- Email: [email protected]
HIV epidemic out of control in Central African Republic
they thought there was uncertainty about the best medical and nursing care in pressure-ulcer prevention and treatment. Nearly 1000 responses were gathered, including questions about the effectiveness of regular turning of patients and the best means of engaging patients in their own care. All intervention questions for which existing research does not provide a reliable or complete answer will be published on the NHS Evidence in the UK Database of Uncertainties about the Effects of Treatments (DUETs). I declare that I have no conflicts of interest.
Mary Madden [email protected] James Lind Alliance Pressure Ulcer Priority Setting Partnership, Department of Health Sciences, Area 2, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK 1 2 3
4
5
Caplan AL. Not my turn. Lancet 2012; 380: 968–69. Cohen D, Billinglsey M. Europeans are left to their own devices. BMJ 2012; 342: d2748. Dumville JC, Soares MO, O’Meara S, Cullum N. Systematic review and mixed treatment comparison: dressings to heal diabetic foot ulcers. Diabetologia 2012; 55: 1902–10. Brölmann FE, Ubbink DT, Nelson EA, Munte K, van der Horst CMAM, Vermeulen H. Evidencebased decisions for local and systemic wound care. Br J Surg 2012; 99: 1172–83. Madden M. Alienating evidence based medicine vs. innovative medical device marketing: a report on the evidence debate at a wounds conference. Soc Sci Med 2012; 74: 2046–52.
Author’s reply The issue of how to manage a patient who does not wish to be turned and who has made a competent and informed decision to allow the resulting sepsis to kill him is, as these thoughtful letters show, disturbing clinically and ethically. Many of those writing seek to find a path towards palliative care in a setting outside the patient’s hospital as a way to resolve the challenge of honouring the patient’s wishes while preserving the ability of the staff to provide care. I have no issue with trying to persuade the patient to pursue this path. However, hospice and home palliative care were not readily available in the rural area where these events took place. Additionally, by the time his condition had deteriorated, the www.thelancet.com Vol 380 December 8, 2012
patient had no interest in being moved anywhere. Once he realised his fate involved nursing-home care and that his independent life at home was over, he vocally resigned himself to death where he was. Some writers argue that they do not see the patient’s decision to die of the consequences of infection related to skin breakdown as a threat or burden to the health of others. I disagree. There are more ways to imperil the care of others than transmission of harmful infection or violent behaviour. The manner of this patient’s death caused grave disruption to many of the patient’s direct care providers and to the morale of the entire facility. If the cost of the patient’s decision grossly interferes with the ability of the staff and facility to carry out its caring mission to provide high-quality care to others, I maintain that this could provide moral grounds for over-riding a competent patient’s autonomous choice. Mary Madden usefully reminds us that what seems simple in wound care is not, and that advances in wound and skin care raise and will continue to raise very difficult ethical questions. I hope my essay contributes to the awareness of the need to engage with those questions in a proactive and forthright manner. I declare that I have no conflicts of interest.
Arthur Caplan [email protected] Division of Medical Ethics, NYU Langone Medical Center, New York, NY 10016, USA
HIV epidemic out of control in Central African Republic The Central African Republic is in the midst of a major health and humanitarian crisis, related particularly to the HIV epidemic, that is largely out of control (Sept 15, p 964).1 The country has the highest adult HIV prevalence
in French-speaking sub-Saharan Africa,2 and one of the highest prevalences of herpes simplex virus type 2 (HSV-2) infection in the world, with more than 80% of HIV-infected adults co-infected. Such co-infection is a major cofactor of heterosexual HIV spread and worsening of AIDS.3 Co-infection with Mycobacterium tuberculosis or hepatitis viruses affect a third of patients.2 Furthermore, antiretroviral treatment (ART) failure has reached uncontainable proportions. The rates of treatment failure in the 15 000 individuals taking first-line ART, including 1400 children, are estimated at 30% in adults and 50% in children.4,5 More than a fifth (3000) of such patients have ARTresistant HIV strains, necessitating a therapeutic shift to second-line ART. The ability of the health system to handle ART failure is insufficient, with few qualified health workers, no second-line ART available, embryonic biological monitoring, and frequent and long-term nationwide shortages of medical supplies. The tragic situation of the HIV epidemic in the Central African Republic urgently requires specific advocacy as well as massive and adapted interventions. The national and international responses have so far not been proportionate to the issue at hand, and international donors are actually disengaging from health provision in the country.2 More effective strategies are needed to tackle this escalating HIV epidemic in the Central African Republic, and the resulting humanitarian disaster.
