- Email: [email protected]
Socioeconomic development to fight malaria, and beyond
Comment
specific, clinically relevant tolerability outcomes that provide a much more detailed assessment of acceptability measures. Ideally, multiple-treatments meta-analyses would become superfluous through the availability of sufficient numbers of high-quality head-to-head studies. However, since such a development is unlikely in the absence of a requirement from regulatory bodies for companies to do such trials, these analyses—such as this exemplary one by Leucht and colleagues—will need to be used, but also must be interpreted with caution, bearing in mind their limitations, to inform clinical decision making. Taken together, we agree with the investigators that their findings support the idea that each antipsychotic drug needs to be assessed on the basis of its individual risk-tobenefit profile and that generalising classifications into first-generation and second-generation antipsychotics is mostly not useful. We also agree that although differences in efficacy were seen, they were smaller than those reported for most of the analysed adverse effects, and that both efficacy and tolerability require careful consideration in clinical practice. Finally, in interpreting these findings, we must keep in mind that data from studies, and even more so from meta-analyses, are based on group means. That individuals can respond rather differently is important for clinicians to remember.
CUC has been variously a consultant, adviser, lecturer, and data safety monitor for, or has received honoraria from: Actelion, Alexza, AstraZeneca, Biotis, Bristol-Myers Squibb, Cephalon, Desitin, Eli Lilly, Genentech, Gerson Lehrman Group, GlaxoSmithKline, IntraCellular Therapies, Lundbeck, MedAvante, Medscape, Merck, the US National Institute of Mental Health (NIMH), Novartis, Ortho-McNeill-Janssen, Otsuka, Pfizer, ProPhase, Roche, Schering-Plough, Sepracor/Sunovion, Takeda, Teva, and Vanda. He has received grant support from Bristol-Myers Squibb, Feinstein Institute for Medical Research, Janssen, NIMH, the National Alliance for Research in Schizophrenia and Depression, and Otsuka. MDH has been a consultant for, received grant or research support and honoraria from, and been on the speakers or advisory boards of: AstraZeneca, Lundbeck, Janssen-Cilag, the European Diabetes Foundation and Eli Lilly, Otsuka, Pfizer, Sanofi-Aventis, Bristol-Myers Squibb, and Takeda. 1 2 3
4 5
6
7
8
9
10
*Christoph U Correll, Marc De Hert Division of Psychiatry Research, Zucker Hillside Hospital, North Shore LIJ Health System, Glen Oaks, NY 11004, USA (CUC); Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA (CUC); Feinstein Institute for Medical Research, Manhasset, NY, USA (CUC); Albert Einstein College of Medicine, Bronx, NY, USA (CUC); and University Psychiatric Centre, Kortenberg Campus, KU Leuven, Kortenberg, and Department of Neurosciences, KU Leuven, Leuven, Belgium (MDH) [email protected]
11
12
Salanti G, Higgins JPT, Ades AE, Ioannidis JPA. Evaluation of networks of randomized trials. Stat Methods Med Res 2008; 17: 279–301. Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment comparisons. Stat Med 2004; 23: 3105–24. Correll CU, Kishimoto T, Kane JM. Randomized controlled trials in schizophrenia: opportunities, limitations and novel trial designs. Dialogues Clin Neurosci 2011; 13: 155–72. Salanti G, Dias S, Welton NJ, et al. Evaluating novel agent effects in multiple-treatments meta-regression. Stat Med 2010; 29: 2369–83. Alphs L, Benedetti F, Fleischhacker WW, Kane JM. Placebo-related effects in clinical trials in schizophrenia: what is driving this phenomenon and what can be done to minimize it? Int J Neuropsychopharmacol 2012; 15: 1003–14. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013; published online June 27. http://dx.doi. org/10.1016/S0140-6736(13)60733-3. Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet 2009; 373: 31–41. Leucht S, Komossa K, Rummel-Kluge C, et al. A meta-analysis of head-to-head comparisons of second-generation antipsychotics in the treatment of schizophrenia. Am J Psychiatry 2009; 166: 152–63. Zhang JP, Gallego JA, Robinson DG, Malhotra AK, Kane JM, Correll CU. Efficacy and safety of individual second-generation vs first-generation antipsychotics in first-episode psychosis: a systematic review and meta-analysis. Int J Neuropsychopharmacol 2012; published online Dec 3. DOI:10.1017/S1461145712001277. De Hert M, Detraux J, van Winkel R, Yu W, Correll CU. Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nat Rev Endocrinol 2011; 8: 114–26. Glick ID, Correll CU, Altamura AC, et al. Mid-term and long-term efficacy and effectiveness of antipsychotic medications for schizophrenia: a data-driven, personalized clinical approach. J Clin Psychiatry 2011; 72: 1616–27. Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Lancet 2011; 378: 1306–15.
