- Email: [email protected]
Immobilisation for acute severe ankle sprain
Comment
The study by Annie Young and colleagues11 in The Lancet today adds to the growing body of evidence suggesting that there is no systematic indication for vitamin K antagonists—at least for regimens that produce an international normalised ratio (INR) of lower than 2·0— for the prevention of catheter-related, upper-limb DVT. In their randomised study in a large series of consecutive patients with cancer who were receiving chemotherapy, neither a fixed-dose regimen of warfarin (1 mg a day) nor a dose targeted at achieving an INR of 1·5–2·0 was effective in preventing catheter-related thromboses. Whether more conventional doses of vitamin K antagonists (ie, doses that produce an INR of 2·0–3·0) might be more effective is unknown, but they are unlikely to be associated with a more favourable benefit-to-risk ratio. On the basis of available evidence, neither lowmolecular-weight heparin nor fixed low-dose vitamin K antagonists should be used to prevent catheter-related upper-limb DVT in patients with cancer on a routine basis. However, DVT still persists despite occurring at a lower rate than in the past; thus, an effort should be made to identify patients at highest risk (and who would therefore potentially benefit from thromboprophylaxis). For example, in a recent subanalysis12 of their randomised trial,7 Verso and co-workers identified several conditions independently associated with an increased risk of catheter-related upper-limb DVT—ie, the misplacement of the catheter tip in the upper half of the superior vena cava, the left-sided insertion of the catheter, chest radiotherapy, and the presence of distant metastases. As the use of emerging antithrombotic (factor Xa or thrombin inhibitors) drugs becomes widespread, we expect to see improvements in the prophylaxis of catheter-related upper-limb DVT in patients with cancer, especially in those who need chemotherapy through central venous lines. Meanwhile, the decision to use available drugs for a specific period is left
to the discretion of the attending physicians, who should assess the personal and familial history of the patient, the carriage of thrombophilia, the presence of comorbidities, and the patient’s preference. Paolo Prandoni Department of Cardiothoracic and Vascular Sciences, Thromboembolism Unit, University of Padua, 35122 Padua, Italy [email protected] I declare that I have no conflict of interest. 1
2
3
4
5
6
7
8
9
10
11
12
Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003; 21: 3665–75. Bern MM, Lokich JJ, Wallach SR, et al. Very low dose of warfarin can prevent thrombosis in central venous catheters: a prospective trial. Ann Intern Med 1990; 112: 423–28. Monreal M, Alastrue A, Rull M, et al. Upper extremity deep venous thrombosis in cancer patients with venous access devices—prophylaxis with a low molecular weight heparin (fragmin). Thromb Haemost 1996; 75: 251–53. Couban S, Goodyear M, Burnell M, et al. Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol 2005; 23: 4063–69. Karthaus M, Kretzschmar A, Kroning H, et al. Dalteparin for prevention of catheter-related complications in cancer patients with central venous catheters: final results of a double-blind, placebo-controlled phase III trial. Ann Oncol 2005; 17: 289–96. Lee AY, Levine MN, Butler G, et al. Incidence, risk factors, and outcomes of catheter-related thrombosis in adult patients with cancer. J Clin Oncol 2006; 24: 1404–08. Verso M, Agnelli G, Bertoglio S, et al. Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: a double-blind, placebo-controlled, randomized study in cancer patients. J Clin Oncol 2005; 23: 4057–62. Carrier M, Tay J, Fergusson D, Wells PS. Thromboprophylaxis for catheter-related thrombosis in patients with cancer: a systematic review of the randomized, controlled trials. J Thromb Haemost 2007; 5: 2552–54. Chaukiyal P, Nautiyal A, Radhakrishnan S, Singh S, Navaneethan SD. Thromboprophylaxis in cancer patients with central venous catheters; a systematic review and meta-analysis. Thromb Haemost 2008; 99: 38–43. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (suppl 6): 381S–453S. Young AM, Billingham LJ, Begum G, et al, on behalf of the WARP Collaborative Group, UK. Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): an open-label randomised trial. Lancet 2009; 373: 567–74. Verso M, Agnelli G, Kamphuisen PW, et al. Risk factors for upper limb deep vein thrombosis associated with the use of central vein catheter in cancer patients. Intern Emerg Med 2008; 3: 117–22.
