and Hamas’ treatment of the people in Gaza must be asserted. Israel’s defence of its own citizens has gone hand in hand with extraordinary efforts to protect the civilians of Gaza. Israel distributes leaflets, sends voicemails and text messages, and uses radio and television announcements to warn Gazan civilians to clear areas of imminent attacks. Israel seeks to minimise civilian casualties through surgical strikes on military objectives, and frequently aborts key missions due to concerns for civilian casualties. Moreover, since the beginning of the war, Israel has transported thousands of kilograms of food and medical supplies to ease the Gazans’ plight. Israel’s efforts to minimise harm to the civilians of Gaza have been confounded by Hamas who consistently place civilians in the line of fire. Hamas, in clear violation of international law, gathers women and children around military targets to use them as human shields. This terrorist regime endangers the people of Gaza by using civilian homes, schools, mosques, and hospitals as launching grounds for rockets fired at Israeli civilians and prides itself on the number of its own people martyred to the destruction of Israel. It preys on the moral conscience of the democratic world, which places a premium on innocent lives, knowing that Israel seeks to avoid killing the same Palestinian civilians whom Hamas militants hide behind and deem dispensable. It is these abominable tactics of Hamas that lead to the “disproportionate” number
of Palestinian civilian casualties and which should evoke international condemnation and outrage. We recognise the hardships and losses incurred by both sides of this conflict, but we also know that simplistic solutions based on distorted facts are not the answer. Calls for an “immediate cessation of hostilities” outside the context of viable and sustainable security are shortsighted. Although it might seem to be an attractive and “humanitarian” solution in the short term, it will not alleviate the plight of Palestinians who suffer under the policies of the Hamas regime nor bring safety to the civilians of Israel who live in terror of rockets. Every person should rightly be pained by the death and suffering of innocent people wherever they might be. Nonetheless, espousing moral indignation in the face of a skewed and one-sided picture of an immensely complex situation simply delays finding appropriate solutions. How can a letter that calls for humanitarianism and civilian protection point to Israel’s “brutal attacks” while ignoring the countless Israeli efforts to protect Gazan civilians? Why was it deemed irrelevant to mention the significant role of Hamas in the number of Palestinian civilian deaths? It pains us that some would attempt to value the lives and security of one people over the lives and security of another, and to express solidarity with some innocents while ignoring others. As medical students committed to the sanctity and preservation of human life, we too express our grave concern for the protection of innocents and hope for a speedy but viable resolution so that both Palestinians and Israelis can live in peace and safety.
Published Online January 19, 2009 DOI:10.1016/S01406736(09)60075-1
Getty Images
Response to medical students’ letter of solidarity with Gaza
We declare that we have no conflict of interest.
Rebecca Braunstein, David Faleck, *David Stern, on behalf of 805 medical students, 503 doctors, 236 health professionals, and 275 other concerned individuals [email protected]
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
377
Correspondence
Albert Einstein College of Medicine of Yeshiva University, Bronx, NY 10461, USA 1
Abdou R, Romm I, Schiff D, et al, on behalf of 753 other medical students. In solidarity with Gaza. Lancet 2009; published online Jan 12. DOI: 10.1016/S0140-6736(09)60042-8.