Socioeconomic development to fight malaria, and beyond Published Online June 19, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61211-8 See Articles page 963
920
The intimate connection between malaria and poverty has been recognised for centuries—hence the notion that malaria is one of the diseases of poverty. Causal links between malaria and poverty were suggested shortly after discovery of the malaria parasite and its mode of transmission in 1897,1 and attempts have been made to quantify the economic effect of malaria.2 However, in view of the complex and
multifactorial nature of poverty and the intricacies of malaria epidemiology and its public health effects in different social-ecological settings, the evidence base for the nature, determinants, and direction of the causal relation between malaria and poverty is weak.3,4 The Commission on Macroeconomics and Health5 emphasised that investment in health promotes economic development and alleviates poverty. With respect www.thelancet.com Vol 382 September 14, 2013
Comment
www.thelancet.com Vol 382 September 14, 2013
acknowledged, and the researchers provide a reasonable justification for the exclusion of older reports (ie, to focus on evidence that is applicable to the present malaria situation). A systematic review that included reports in other languages, particularly those published in Spanish, but also in Portuguese, French, and Chinese, would be useful to ascertain whether the reported direction and strength of the association remain. Second, from more than 4600 records screened, only 15 studies were included in the quantitative analysis to estimate the direction and effect size for the association. 11 of these studies had a cross-sectional design, and the remaining four were case-control studies. The strength of the evidence derived from observational studies is weaker than that from randomised controlled trials.10 Although further investigations based on controlled intervention studies are highly desirable, the 15 studies meta-analysed included many children (19 620 overall; range per study 283–3915), which strengthens the evidence for the investigators’ conclusions. Third, perhaps the most important methodological limitations were that Tusting and colleagues did not account for other diseases, disabilities, and health issues that often coexist in malaria-endemic settings, and that they did not assess socioeconomic inequalities in care-seeking behaviour. For example, investigators of a study in rural Tanzania noted that poor families were less likely than better-off families to bring their sick children to a health facility, and that the poorest children were at a higher risk of not having received antimalarials than were children from better-off families.11 Infection with
Corbis
to malaria, a 25-year (1965–90), cross-country regression analysis revealed annual rates of economic growth to be 1·3% lower in countries with an intense malaria burden than in countries with less malaria.6 However, regression over a shorter timeframe and from a different database found a smaller reduction in annual growth rate associated with malaria (0·25%).7 Despite the substantial difference in these macroeconomic-level estimates and the limitations of such analyses to infer causality, these findings provided strong leverage to massively scale up malaria control interventions and to renew efforts towards elimination, as laid out in the Global Malaria Action Plan in 2008.8 Besides macroeconomic estimates, we also need data for the economic effects of malaria on households to deepen our understanding and to guide local and national health and social interventions. In The Lancet, Lucy Tusting and colleagues9 shed new light on the association of malaria risk and socioeconomic status, as assessed by a systematic review and meta-analysis. Focusing on children aged 15 years and younger, the investigators report that the odds of parasitologically confirmed malaria (ie, Plasmodium falciparum infection confirmed by microscopy or rapid diagnostic test) or clinical malaria (fever plus P falciparum infection) in the poorest children is roughly twice that in their economically better-off counterparts (adjusted odds ratio 2·06, 95% CI 1·42–2·97). Importantly, the effect was consistent across subgroups defined by different measures of socioeconomic development. These are important micro-tomeso-level findings and suggest that, although malaria control efforts with an established track record should be continued and further expanded, broad investment to promote socioeconomic development in areas where malaria is still highly endemic should be used to complement disease-specific activities. In the long term, such an approach might well prove an effective and sustainable reinforcement mechanism for public health and social interventions to roll back and eventually eliminate malaria. Nonetheless, caution is needed before the reported negative association between malaria risk and low socioeconomic status in children can be generalised more widely. First, the investigators’ search strategy was restricted, both by language and year of publication; only English-language reports published from the beginning of 1980 to mid-2011 were included. This issue is
921
Comment
For INDEPTH see http://www. indepth-network.org/
several different parasite species is the norm rather than the exception in developing countries, and poor people are especially vulnerable.12,13 Several factors are involved (eg, poor access to clean water, adequate sanitation, and other essential commodities; crowding and low-quality housing; and high exposure to pathogens, disease vectors, and intermediate hosts), all of which contribute to the association between the risk of malaria—and other diseases and health issues—and socioeconomic status. We agree with the conclusions of Tusting and colleagues and are convinced that investments that support socioeconomic development in malarious settings will prove an effective and sustainable intervention against not only malaria, but also a host of other poverty-related diseases, including the neglected tropical diseases.14 Such action requires innovative multidisease, multi-intervention, cross-sectoral collaboration, coupled with further longitudinal intervention studies. These studies should have a systemic approach that is best achieved within established networks with large cohorts that are followed for many years, such as the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH). Indeed, INDEPTH provides a unique platform of some 50 health demographic surveillance systems, with tens of thousands of people followed longitudinally in both rural and urban settings in developing countries. This platform complements macroeconomic findings with disease-specific and setting-specific evidence, allowing direct public health and development actions that can contribute to the effective pursuit of the Millennium Development Goals and the post-2015 era of sustainable development.
