- Email: [email protected]
Systems thinking for the post-2015 agenda
Correspondence
advocates recognise the dynamic and sometimes unpredictable interactions among actors (such as policy makers, providers, organisations, and communities) in complex systems such as health. By contrast with selective approaches, systems thinking is based on understanding relationships, a commitment to multiple perspectives, and an awareness of boundaries (table).4,5
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Correspondence
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Lozano R, Wang H, Foreman KJ, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011; 378: 1139–65. Waage J, Banerji R, Campbell O, et al. The Millennium Development Goals: a crosssectoral analysis and principles for goal setting after 2015. Lancet 2010; 376: 991–1023. Williams B, Hummelbrunner R. Systems concepts in action: a practitioner’s toolkit. Stanford: Stanford Business Books, 2010. Swanson RC, Cattaneo A, Bradley E, et al. Rethinking health systems strengthening: key systems thinking tools and strategies for transformational change. Health Policy Plan 2012; 27: iv54–61. Russell E, Johnson B, Larsen H, Novilla MLB, van Olmen J, Swanson RC. Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks. Rev Panam Salud Publica 2013; 34: 461–67.
The effect of cultural practices on air pollution is often overlooked. However, the smog generated by Nian festivities cannot be overlooked in China nowadays. Chinese people need to reduce the use of fireworks or find a substitute to reduce air pollution. Tensions between cultural practices and environmental protections will not be easy to solve, because such traditional practices are deeply embedded in Chinese society, but it is time to reassess and improve the relations between culture and environmental issues. We declare no competing interests.
Nian: when Chinese mythology affects air pollution Air pollution is an important issue in China, with great consequences for health, especially in periods with extremely high particulate matter <2·5 μm in diameter (PM2·5)—such as the Chinese New Year. During the Chinese New Year air pollution is more serious and widespread than usual. This is not a coincidence. In Chinese mythology, Nian is a fierce monster that emerges on New Year’s Eve to kill people. To scare it off, people must make loud noises and maintain fires continuously throughout the New Year period. Setting off firecrackers is a popular and well established ceremony and almost every Chinese household celebrates the New Year this way. Setting off fireworks produces increased noise pollution and waste, but more importantly this releases harmful smokes and particles that increase smog and air pollution.1,2 PM2·5 concentration is substantially increased during Chinese New Year.3 According to the Chinese Ministry of Environmental Protection, 128 of 161 cities had an average PM2·5 concentration of more than 150 μg/m³ on Jan 31, 2014.4 www.thelancet.com Vol 383 June 21, 2014
Chao Ye, *Ruishan Chen, Craig Young [email protected] College of Geographic Sciences, Nanjing Normal University, Nanjing, China (CYe); School of Public Administration, Hohai University, Nanjing, 210098, China (RC); and School of Science and Environment, Manchester Metropolitan University, Manchester, UK (CYo) 1
2
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4
Shi Y, Zhang N, Gao J, Li X, Cai Y. Effect of fireworks display on perchlorate in air aerosols during the Spring Festival. Atmos Environ 2011; 45: 1323–27. Wang Y, Zhuang G, Xu C, An Z. The air pollution caused by the burning of fireworks during the lantern festival in Beijing. Atmos Environ 2007; 41: 417–31. Zhang M, Wang X, Chen J, et al. Physical characterization of aerosol particles during the Chinese New Year’s firework events. Atmos Environ 2010; 44: 5191–98. Xinhua News Agency. 128 cities were heavily polluted owing to set off fireworks on Chinese New Year’s Eve, 2014. (in Chinese). http://bjwb. bjd.com.cn/html/2014-02/01/content_147860. htm (accessed April 18, 2014).
Adverse drug reaction: pomalidomide-induced liver injury Survival after multiple myeloma has improved with the use of immunomodulator y drugs— thalidomide, lenalidomide, and pomalidomide. Pomalidomide, the latest immunomodulatory drug to be approved by the US Food and Drug Administration, was developed by modifying thalidomide’s chemical structure to increase potency and
improve safety. Pomalidomide undergoes extensive cytochrome P450-mediated metabolism and has a toxicity profile mainly characterised by myelosuppression.1 Here, we discuss the first case of pomalidomideinduced hepatotoxicity reported under post-marketing surveillance. A 50-year-old man undergoing treatment for multiple myeloma presented with jaundice and dark-yellow-coloured urine. His multiple myeloma was diagnosed 3 years earlier, with conventional cy togenetic analysis revealing deletion 13 and translocation [11,14] (without deletion 17p). After failed induction with several bortezomib-based chemotherapy regimens, he underwent autologous stem cell transplantation and achieved complete response. He received maintenance treatment with lenalidomide (15 mg daily) plus dexamethasone in 3-week cycles. However, he experienced grade 3 transaminitis (alanine aminotransferase 433 U/L) and the lenalidomide dose was reduced to 5 mg daily. This attenuated dose was associated with disease progression. Subs e quently, the patient received salvage platinum-based chemotherapy, a second autologous stem cell transplant, and then allogeneic stem cell transplantation from an HL A-matched sibling donor. Engraftment and full donor chimerism were achieved and he received graft-versus-host disease (GVHD) prophylaxis for 5 months. At this time, his multiple myeloma relapsed and he started pomalidomide plus dexamethasone. In view of lenalidomide’s hepatotoxicit y, pomalidomide was dosed at 2 mg three times weekly and then increased to daily while liver function was monitored. He achieved complete response, but 5 days later there was a mild increase in transaminases (alanine aminotransferase 200 U/L). Pomalidomide dose was reduced again to three times weekly, which 2125
advocates recognise the dynamic and sometimes unpredictable interactions among actors (such as policy makers, providers, organisations, and communities) in complex systems such as health. By contrast with selective approaches, systems thinking is based on understanding relationships, a commitment to multiple perspectives, and an awareness of boundaries (table).4,5
2124
www.thelancet.com Vol 383 June 21, 2014
Correspondence
2
3
4
5
6
Lozano R, Wang H, Foreman KJ, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011; 378: 1139–65. Waage J, Banerji R, Campbell O, et al. The Millennium Development Goals: a crosssectoral analysis and principles for goal setting after 2015. Lancet 2010; 376: 991–1023. Williams B, Hummelbrunner R. Systems concepts in action: a practitioner’s toolkit. Stanford: Stanford Business Books, 2010. Swanson RC, Cattaneo A, Bradley E, et al. Rethinking health systems strengthening: key systems thinking tools and strategies for transformational change. Health Policy Plan 2012; 27: iv54–61. Russell E, Johnson B, Larsen H, Novilla MLB, van Olmen J, Swanson RC. Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks. Rev Panam Salud Publica 2013; 34: 461–67.
