- Email: [email protected]
Prostitution and health
Correspondence
1 2
The Lancet. China must not neglect reform of primary care. Lancet 2005; 365: 1362. Hesketh T, Zhu WX. Effect of restricted freedom on health in China. BMJ 2004; 329: 1427.
A Chinese-style onechild policy for India In response to Patralekha Chatterjee’s World Report (May 7, p 1609),1 it is important to note that China’s onechild policy does not apply to all of its regions and ethnic groups. Couples in poor rural regions are permitted to have two children, and national minority groups of a small population size have no birth restrictions. Even so, China’s achievement of rapid fertility declines has incurred high social, demographic, and health costs.2,3 North and Central India share one main feature of the patrilineal family system found in rural China (where 75% of the population resides), namely son preference.2,4 Son preference in such family systems implies that at least one son is wanted to continue the patrilineal family line and to perform religious, social, economic, and reproductive functions for the family. This imperative poses a formidable challenge to population policies that impose birth restrictions on rural families, as occurred in rural China.2 India’s sex imbalances are already very high. A forced family planning programme would further exacerbate them. Parents’ preferences for male offspring are intimately connected with women’s status in the larger society and are an indicator of sex inequality.2 In societies where men and women have relatively equal roles in social, economic, and political spheres, parents tend to value sons and daughters more equally than in settings where sex differentiation is more pronounced. The effects of son preference on mortality and fertility www.thelancet.com Vol 366 July 9, 2005
are well documented. It is no coincidence that the southern Indian state of Kerala has achieved remarkable population control and this is also a state where son preference is the weakest in India.4 Women’s status (eg, literacy, mass media exposure, domestic decision-making power, and social economic opportunity in the public domain) affects fertility through two mechanisms. It stops the cycle of high infant mortality and high fertility by improving infant survival chances, and it provides women with other social alternatives to early childbearing and motherhood, thus ultimately contributing to low fertility. The demographic experiences of other Asian countries show multiple pathways to low fertility and that broad social and economic development and, in particular, the elevation of women’s social position are the driving force for low birth rates in the absence of mandatory family planning programmes.5 Chinese history has proven that wars, natural disasters, diseases, and non-functional social and economic systems, rather than population size itself, are the main causes of famines. The Great Leap Forward campaign in the late 1950s that led to large-scale starvation in rural China is a prime example. I declare that I have no conflict of interest.
Jianghong Li [email protected] Division of Population Sciences, Telethon Institute for Child Health Research, PO Box 855, West Perth, Western Australia 6872, Australia. 1
2
3
4
5
Chatterjee P. Doctors’ group proposes a one-child policy for India. Lancet 2005; 365: 1609. Li J, Lavely W. Village context, women’s status and son preference among rural Chinese women. Rural Sociology 2003; 68: 87–108. Coale A, Banister J. Five decades of missing females in China. Demography 1994; 31: 459–80. Mutharayappa R, Choe MK, Arnold F, Roy TK. Is son preference slowing down India’s transition to low fertility? Nat Family Health Survey Bull 1997; 4: 1–4. Freedman R. Asia’s recent fertility decline and prospects for future demographic change. Asia-Pacific Pop Res Rep 1995; 1: 1–27.
Clear signs In your Apr 23 issue, the diagnoses in the Uses of Error article (p 1513)1 and Case Report (p 1514)2 seem obvious. Pain confined to the lower jaw is not uncommon in myocardial ischaemia, and severe chest pain associated with symptoms in the legs suggests an aneurism. The diagnoses here would cause no trouble in those taught by the apprenticeship system 50 years ago rather than by the guidelines and governance used today. I declare that I have no conflict of interest.
P B S Fowler [email protected]
Rights were not granted to include this image in electronic media. Please refer to the printed journal
Shirley Holms, 4 South Park Drive, Gerrards Cross SL9 8JK, UK 1 2
McQueen A. “I think she’s just crazy”. Lancet 2005; 365: 1513. Beggs AD, Al-Rawi H, Parfitt A. Chest pain and fleeting neurological signs. Lancet 2005; 365: 1514.
