- Email: [email protected]
Joined-up thinking in reduction of cardiovascular risk
Correspondence
Treatment must be linked to prevention, including mass vaccination, expanded water and sanitation efforts, and public health messaging that is tied to delivery of needed resources (such as soap). All of this must be led by the Haitian Government to mitigate the acute problem of cholera in the short term while also strengthening Haiti’s public water, sanitation, and health systems in the long term. We declare that we have no conflicts of interest.
*Paul Farmer, Louise Ivers [email protected] Harvard Medical School, Boston, MA 02115, USA 1
2
3
4
Roy SK, Hossain M, Khatun W, et al. Zinc supplementation in children with cholera in Bangladesh: randomized controlled trial. BMJ 2008; 336: 266–68. Walker CL, Black RE. Zinc for the treatment of diarrhoea: effect on diarrhoea morbidity, mortality and incidence of future episodes. Int J Epidemiol 2010; 39 (suppl 1): i63–69. World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers. http://whqlibdoc.who. int/publications/2005/9241593180.pdf (accessed Dec 11, 2010). Alam DS, Yunus M, Arifeen S, et al. Zinc treatment for 5 or 10 days is equally efficacious in preventing diarrhea in the subsequent 3 months among Bangladeshi children. J Nutr 2011; 141: 312–15.
often unnecessary, drugs, diagnostics, and procedures. These growing out-ofpocket payments place a heavy burden on poor households. Poor workers and their dependants (children, spouses, and parents) have high expectations of the therapeutic efficacy of such expensive treatments. The situation above stems from a common lack of medical understanding among the general public. Many patients, if a disease progresses, will instinctively blame doctors rather than taking a reasonable attitude to the disease. The Chinese mass media have reported many medical disputes in recent years, but they have not taken the opportunity to spread general medical knowledge. Finally, the low quality of medical services in Chinese hospitals is universal. Some junior doctors receive little regular training, meaning that their clinical skills are inadequate. Additionally, many health-care workers are not medically qualified at all, and currently it is still a great challenge for hospitals to verify the qualifications of their staff. We declare that we have no conflicts of interest.
Violence against Chinese health-care workers The Lancet has kept a close watch on the situation of Chinese health-care workers who have been wounded, disabled, or even killed by patients or their relatives (Feb 19, p 639).1,2 We give some possible causes of this situation. First, under the family control policy, most Chinese families have only one child who becomes the core of the family. Thus parents and grandparents pay great attention to the health of their child. High-income and uppermiddle-income parents particularly demand higher-quality health services for their children. Second, out-of-pocket health-care payments are high. Starved of funds from the government, Chinese hospitals resort to prescribing expensive, and www.thelancet.com Vol 377 May 21, 2011
*Sheng-Li Huang, Xiao-Yan Ding
Forum—a popular social media website in China. The author suggested that the children of these doctor victims would never become doctors themselves in China because of the escalating violence meted out by patients in recent years. The topic received more than 90 000 clicks and nearly 2000 replies within 2 weeks, and was reposted on hundreds of websites and personal blogs. China has about 20% of the world’s population, yet its national health expenditure is only 2% of the total world expenditure on health.2 Although China’s gross domestic product (GDP) has become one of the world’s largest, the total expenditure on health is only 4·3% of GDP, only 44·7% of which is government expenditure.3 Insufficient investment in public health has become a bottleneck in the development of Chinese society. Improving the financial input into public health and rebuilding a harmonious doctor– patient relationship are vital for China’s health-system reform. We declare that we have no conflicts of interest.
*Shengkun Sun, Wei Wang [email protected] PLA General Hospital, Beijing, China 1
[email protected] Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Xi’an Jiaotong University, Xi’an 710004, China (SLH); and Department of Ophthalmology, Xi’an Second Hospital, Xi’an, China (XYD) 1 2
The Lancet. Chinese doctors are under threat. Lancet 2010; 376: 657. Yu D, Li T. Doctor stabbed to death two days after warning in The Lancet. Lancet 2011; 377: 639.