Science Photo Library
N-3 polyunsaturated fatty acids and statins in heart failure
See Department of Error page 382
378
The cover of The Lancet Oct 4 issue confidently declares that “Supplementation with N-3 polyunsaturated fatty acids should join the short list of evidence-based life-prolonging therapies for heart failure”. However, the GISSI-HF trial, on which this statement is based (p 1223),1 does not support such a strong conclusion. In unadjusted analyses (the “main” analyses according to the trial protocol2) there was only modest evidence of beneficial effects on the primary outcomes of all-cause mortality (hazard ratio 0·93, 95% CI 0·85–1·02; p=0·12) and death or admission for cardiovascular reasons (0·94, 0·87–1·02; p=0·06). These estimates exclude the 20% reduction in risk that was specified as the minimal clinically beneficial effect.2 However, the results highlighted in the Summary and featured in the associated Comment3 were adjusted for prognostic factors (“subsequent analyses” according to the protocol2). Although the size of estimates was barely changed by adjustment, the p values declined to 0·04 and 0·01—ie, below the much-over-interpreted significance threshold of 0·05.4 The protocol states that “any unbalance for baseline characteristics thought to be of prognostic importance will be considered for multivariate adjustment.”2 As noted by the CONSORT investigators,5 multiple analyses of the same data create a risk of false-positive findings. The chosen adjustments were for three (presumably adverse) prognostic indicators, all of which were
more prevalent in the fish oil group. Adjustment therefore increases the apparently beneficial intervention effect. We would be interested to see further analyses adjusting for characteristics such as the presence of chronic obstructive pulmonary disease and having had a coronary artery bypass graft. These were more prevalent in the placebo group so that adjustment would reduce the beneficial effect of fish oil. A reasonable interpretation of the GISSI-HF trial would be that the modest estimated effect of fish oil requires replication. It is disappointing that The Lancet seems to have succumbed to the lure of the significant p value.
could have affected the findings. Whether or not they did, however, is impossible to tell because these data were not recorded. Dietary n-3 PUFA are associated with beneficial cardiovascular effects including reduced incidence of heart failure and lower systolic blood pressure,3 but the effects of dietary n-3 PUFA on the prognosis of heart failure are not known. The GISSI-HF trial addressed an important clinical question, but further research should take into account dietary intake of n-3 PUFA before concluding that supplements clinically benefit patients with heart failure.
We declare that we have no conflict of interest.
Lorna M Gibson
George Davey Smith, Marie-Jo Brion, *Jonathan A C Sterne
[email protected]
[email protected] University of Bristol, Department of Social Medicine, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK 1
2
3
4
5
GISSI-HF Investigators. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double blind, placebocontrolled trial. Lancet 2008; 372: 1223–30. Tavazzi L, Tognoni G, Franzosi MG, et al. Rationale and design of the GISSI heart failure trial: a large trial to assess the effects of n-3 polyunsaturated fatty acids and rosuvastatin in symptomatic congestive heart failure. Eur J Heart Failure 2004; 6: 635–41. Fonarow GC. Statins and n-3 fatty acid supplementation in heart failure. Lancet 2008; 372: 1195–96. Sterne JA, Davey Smith G. Sifting the evidence—what’s wrong with significance tests? BMJ 2001; 322: 226–31. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001; 134: 663–94.
The GISSI-HF investigators provide evidence that n-3 polyunsaturated fatty acid (PUFA) supplements are safe in patients with heart failure,1 but their conclusions about the supplements’ benefits on survival and admission to hospital might be limited because the trial could be confounded by dietary n-3 PUFA intake. Although daily intake of n-3 PUFA can be as low as 0·2–0·3 g,2 differences between the treatment groups
I declare that I have no conflict of interest.
College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH16 4SB, UK 1
2
3
GISSI-HF Investigators. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebocontrolled trial. Lancet 2008; 372: 1223–30. Kris-Etherton PM, Harris WS, Appel LJ. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 2002; 106: 2747–57. Mozaffarian D, Bryson CL, Lemaitre RN, Burke GL, Siscovick DS. Fish intake and risk of incident heart failure. J Am Coll Cardiol 2005; 45: 2015–21.
In the GISSI-HF study,1 there were fewer first hospital admissions for ventricular arrhythmia in patients treated with n-3 polyunsaturated fatty acids (PUFA) than in the placebo group. A major risk underlying arrhythmias is cardiac dilatation. Dilatation was the cause of heart failure in 30·1% of patients taking n-3 PUFA versus 27·9% of those on placebo. We have shown that, in patients with heart failure, dilatation per se reduced the concentration of antiarrhythmic docosahexaenoic acid in patients with a wide range of leftventricular end-diastolic diameters and dysfunction; for diameters of 68–90 mm (upper tertile) versus 48–61 mm (lower tertile) or ejection fraction 9–25% (lower tertile) versus 35–50% (upper tertile), serum docowww.thelancet.com Vol 373 January 31, 2009