Immobilisation for acute severe ankle sprain See Articles page 575
524
In The Lancet today, Sarah Lamb and colleagues1 present a randomised trial in which they aimed to evaluate the effects of four different types of immobilisation devices (Tubigrip compression bandage, Bledsoe boot, Aircast brace, and below-knee cast) on the outcomes of patients recovering from severe ankle sprains. The investigators
conclude that a below-knee cast for 10 days resulted in more rapid resolution of symptoms and pain and greatest recovery of self-reported ankle function at 3 months’ follow-up compared with the other three treatments. This finding is likely to be viewed as controversial because consensus recommendations in www.thelancet.com Vol 373 February 14, 2009
recent decades have been towards functional treatment of ankle sprains. These recommendations emphasise little, if any, immobilisation, an early return to weight bearing, and progressive range of motion, balance, and coordination exercises.2 Ankle sprains are often considered by patients and clinicians to be innocuous injuries with no lasting consequences,3 when in fact lingering symptoms,4,5 self-reported disability,5 lower levels of physical activity levels,6 and recurrent ankle sprains7 are often reported for months and years after initial injury. About 30% of patients with an initial ankle sprain develop chronic ankle instability,8 or repetitive giving way of the ankle during functional activities.9 There is also emergent evidence to link severe and repetitive ankle sprains to increased risk of ankle osteoarthritis.10 On the basis of these sequelae, there is clearly a need to re-evaluate the treatment of this common injury. Functional treatment of ankle sprains seems to contrast with that of ligamentous injuries of the other major joints. For example, sprains to the collateral ligaments of the knee are typically treated with immobilisation and assisted weight-bearing with crutches. Similarly, sprains to the ligaments that support the acromioclavicular or glenohumeral joints are treated with immobilisation of the injured extremity in a sling. These decisions are made in an effort to protect the injured joints and allow scar tissue to form in the healing ligaments. Curiously, for ankle ligament sprains, clinicians seem willing to ignore these tenets of protecting injured tissues and creating an environment in which healing can occur in favour of more aggressive functional treatment that is aimed at providing a swift return to previous levels of physical activity. There is emerging evidence that post-traumatic ankle joint laxity is an important factor that discriminates individuals with chronic ankle instability from those without any history of ankle sprain.11 Perhaps one reason, in Lamb and colleagues’ study, that the below-knee cast was associated with diminished symptoms and pain and increased function 3 months after ankle sprain was that better ligamentous healing was allowed to occur with the prolonged immobilisation. In Lamb and colleagues’ study, there was no significant difference between the four treatment groups at 9-months’ follow-up, which suggests that www.thelancet.com Vol 373 February 14, 2009
Photolibrary
Comment
over time the groups became more equal. This finding is interesting because the risk of recurrent ankle sprain is highest within the first 6 months of previous sprain, still increased between 6 and 12 months, but returns to preinjury level of risk after 12 months.12 Lamb and colleagues did not report the incidence of recurrent ankle sprains in the four groups. This information would be helpful to establish whether there are other clinically beneficial effects associated with below-knee casting of patients with ankle sprain. There are some clinicians who advocate immediate surgical stabilisation of severely sprained ankles. Lamb and colleagues did not address this approach. Whilst there is inconclusive evidence to favour surgical or conservative care of patients with severe ankle sprains,13 this area is worthy of further study in view of Lamb and colleagues’ unexpected findings. Clearly the optimum treatment for patients with acute ankle sprains is not known and must continue to be studied. Lamb and colleagues have presented provocative results that show the benefits of 10 days of below-knee casting in patients with acute ankle sprains. Since short-term benefits were identified at 3 months, but intermediate-term benefits at 9-months’ follow-up were not found, the results of this study call into question the current standard of aggressive functional treatment of patients recovering from acute ankle sprains. Jay Hertel University of Virginia, Charlottesville, VA 22904, USA [email protected]
525
Comment
I declare that I have no conflict of interest. 1
2
3 4 5 6
Lamb SE, Marsh J, Hutton J, Nakash R, Cooke MW, on behalf of the Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet 2008; 373: 575–81. Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res 2007; 455: 169–72. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001; 35: 103–08. Braun BL. Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation. Arch Fam Med 1999; 8: 143–48. Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med 2005; 39: e14. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg 1995; 114: 92–96.