Prostitution and health Your concern about the health effects of prostitution (May 7, p 1598)1 might go a lot further than advocating decriminalisation and better health care. You could actively campaign against the practice itself. You could, for example, draw the attention of your readers more pointedly to the disastrous consequences of prostitution for the mental and physical wellbeing of those involved.2,3 Sadly, your Editorial adopts a morally neutral tone, describing prostitution as a “profession” and an “occupation”, although it is really a trade, rather like the slave trade in many respects. Naturally you advocate measures that will improve the situation for those involved, since prostitution is, after all, a fact of life. But will you speak out against prostitution itself? The truth is that prostitution is an evil of global proportions, and not only in terms of its adverse health effects. It is associated with casual violence, organised crime, drugs, and the most vicious forms of trafficking 121
Panos Pictures
TCM Department, 2nd Teaching Hospital, Jilin University, Changchun, Jilin Province, 130041 China
Correspondence
in human lives.4,5 Did Dickens ask for health clinics in the mines and factories? Did Wilberforce ask for “tailored medical care” on the slave ships and the plantations? Are you against prostitution, on health grounds, or not? I declare that I have no conflict of interest.
Stephen Due [email protected] Barwon Health Library Service, PO Box 281, Geelong, Victoria 3220, Australia 1 2
3
4
5
The Lancet. Prostitutes are people too. Lancet 2005; 365: 1598. Jeal N, Salisbury C. A health needs assessment of street-based prostitutes: cross-sectional survey. J Public Health 2004; 26: 147–51. Potterat JJ, Brewer DD, Muth SQ, et al. Mortality in a long-term open cohort of prostitute women. Am J Epidemiol 2004; 159: 778–85. Romero-Daza N, Weeks M, Singer M. “Nobody gives a damn if I live or die”: violence, drugs, and street-level prostitution in inner-city Hartford, Connecticut. Med Anthropol 2003; 22: 233–59. Home Office. Paying the price: a consultation paper on prostitution. London: Home Office, 2004. http://www.homeoffice.gov.uk/docs3/ paying_the_price.html (accessed May 31, 2005).
Evidence-based medicine in Japan
Rights were not granted to include this image in electronic media. Please refer to the printed journal
122
Despite a sudden interest in evidencebased medicine in Japan in the late 1990s, attention is now waning and the concept has not been widely accepted by clinicians.1 What is the reason for this, and has the introduction of evidence-based medicine resulted in any changes in the way clinicians in Japan practice medicine? The main reason for evidence-based medicine not having been widely accepted in Japan seems to stem from an image problem. Evidence-based medicine was mainly promoted by public-health researchers and epidemiologists who had little knowledge of the clinical field, and only the techniques for literature searching and evaluation of information obtained were emphasised. This concentration on theory resulted in criticism from clinicians that researchers were not
involved with patients and were disregarding the value of experience and skill. However, the principle of evidence-based medicine is selection and execution of the optimum treatment plan based on scientific evidence, and experience of clinicians is an important factor. The most frequently voiced criticisms against evidence-based medicine in Japan are “Is the clinician’s experience not needed if there are sufficient data?” and “Are the various backgrounds of patients not important?” Clinicians in Japan realise that errors will be made if they rely only on clinical data such as those obtained from randomised controlled trials of large numbers of patients with backgrounds that might be quite different, and have thus probably rejected evidence-based medicine as unrealistic. However, the true message from those who promote evidence-based medicine is that the background and needs of each patient are more important than trial data. Until very recently in Japan, young clinicians have been in a situation in which they learned and accepted methods used by older, experienced clinicians and then continued to use those methods. At face value, evidence-based medicine seems to deny the validity of this Japanese system. Efforts must be made in the clinical field to avoid both over-reliance on data and use of outdated methods. The true objective of evidence-based medicine should be to narrow the gap between a clinician’s knowledge at the time of graduation and currently available information. We declare that we have no conflict of interest.