Medical disputes and tension between doctors and patients have increased in recent years in China, and doctors have become progressively demonised.1 On Jan 31, 2011, 2 days before the Lunar New Year in China, six surgeons in Xinhua Hospital, Shanghai, were stabbed by about 20 relatives of a patient, who had undergone aortic valve replacement and died of mediastinitis 47 days after surgey. A doctor posted a condemnation of this vicious crime on the Tianya
2
3
The Lancet. Chinese doctors are under threat. Lancet 2010; 376: 657. Li S, Liu Y. The achievements, problems and experiences of the health service development in China’s 30 year reform and opening-up. Chin J Health Policy 2008; 11: 3–8. WHO. World health statistics 2010. http:// www.who.int/whosis/whostat/2010/en/ index.html (accessed May 4, 2011).
Joined-up thinking in reduction of cardiovascular risk Your Editorial highlighting an expected epidemic of premature cardiovascular mortality (Feb 12, p 527)1 makes for interesting and rather frightening reading for any frontline clinician already labouring under this seemingly insurmountable burden. But surely extraordinary circumstances call for extraordinary
For the Tianya Forum see http:// www.tianya.cn/
1747
Correspondence
Science Photo Library
measures? Rather than the research and clinical communities retreating into their own silos of expertise to develop solutions, surely now more than ever we require joined-up thinking in the context of cardiovascular risk. It is no longer feasible to divide up both clinical and research resources to tackle these problems individually, since, as Geoffrey Rose has clearly shown,2 the real solutions lie in small improvements in all risk factors across large populations. Modifiable cardiovascular risk factors should undoubtedly be vigorously tackled to avoid “catastrophic outcomes” down the line. However, rather than continuing the tradition of disease-specific research and clinical guidelines, we are calling for a fresh, integrated approach to cardiovascular risk. This is crucial to equip clinicians to adequately deal with the complex patients with multiple diseases seen as the rule rather than the exception in everyday practice. A step in the right direction is the concept of cardiovascular multimorbidity (coexisting cardiovascular disease, diabetes, and chronic kidney disease), which has already been shown to be an independent predictor of prognosis in patients with established cardiovascular disease.3 Patients with cardiovascular multimorbidity, therefore, do not simply represent an accumulation of conditions but rather an important collision of risk factors promoting the specific outcomes of death and cardiovascular events.3 Every time a new guideline on obesity arrives on my desk, my heart sinks at this missed opportunity to develop a “guideline for each patient not a guideline for each disease”, as so eloquently argued by Martin Dawes.4 We declare that we have no conflicts of interest.
*Joan Mulqueen, Liam Glynn [email protected] Discipline of General Practice, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland 1
1748
The Lancet. An epidemic of risk factors for cardiovascular disease. Lancet 2011; 377: 527.
2
3
4
Rose G, ed. Rose’s strategy of preventive medicine. New York: Oxford University Press, 1992. Glynn LG, Buckley B, Reddan D, et al. Multimorbidity and risk among patients with established cardiovascular disease: a cohort study. Br J Gen Pract 2008; 58: 488–94. Dawes M. Co-morbidity: we need a guideline for each patient not a guideline for each disease. Fam Pract 2010; 27: 1–2.
HIV counselling and testing in South African schools The Editorial “School: a place for children to learn their HIV status?” (Feb 12, p 528)1 raises important questions about HIV counselling and testing programmes in South African schools. In particular, will confidential counselling and testing be feasible in schools, will those testing positive have access to antiretroviral treatment, and will high levels of linkage to care be achieved? Our experience is that voluntary counselling and testing in schools is feasible, but ensuring linkage to care for those who test positive is a major challenge. Madwaleni Hospital is in a deeply rural district of South Africa and runs a comprehensive HIV service with an integrated orphans and vulnerable children component providing social support to HIV-positive children. Voluntary counselling and testing outreach teams visited 12 schools between June, 2008, and August, 2009, with the aim of educating and testing all children older than 12 years. Retrospective analysis found that 758 people younger than 21 years accepted voluntary counselling and testing. Seven (0·9%) were positive by point-of-care test, six of whom were female. The median age of those testing positive was 18 years.2 To ensure linkage to HIV care, multiple follow-up attempts were made by phone and in person by trained lay counsellors, and a dedicated adolescent HIV support group with subsidised travel costs was created.