7 8 9 10 11 12
13
Yeung MS, Chan KM, So CH, Wuan WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994; 28: 112–16. Itay SA, Ganel H, Horoszowski H, Farine I. Clinical and functional status following lateral ankle sprains. Orthop Rev 1982; 11: 73–76. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train 2002; 37: 364–75. Valderrabano V, Hintermann B, Horisberger M, Fung T. Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med 2006; 34: 612–20. Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int 2007; 28: 343–54. Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The effect of a proprioceptive balance board training program for the prevention of ankle sprains. Am J Sports Med 2004; 32: 1385–93. Kerkhoffs GM,Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev 2007; 2: CD000380.
Italian G8 Summit: a critical juncture for global health
Getty Images
In 2009, humanity should reaffirm its commitment to the health of the poorest, just when they are suffering the most. Or we could turn our back on poor people, relegating health for them to nothing more than a passing fad, affordable only when the going is good for the rich. We are at a critical juncture and the focal point is Italy—the La Maddalena G8 Summit this summer. Only 9 years ago, at the 2000 Kyushu Okinawa Summit, global health first appeared as a major focus for the G8.1 That focus led to the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Since then, global health has had a continuous presence on the G8 agenda, and the G8 has expanded its promises on global health through a series of initiatives.2 Resources deployed in the field soared from US$6·8 billion in 2000 to $17 billion in 2006,3 backed by robust global economic growth. This situation is all about to change, unless the global-health community gets its act together. The 2008 experience, with Japan as the G8 chair, provides some valuable lessons. In 2008, the world was already heading into recession. There were other pressing agenda items ready to crowd out global health: financial crisis, economic downturn, food shortages, fuel prices, climate-change negotiations, to name a few. And yet, global health managed to stay on the agenda.4 Why? There are three lessons. First, obvious but crucial, is that politicians respond primarily to their domestic constituency, and unless there is domestic political support, it is difficult for the G8 chair to step up. In 2008, former Prime Ministers Mori and Koizumi rallied the public, while Prime Minister Fukuda 526
and Foreign Minister Koumura spoke from almost a year before the Summit about setting global health on the agenda.5,6 The Hideyo Noguchi Africa prize, established by Koizumi’s initiative, presented its inaugural award in May, galvanising Japan’s commitment on health.7 Broadcasters and newspapers also carried special programming on global health, giving a Japanese angle that resonated with the public.8,9 Early, personal, and broad engagement is a must. Second, a multistakeholder approach is indispensable, particularly in a “flattening world”. Government alone has neither the resources nor skills to undertake global initiatives. In 2008, leaders from government, business, academia, non-governmental organisations (NGO), and media were brought together in various forums. The Global Health Summit co-organised by Health Policy Institute, Japan, and the World Bank, in collaboration with the Bill & Melinda Gates Foundation, brought all key stakeholders together 6 months before the Summit.10 The Working Group on Challenges in Global Health and Japan’s Contributions, organised by the Japan Center for International Exchange, prepared policy recommendations on health-system strengthening with broad participation by stakeholders.11,12 The participatory approach, as described in the Chair’s summary of the Hokkaido Toyako Summit must become the norm.13 Third, international outreach by each stakeholder—in which countries and stakeholders cross—cemented the initiatives. For example, G8 Summit NGO Forum, a well-coordinated body of more than 140 NGOs with a special task-force on global health, coordinated their activities with NGOs around the world.14 The www.thelancet.com Vol 373 February 14, 2009