*Takashi Yokota, Seiichi Kojima, Hidemi Yamauchi, Masahito Hatori [email protected] Department of Surgery, National Sanatorium Tohoku Shinseien, Miyagi 989-4601, Japan (TY, SK); Kosei Sendai Clinic, Sendai, Japan (HY); and Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan (MH) 1
Nomura K. What did EBM leave? Nikkei Medical 2005; 447: 42–53.
Could evidence-based medicine be a danger to progress? In this 100th year of celebration of Albert Einstein, I have been thinking about his papers on theoretical physics, done purely by deduction, and how they changed our view of the world. His way of thinking is in sharp contrast to that of evidencebased medicine, which has become almost a dogma in some medical circles. Yet if everything has to be double-blinded, randomised, and evidence-based, where does that leave new ideas? I do worry that if evidence-based medicine becomes the dominant thinking, it could impede advances in medicine. I declare that I have no conflict of interest.
John Wu [email protected] Alberta Children’s Hospital, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada.
Department of Error Baxter EJ, Scott LM, Campbell PJ, et al. Acquired mutation of the tyrosine kinase JAK2 in human myeloproliferative disorders. Lancet 2005; 365: 1054–61—In this Mechanisms of Disease report (March 19), the black box in the lower panel of figure 2 (p 1056) should be moved seven residues to the right. Levy B, Gibot S, Franck P, Cravoisy A, Bollaert P-E. Relation between muscle Na+K+ATPase activity and raised lactate concentrations in septic shock: a prospective study. Lancet 2005; 365: 871–75—In this Mechanisms of Disease article (Mar 5), the global reaction of glycolysis in the glossary on page 871 should have been: “Glucose+2NAD++2ADP+2Pi→2NADH+2 pyruvate+2ATP+2H2O+2H+”. On page 872, the last sentence of the first paragraph should have read: “Inspiratory fraction of oxygen (FIO2) was adjusted to accomplish an oxygen arterial saturation of more than 92%” and the fourth sentence of the third paragraph should have read “Adequate reactivity of the oxygen sensor element of the Licox probe was tested by briefly increasing FIO2 concentrations to 100%. . . ”.
www.thelancet.com Vol 366 July 9, 2005
1 2
The Lancet. China must not neglect reform of primary care. Lancet 2005; 365: 1362. Hesketh T, Zhu WX. Effect of restricted freedom on health in China. BMJ 2004; 329: 1427.
A Chinese-style onechild policy for India In response to Patralekha Chatterjee’s World Report (May 7, p 1609),1 it is important to note that China’s onechild policy does not apply to all of its regions and ethnic groups. Couples in poor rural regions are permitted to have two children, and national minority groups of a small population size have no birth restrictions. Even so, China’s achievement of rapid fertility declines has incurred high social, demographic, and health costs.2,3 North and Central India share one main feature of the patrilineal family system found in rural China (where 75% of the population resides), namely son preference.2,4 Son preference in such family systems implies that at least one son is wanted to continue the patrilineal family line and to perform religious, social, economic, and reproductive functions for the family. This imperative poses a formidable challenge to population policies that impose birth restrictions on rural families, as occurred in rural China.2 India’s sex imbalances are already very high. A forced family planning programme would further exacerbate them. Parents’ preferences for male offspring are intimately connected with women’s status in the larger society and are an indicator of sex inequality.2 In societies where men and women have relatively equal roles in social, economic, and political spheres, parents tend to value sons and daughters more equally than in settings where sex differentiation is more pronounced. The effects of son preference on mortality and fertility www.thelancet.com Vol 366 July 9, 2005
are well documented. It is no coincidence that the southern Indian state of Kerala has achieved remarkable population control and this is also a state where son preference is the weakest in India.4 Women’s status (eg, literacy, mass media exposure, domestic decision-making power, and social economic opportunity in the public domain) affects fertility through two mechanisms. It stops the cycle of high infant mortality and high fertility by improving infant survival chances, and it provides women with other social alternatives to early childbearing and motherhood, thus ultimately contributing to low fertility. The demographic experiences of other Asian countries show multiple pathways to low fertility and that broad social and economic development and, in particular, the elevation of women’s social position are the driving force for low birth rates in the absence of mandatory family planning programmes.5 Chinese history has proven that wars, natural disasters, diseases, and non-functional social and economic systems, rather than population size itself, are the main causes of famines. The Great Leap Forward campaign in the late 1950s that led to large-scale starvation in rural China is a prime example. I declare that I have no conflict of interest.