The effect of cultural practices on air pollution is often overlooked. However, the smog generated by Nian festivities cannot be overlooked in China nowadays. Chinese people need to reduce the use of fireworks or find a substitute to reduce air pollution. Tensions between cultural practices and environmental protections will not be easy to solve, because such traditional practices are deeply embedded in Chinese society, but it is time to reassess and improve the relations between culture and environmental issues. We declare no competing interests.
Nian: when Chinese mythology affects air pollution Air pollution is an important issue in China, with great consequences for health, especially in periods with extremely high particulate matter <2·5 μm in diameter (PM2·5)—such as the Chinese New Year. During the Chinese New Year air pollution is more serious and widespread than usual. This is not a coincidence. In Chinese mythology, Nian is a fierce monster that emerges on New Year’s Eve to kill people. To scare it off, people must make loud noises and maintain fires continuously throughout the New Year period. Setting off firecrackers is a popular and well established ceremony and almost every Chinese household celebrates the New Year this way. Setting off fireworks produces increased noise pollution and waste, but more importantly this releases harmful smokes and particles that increase smog and air pollution.1,2 PM2·5 concentration is substantially increased during Chinese New Year.3 According to the Chinese Ministry of Environmental Protection, 128 of 161 cities had an average PM2·5 concentration of more than 150 μg/m³ on Jan 31, 2014.4 www.thelancet.com Vol 383 June 21, 2014
Chao Ye, *Ruishan Chen, Craig Young [email protected] College of Geographic Sciences, Nanjing Normal University, Nanjing, China (CYe); School of Public Administration, Hohai University, Nanjing, 210098, China (RC); and School of Science and Environment, Manchester Metropolitan University, Manchester, UK (CYo) 1
2
3
4
Shi Y, Zhang N, Gao J, Li X, Cai Y. Effect of fireworks display on perchlorate in air aerosols during the Spring Festival. Atmos Environ 2011; 45: 1323–27. Wang Y, Zhuang G, Xu C, An Z. The air pollution caused by the burning of fireworks during the lantern festival in Beijing. Atmos Environ 2007; 41: 417–31. Zhang M, Wang X, Chen J, et al. Physical characterization of aerosol particles during the Chinese New Year’s firework events. Atmos Environ 2010; 44: 5191–98. Xinhua News Agency. 128 cities were heavily polluted owing to set off fireworks on Chinese New Year’s Eve, 2014. (in Chinese). http://bjwb. bjd.com.cn/html/2014-02/01/content_147860. htm (accessed April 18, 2014).
Adverse drug reaction: pomalidomide-induced liver injury Survival after multiple myeloma has improved with the use of immunomodulator y drugs— thalidomide, lenalidomide, and pomalidomide. Pomalidomide, the latest immunomodulatory drug to be approved by the US Food and Drug Administration, was developed by modifying thalidomide’s chemical structure to increase potency and
improve safety. Pomalidomide undergoes extensive cytochrome P450-mediated metabolism and has a toxicity profile mainly characterised by myelosuppression.1 Here, we discuss the first case of pomalidomideinduced hepatotoxicity reported under post-marketing surveillance. A 50-year-old man undergoing treatment for multiple myeloma presented with jaundice and dark-yellow-coloured urine. His multiple myeloma was diagnosed 3 years earlier, with conventional cy togenetic analysis revealing deletion 13 and translocation [11,14] (without deletion 17p). After failed induction with several bortezomib-based chemotherapy regimens, he underwent autologous stem cell transplantation and achieved complete response. He received maintenance treatment with lenalidomide (15 mg daily) plus dexamethasone in 3-week cycles. However, he experienced grade 3 transaminitis (alanine aminotransferase 433 U/L) and the lenalidomide dose was reduced to 5 mg daily. This attenuated dose was associated with disease progression. Subs e quently, the patient received salvage platinum-based chemotherapy, a second autologous stem cell transplant, and then allogeneic stem cell transplantation from an HL A-matched sibling donor. Engraftment and full donor chimerism were achieved and he received graft-versus-host disease (GVHD) prophylaxis for 5 months. At this time, his multiple myeloma relapsed and he started pomalidomide plus dexamethasone. In view of lenalidomide’s hepatotoxicit y, pomalidomide was dosed at 2 mg three times weekly and then increased to daily while liver function was monitored. He achieved complete response, but 5 days later there was a mild increase in transaminases (alanine aminotransferase 200 U/L). Pomalidomide dose was reduced again to three times weekly, which 2125