- Email: [email protected]
What can Japan learn from tobacco control in the UK?
Correspondence
We declare no competing interests.
*Jason Chertoff, Abhishek Biswas, Divya Patel [email protected] Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL 32608, USA
Naming of the victims of Nazi medicine I read with great interest the Pers pectives piece by Philip Ball (June 3, p 2182),1 who reported on the Science and Suffering exhibition at the Wiener Library for the Study of the Holocaust and Genocide in London. He rightly highlighted the goal of discovering www.thelancet.com Vol 390 September 2, 2017
the names and life stories of victims of the Nazi-era medical experiments. He stated that some of their 15 000— perhaps as many as 27 000—names are projected onto the library’s wall. My concern is with his statement that is surprising and warrants precision: “one surprise, for me, was that only about a fifth of the victims were Jewish”. I would suggest, as an explanation, that Nazi medicine exactions were not limited to extermination camps—namely, Auschwitz-Birkenau, Bełżec, Chelmno, Jasenovac, Majdanek, Maly Trostenets, Sajmište, Sobibor, and Treblinka—where more than 90% of the victims were Jews (the primary target of the so-called Final Solution). Nazi medicine exactions also concerned many concentration camps, as stated in the second count of indictment at the second postwar Nuremberg trial (Doctors’ trial).2 These camps included Dachau, Buchenwald, Mauthausen-Gusen, Natzweiler-Struthof, OranienburgSachsenhausen, and Ravensbrück, of which the deportees, besides Jews, were political or war prisoners, homo sexuals, Romanians, and individuals with disabilities.2–5 Finally, Aktion T4 (the Euthanasia Programme in 1940–41) was a programme followed by the Shoah of European Jewish people and implemented gassing of adults with physical or mental disabilities in six gassing centres in Germany.2,5 These observations might account for the surprise that only about a fifth of the victims of Nazi medicine were Jewish. I declare no competing interests.
Claude Matuchansky [email protected] Faculty of Medicine, Paris-Diderot University, 75010 Paris, France 1 2 3 4 5
Ball P. Naming the victims of Nazi medicine. Lancet 2017; 389: 2182–83. Halioua B. Le procès des médecins de Nuremberg. L’irruption de l’éthique médicale moderne. Paris: Vuibert, 2008 (in French). Bloch F. Medical scientists in the Nazi era. Lancet 1986; 327: 375. Roelcke V. Nazi medicine and research on human beings. Lancet 2004; 364 (special issue): 6–7. Seidelman WE. Nuremberg lamentation: for the forgotten victims of medical science. BMJ 1996; 313: 1463–67.
What can Japan learn from tobacco control in the UK? A Lancet Editorial (July 8, p 96)1 on tobacco control in the UK described how people are protected from secondhand smoke as a result of the country going smoke free in 2007. This is in stark contrast to people in Japan who, unfortunately, are likely to continue to be affected by passive smoking in public spaces for the next decade. Japan, and other countries that are currently struggling to introduce policies for the prevention of second-hand smoke in public places, might be able to learn from the success of tobacco control in the UK. One of the key determinants for the UK’s success was the government’s leadership and commitment to legislate control policies, accompanied by robust scientific evidence, and strong support from health-care professionals to improve population health. In 2017, the Japanese Ministry of Health, Labour and Welfare (MHLW) tried to introduce a smoking ban in public indoor spaces such as workplaces, restaurants, and bars, with the longterm goal of making the 2020 Tokyo Olympics smoke free. The policy was strongly supported by the general public, patient groups, academia, and health-care professionals, including the Japan Medical Association.2 However, the policy was fiercely opposed by pro-tobacco policy makers, tobacco industries led by Japan Tobacco, and bar and restaurant owners concerned about the effect the ban would have on revenue.3,4 The situation in Japan is unique because the Japanese Minister of Finance owns about 33% of Japan Tobacco,5 which has made it difficult for the Japanese Government to introduce any policies that might influence the sale of tobacco products in the country.6 In response to the MHLW’s proposed smoking ban, the pro-tobacco law makers proposed an alternative bill that consists of partial indoor smoking bans and voluntary smoking restrictions by
iStock
puncture yielded yellow cerebrospinal fluid that was sent for analysis. The results showed noteworthy increased proteins (1052 mg/dL) and white blood cells (1978 cells per µL, with predominant neutrophils), and low glucose (<35 mg/dL). Although the cerebrospinal fluid gram stain and culture were normal, the patient’s blood cultures were positive for Streptococcus pneumoniae. A diagnosis of streptococcal meningitis was made and appropriate antimicrobial therapy and dexamethasone was initiated. Thereafter, the patient’s mental status and overall health improved and he was discharged. Anchoring is a cognitive bias that describes the reliance of human beings on the first piece of information offered (ie, the anchor) when making decisions. Once an anchor is set, there is a bias toward interpreting other information around the anchor. In this case, we anchored on unverified information that the patient had ingested a moodaltering or mind-altering substance. This anchoring caused a delay in the diagnosis and management of a lifethreatening meningitis. This case is a reminder that physicians should diligently and objectively question and test their diagnoses as new information presents itself.
