- Email: [email protected]
The weighty matter of care for all
Editorial
A global famine
Panos Pictures
Rights were not granted to include this image in electronic media. Please refer to the printed journal
See World Report page 891
Starvation is the biggest killer in the world and contributes significantly to the 10·9 million deaths annually among children aged younger than 5 years. The first Millennium Development Goal aims to halve the prevalence of hunger by 2015. Although the overall proportion of malnutrition has decreased since 1990, progress has been uneven, favouring more developed regions. The proportional reduction of malnutrition from 38% to 36% in least-developed nations has been more than offset by growth in population. Furthermore, the rate of proportional reduction has slowed in recent years to little more than 1% annually. The recurrent nature of famines in Africa reflects the fact that over the past 20 years, this continent has received disproportionately less aid in terms of need than eastern Europe and Asia. It is not just a lack of rain, but season upon season of inadequate external investment in infrastructure that has left so many so vulnerable. According to the principles of good humanitarian donorship, agreed in Stockholm in 2003, aid should “strengthen local capacity to prevent, prepare for and mitigate crises”. Just as important as feeding the
starving today is helping them to rebuild their livelihoods tomorrow. Achieving this aim will not be easy in countries where hydroelectric power generation has been halved by drought, and administrative and social structures are crumbling. HIV in sub-Saharan Africa and war in Somalia and Afghanistan combine to complicate regeneration and create a potentially apocalyptic situation. The expanding geography of famine should also cause alarm. The World Food Programme highlights a band of malnutrition between the tropics of Cancer and Capricorn, which is now extending north to the Commonwealth of Independent States and China. Such extensions in the pattern of hunger demonstrate the global scale of malnutrition—over 800 million people worldwide—and emphasise the need for a radical reappraisal of aid. Although emergency food aid is essential to avoid starvation in the short-term, it resembles only the interest payments on an accumulating debt. Longer-term strategies are required urgently to address local factors that tip the balance from drought to famine. ■ The Lancet
The weighty matter of care for all Obese patients who need joint replacement and who have the misfortune to live in east Suffolk, UK, are apparently out of luck when it comes to surgical treatment. Because of financial pressures, denial of jointreplacement surgery to patients with a body-mass index greater than 30 became a policy of that area’s primarycare trust in November, 2005. This decision is not only illconsidered, but also sets a very unwise precedent. The trend already appears to be spreading. Obese Americans are finding similar attitudes among surgeons: some refuse to operate on them at all; some insist they lose weight first. As a result of patients’ complaints, the American Association of Hip and Knee Surgeons is expected to formulate guidance on the issue later this month. The Lancet urges that patients’ concerns be given top priority in these deliberations. Surgeons fairly say obese patients are harder to operate on than those who are not obese, require longer incisions and more specialised equipment, lose more blood, heal 876
more slowly, and have higher rates of complications. Not insignificantly in a fee-for-service environment, operating on fat people can also cost more. Clinically, it is a maddeningly circular problem: excess weight creates strain and pressure on joints, causing pain, which limits the mobility obese patients need to be able to lose weight. And, as the general population gets fatter and older, demand for joint-replacement surgery is increasing. The situation poses clinical and ethical challenges. 40% of doctors recently surveyed by the British Medical Association agreed that rationing is appropriate for obese patients, and for smokers and drinkers, whose “lifestyle choices” have affected their health, and which, they argue, should play a part in decisions about treatment. Denying a service to a consumer may be an appropriate, if hard-nosed, business decision. But medicine is not just any business. Obese patients deserve care, just like their non-obese counterparts. ■ The Lancet www.thelancet.com Vol 367 March 18, 2006
A global famine
Panos Pictures
Rights were not granted to include this image in electronic media. Please refer to the printed journal
See World Report page 891
Starvation is the biggest killer in the world and contributes significantly to the 10·9 million deaths annually among children aged younger than 5 years. The first Millennium Development Goal aims to halve the prevalence of hunger by 2015. Although the overall proportion of malnutrition has decreased since 1990, progress has been uneven, favouring more developed regions. The proportional reduction of malnutrition from 38% to 36% in least-developed nations has been more than offset by growth in population. Furthermore, the rate of proportional reduction has slowed in recent years to little more than 1% annually. The recurrent nature of famines in Africa reflects the fact that over the past 20 years, this continent has received disproportionately less aid in terms of need than eastern Europe and Asia. It is not just a lack of rain, but season upon season of inadequate external investment in infrastructure that has left so many so vulnerable. According to the principles of good humanitarian donorship, agreed in Stockholm in 2003, aid should “strengthen local capacity to prevent, prepare for and mitigate crises”. Just as important as feeding the
starving today is helping them to rebuild their livelihoods tomorrow. Achieving this aim will not be easy in countries where hydroelectric power generation has been halved by drought, and administrative and social structures are crumbling. HIV in sub-Saharan Africa and war in Somalia and Afghanistan combine to complicate regeneration and create a potentially apocalyptic situation. The expanding geography of famine should also cause alarm. The World Food Programme highlights a band of malnutrition between the tropics of Cancer and Capricorn, which is now extending north to the Commonwealth of Independent States and China. Such extensions in the pattern of hunger demonstrate the global scale of malnutrition—over 800 million people worldwide—and emphasise the need for a radical reappraisal of aid. Although emergency food aid is essential to avoid starvation in the short-term, it resembles only the interest payments on an accumulating debt. Longer-term strategies are required urgently to address local factors that tip the balance from drought to famine. ■ The Lancet
The weighty matter of care for all Obese patients who need joint replacement and who have the misfortune to live in east Suffolk, UK, are apparently out of luck when it comes to surgical treatment. Because of financial pressures, denial of jointreplacement surgery to patients with a body-mass index greater than 30 became a policy of that area’s primarycare trust in November, 2005. This decision is not only illconsidered, but also sets a very unwise precedent. The trend already appears to be spreading. Obese Americans are finding similar attitudes among surgeons: some refuse to operate on them at all; some insist they lose weight first. As a result of patients’ complaints, the American Association of Hip and Knee Surgeons is expected to formulate guidance on the issue later this month. The Lancet urges that patients’ concerns be given top priority in these deliberations. Surgeons fairly say obese patients are harder to operate on than those who are not obese, require longer incisions and more specialised equipment, lose more blood, heal 876
more slowly, and have higher rates of complications. Not insignificantly in a fee-for-service environment, operating on fat people can also cost more. Clinically, it is a maddeningly circular problem: excess weight creates strain and pressure on joints, causing pain, which limits the mobility obese patients need to be able to lose weight. And, as the general population gets fatter and older, demand for joint-replacement surgery is increasing. The situation poses clinical and ethical challenges. 40% of doctors recently surveyed by the British Medical Association agreed that rationing is appropriate for obese patients, and for smokers and drinkers, whose “lifestyle choices” have affected their health, and which, they argue, should play a part in decisions about treatment. Denying a service to a consumer may be an appropriate, if hard-nosed, business decision. But medicine is not just any business. Obese patients deserve care, just like their non-obese counterparts. ■ The Lancet www.thelancet.com Vol 367 March 18, 2006