Corbis
Correspondence
For DUETs see http://www. library.nhs.uk/duets/
We declare that we have no conflicts of interest.
*Laurent Bélec, François-Xavier Mbopi-Kéou [email protected] Laboratoire de Virologie, Hôpital Européen Georges Pompidou, 75908 Paris Cedex 15, France (LB); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (LB); International Society for Infectious Diseases, Brookline, MA, USA (F-XM-K); and Université de Yaoundé I, Yaoundé, Cameroon (F-XM-K)
1993
Correspondence
1 2
3
4
5
Green A. The Central African Republic’s silent health crisis. Lancet 2012; 380: 964–65. Médecins Sans Frontières. Central African Republic: a state of silent crisis. http://www. msf.org/shadomx/apps/fms/fmsdownload. cfm?file_uuid=59E8398E-B0FF-40EA-94F9177AF5D108B4&siteName=msf (accessed Oct 17, 2012). Mbopi-Kéou FX, Grésenguet G, Mayaud P, et al. Interactions between herpes simplex virus type 2 and human immunodeficiency virus type 1 infection in African women: opportunities for intervention. J Infect Dis 2000; 182: 1090–96. Charpentier C, Gody JC, Mbitikon O, et al. Virological response and resistance profiles after 18 to 30 months of first- or second-/third-line antiretroviral treatment: a cross-sectional evaluation in HIV type 1-infected children living in the Central African Republic. AIDS Res Hum Retroviruses 2012; 28: 87–94. Péré H, Charpentier C, Mbelesso P, et al. Virological response and resistance profiles after 24 months of first-line antiretroviral treatment in adults living in Bangui, Central African Republic. AIDS Res Hum Retroviruses 2012; 28: 315–23.
Charles Dickens at Christmas at 200 Science Photo Library
As the year draws to a close, we tend to reflect on the events of the previous 12 months, and perhaps further back, take stock of the present, and make resolutions for the future. This is of course the structure around which Charles Dickens (1812–70) wrote his seemingly timeless classic, A Christmas Carol, published for a mass market in 1843. As the bicentenary of Dickens’s birth also comes to an end, it is doubly appropriate to consider his many contributions to literature and beyond which continue to touch our lives. Many of Dickens’s characters have come to embody certain personality types: the irrepressible and rotund Mr Pickwick, the hard-working stalwarts Little Nell and Jenny Wren, the unctuous Uriah Heep, the forever fretful Mr McCawber, the jilted Miss Havisham, the Artful Dodger, Fagin, and of course Scrooge. These are vivid character portrayals, often comically drawn from real life with both insight and sympathy, which still live and breathe on the page, in the memory, and in contemporary culture. 1994
The great themes of the stories are themselves of abiding appeal and relevance. Scrooge’s misfortune warns of the untoward effects of greed, miserliness, and selfishness, and his salvation comes when he pities the young self he remembers and learns to spare a thought for the less fortunate. In David Copperfield, which might have started out as an autobiography, Dickens describes the unhappiness and neediness of the neglected child. As Claire Tomalin says in her searching but compassionate biography,1 this was decades before Freud or “any of the child experts”. Tomalin highlights another example of Dickens’s insight, from Hard Times, in which Dickens has Sleary, who has a lisp, be the vehicle of his view that work and learning are not sufficient, and that people also need to be amused, thus “showing that people with handicaps can be likeable, intelligent and perceptive”. Such psychological awareness can be traced to Dickens’s own difficult upbringing, in poverty and with little formal education. Dickens is also renowned for his social concern and kindness to others, especially those in adverse legal or financial circumstances, and those seeking to avoid or emerge from the asylums of the era. Together with A B Coutts, he funded and ran a home for destitute women, and did much to help set up London’s Great Ormond Street Hospital. Dickens was therefore a visionary— both immersed in and ahead of his time—but his was a tainted genius. He suffered from what he called “fits” of depression,1 and had what he regarded as a desperate need for long, latenight walks to sustain his wellbeing and writing. However, even though he composed A Christmas Carol “weeping and laughing and weeping again”,1 Tomalin is clear that these were facets of his creative personality rather than any trendy notions that he might have had bipolar disorder. Dickens was also, however, no saint. He was irreligious and intolerant
of piety; yet, and concerningly, he had “faith in Mesmerism”1 to the extent that he even tried to treat the wife of a friend despite having no qualifications. In his last decade, Dickens married a girl almost 30 years his junior, during the process trying to get his previous wife committed to an asylum, apparently aided by his long-time best friend and chosen biographer John Forster, who happened to be a Lunacy Commissioner. Perhaps because of these personal shortcomings, Dickens requested a simple funeral and an unadorned tomb, wanting simply to be remembered for his works. This he has, at least for 200 years, achieved: it is for his great literature and kind acts that we honour him. I declare that I have no conflicts of interest.