*Jürg Utzinger, Marcel Tanner Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, CH-4002 Basel, Switzerland (JU, MT); and University of Basel, Basel, Switzerland (JU, MT) [email protected] JU and MT have served as experts on committees of WHO and the Bill & Melinda Gates Foundation. MT currently chairs the Drugs for Neglected Diseases initiative and the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH network). 1 2 3 4
5
6 7 8 9
10 11 12
13 14
Ross R. The prevention of malaria. London: John Murray, 1911. MacDonald G. The economic importance of malaria in Africa. Geneva: World Health Organization, 1950. Worrall E, Basu S, Hanson K. Is malaria a disease of poverty? A review of the literature. Trop Med Int Health 2005; 10: 1047–59. Castro MC, Fisher MG. Is malaria illness among young children a cause or a consequence of low socioeconomic status? Evidence from the United Republic of Tanzania. Malar J 2012; 11: 161. Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization, 2001. Gallup JL, Sachs JD. The economic burden of malaria. Am J Trop Med Hyg 2001; 64 (suppl 1–2): 85–96. McCarthy FD, Wolf H, Wu Y. Malaria and growth. Washington, DC: World Bank, 2000. Roll Back Malaria Partnership. The global malaria action plan: for a malaria free world. Geneva: Roll Back Malaria Partnership, 2008. Tusting LS, Willey B, Lucas H, et al. Socioeconomic development as an intervention against malaria: a systematic review and meta-analysis. Lancet 2013; published online June 19. http://dx.doi.org/10.1016/S01406736(13)60851-X. Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet 2002; 359: 57–61. Schellenberg JA, Victora CG, Mushi A, et al. Inequities among the very poor: health care for children in rural southern Tanzania. Lancet 2003; 361: 561–66. Raso G, Utzinger J, Silué KD, et al. Disparities in parasitic infections, perceived ill health and access to health care among poorer and less poor schoolchildren of rural Côte d’Ivoire. Trop Med Int Health 2005; 10: 42–57. Steinmann P, Utzinger J, Du ZW, Zhou XN. Multiparasitism: a neglected reality on global, regional and local scale. Adv Parasitol 2010; 73: 21–50. Utzinger J, Raso G, Brooker S, et al. Schistosomiasis and neglected tropical diseases: towards integrated and sustainable control and a word of caution. Parasitology 2009; 136: 1859–74.