Jianghong Li [email protected] Division of Population Sciences, Telethon Institute for Child Health Research, PO Box 855, West Perth, Western Australia 6872, Australia. 1
2
3
4
5
Chatterjee P. Doctors’ group proposes a one-child policy for India. Lancet 2005; 365: 1609. Li J, Lavely W. Village context, women’s status and son preference among rural Chinese women. Rural Sociology 2003; 68: 87–108. Coale A, Banister J. Five decades of missing females in China. Demography 1994; 31: 459–80. Mutharayappa R, Choe MK, Arnold F, Roy TK. Is son preference slowing down India’s transition to low fertility? Nat Family Health Survey Bull 1997; 4: 1–4. Freedman R. Asia’s recent fertility decline and prospects for future demographic change. Asia-Pacific Pop Res Rep 1995; 1: 1–27.
Clear signs In your Apr 23 issue, the diagnoses in the Uses of Error article (p 1513)1 and Case Report (p 1514)2 seem obvious. Pain confined to the lower jaw is not uncommon in myocardial ischaemia, and severe chest pain associated with symptoms in the legs suggests an aneurism. The diagnoses here would cause no trouble in those taught by the apprenticeship system 50 years ago rather than by the guidelines and governance used today. I declare that I have no conflict of interest.
P B S Fowler [email protected]
Rights were not granted to include this image in electronic media. Please refer to the printed journal
Shirley Holms, 4 South Park Drive, Gerrards Cross SL9 8JK, UK 1 2
McQueen A. “I think she’s just crazy”. Lancet 2005; 365: 1513. Beggs AD, Al-Rawi H, Parfitt A. Chest pain and fleeting neurological signs. Lancet 2005; 365: 1514.
Prostitution and health Your concern about the health effects of prostitution (May 7, p 1598)1 might go a lot further than advocating decriminalisation and better health care. You could actively campaign against the practice itself. You could, for example, draw the attention of your readers more pointedly to the disastrous consequences of prostitution for the mental and physical wellbeing of those involved.2,3 Sadly, your Editorial adopts a morally neutral tone, describing prostitution as a “profession” and an “occupation”, although it is really a trade, rather like the slave trade in many respects. Naturally you advocate measures that will improve the situation for those involved, since prostitution is, after all, a fact of life. But will you speak out against prostitution itself? The truth is that prostitution is an evil of global proportions, and not only in terms of its adverse health effects. It is associated with casual violence, organised crime, drugs, and the most vicious forms of trafficking 121
Panos Pictures
TCM Department, 2nd Teaching Hospital, Jilin University, Changchun, Jilin Province, 130041 China
Correspondence
in human lives.4,5 Did Dickens ask for health clinics in the mines and factories? Did Wilberforce ask for “tailored medical care” on the slave ships and the plantations? Are you against prostitution, on health grounds, or not? I declare that I have no conflict of interest.
Stephen Due [email protected] Barwon Health Library Service, PO Box 281, Geelong, Victoria 3220, Australia 1 2
3
4
5
The Lancet. Prostitutes are people too. Lancet 2005; 365: 1598. Jeal N, Salisbury C. A health needs assessment of street-based prostitutes: cross-sectional survey. J Public Health 2004; 26: 147–51. Potterat JJ, Brewer DD, Muth SQ, et al. Mortality in a long-term open cohort of prostitute women. Am J Epidemiol 2004; 159: 778–85. Romero-Daza N, Weeks M, Singer M. “Nobody gives a damn if I live or die”: violence, drugs, and street-level prostitution in inner-city Hartford, Connecticut. Med Anthropol 2003; 22: 233–59. Home Office. Paying the price: a consultation paper on prostitution. London: Home Office, 2004. http://www.homeoffice.gov.uk/docs3/ paying_the_price.html (accessed May 31, 2005).