Despite these efforts, none of the seven had enrolled in HIV care by September, 2009. Widespread HIV counselling and testing is likely to be feasible in South African schools and provide many benefits including HIV prevention education and familiarisation with the testing process. Innovative approaches might be necessary to ensure adequate linkage to care for those testing positive. We declare that we have no conflicts of interest.
*Jamie Naughton, Harriet Hughes, Lynne Wilkinson, Tom Boyles [email protected] Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taff CF72 8XR, UK (JN); University Hospital Wales, Heath Park, Cardiff, UK (HH); and Madwelani Hospital, Elliotdale, Eastern Cape, South Africa (LW, TB) 1 2
The Lancet. School: a place for children to learn their HIV status?. Lancet 2011; 377: 528. Hughes HC, Naughton JP, Greenhough J, Boyles T. Voluntary counselling and HIV testing in schools of the Mbashe District, Eastern Cape in rural South Africa: retrospective analysis. Presented at the Federation of Infection Societies meeting; Nov 17–19, 2010; Edinburgh, UK.
Department of Error Coriat R, Mir O, Ropert S, Clerc J, Goldwasser F. A painful cranial bulge. Lancet 2011; 377: 1777—In this Clinical Picture (May 21) the fifth sentence should have read: “Her serum thyroglobulin concentration was 102 300 μg/L (normal range <55 μg/L)”. The eighth sentence should have read: “Her serum thyroglobulin concentration had decreased to 47 500 μg/L”. These corrections have been made to the online version as of May 20, 2011, and to the printed version.
www.thelancet.com Vol 377 May 21, 2011
Treatment must be linked to prevention, including mass vaccination, expanded water and sanitation efforts, and public health messaging that is tied to delivery of needed resources (such as soap). All of this must be led by the Haitian Government to mitigate the acute problem of cholera in the short term while also strengthening Haiti’s public water, sanitation, and health systems in the long term. We declare that we have no conflicts of interest.
*Paul Farmer, Louise Ivers [email protected] Harvard Medical School, Boston, MA 02115, USA 1
2
3
4
Roy SK, Hossain M, Khatun W, et al. Zinc supplementation in children with cholera in Bangladesh: randomized controlled trial. BMJ 2008; 336: 266–68. Walker CL, Black RE. Zinc for the treatment of diarrhoea: effect on diarrhoea morbidity, mortality and incidence of future episodes. Int J Epidemiol 2010; 39 (suppl 1): i63–69. World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers. http://whqlibdoc.who. int/publications/2005/9241593180.pdf (accessed Dec 11, 2010). Alam DS, Yunus M, Arifeen S, et al. Zinc treatment for 5 or 10 days is equally efficacious in preventing diarrhea in the subsequent 3 months among Bangladeshi children. J Nutr 2011; 141: 312–15.
often unnecessary, drugs, diagnostics, and procedures. These growing out-ofpocket payments place a heavy burden on poor households. Poor workers and their dependants (children, spouses, and parents) have high expectations of the therapeutic efficacy of such expensive treatments. The situation above stems from a common lack of medical understanding among the general public. Many patients, if a disease progresses, will instinctively blame doctors rather than taking a reasonable attitude to the disease. The Chinese mass media have reported many medical disputes in recent years, but they have not taken the opportunity to spread general medical knowledge. Finally, the low quality of medical services in Chinese hospitals is universal. Some junior doctors receive little regular training, meaning that their clinical skills are inadequate. Additionally, many health-care workers are not medically qualified at all, and currently it is still a great challenge for hospitals to verify the qualifications of their staff. We declare that we have no conflicts of interest.
