- Email: [email protected]
Anchors aweigh
Correspondence
School of Social Science and Public Policy, Keele University, Staffordshire ST5 5BG, UK 1 2
3 4
5
Horton R. Offline: Racism—the pathology we choose to ignore. Lancet 2017; 390: 14. Macpherson W. The Stephen Lawrence Inquiry. February, 1999. https://www.gov.uk/ government/uploads/system/uploads/ attachment_data/file/277111/4262.pdf (accessed Aug 1, 2017). Welshman J. From transmitted deprivation to social exclusion: policy, poverty, and parenting. Bristol: Policy Press, 2007. Showell C, Turner P. The PLU problem: are we designing personal ehealth for people like us? Stud Health Technol Inform 2013; 183: 276–80. WHO. Health in all policies: framework for country action. 2014. http://www.who.int/ healthpromotion/frameworkforcountryaction/ en/ (accessed Aug 1, 2017).
Intertwining migration, ethnicity, racism, and health
For more on the World Congress see http://www.merhcongress. com/
For the WHO World Health Assembly Agenda see http://apps.who.int/iris/ bitstream/10665/23533/1/A61_ R17-en.pdf
932
Johanna Hanefeld and colleagues’ Comment (June 17, p 2358) 1 on research into migration, mobility, and health, and Richard Horton’s Offline Comment (July 1, p 14)2 on racism need integrating. Racism is not in Hanefeld and colleagues’ research agenda;1 their agenda is researcher orientated, which is similar to those agendas proposed for ethnicity, 3 but distant from the grave threats and challenges in Horton’s piece 2 on racism. Hanefeld and colleagues1 contend, correctly in my view, that the resolutions of the 2008 World Health Assembly and the WHO global consultation of Migrant Health 4 in 2010 have had little effect. However, this is not a new problem. WHO pub lished detailed recommendations,5 similar to contemporary recommend ations, following a comprehensive examination of migration in 1983. The reiteration, rather than imple mentation, of policy is a result of in sufficient prioritisation, management, and resources. Racism and xenophobia are among the most dangerous threats to public health, with death rates that cannot be equalled even by the deadliest contagion.6,7 Racism and xenophobia
are surely on a par with climate change as a threat to health. The increase in multiethnic and multiracial societies in the modern era puts humanity on a perilous but necessary journey. Horton2 and Hanefeld and colleagues1 concur that the anti-immigration rhetoric needs to stop, and, to para phrase, we need to embrace the full humanity of our neighbourhoods,2 and recognise migration as a social norm.1 Bridging the gap between work on racism, migration, race, and ethnicity is difficult but necessary.3 In these efforts, we should not forget the emigration of white Europeans, displacing and decimating indigenous people, with consequences still cascading across the centuries. An integration of migration, ethnicity, and race (including racism) is occurring, albeit slowly. For example, in 2008, the Migrant Health Section of the European Public Health Association incorporated ethnicity into its name and mission. Scholars, researchers, policy makers, practitioners, community groups, and the public will confer at the first World Congress on Migration, Ethnicity, Race, and Health in Edinburgh, Scotland, in May, 2018. Among other tasks, they will aim to establish a new academic body to advance this field globally. This will be an unparal leled opportunity to integrate cognate fields. I am the chairman of the executive committee of the World Congress on Migration, Ethnicity, Race and Health, a not-for-profit conference with, solely, educational and scholarly work.
Raj S Bhopal [email protected] University of Edinburgh, Edinburgh, Scotland EH8 9AG, UK 1
2 3 4
Hanefeld J, Vearey J, Lunt N, on behalf of the Researchers on Migration, Mobility and Health Group. A global research agenda on migration, mobility, and health. Lancet 2017; 389: 2358–59. Horton R. Offline: racism—the pathology we choose to ignore. Lancet 2017; 390: 14. Bhopal RS. Migration, ethnicity, race, and health in multicultural societies, 2nd edn. Oxford: Oxford University Press, 2014. WHO. Health of migrants: the way forward: report of a global consultation, Madrid, Spain, 3–5 March 2010. Geneva: World Health Organization, 2010.
5
6 7
Colledge M, van Geuns HA, Svensson PG. Migration and health: towards an understanding of the health care needs of ethnic minorities. Netherlands: World Health Organization, 1983. Montagu A. Man’s most dangerous myth: the fallacy of race, 6th edn. London: Sage Publications Ltd, 1997. Blum R, Stanton GH, Sagi S, Richter ED. ‘Ethnic cleansing’ bleaches the atrocities of genocide. Eur J Public Health 2008; 18: 204–09.