933
Correspondence
bar and restaurant owners. However, such an unrestrictive ban is likely to be totally ineffective for the prevention of passive smoking among children and non-smoking adults. Ultimately, the decision will be made by the Japanese Prime Minister, Shinzo Abe, the newly appointed Minister of Health, Labour and Welfare, Katsunobu Kato, and other lawmakers as to whether Japan can make the 2020 Tokyo Olympics smoke free and maintain population health, or alternatively, whether the country will have one of the most unrestrictive second-hand smoking bans in the world. We declare no competing interests.
Yusuke Tsugawa, Ken Hashimoto, Takahiro Tabuchi,*Kenji Shibuya [email protected] Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA (YT); Haitian Ministry of Health, Port-au-Prince, Haiti (KH); Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan (TT); Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan (KS); and Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo 113-0033, Japan (KS) 1 2
3
4 5
6
Published Online August 17, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)32236-5
The Lancet. Where next for UK tobacco control? Lancet 2017; 390: 96. Japan Medical Association. Petition to support a policy that prevent secondhand smoke (in Japanese). 2017. http://www.med.or.jp/people/ info/people_info/005096.html (accessed Aug 1, 2017). Payne M. ‘How would I live if smoking is banned?’ Japanese politicians decry calls for smoke-free Olympics. Washington Post (Washington DC), May 2, 2017. McCurry J. Japan urged to go smoke-free by 2020 Tokyo Olympics. The Guardian (London), Jan 31, 2017. Japan Tobacco. Shareholder composition as of March 31, 2017 (in Japanese). https://www.jti. co.jp/investors/stock/overview/index.html on (accessed Aug 1, 2017). Japan’s government is in two minds about smoking. The Economist (London), June 22, 2017.
Prevention of hearing loss in patients with multidrug-resistant tuberculosis In their Lancet Review, Blake S Wilson and colleagues (July 10)1 describe the
934
growing global burden of hearing loss caused by a range of possible factors. The use of ototoxic medication is a considerable contributor to hearing loss for both children and adults. The authors suggest a primary prevention strategy for reducing hearing loss, which includes the use of ototoxic drugs only when no alternatives are available and only for serious conditions. Multidrug-resistant tuberculosis is a serious disease, for which, until 2012, few treatment options were available. In most countries, treatment for the disease includes the use of injectable drugs (eg, capreomycin, aminoglycosides). However, these drugs result in hearing loss in up to 50% of patients.2 This iatrogenic adverse effect has a considerable effect on individuals’ lives, restricting their ability to find meaningful work and participate in social relationships. Many survivors of the disease and individuals who have been cured describe a fate that is worse than death. Encouragingly, new drugs to treat multidrug-resistant tuberculosis are now available. Bedaquiline and delamanid, and repurposed drugs such as linezolid and clofazimine, are now recommended and can be used as effective alternatives to injectable drugs.3 However, access to these drugs has been slow to scale up and patients in most settings are still faced with the unenviable choice of death or deaf.4 Globally, half a million individuals are estimated to develop multidrugresistant tuberculosis annually. 5 Offering these individuals the best possible treatment, without the risk of iatrogenic lifelong hearing disability, is both an urgent ethical responsibility and an essential preventive response to the global burden of hearing loss. HC reports grants from the Wellcome Trust and the National Research Foundation of South Africa, outside the submitted work. AR, JF, and JS declare no competing interests.