The Future Hospital Commission Published Online September 12, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61894-2 See Comment page 925
922
Hospital inpatients deserve to receive safe, high quality, sustainable care centred on their needs, which is delivered in an appropriate setting by respectful, compassionate, and expert health professionals. However, fewer hospital beds in the UK than 25 years ago must accommodate the 37% increase in emergency admissions seen over the past decade.1 Although reduction of the average patient length of hospital stay has helped reconcile this imbalance, the fall has plateaued in the past 3 years, and has started to reverse for patients older than 85 years, who present frequently
with multiple comorbidities including cognitive impairment and general frailty.1 Although emergency admissions fall at weekends, findings from some studies show rises in out-of-hours mortality.2 In the UK, recruitment into emergency medicine is becoming increasingly difficult, and trainee physicians are actively avoiding specialties that include duties as a general medical registrar.2,3 The response of the Royal College of Physicians (RCP) to these problems was to establish an independent Future Hospital Commission in March, 2012, chaired www.thelancet.com Vol 382 September 14, 2013
specific, clinically relevant tolerability outcomes that provide a much more detailed assessment of acceptability measures. Ideally, multiple-treatments meta-analyses would become superfluous through the availability of sufficient numbers of high-quality head-to-head studies. However, since such a development is unlikely in the absence of a requirement from regulatory bodies for companies to do such trials, these analyses—such as this exemplary one by Leucht and colleagues—will need to be used, but also must be interpreted with caution, bearing in mind their limitations, to inform clinical decision making. Taken together, we agree with the investigators that their findings support the idea that each antipsychotic drug needs to be assessed on the basis of its individual risk-tobenefit profile and that generalising classifications into first-generation and second-generation antipsychotics is mostly not useful. We also agree that although differences in efficacy were seen, they were smaller than those reported for most of the analysed adverse effects, and that both efficacy and tolerability require careful consideration in clinical practice. Finally, in interpreting these findings, we must keep in mind that data from studies, and even more so from meta-analyses, are based on group means. That individuals can respond rather differently is important for clinicians to remember.
CUC has been variously a consultant, adviser, lecturer, and data safety monitor for, or has received honoraria from: Actelion, Alexza, AstraZeneca, Biotis, Bristol-Myers Squibb, Cephalon, Desitin, Eli Lilly, Genentech, Gerson Lehrman Group, GlaxoSmithKline, IntraCellular Therapies, Lundbeck, MedAvante, Medscape, Merck, the US National Institute of Mental Health (NIMH), Novartis, Ortho-McNeill-Janssen, Otsuka, Pfizer, ProPhase, Roche, Schering-Plough, Sepracor/Sunovion, Takeda, Teva, and Vanda. He has received grant support from Bristol-Myers Squibb, Feinstein Institute for Medical Research, Janssen, NIMH, the National Alliance for Research in Schizophrenia and Depression, and Otsuka. MDH has been a consultant for, received grant or research support and honoraria from, and been on the speakers or advisory boards of: AstraZeneca, Lundbeck, Janssen-Cilag, the European Diabetes Foundation and Eli Lilly, Otsuka, Pfizer, Sanofi-Aventis, Bristol-Myers Squibb, and Takeda. 1 2 3
4 5
6
7
8
9
10
*Christoph U Correll, Marc De Hert Division of Psychiatry Research, Zucker Hillside Hospital, North Shore LIJ Health System, Glen Oaks, NY 11004, USA (CUC); Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA (CUC); Feinstein Institute for Medical Research, Manhasset, NY, USA (CUC); Albert Einstein College of Medicine, Bronx, NY, USA (CUC); and University Psychiatric Centre, Kortenberg Campus, KU Leuven, Kortenberg, and Department of Neurosciences, KU Leuven, Leuven, Belgium (MDH) [email protected]
11
12
Salanti G, Higgins JPT, Ades AE, Ioannidis JPA. Evaluation of networks of randomized trials. Stat Methods Med Res 2008; 17: 279–301. Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment comparisons. Stat Med 2004; 23: 3105–24. Correll CU, Kishimoto T, Kane JM. Randomized controlled trials in schizophrenia: opportunities, limitations and novel trial designs. Dialogues Clin Neurosci 2011; 13: 155–72. Salanti G, Dias S, Welton NJ, et al. Evaluating novel agent effects in multiple-treatments meta-regression. Stat Med 2010; 29: 2369–83. Alphs L, Benedetti F, Fleischhacker WW, Kane JM. Placebo-related effects in clinical trials in schizophrenia: what is driving this phenomenon and what can be done to minimize it? Int J Neuropsychopharmacol 2012; 15: 1003–14. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013; published online June 27. http://dx.doi. org/10.1016/S0140-6736(13)60733-3. Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet 2009; 373: 31–41. Leucht S, Komossa K, Rummel-Kluge C, et al. A meta-analysis of head-to-head comparisons of second-generation antipsychotics in the treatment of schizophrenia. Am J Psychiatry 2009; 166: 152–63. Zhang JP, Gallego JA, Robinson DG, Malhotra AK, Kane JM, Correll CU. Efficacy and safety of individual second-generation vs first-generation antipsychotics in first-episode psychosis: a systematic review and meta-analysis. Int J Neuropsychopharmacol 2012; published online Dec 3. DOI:10.1017/S1461145712001277. De Hert M, Detraux J, van Winkel R, Yu W, Correll CU. Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nat Rev Endocrinol 2011; 8: 114–26. Glick ID, Correll CU, Altamura AC, et al. Mid-term and long-term efficacy and effectiveness of antipsychotic medications for schizophrenia: a data-driven, personalized clinical approach. J Clin Psychiatry 2011; 72: 1616–27. Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Lancet 2011; 378: 1306–15.