Stephen M Lawrie [email protected] Division of Psychiatry, School of Clinical Sciences, University of Edinburgh, Edinburgh EH10 5HF, UK 1
Tomalin C. Charles Dickens: a life. London: Viking, 2011.
Department of Error Budde K, Becker T, Arns W, et al, on behalf of the ZEUS Study Investigators. Everolimus-based, calcineurin-inhibitor-free regimen in recipients of de-novo kidney transplants: an open-label, randomised, controlled trial. Lancet 2011; 377: 837–47—In this Article (March 5), “Hypotension” should have read “Hypertension” in table 3; some of the data for this row also needed amending; a row has been added for “Hypotension”. These corrections have been made to the online version as of Dec 7, 2012. Dorhout Mees SM, Algra A, Vandertop WP, et al, on behalf of the MASH-2 study group. Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebocontrolled trial. Lancet 2012; 380: 44–49—In this Article (July 7), the author list should have ended with “on behalf of the MASH-2 Study Group”. Also, the study group members at the Medical Center Haaglanden, the Hague, Netherlands should have been J Boiten, J Kerklaan, and P J W Dennesen. These corrections have been made to the online version as of Dec 7, 2012.
www.thelancet.com Vol 380 December 8, 2012
Mary Madden [email protected] James Lind Alliance Pressure Ulcer Priority Setting Partnership, Department of Health Sciences, Area 2, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK 1 2 3
4
5
Caplan AL. Not my turn. Lancet 2012; 380: 968–69. Cohen D, Billinglsey M. Europeans are left to their own devices. BMJ 2012; 342: d2748. Dumville JC, Soares MO, O’Meara S, Cullum N. Systematic review and mixed treatment comparison: dressings to heal diabetic foot ulcers. Diabetologia 2012; 55: 1902–10. Brölmann FE, Ubbink DT, Nelson EA, Munte K, van der Horst CMAM, Vermeulen H. Evidencebased decisions for local and systemic wound care. Br J Surg 2012; 99: 1172–83. Madden M. Alienating evidence based medicine vs. innovative medical device marketing: a report on the evidence debate at a wounds conference. Soc Sci Med 2012; 74: 2046–52.
Author’s reply The issue of how to manage a patient who does not wish to be turned and who has made a competent and informed decision to allow the resulting sepsis to kill him is, as these thoughtful letters show, disturbing clinically and ethically. Many of those writing seek to find a path towards palliative care in a setting outside the patient’s hospital as a way to resolve the challenge of honouring the patient’s wishes while preserving the ability of the staff to provide care. I have no issue with trying to persuade the patient to pursue this path. However, hospice and home palliative care were not readily available in the rural area where these events took place. Additionally, by the time his condition had deteriorated, the www.thelancet.com Vol 380 December 8, 2012
patient had no interest in being moved anywhere. Once he realised his fate involved nursing-home care and that his independent life at home was over, he vocally resigned himself to death where he was. Some writers argue that they do not see the patient’s decision to die of the consequences of infection related to skin breakdown as a threat or burden to the health of others. I disagree. There are more ways to imperil the care of others than transmission of harmful infection or violent behaviour. The manner of this patient’s death caused grave disruption to many of the patient’s direct care providers and to the morale of the entire facility. If the cost of the patient’s decision grossly interferes with the ability of the staff and facility to carry out its caring mission to provide high-quality care to others, I maintain that this could provide moral grounds for over-riding a competent patient’s autonomous choice. Mary Madden usefully reminds us that what seems simple in wound care is not, and that advances in wound and skin care raise and will continue to raise very difficult ethical questions. I hope my essay contributes to the awareness of the need to engage with those questions in a proactive and forthright manner. I declare that I have no conflicts of interest.