The study by Annie Young and colleagues11 in The Lancet today adds to the growing body of evidence suggesting that there is no systematic indication for vitamin K antagonists—at least for regimens that produce an international normalised ratio (INR) of lower than 2·0— for the prevention of catheter-related, upper-limb DVT. In their randomised study in a large series of consecutive patients with cancer who were receiving chemotherapy, neither a fixed-dose regimen of warfarin (1 mg a day) nor a dose targeted at achieving an INR of 1·5–2·0 was effective in preventing catheter-related thromboses. Whether more conventional doses of vitamin K antagonists (ie, doses that produce an INR of 2·0–3·0) might be more effective is unknown, but they are unlikely to be associated with a more favourable benefit-to-risk ratio. On the basis of available evidence, neither lowmolecular-weight heparin nor fixed low-dose vitamin K antagonists should be used to prevent catheter-related upper-limb DVT in patients with cancer on a routine basis. However, DVT still persists despite occurring at a lower rate than in the past; thus, an effort should be made to identify patients at highest risk (and who would therefore potentially benefit from thromboprophylaxis). For example, in a recent subanalysis12 of their randomised trial,7 Verso and co-workers identified several conditions independently associated with an increased risk of catheter-related upper-limb DVT—ie, the misplacement of the catheter tip in the upper half of the superior vena cava, the left-sided insertion of the catheter, chest radiotherapy, and the presence of distant metastases. As the use of emerging antithrombotic (factor Xa or thrombin inhibitors) drugs becomes widespread, we expect to see improvements in the prophylaxis of catheter-related upper-limb DVT in patients with cancer, especially in those who need chemotherapy through central venous lines. Meanwhile, the decision to use available drugs for a specific period is left
to the discretion of the attending physicians, who should assess the personal and familial history of the patient, the carriage of thrombophilia, the presence of comorbidities, and the patient’s preference. Paolo Prandoni Department of Cardiothoracic and Vascular Sciences, Thromboembolism Unit, University of Padua, 35122 Padua, Italy [email protected] I declare that I have no conflict of interest. 1
2
3
4
5
6
7
8
9
10
11
12
Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003; 21: 3665–75. Bern MM, Lokich JJ, Wallach SR, et al. Very low dose of warfarin can prevent thrombosis in central venous catheters: a prospective trial. Ann Intern Med 1990; 112: 423–28. Monreal M, Alastrue A, Rull M, et al. Upper extremity deep venous thrombosis in cancer patients with venous access devices—prophylaxis with a low molecular weight heparin (fragmin). Thromb Haemost 1996; 75: 251–53. Couban S, Goodyear M, Burnell M, et al. Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol 2005; 23: 4063–69. Karthaus M, Kretzschmar A, Kroning H, et al. Dalteparin for prevention of catheter-related complications in cancer patients with central venous catheters: final results of a double-blind, placebo-controlled phase III trial. Ann Oncol 2005; 17: 289–96. Lee AY, Levine MN, Butler G, et al. Incidence, risk factors, and outcomes of catheter-related thrombosis in adult patients with cancer. J Clin Oncol 2006; 24: 1404–08. Verso M, Agnelli G, Bertoglio S, et al. Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: a double-blind, placebo-controlled, randomized study in cancer patients. J Clin Oncol 2005; 23: 4057–62. Carrier M, Tay J, Fergusson D, Wells PS. Thromboprophylaxis for catheter-related thrombosis in patients with cancer: a systematic review of the randomized, controlled trials. J Thromb Haemost 2007; 5: 2552–54. Chaukiyal P, Nautiyal A, Radhakrishnan S, Singh S, Navaneethan SD. Thromboprophylaxis in cancer patients with central venous catheters; a systematic review and meta-analysis. Thromb Haemost 2008; 99: 38–43. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (suppl 6): 381S–453S. Young AM, Billingham LJ, Begum G, et al, on behalf of the WARP Collaborative Group, UK. Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): an open-label randomised trial. Lancet 2009; 373: 567–74. Verso M, Agnelli G, Kamphuisen PW, et al. Risk factors for upper limb deep vein thrombosis associated with the use of central vein catheter in cancer patients. Intern Emerg Med 2008; 3: 117–22.