Socioeconomic development to fight malaria, and beyond Published Online June 19, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61211-8 See Articles page 963
920
The intimate connection between malaria and poverty has been recognised for centuries—hence the notion that malaria is one of the diseases of poverty. Causal links between malaria and poverty were suggested shortly after discovery of the malaria parasite and its mode of transmission in 1897,1 and attempts have been made to quantify the economic effect of malaria.2 However, in view of the complex and
multifactorial nature of poverty and the intricacies of malaria epidemiology and its public health effects in different social-ecological settings, the evidence base for the nature, determinants, and direction of the causal relation between malaria and poverty is weak.3,4 The Commission on Macroeconomics and Health5 emphasised that investment in health promotes economic development and alleviates poverty. With respect www.thelancet.com Vol 382 September 14, 2013
Comment
www.thelancet.com Vol 382 September 14, 2013
acknowledged, and the researchers provide a reasonable justification for the exclusion of older reports (ie, to focus on evidence that is applicable to the present malaria situation). A systematic review that included reports in other languages, particularly those published in Spanish, but also in Portuguese, French, and Chinese, would be useful to ascertain whether the reported direction and strength of the association remain. Second, from more than 4600 records screened, only 15 studies were included in the quantitative analysis to estimate the direction and effect size for the association. 11 of these studies had a cross-sectional design, and the remaining four were case-control studies. The strength of the evidence derived from observational studies is weaker than that from randomised controlled trials.10 Although further investigations based on controlled intervention studies are highly desirable, the 15 studies meta-analysed included many children (19 620 overall; range per study 283–3915), which strengthens the evidence for the investigators’ conclusions. Third, perhaps the most important methodological limitations were that Tusting and colleagues did not account for other diseases, disabilities, and health issues that often coexist in malaria-endemic settings, and that they did not assess socioeconomic inequalities in care-seeking behaviour. For example, investigators of a study in rural Tanzania noted that poor families were less likely than better-off families to bring their sick children to a health facility, and that the poorest children were at a higher risk of not having received antimalarials than were children from better-off families.11 Infection with
Corbis
to malaria, a 25-year (1965–90), cross-country regression analysis revealed annual rates of economic growth to be 1·3% lower in countries with an intense malaria burden than in countries with less malaria.6 However, regression over a shorter timeframe and from a different database found a smaller reduction in annual growth rate associated with malaria (0·25%).7 Despite the substantial difference in these macroeconomic-level estimates and the limitations of such analyses to infer causality, these findings provided strong leverage to massively scale up malaria control interventions and to renew efforts towards elimination, as laid out in the Global Malaria Action Plan in 2008.8 Besides macroeconomic estimates, we also need data for the economic effects of malaria on households to deepen our understanding and to guide local and national health and social interventions. In The Lancet, Lucy Tusting and colleagues9 shed new light on the association of malaria risk and socioeconomic status, as assessed by a systematic review and meta-analysis. Focusing on children aged 15 years and younger, the investigators report that the odds of parasitologically confirmed malaria (ie, Plasmodium falciparum infection confirmed by microscopy or rapid diagnostic test) or clinical malaria (fever plus P falciparum infection) in the poorest children is roughly twice that in their economically better-off counterparts (adjusted odds ratio 2·06, 95% CI 1·42–2·97). Importantly, the effect was consistent across subgroups defined by different measures of socioeconomic development. These are important micro-tomeso-level findings and suggest that, although malaria control efforts with an established track record should be continued and further expanded, broad investment to promote socioeconomic development in areas where malaria is still highly endemic should be used to complement disease-specific activities. In the long term, such an approach might well prove an effective and sustainable reinforcement mechanism for public health and social interventions to roll back and eventually eliminate malaria. Nonetheless, caution is needed before the reported negative association between malaria risk and low socioeconomic status in children can be generalised more widely. First, the investigators’ search strategy was restricted, both by language and year of publication; only English-language reports published from the beginning of 1980 to mid-2011 were included. This issue is
921
Comment
For INDEPTH see http://www. indepth-network.org/
several different parasite species is the norm rather than the exception in developing countries, and poor people are especially vulnerable.12,13 Several factors are involved (eg, poor access to clean water, adequate sanitation, and other essential commodities; crowding and low-quality housing; and high exposure to pathogens, disease vectors, and intermediate hosts), all of which contribute to the association between the risk of malaria—and other diseases and health issues—and socioeconomic status. We agree with the conclusions of Tusting and colleagues and are convinced that investments that support socioeconomic development in malarious settings will prove an effective and sustainable intervention against not only malaria, but also a host of other poverty-related diseases, including the neglected tropical diseases.14 Such action requires innovative multidisease, multi-intervention, cross-sectoral collaboration, coupled with further longitudinal intervention studies. These studies should have a systemic approach that is best achieved within established networks with large cohorts that are followed for many years, such as the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH). Indeed, INDEPTH provides a unique platform of some 50 health demographic surveillance systems, with tens of thousands of people followed longitudinally in both rural and urban settings in developing countries. This platform complements macroeconomic findings with disease-specific and setting-specific evidence, allowing direct public health and development actions that can contribute to the effective pursuit of the Millennium Development Goals and the post-2015 era of sustainable development.