*Helen Cox, Anja Reuter, Jennifer Furin, James Seddon [email protected]
Division of Medical Microbiology and the Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa (HC); Médecins Sans Frontières, Cape Town, South Africa (AR); Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA (JF); and Centre for International Child Health, Imperial College London, London, UK (JS) 1
2
3
4 5
Wilson BS, Tucci DL, Merson MH, O’Donoghue GM. Global hearing health care: new findings and perspectives. Lancet 2017; published online July 10. http://dx.doi. org/10.1016/S0140-6736(17)31073-5. Seddon JA, Godfrey-Faussett P, Jacobs K, Ebrahim A, Hesseling AC, Schaaf HS. Hearing loss in patients on treatment for drugresistant tuberculosis. Eur Respir J 2012; 40: 1277–86. WHO. WHO treatment guidelines for drugresistant tuberculosis: 2016 update. 2016. http://www.who.int/tb/areas-of-work/drugresistant-tb/MDRTBguidelines2016.pdf (accessed July 14, 2016). DR-TB STAT Task Force. Country updates. April, 2017. http://drtb-stat.org/countryupdates/ (accessed July 21, 2017). WHO. Global tuberculosis report 2016. 2016. http://apps.who.int/iris/bitstream/10665/250 441/1/9789241565394-eng.pdf (accessed Oct 14, 2016).
Department of Error Loewenberg S. Treating and preventing cholera in Bangladesh. Lancet 2017; 390: 637–38—This World Report benefited from external funding from the European Journalism Centre via its Innovation in Development Reporting Grant Programme, which should have been declared. This information was added to the online version as of Aug 17, 2017.
www.thelancet.com Vol 390 September 2, 2017
We declare no competing interests.
*Jason Chertoff, Abhishek Biswas, Divya Patel [email protected] Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL 32608, USA
Naming of the victims of Nazi medicine I read with great interest the Pers pectives piece by Philip Ball (June 3, p 2182),1 who reported on the Science and Suffering exhibition at the Wiener Library for the Study of the Holocaust and Genocide in London. He rightly highlighted the goal of discovering www.thelancet.com Vol 390 September 2, 2017
the names and life stories of victims of the Nazi-era medical experiments. He stated that some of their 15 000— perhaps as many as 27 000—names are projected onto the library’s wall. My concern is with his statement that is surprising and warrants precision: “one surprise, for me, was that only about a fifth of the victims were Jewish”. I would suggest, as an explanation, that Nazi medicine exactions were not limited to extermination camps—namely, Auschwitz-Birkenau, Bełżec, Chelmno, Jasenovac, Majdanek, Maly Trostenets, Sajmište, Sobibor, and Treblinka—where more than 90% of the victims were Jews (the primary target of the so-called Final Solution). Nazi medicine exactions also concerned many concentration camps, as stated in the second count of indictment at the second postwar Nuremberg trial (Doctors’ trial).2 These camps included Dachau, Buchenwald, Mauthausen-Gusen, Natzweiler-Struthof, OranienburgSachsenhausen, and Ravensbrück, of which the deportees, besides Jews, were political or war prisoners, homo sexuals, Romanians, and individuals with disabilities.2–5 Finally, Aktion T4 (the Euthanasia Programme in 1940–41) was a programme followed by the Shoah of European Jewish people and implemented gassing of adults with physical or mental disabilities in six gassing centres in Germany.2,5 These observations might account for the surprise that only about a fifth of the victims of Nazi medicine were Jewish. I declare no competing interests.