Anchors aweigh Cognitive biases frequently result in diagnostic inaccuracies and medical mismanagement, resulting in adverse outcomes or inadequate use of resources. In June, 2017, an African-American man aged 64 years presented to our emergency room from prison, accompanied by three security guards, with a chief complaint of altered mental status, confusion, and lethargy. The man had a medical history of systolic congestive heart failure and had previously been fitted with a dualchamber implantable cardioverter defibrillator. Pertinent history was obtained by the guards, who stated that the patient might have ingested ketamine or a synthetic cannabinoid. Physical examination showed that the patient was afebrile, haemodynamically stable, lethargic (with a Glasgow Coma Scale score of 10), unable to follow commands, and jaundiced with scleral icterus, with no other notable physical findings. Laboratory investigations showed noteworthy increased total bilirubin and ammonia concentrations, and a leucocytosis with bandaemia. The urine drug screen was negative and his abdominal ultrasound was normal. He was admitted to our medical intensive care unit for presumed drug intoxication and hepatic en cephalopathy, and supportive care was initiated with intravenous fluids and lactulose. The patient’s mental status continued to deteriorate des pite supportive care, and the de cision was made to proceed with endotracheal intubation and lumbar puncture. An uncomplicated lumbar www.thelancet.com Vol 390 September 2, 2017
Correspondence
We declare no competing interests.
*Jason Chertoff, Abhishek Biswas, Divya Patel [email protected] Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL 32608, USA
Naming of the victims of Nazi medicine I read with great interest the Pers pectives piece by Philip Ball (June 3, p 2182),1 who reported on the Science and Suffering exhibition at the Wiener Library for the Study of the Holocaust and Genocide in London. He rightly highlighted the goal of discovering www.thelancet.com Vol 390 September 2, 2017
the names and life stories of victims of the Nazi-era medical experiments. He stated that some of their 15 000— perhaps as many as 27 000—names are projected onto the library’s wall. My concern is with his statement that is surprising and warrants precision: “one surprise, for me, was that only about a fifth of the victims were Jewish”. I would suggest, as an explanation, that Nazi medicine exactions were not limited to extermination camps—namely, Auschwitz-Birkenau, Bełżec, Chelmno, Jasenovac, Majdanek, Maly Trostenets, Sajmište, Sobibor, and Treblinka—where more than 90% of the victims were Jews (the primary target of the so-called Final Solution). Nazi medicine exactions also concerned many concentration camps, as stated in the second count of indictment at the second postwar Nuremberg trial (Doctors’ trial).2 These camps included Dachau, Buchenwald, Mauthausen-Gusen, Natzweiler-Struthof, OranienburgSachsenhausen, and Ravensbrück, of which the deportees, besides Jews, were political or war prisoners, homo sexuals, Romanians, and individuals with disabilities.2–5 Finally, Aktion T4 (the Euthanasia Programme in 1940–41) was a programme followed by the Shoah of European Jewish people and implemented gassing of adults with physical or mental disabilities in six gassing centres in Germany.2,5 These observations might account for the surprise that only about a fifth of the victims of Nazi medicine were Jewish. I declare no competing interests.
Claude Matuchansky [email protected] Faculty of Medicine, Paris-Diderot University, 75010 Paris, France 1 2 3 4 5
Ball P. Naming the victims of Nazi medicine. Lancet 2017; 389: 2182–83. Halioua B. Le procès des médecins de Nuremberg. L’irruption de l’éthique médicale moderne. Paris: Vuibert, 2008 (in French). Bloch F. Medical scientists in the Nazi era. Lancet 1986; 327: 375. Roelcke V. Nazi medicine and research on human beings. Lancet 2004; 364 (special issue): 6–7. Seidelman WE. Nuremberg lamentation: for the forgotten victims of medical science. BMJ 1996; 313: 1463–67.