*Jürg Utzinger, Marcel Tanner Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, CH-4002 Basel, Switzerland (JU, MT); and University of Basel, Basel, Switzerland (JU, MT) [email protected] JU and MT have served as experts on committees of WHO and the Bill & Melinda Gates Foundation. MT currently chairs the Drugs for Neglected Diseases initiative and the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH network). 1 2 3 4
5
6 7 8 9
10 11 12
13 14
Ross R. The prevention of malaria. London: John Murray, 1911. MacDonald G. The economic importance of malaria in Africa. Geneva: World Health Organization, 1950. Worrall E, Basu S, Hanson K. Is malaria a disease of poverty? A review of the literature. Trop Med Int Health 2005; 10: 1047–59. Castro MC, Fisher MG. Is malaria illness among young children a cause or a consequence of low socioeconomic status? Evidence from the United Republic of Tanzania. Malar J 2012; 11: 161. Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization, 2001. Gallup JL, Sachs JD. The economic burden of malaria. Am J Trop Med Hyg 2001; 64 (suppl 1–2): 85–96. McCarthy FD, Wolf H, Wu Y. Malaria and growth. Washington, DC: World Bank, 2000. Roll Back Malaria Partnership. The global malaria action plan: for a malaria free world. Geneva: Roll Back Malaria Partnership, 2008. Tusting LS, Willey B, Lucas H, et al. Socioeconomic development as an intervention against malaria: a systematic review and meta-analysis. Lancet 2013; published online June 19. http://dx.doi.org/10.1016/S01406736(13)60851-X. Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet 2002; 359: 57–61. Schellenberg JA, Victora CG, Mushi A, et al. Inequities among the very poor: health care for children in rural southern Tanzania. Lancet 2003; 361: 561–66. Raso G, Utzinger J, Silué KD, et al. Disparities in parasitic infections, perceived ill health and access to health care among poorer and less poor schoolchildren of rural Côte d’Ivoire. Trop Med Int Health 2005; 10: 42–57. Steinmann P, Utzinger J, Du ZW, Zhou XN. Multiparasitism: a neglected reality on global, regional and local scale. Adv Parasitol 2010; 73: 21–50. Utzinger J, Raso G, Brooker S, et al. Schistosomiasis and neglected tropical diseases: towards integrated and sustainable control and a word of caution. Parasitology 2009; 136: 1859–74.
The Future Hospital Commission Published Online September 12, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61894-2 See Comment page 925
922
Hospital inpatients deserve to receive safe, high quality, sustainable care centred on their needs, which is delivered in an appropriate setting by respectful, compassionate, and expert health professionals. However, fewer hospital beds in the UK than 25 years ago must accommodate the 37% increase in emergency admissions seen over the past decade.1 Although reduction of the average patient length of hospital stay has helped reconcile this imbalance, the fall has plateaued in the past 3 years, and has started to reverse for patients older than 85 years, who present frequently
with multiple comorbidities including cognitive impairment and general frailty.1 Although emergency admissions fall at weekends, findings from some studies show rises in out-of-hours mortality.2 In the UK, recruitment into emergency medicine is becoming increasingly difficult, and trainee physicians are actively avoiding specialties that include duties as a general medical registrar.2,3 The response of the Royal College of Physicians (RCP) to these problems was to establish an independent Future Hospital Commission in March, 2012, chaired www.thelancet.com Vol 382 September 14, 2013