Claude Matuchansky [email protected] Faculty of Medicine, Paris-Diderot University, 75010 Paris, France 1 2 3 4 5
Ball P. Naming the victims of Nazi medicine. Lancet 2017; 389: 2182–83. Halioua B. Le procès des médecins de Nuremberg. L’irruption de l’éthique médicale moderne. Paris: Vuibert, 2008 (in French). Bloch F. Medical scientists in the Nazi era. Lancet 1986; 327: 375. Roelcke V. Nazi medicine and research on human beings. Lancet 2004; 364 (special issue): 6–7. Seidelman WE. Nuremberg lamentation: for the forgotten victims of medical science. BMJ 1996; 313: 1463–67.
What can Japan learn from tobacco control in the UK? A Lancet Editorial (July 8, p 96)1 on tobacco control in the UK described how people are protected from secondhand smoke as a result of the country going smoke free in 2007. This is in stark contrast to people in Japan who, unfortunately, are likely to continue to be affected by passive smoking in public spaces for the next decade. Japan, and other countries that are currently struggling to introduce policies for the prevention of second-hand smoke in public places, might be able to learn from the success of tobacco control in the UK. One of the key determinants for the UK’s success was the government’s leadership and commitment to legislate control policies, accompanied by robust scientific evidence, and strong support from health-care professionals to improve population health. In 2017, the Japanese Ministry of Health, Labour and Welfare (MHLW) tried to introduce a smoking ban in public indoor spaces such as workplaces, restaurants, and bars, with the longterm goal of making the 2020 Tokyo Olympics smoke free. The policy was strongly supported by the general public, patient groups, academia, and health-care professionals, including the Japan Medical Association.2 However, the policy was fiercely opposed by pro-tobacco policy makers, tobacco industries led by Japan Tobacco, and bar and restaurant owners concerned about the effect the ban would have on revenue.3,4 The situation in Japan is unique because the Japanese Minister of Finance owns about 33% of Japan Tobacco,5 which has made it difficult for the Japanese Government to introduce any policies that might influence the sale of tobacco products in the country.6 In response to the MHLW’s proposed smoking ban, the pro-tobacco law makers proposed an alternative bill that consists of partial indoor smoking bans and voluntary smoking restrictions by
iStock
puncture yielded yellow cerebrospinal fluid that was sent for analysis. The results showed noteworthy increased proteins (1052 mg/dL) and white blood cells (1978 cells per µL, with predominant neutrophils), and low glucose (<35 mg/dL). Although the cerebrospinal fluid gram stain and culture were normal, the patient’s blood cultures were positive for Streptococcus pneumoniae. A diagnosis of streptococcal meningitis was made and appropriate antimicrobial therapy and dexamethasone was initiated. Thereafter, the patient’s mental status and overall health improved and he was discharged. Anchoring is a cognitive bias that describes the reliance of human beings on the first piece of information offered (ie, the anchor) when making decisions. Once an anchor is set, there is a bias toward interpreting other information around the anchor. In this case, we anchored on unverified information that the patient had ingested a moodaltering or mind-altering substance. This anchoring caused a delay in the diagnosis and management of a lifethreatening meningitis. This case is a reminder that physicians should diligently and objectively question and test their diagnoses as new information presents itself.
933
Correspondence
bar and restaurant owners. However, such an unrestrictive ban is likely to be totally ineffective for the prevention of passive smoking among children and non-smoking adults. Ultimately, the decision will be made by the Japanese Prime Minister, Shinzo Abe, the newly appointed Minister of Health, Labour and Welfare, Katsunobu Kato, and other lawmakers as to whether Japan can make the 2020 Tokyo Olympics smoke free and maintain population health, or alternatively, whether the country will have one of the most unrestrictive second-hand smoking bans in the world. We declare no competing interests.