What can Japan learn from tobacco control in the UK? A Lancet Editorial (July 8, p 96)1 on tobacco control in the UK described how people are protected from secondhand smoke as a result of the country going smoke free in 2007. This is in stark contrast to people in Japan who, unfortunately, are likely to continue to be affected by passive smoking in public spaces for the next decade. Japan, and other countries that are currently struggling to introduce policies for the prevention of second-hand smoke in public places, might be able to learn from the success of tobacco control in the UK. One of the key determinants for the UK’s success was the government’s leadership and commitment to legislate control policies, accompanied by robust scientific evidence, and strong support from health-care professionals to improve population health. In 2017, the Japanese Ministry of Health, Labour and Welfare (MHLW) tried to introduce a smoking ban in public indoor spaces such as workplaces, restaurants, and bars, with the longterm goal of making the 2020 Tokyo Olympics smoke free. The policy was strongly supported by the general public, patient groups, academia, and health-care professionals, including the Japan Medical Association.2 However, the policy was fiercely opposed by pro-tobacco policy makers, tobacco industries led by Japan Tobacco, and bar and restaurant owners concerned about the effect the ban would have on revenue.3,4 The situation in Japan is unique because the Japanese Minister of Finance owns about 33% of Japan Tobacco,5 which has made it difficult for the Japanese Government to introduce any policies that might influence the sale of tobacco products in the country.6 In response to the MHLW’s proposed smoking ban, the pro-tobacco law makers proposed an alternative bill that consists of partial indoor smoking bans and voluntary smoking restrictions by
iStock
puncture yielded yellow cerebrospinal fluid that was sent for analysis. The results showed noteworthy increased proteins (1052 mg/dL) and white blood cells (1978 cells per µL, with predominant neutrophils), and low glucose (<35 mg/dL). Although the cerebrospinal fluid gram stain and culture were normal, the patient’s blood cultures were positive for Streptococcus pneumoniae. A diagnosis of streptococcal meningitis was made and appropriate antimicrobial therapy and dexamethasone was initiated. Thereafter, the patient’s mental status and overall health improved and he was discharged. Anchoring is a cognitive bias that describes the reliance of human beings on the first piece of information offered (ie, the anchor) when making decisions. Once an anchor is set, there is a bias toward interpreting other information around the anchor. In this case, we anchored on unverified information that the patient had ingested a moodaltering or mind-altering substance. This anchoring caused a delay in the diagnosis and management of a lifethreatening meningitis. This case is a reminder that physicians should diligently and objectively question and test their diagnoses as new information presents itself.
933
School of Social Science and Public Policy, Keele University, Staffordshire ST5 5BG, UK 1 2
3 4
5
Horton R. Offline: Racism—the pathology we choose to ignore. Lancet 2017; 390: 14. Macpherson W. The Stephen Lawrence Inquiry. February, 1999. https://www.gov.uk/ government/uploads/system/uploads/ attachment_data/file/277111/4262.pdf (accessed Aug 1, 2017). Welshman J. From transmitted deprivation to social exclusion: policy, poverty, and parenting. Bristol: Policy Press, 2007. Showell C, Turner P. The PLU problem: are we designing personal ehealth for people like us? Stud Health Technol Inform 2013; 183: 276–80. WHO. Health in all policies: framework for country action. 2014. http://www.who.int/ healthpromotion/frameworkforcountryaction/ en/ (accessed Aug 1, 2017).
Intertwining migration, ethnicity, racism, and health
For more on the World Congress see http://www.merhcongress. com/
For the WHO World Health Assembly Agenda see http://apps.who.int/iris/ bitstream/10665/23533/1/A61_ R17-en.pdf
932
Johanna Hanefeld and colleagues’ Comment (June 17, p 2358) 1 on research into migration, mobility, and health, and Richard Horton’s Offline Comment (July 1, p 14)2 on racism need integrating. Racism is not in Hanefeld and colleagues’ research agenda;1 their agenda is researcher orientated, which is similar to those agendas proposed for ethnicity, 3 but distant from the grave threats and challenges in Horton’s piece 2 on racism. Hanefeld and colleagues1 contend, correctly in my view, that the resolutions of the 2008 World Health Assembly and the WHO global consultation of Migrant Health 4 in 2010 have had little effect. However, this is not a new problem. WHO pub lished detailed recommendations,5 similar to contemporary recommend ations, following a comprehensive examination of migration in 1983. The reiteration, rather than imple mentation, of policy is a result of in sufficient prioritisation, management, and resources. Racism and xenophobia are among the most dangerous threats to public health, with death rates that cannot be equalled even by the deadliest contagion.6,7 Racism and xenophobia
are surely on a par with climate change as a threat to health. The increase in multiethnic and multiracial societies in the modern era puts humanity on a perilous but necessary journey. Horton2 and Hanefeld and colleagues1 concur that the anti-immigration rhetoric needs to stop, and, to para phrase, we need to embrace the full humanity of our neighbourhoods,2 and recognise migration as a social norm.1 Bridging the gap between work on racism, migration, race, and ethnicity is difficult but necessary.3 In these efforts, we should not forget the emigration of white Europeans, displacing and decimating indigenous people, with consequences still cascading across the centuries. An integration of migration, ethnicity, and race (including racism) is occurring, albeit slowly. For example, in 2008, the Migrant Health Section of the European Public Health Association incorporated ethnicity into its name and mission. Scholars, researchers, policy makers, practitioners, community groups, and the public will confer at the first World Congress on Migration, Ethnicity, Race, and Health in Edinburgh, Scotland, in May, 2018. Among other tasks, they will aim to establish a new academic body to advance this field globally. This will be an unparal leled opportunity to integrate cognate fields. I am the chairman of the executive committee of the World Congress on Migration, Ethnicity, Race and Health, a not-for-profit conference with, solely, educational and scholarly work.