Immobilisation for acute severe ankle sprain See Articles page 575
524
In The Lancet today, Sarah Lamb and colleagues1 present a randomised trial in which they aimed to evaluate the effects of four different types of immobilisation devices (Tubigrip compression bandage, Bledsoe boot, Aircast brace, and below-knee cast) on the outcomes of patients recovering from severe ankle sprains. The investigators
conclude that a below-knee cast for 10 days resulted in more rapid resolution of symptoms and pain and greatest recovery of self-reported ankle function at 3 months’ follow-up compared with the other three treatments. This finding is likely to be viewed as controversial because consensus recommendations in www.thelancet.com Vol 373 February 14, 2009
recent decades have been towards functional treatment of ankle sprains. These recommendations emphasise little, if any, immobilisation, an early return to weight bearing, and progressive range of motion, balance, and coordination exercises.2 Ankle sprains are often considered by patients and clinicians to be innocuous injuries with no lasting consequences,3 when in fact lingering symptoms,4,5 self-reported disability,5 lower levels of physical activity levels,6 and recurrent ankle sprains7 are often reported for months and years after initial injury. About 30% of patients with an initial ankle sprain develop chronic ankle instability,8 or repetitive giving way of the ankle during functional activities.9 There is also emergent evidence to link severe and repetitive ankle sprains to increased risk of ankle osteoarthritis.10 On the basis of these sequelae, there is clearly a need to re-evaluate the treatment of this common injury. Functional treatment of ankle sprains seems to contrast with that of ligamentous injuries of the other major joints. For example, sprains to the collateral ligaments of the knee are typically treated with immobilisation and assisted weight-bearing with crutches. Similarly, sprains to the ligaments that support the acromioclavicular or glenohumeral joints are treated with immobilisation of the injured extremity in a sling. These decisions are made in an effort to protect the injured joints and allow scar tissue to form in the healing ligaments. Curiously, for ankle ligament sprains, clinicians seem willing to ignore these tenets of protecting injured tissues and creating an environment in which healing can occur in favour of more aggressive functional treatment that is aimed at providing a swift return to previous levels of physical activity. There is emerging evidence that post-traumatic ankle joint laxity is an important factor that discriminates individuals with chronic ankle instability from those without any history of ankle sprain.11 Perhaps one reason, in Lamb and colleagues’ study, that the below-knee cast was associated with diminished symptoms and pain and increased function 3 months after ankle sprain was that better ligamentous healing was allowed to occur with the prolonged immobilisation. In Lamb and colleagues’ study, there was no significant difference between the four treatment groups at 9-months’ follow-up, which suggests that www.thelancet.com Vol 373 February 14, 2009
Photolibrary
Comment
over time the groups became more equal. This finding is interesting because the risk of recurrent ankle sprain is highest within the first 6 months of previous sprain, still increased between 6 and 12 months, but returns to preinjury level of risk after 12 months.12 Lamb and colleagues did not report the incidence of recurrent ankle sprains in the four groups. This information would be helpful to establish whether there are other clinically beneficial effects associated with below-knee casting of patients with ankle sprain. There are some clinicians who advocate immediate surgical stabilisation of severely sprained ankles. Lamb and colleagues did not address this approach. Whilst there is inconclusive evidence to favour surgical or conservative care of patients with severe ankle sprains,13 this area is worthy of further study in view of Lamb and colleagues’ unexpected findings. Clearly the optimum treatment for patients with acute ankle sprains is not known and must continue to be studied. Lamb and colleagues have presented provocative results that show the benefits of 10 days of below-knee casting in patients with acute ankle sprains. Since short-term benefits were identified at 3 months, but intermediate-term benefits at 9-months’ follow-up were not found, the results of this study call into question the current standard of aggressive functional treatment of patients recovering from acute ankle sprains. Jay Hertel University of Virginia, Charlottesville, VA 22904, USA [email protected]
525
Comment
I declare that I have no conflict of interest. 1
2
3 4 5 6
Lamb SE, Marsh J, Hutton J, Nakash R, Cooke MW, on behalf of the Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet 2008; 373: 575–81. Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res 2007; 455: 169–72. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001; 35: 103–08. Braun BL. Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation. Arch Fam Med 1999; 8: 143–48. Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med 2005; 39: e14. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg 1995; 114: 92–96.