Violence against Chinese health-care workers The Lancet has kept a close watch on the situation of Chinese health-care workers who have been wounded, disabled, or even killed by patients or their relatives (Feb 19, p 639).1,2 We give some possible causes of this situation. First, under the family control policy, most Chinese families have only one child who becomes the core of the family. Thus parents and grandparents pay great attention to the health of their child. High-income and uppermiddle-income parents particularly demand higher-quality health services for their children. Second, out-of-pocket health-care payments are high. Starved of funds from the government, Chinese hospitals resort to prescribing expensive, and www.thelancet.com Vol 377 May 21, 2011
*Sheng-Li Huang, Xiao-Yan Ding
Forum—a popular social media website in China. The author suggested that the children of these doctor victims would never become doctors themselves in China because of the escalating violence meted out by patients in recent years. The topic received more than 90 000 clicks and nearly 2000 replies within 2 weeks, and was reposted on hundreds of websites and personal blogs. China has about 20% of the world’s population, yet its national health expenditure is only 2% of the total world expenditure on health.2 Although China’s gross domestic product (GDP) has become one of the world’s largest, the total expenditure on health is only 4·3% of GDP, only 44·7% of which is government expenditure.3 Insufficient investment in public health has become a bottleneck in the development of Chinese society. Improving the financial input into public health and rebuilding a harmonious doctor– patient relationship are vital for China’s health-system reform. We declare that we have no conflicts of interest.
*Shengkun Sun, Wei Wang [email protected] PLA General Hospital, Beijing, China 1
[email protected] Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Xi’an Jiaotong University, Xi’an 710004, China (SLH); and Department of Ophthalmology, Xi’an Second Hospital, Xi’an, China (XYD) 1 2
The Lancet. Chinese doctors are under threat. Lancet 2010; 376: 657. Yu D, Li T. Doctor stabbed to death two days after warning in The Lancet. Lancet 2011; 377: 639.
Medical disputes and tension between doctors and patients have increased in recent years in China, and doctors have become progressively demonised.1 On Jan 31, 2011, 2 days before the Lunar New Year in China, six surgeons in Xinhua Hospital, Shanghai, were stabbed by about 20 relatives of a patient, who had undergone aortic valve replacement and died of mediastinitis 47 days after surgey. A doctor posted a condemnation of this vicious crime on the Tianya
2
3
The Lancet. Chinese doctors are under threat. Lancet 2010; 376: 657. Li S, Liu Y. The achievements, problems and experiences of the health service development in China’s 30 year reform and opening-up. Chin J Health Policy 2008; 11: 3–8. WHO. World health statistics 2010. http:// www.who.int/whosis/whostat/2010/en/ index.html (accessed May 4, 2011).
Joined-up thinking in reduction of cardiovascular risk Your Editorial highlighting an expected epidemic of premature cardiovascular mortality (Feb 12, p 527)1 makes for interesting and rather frightening reading for any frontline clinician already labouring under this seemingly insurmountable burden. But surely extraordinary circumstances call for extraordinary
For the Tianya Forum see http:// www.tianya.cn/
1747
Correspondence
Science Photo Library
measures? Rather than the research and clinical communities retreating into their own silos of expertise to develop solutions, surely now more than ever we require joined-up thinking in the context of cardiovascular risk. It is no longer feasible to divide up both clinical and research resources to tackle these problems individually, since, as Geoffrey Rose has clearly shown,2 the real solutions lie in small improvements in all risk factors across large populations. Modifiable cardiovascular risk factors should undoubtedly be vigorously tackled to avoid “catastrophic outcomes” down the line. However, rather than continuing the tradition of disease-specific research and clinical guidelines, we are calling for a fresh, integrated approach to cardiovascular risk. This is crucial to equip clinicians to adequately deal with the complex patients with multiple diseases seen as the rule rather than the exception in everyday practice. A step in the right direction is the concept of cardiovascular multimorbidity (coexisting cardiovascular disease, diabetes, and chronic kidney disease), which has already been shown to be an independent predictor of prognosis in patients with established cardiovascular disease.3 Patients with cardiovascular multimorbidity, therefore, do not simply represent an accumulation of conditions but rather an important collision of risk factors promoting the specific outcomes of death and cardiovascular events.3 Every time a new guideline on obesity arrives on my desk, my heart sinks at this missed opportunity to develop a “guideline for each patient not a guideline for each disease”, as so eloquently argued by Martin Dawes.4 We declare that we have no conflicts of interest.