Raj S Bhopal [email protected] University of Edinburgh, Edinburgh, Scotland EH8 9AG, UK 1
2 3 4
Hanefeld J, Vearey J, Lunt N, on behalf of the Researchers on Migration, Mobility and Health Group. A global research agenda on migration, mobility, and health. Lancet 2017; 389: 2358–59. Horton R. Offline: racism—the pathology we choose to ignore. Lancet 2017; 390: 14. Bhopal RS. Migration, ethnicity, race, and health in multicultural societies, 2nd edn. Oxford: Oxford University Press, 2014. WHO. Health of migrants: the way forward: report of a global consultation, Madrid, Spain, 3–5 March 2010. Geneva: World Health Organization, 2010.
5
6 7
Colledge M, van Geuns HA, Svensson PG. Migration and health: towards an understanding of the health care needs of ethnic minorities. Netherlands: World Health Organization, 1983. Montagu A. Man’s most dangerous myth: the fallacy of race, 6th edn. London: Sage Publications Ltd, 1997. Blum R, Stanton GH, Sagi S, Richter ED. ‘Ethnic cleansing’ bleaches the atrocities of genocide. Eur J Public Health 2008; 18: 204–09.
Anchors aweigh Cognitive biases frequently result in diagnostic inaccuracies and medical mismanagement, resulting in adverse outcomes or inadequate use of resources. In June, 2017, an African-American man aged 64 years presented to our emergency room from prison, accompanied by three security guards, with a chief complaint of altered mental status, confusion, and lethargy. The man had a medical history of systolic congestive heart failure and had previously been fitted with a dualchamber implantable cardioverter defibrillator. Pertinent history was obtained by the guards, who stated that the patient might have ingested ketamine or a synthetic cannabinoid. Physical examination showed that the patient was afebrile, haemodynamically stable, lethargic (with a Glasgow Coma Scale score of 10), unable to follow commands, and jaundiced with scleral icterus, with no other notable physical findings. Laboratory investigations showed noteworthy increased total bilirubin and ammonia concentrations, and a leucocytosis with bandaemia. The urine drug screen was negative and his abdominal ultrasound was normal. He was admitted to our medical intensive care unit for presumed drug intoxication and hepatic en cephalopathy, and supportive care was initiated with intravenous fluids and lactulose. The patient’s mental status continued to deteriorate des pite supportive care, and the de cision was made to proceed with endotracheal intubation and lumbar puncture. An uncomplicated lumbar www.thelancet.com Vol 390 September 2, 2017
Correspondence
We declare no competing interests.