7 8 9 10 11 12
13
Yeung MS, Chan KM, So CH, Wuan WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994; 28: 112–16. Itay SA, Ganel H, Horoszowski H, Farine I. Clinical and functional status following lateral ankle sprains. Orthop Rev 1982; 11: 73–76. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train 2002; 37: 364–75. Valderrabano V, Hintermann B, Horisberger M, Fung T. Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med 2006; 34: 612–20. Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int 2007; 28: 343–54. Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The effect of a proprioceptive balance board training program for the prevention of ankle sprains. Am J Sports Med 2004; 32: 1385–93. Kerkhoffs GM,Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev 2007; 2: CD000380.
Italian G8 Summit: a critical juncture for global health
Getty Images
In 2009, humanity should reaffirm its commitment to the health of the poorest, just when they are suffering the most. Or we could turn our back on poor people, relegating health for them to nothing more than a passing fad, affordable only when the going is good for the rich. We are at a critical juncture and the focal point is Italy—the La Maddalena G8 Summit this summer. Only 9 years ago, at the 2000 Kyushu Okinawa Summit, global health first appeared as a major focus for the G8.1 That focus led to the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Since then, global health has had a continuous presence on the G8 agenda, and the G8 has expanded its promises on global health through a series of initiatives.2 Resources deployed in the field soared from US$6·8 billion in 2000 to $17 billion in 2006,3 backed by robust global economic growth. This situation is all about to change, unless the global-health community gets its act together. The 2008 experience, with Japan as the G8 chair, provides some valuable lessons. In 2008, the world was already heading into recession. There were other pressing agenda items ready to crowd out global health: financial crisis, economic downturn, food shortages, fuel prices, climate-change negotiations, to name a few. And yet, global health managed to stay on the agenda.4 Why? There are three lessons. First, obvious but crucial, is that politicians respond primarily to their domestic constituency, and unless there is domestic political support, it is difficult for the G8 chair to step up. In 2008, former Prime Ministers Mori and Koizumi rallied the public, while Prime Minister Fukuda 526
and Foreign Minister Koumura spoke from almost a year before the Summit about setting global health on the agenda.5,6 The Hideyo Noguchi Africa prize, established by Koizumi’s initiative, presented its inaugural award in May, galvanising Japan’s commitment on health.7 Broadcasters and newspapers also carried special programming on global health, giving a Japanese angle that resonated with the public.8,9 Early, personal, and broad engagement is a must. Second, a multistakeholder approach is indispensable, particularly in a “flattening world”. Government alone has neither the resources nor skills to undertake global initiatives. In 2008, leaders from government, business, academia, non-governmental organisations (NGO), and media were brought together in various forums. The Global Health Summit co-organised by Health Policy Institute, Japan, and the World Bank, in collaboration with the Bill & Melinda Gates Foundation, brought all key stakeholders together 6 months before the Summit.10 The Working Group on Challenges in Global Health and Japan’s Contributions, organised by the Japan Center for International Exchange, prepared policy recommendations on health-system strengthening with broad participation by stakeholders.11,12 The participatory approach, as described in the Chair’s summary of the Hokkaido Toyako Summit must become the norm.13 Third, international outreach by each stakeholder—in which countries and stakeholders cross—cemented the initiatives. For example, G8 Summit NGO Forum, a well-coordinated body of more than 140 NGOs with a special task-force on global health, coordinated their activities with NGOs around the world.14 The www.thelancet.com Vol 373 February 14, 2009