Evidence-based medicine in Japan
Rights were not granted to include this image in electronic media. Please refer to the printed journal
122
Despite a sudden interest in evidencebased medicine in Japan in the late 1990s, attention is now waning and the concept has not been widely accepted by clinicians.1 What is the reason for this, and has the introduction of evidence-based medicine resulted in any changes in the way clinicians in Japan practice medicine? The main reason for evidence-based medicine not having been widely accepted in Japan seems to stem from an image problem. Evidence-based medicine was mainly promoted by public-health researchers and epidemiologists who had little knowledge of the clinical field, and only the techniques for literature searching and evaluation of information obtained were emphasised. This concentration on theory resulted in criticism from clinicians that researchers were not
involved with patients and were disregarding the value of experience and skill. However, the principle of evidence-based medicine is selection and execution of the optimum treatment plan based on scientific evidence, and experience of clinicians is an important factor. The most frequently voiced criticisms against evidence-based medicine in Japan are “Is the clinician’s experience not needed if there are sufficient data?” and “Are the various backgrounds of patients not important?” Clinicians in Japan realise that errors will be made if they rely only on clinical data such as those obtained from randomised controlled trials of large numbers of patients with backgrounds that might be quite different, and have thus probably rejected evidence-based medicine as unrealistic. However, the true message from those who promote evidence-based medicine is that the background and needs of each patient are more important than trial data. Until very recently in Japan, young clinicians have been in a situation in which they learned and accepted methods used by older, experienced clinicians and then continued to use those methods. At face value, evidence-based medicine seems to deny the validity of this Japanese system. Efforts must be made in the clinical field to avoid both over-reliance on data and use of outdated methods. The true objective of evidence-based medicine should be to narrow the gap between a clinician’s knowledge at the time of graduation and currently available information. We declare that we have no conflict of interest.
*Takashi Yokota, Seiichi Kojima, Hidemi Yamauchi, Masahito Hatori [email protected] Department of Surgery, National Sanatorium Tohoku Shinseien, Miyagi 989-4601, Japan (TY, SK); Kosei Sendai Clinic, Sendai, Japan (HY); and Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan (MH) 1
Nomura K. What did EBM leave? Nikkei Medical 2005; 447: 42–53.
Could evidence-based medicine be a danger to progress? In this 100th year of celebration of Albert Einstein, I have been thinking about his papers on theoretical physics, done purely by deduction, and how they changed our view of the world. His way of thinking is in sharp contrast to that of evidencebased medicine, which has become almost a dogma in some medical circles. Yet if everything has to be double-blinded, randomised, and evidence-based, where does that leave new ideas? I do worry that if evidence-based medicine becomes the dominant thinking, it could impede advances in medicine. I declare that I have no conflict of interest.
John Wu [email protected] Alberta Children’s Hospital, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada.
Department of Error Baxter EJ, Scott LM, Campbell PJ, et al. Acquired mutation of the tyrosine kinase JAK2 in human myeloproliferative disorders. Lancet 2005; 365: 1054–61—In this Mechanisms of Disease report (March 19), the black box in the lower panel of figure 2 (p 1056) should be moved seven residues to the right. Levy B, Gibot S, Franck P, Cravoisy A, Bollaert P-E. Relation between muscle Na+K+ATPase activity and raised lactate concentrations in septic shock: a prospective study. Lancet 2005; 365: 871–75—In this Mechanisms of Disease article (Mar 5), the global reaction of glycolysis in the glossary on page 871 should have been: “Glucose+2NAD++2ADP+2Pi→2NADH+2 pyruvate+2ATP+2H2O+2H+”. On page 872, the last sentence of the first paragraph should have read: “Inspiratory fraction of oxygen (FIO2) was adjusted to accomplish an oxygen arterial saturation of more than 92%” and the fourth sentence of the third paragraph should have read “Adequate reactivity of the oxygen sensor element of the Licox probe was tested by briefly increasing FIO2 concentrations to 100%. . . ”.
www.thelancet.com Vol 366 July 9, 2005