*Jason Chertoff, Abhishek Biswas, Divya Patel [email protected] Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL 32608, USA
Naming of the victims of Nazi medicine I read with great interest the Pers pectives piece by Philip Ball (June 3, p 2182),1 who reported on the Science and Suffering exhibition at the Wiener Library for the Study of the Holocaust and Genocide in London. He rightly highlighted the goal of discovering www.thelancet.com Vol 390 September 2, 2017
the names and life stories of victims of the Nazi-era medical experiments. He stated that some of their 15 000— perhaps as many as 27 000—names are projected onto the library’s wall. My concern is with his statement that is surprising and warrants precision: “one surprise, for me, was that only about a fifth of the victims were Jewish”. I would suggest, as an explanation, that Nazi medicine exactions were not limited to extermination camps—namely, Auschwitz-Birkenau, Bełżec, Chelmno, Jasenovac, Majdanek, Maly Trostenets, Sajmište, Sobibor, and Treblinka—where more than 90% of the victims were Jews (the primary target of the so-called Final Solution). Nazi medicine exactions also concerned many concentration camps, as stated in the second count of indictment at the second postwar Nuremberg trial (Doctors’ trial).2 These camps included Dachau, Buchenwald, Mauthausen-Gusen, Natzweiler-Struthof, OranienburgSachsenhausen, and Ravensbrück, of which the deportees, besides Jews, were political or war prisoners, homo sexuals, Romanians, and individuals with disabilities.2–5 Finally, Aktion T4 (the Euthanasia Programme in 1940–41) was a programme followed by the Shoah of European Jewish people and implemented gassing of adults with physical or mental disabilities in six gassing centres in Germany.2,5 These observations might account for the surprise that only about a fifth of the victims of Nazi medicine were Jewish. I declare no competing interests.
Claude Matuchansky [email protected] Faculty of Medicine, Paris-Diderot University, 75010 Paris, France 1 2 3 4 5
Ball P. Naming the victims of Nazi medicine. Lancet 2017; 389: 2182–83. Halioua B. Le procès des médecins de Nuremberg. L’irruption de l’éthique médicale moderne. Paris: Vuibert, 2008 (in French). Bloch F. Medical scientists in the Nazi era. Lancet 1986; 327: 375. Roelcke V. Nazi medicine and research on human beings. Lancet 2004; 364 (special issue): 6–7. Seidelman WE. Nuremberg lamentation: for the forgotten victims of medical science. BMJ 1996; 313: 1463–67.
What can Japan learn from tobacco control in the UK? A Lancet Editorial (July 8, p 96)1 on tobacco control in the UK described how people are protected from secondhand smoke as a result of the country going smoke free in 2007. This is in stark contrast to people in Japan who, unfortunately, are likely to continue to be affected by passive smoking in public spaces for the next decade. Japan, and other countries that are currently struggling to introduce policies for the prevention of second-hand smoke in public places, might be able to learn from the success of tobacco control in the UK. One of the key determinants for the UK’s success was the government’s leadership and commitment to legislate control policies, accompanied by robust scientific evidence, and strong support from health-care professionals to improve population health. In 2017, the Japanese Ministry of Health, Labour and Welfare (MHLW) tried to introduce a smoking ban in public indoor spaces such as workplaces, restaurants, and bars, with the longterm goal of making the 2020 Tokyo Olympics smoke free. The policy was strongly supported by the general public, patient groups, academia, and health-care professionals, including the Japan Medical Association.2 However, the policy was fiercely opposed by pro-tobacco policy makers, tobacco industries led by Japan Tobacco, and bar and restaurant owners concerned about the effect the ban would have on revenue.3,4 The situation in Japan is unique because the Japanese Minister of Finance owns about 33% of Japan Tobacco,5 which has made it difficult for the Japanese Government to introduce any policies that might influence the sale of tobacco products in the country.6 In response to the MHLW’s proposed smoking ban, the pro-tobacco law makers proposed an alternative bill that consists of partial indoor smoking bans and voluntary smoking restrictions by
iStock
puncture yielded yellow cerebrospinal fluid that was sent for analysis. The results showed noteworthy increased proteins (1052 mg/dL) and white blood cells (1978 cells per µL, with predominant neutrophils), and low glucose (<35 mg/dL). Although the cerebrospinal fluid gram stain and culture were normal, the patient’s blood cultures were positive for Streptococcus pneumoniae. A diagnosis of streptococcal meningitis was made and appropriate antimicrobial therapy and dexamethasone was initiated. Thereafter, the patient’s mental status and overall health improved and he was discharged. Anchoring is a cognitive bias that describes the reliance of human beings on the first piece of information offered (ie, the anchor) when making decisions. Once an anchor is set, there is a bias toward interpreting other information around the anchor. In this case, we anchored on unverified information that the patient had ingested a moodaltering or mind-altering substance. This anchoring caused a delay in the diagnosis and management of a lifethreatening meningitis. This case is a reminder that physicians should diligently and objectively question and test their diagnoses as new information presents itself.
933