Arthur Caplan [email protected] Division of Medical Ethics, NYU Langone Medical Center, New York, NY 10016, USA
HIV epidemic out of control in Central African Republic The Central African Republic is in the midst of a major health and humanitarian crisis, related particularly to the HIV epidemic, that is largely out of control (Sept 15, p 964).1 The country has the highest adult HIV prevalence
in French-speaking sub-Saharan Africa,2 and one of the highest prevalences of herpes simplex virus type 2 (HSV-2) infection in the world, with more than 80% of HIV-infected adults co-infected. Such co-infection is a major cofactor of heterosexual HIV spread and worsening of AIDS.3 Co-infection with Mycobacterium tuberculosis or hepatitis viruses affect a third of patients.2 Furthermore, antiretroviral treatment (ART) failure has reached uncontainable proportions. The rates of treatment failure in the 15 000 individuals taking first-line ART, including 1400 children, are estimated at 30% in adults and 50% in children.4,5 More than a fifth (3000) of such patients have ARTresistant HIV strains, necessitating a therapeutic shift to second-line ART. The ability of the health system to handle ART failure is insufficient, with few qualified health workers, no second-line ART available, embryonic biological monitoring, and frequent and long-term nationwide shortages of medical supplies. The tragic situation of the HIV epidemic in the Central African Republic urgently requires specific advocacy as well as massive and adapted interventions. The national and international responses have so far not been proportionate to the issue at hand, and international donors are actually disengaging from health provision in the country.2 More effective strategies are needed to tackle this escalating HIV epidemic in the Central African Republic, and the resulting humanitarian disaster.
Corbis
Correspondence
For DUETs see http://www. library.nhs.uk/duets/
We declare that we have no conflicts of interest.
*Laurent Bélec, François-Xavier Mbopi-Kéou [email protected] Laboratoire de Virologie, Hôpital Européen Georges Pompidou, 75908 Paris Cedex 15, France (LB); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (LB); International Society for Infectious Diseases, Brookline, MA, USA (F-XM-K); and Université de Yaoundé I, Yaoundé, Cameroon (F-XM-K)
1993
Correspondence
1 2
3
4
5
Green A. The Central African Republic’s silent health crisis. Lancet 2012; 380: 964–65. Médecins Sans Frontières. Central African Republic: a state of silent crisis. http://www. msf.org/shadomx/apps/fms/fmsdownload. cfm?file_uuid=59E8398E-B0FF-40EA-94F9177AF5D108B4&siteName=msf (accessed Oct 17, 2012). Mbopi-Kéou FX, Grésenguet G, Mayaud P, et al. Interactions between herpes simplex virus type 2 and human immunodeficiency virus type 1 infection in African women: opportunities for intervention. J Infect Dis 2000; 182: 1090–96. Charpentier C, Gody JC, Mbitikon O, et al. Virological response and resistance profiles after 18 to 30 months of first- or second-/third-line antiretroviral treatment: a cross-sectional evaluation in HIV type 1-infected children living in the Central African Republic. AIDS Res Hum Retroviruses 2012; 28: 87–94. Péré H, Charpentier C, Mbelesso P, et al. Virological response and resistance profiles after 24 months of first-line antiretroviral treatment in adults living in Bangui, Central African Republic. AIDS Res Hum Retroviruses 2012; 28: 315–23.