*Joan Mulqueen, Liam Glynn [email protected] Discipline of General Practice, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland 1
1748
The Lancet. An epidemic of risk factors for cardiovascular disease. Lancet 2011; 377: 527.
2
3
4
Rose G, ed. Rose’s strategy of preventive medicine. New York: Oxford University Press, 1992. Glynn LG, Buckley B, Reddan D, et al. Multimorbidity and risk among patients with established cardiovascular disease: a cohort study. Br J Gen Pract 2008; 58: 488–94. Dawes M. Co-morbidity: we need a guideline for each patient not a guideline for each disease. Fam Pract 2010; 27: 1–2.
HIV counselling and testing in South African schools The Editorial “School: a place for children to learn their HIV status?” (Feb 12, p 528)1 raises important questions about HIV counselling and testing programmes in South African schools. In particular, will confidential counselling and testing be feasible in schools, will those testing positive have access to antiretroviral treatment, and will high levels of linkage to care be achieved? Our experience is that voluntary counselling and testing in schools is feasible, but ensuring linkage to care for those who test positive is a major challenge. Madwaleni Hospital is in a deeply rural district of South Africa and runs a comprehensive HIV service with an integrated orphans and vulnerable children component providing social support to HIV-positive children. Voluntary counselling and testing outreach teams visited 12 schools between June, 2008, and August, 2009, with the aim of educating and testing all children older than 12 years. Retrospective analysis found that 758 people younger than 21 years accepted voluntary counselling and testing. Seven (0·9%) were positive by point-of-care test, six of whom were female. The median age of those testing positive was 18 years.2 To ensure linkage to HIV care, multiple follow-up attempts were made by phone and in person by trained lay counsellors, and a dedicated adolescent HIV support group with subsidised travel costs was created.
Despite these efforts, none of the seven had enrolled in HIV care by September, 2009. Widespread HIV counselling and testing is likely to be feasible in South African schools and provide many benefits including HIV prevention education and familiarisation with the testing process. Innovative approaches might be necessary to ensure adequate linkage to care for those testing positive. We declare that we have no conflicts of interest.
*Jamie Naughton, Harriet Hughes, Lynne Wilkinson, Tom Boyles [email protected] Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taff CF72 8XR, UK (JN); University Hospital Wales, Heath Park, Cardiff, UK (HH); and Madwelani Hospital, Elliotdale, Eastern Cape, South Africa (LW, TB) 1 2
The Lancet. School: a place for children to learn their HIV status?. Lancet 2011; 377: 528. Hughes HC, Naughton JP, Greenhough J, Boyles T. Voluntary counselling and HIV testing in schools of the Mbashe District, Eastern Cape in rural South Africa: retrospective analysis. Presented at the Federation of Infection Societies meeting; Nov 17–19, 2010; Edinburgh, UK.
Department of Error Coriat R, Mir O, Ropert S, Clerc J, Goldwasser F. A painful cranial bulge. Lancet 2011; 377: 1777—In this Clinical Picture (May 21) the fifth sentence should have read: “Her serum thyroglobulin concentration was 102 300 μg/L (normal range <55 μg/L)”. The eighth sentence should have read: “Her serum thyroglobulin concentration had decreased to 47 500 μg/L”. These corrections have been made to the online version as of May 20, 2011, and to the printed version.
www.thelancet.com Vol 377 May 21, 2011