Charles Dickens at Christmas at 200 Science Photo Library
As the year draws to a close, we tend to reflect on the events of the previous 12 months, and perhaps further back, take stock of the present, and make resolutions for the future. This is of course the structure around which Charles Dickens (1812–70) wrote his seemingly timeless classic, A Christmas Carol, published for a mass market in 1843. As the bicentenary of Dickens’s birth also comes to an end, it is doubly appropriate to consider his many contributions to literature and beyond which continue to touch our lives. Many of Dickens’s characters have come to embody certain personality types: the irrepressible and rotund Mr Pickwick, the hard-working stalwarts Little Nell and Jenny Wren, the unctuous Uriah Heep, the forever fretful Mr McCawber, the jilted Miss Havisham, the Artful Dodger, Fagin, and of course Scrooge. These are vivid character portrayals, often comically drawn from real life with both insight and sympathy, which still live and breathe on the page, in the memory, and in contemporary culture. 1994
The great themes of the stories are themselves of abiding appeal and relevance. Scrooge’s misfortune warns of the untoward effects of greed, miserliness, and selfishness, and his salvation comes when he pities the young self he remembers and learns to spare a thought for the less fortunate. In David Copperfield, which might have started out as an autobiography, Dickens describes the unhappiness and neediness of the neglected child. As Claire Tomalin says in her searching but compassionate biography,1 this was decades before Freud or “any of the child experts”. Tomalin highlights another example of Dickens’s insight, from Hard Times, in which Dickens has Sleary, who has a lisp, be the vehicle of his view that work and learning are not sufficient, and that people also need to be amused, thus “showing that people with handicaps can be likeable, intelligent and perceptive”. Such psychological awareness can be traced to Dickens’s own difficult upbringing, in poverty and with little formal education. Dickens is also renowned for his social concern and kindness to others, especially those in adverse legal or financial circumstances, and those seeking to avoid or emerge from the asylums of the era. Together with A B Coutts, he funded and ran a home for destitute women, and did much to help set up London’s Great Ormond Street Hospital. Dickens was therefore a visionary— both immersed in and ahead of his time—but his was a tainted genius. He suffered from what he called “fits” of depression,1 and had what he regarded as a desperate need for long, latenight walks to sustain his wellbeing and writing. However, even though he composed A Christmas Carol “weeping and laughing and weeping again”,1 Tomalin is clear that these were facets of his creative personality rather than any trendy notions that he might have had bipolar disorder. Dickens was also, however, no saint. He was irreligious and intolerant
of piety; yet, and concerningly, he had “faith in Mesmerism”1 to the extent that he even tried to treat the wife of a friend despite having no qualifications. In his last decade, Dickens married a girl almost 30 years his junior, during the process trying to get his previous wife committed to an asylum, apparently aided by his long-time best friend and chosen biographer John Forster, who happened to be a Lunacy Commissioner. Perhaps because of these personal shortcomings, Dickens requested a simple funeral and an unadorned tomb, wanting simply to be remembered for his works. This he has, at least for 200 years, achieved: it is for his great literature and kind acts that we honour him. I declare that I have no conflicts of interest.
Stephen M Lawrie [email protected] Division of Psychiatry, School of Clinical Sciences, University of Edinburgh, Edinburgh EH10 5HF, UK 1
Tomalin C. Charles Dickens: a life. London: Viking, 2011.
Department of Error Budde K, Becker T, Arns W, et al, on behalf of the ZEUS Study Investigators. Everolimus-based, calcineurin-inhibitor-free regimen in recipients of de-novo kidney transplants: an open-label, randomised, controlled trial. Lancet 2011; 377: 837–47—In this Article (March 5), “Hypotension” should have read “Hypertension” in table 3; some of the data for this row also needed amending; a row has been added for “Hypotension”. These corrections have been made to the online version as of Dec 7, 2012. Dorhout Mees SM, Algra A, Vandertop WP, et al, on behalf of the MASH-2 study group. Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebocontrolled trial. Lancet 2012; 380: 44–49—In this Article (July 7), the author list should have ended with “on behalf of the MASH-2 Study Group”. Also, the study group members at the Medical Center Haaglanden, the Hague, Netherlands should have been J Boiten, J Kerklaan, and P J W Dennesen. These corrections have been made to the online version as of Dec 7, 2012.
www.thelancet.com Vol 380 December 8, 2012