Yusuke Tsugawa, Ken Hashimoto, Takahiro Tabuchi,*Kenji Shibuya [email protected] Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA (YT); Haitian Ministry of Health, Port-au-Prince, Haiti (KH); Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan (TT); Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan (KS); and Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo 113-0033, Japan (KS) 1 2
3
4 5
6
Published Online August 17, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)32236-5
The Lancet. Where next for UK tobacco control? Lancet 2017; 390: 96. Japan Medical Association. Petition to support a policy that prevent secondhand smoke (in Japanese). 2017. http://www.med.or.jp/people/ info/people_info/005096.html (accessed Aug 1, 2017). Payne M. ‘How would I live if smoking is banned?’ Japanese politicians decry calls for smoke-free Olympics. Washington Post (Washington DC), May 2, 2017. McCurry J. Japan urged to go smoke-free by 2020 Tokyo Olympics. The Guardian (London), Jan 31, 2017. Japan Tobacco. Shareholder composition as of March 31, 2017 (in Japanese). https://www.jti. co.jp/investors/stock/overview/index.html on (accessed Aug 1, 2017). Japan’s government is in two minds about smoking. The Economist (London), June 22, 2017.
Prevention of hearing loss in patients with multidrug-resistant tuberculosis In their Lancet Review, Blake S Wilson and colleagues (July 10)1 describe the
934
growing global burden of hearing loss caused by a range of possible factors. The use of ototoxic medication is a considerable contributor to hearing loss for both children and adults. The authors suggest a primary prevention strategy for reducing hearing loss, which includes the use of ototoxic drugs only when no alternatives are available and only for serious conditions. Multidrug-resistant tuberculosis is a serious disease, for which, until 2012, few treatment options were available. In most countries, treatment for the disease includes the use of injectable drugs (eg, capreomycin, aminoglycosides). However, these drugs result in hearing loss in up to 50% of patients.2 This iatrogenic adverse effect has a considerable effect on individuals’ lives, restricting their ability to find meaningful work and participate in social relationships. Many survivors of the disease and individuals who have been cured describe a fate that is worse than death. Encouragingly, new drugs to treat multidrug-resistant tuberculosis are now available. Bedaquiline and delamanid, and repurposed drugs such as linezolid and clofazimine, are now recommended and can be used as effective alternatives to injectable drugs.3 However, access to these drugs has been slow to scale up and patients in most settings are still faced with the unenviable choice of death or deaf.4 Globally, half a million individuals are estimated to develop multidrugresistant tuberculosis annually. 5 Offering these individuals the best possible treatment, without the risk of iatrogenic lifelong hearing disability, is both an urgent ethical responsibility and an essential preventive response to the global burden of hearing loss. HC reports grants from the Wellcome Trust and the National Research Foundation of South Africa, outside the submitted work. AR, JF, and JS declare no competing interests.
*Helen Cox, Anja Reuter, Jennifer Furin, James Seddon [email protected]
Division of Medical Microbiology and the Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa (HC); Médecins Sans Frontières, Cape Town, South Africa (AR); Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA (JF); and Centre for International Child Health, Imperial College London, London, UK (JS) 1
2
3
4 5
Wilson BS, Tucci DL, Merson MH, O’Donoghue GM. Global hearing health care: new findings and perspectives. Lancet 2017; published online July 10. http://dx.doi. org/10.1016/S0140-6736(17)31073-5. Seddon JA, Godfrey-Faussett P, Jacobs K, Ebrahim A, Hesseling AC, Schaaf HS. Hearing loss in patients on treatment for drugresistant tuberculosis. Eur Respir J 2012; 40: 1277–86. WHO. WHO treatment guidelines for drugresistant tuberculosis: 2016 update. 2016. http://www.who.int/tb/areas-of-work/drugresistant-tb/MDRTBguidelines2016.pdf (accessed July 14, 2016). DR-TB STAT Task Force. Country updates. April, 2017. http://drtb-stat.org/countryupdates/ (accessed July 21, 2017). WHO. Global tuberculosis report 2016. 2016. http://apps.who.int/iris/bitstream/10665/250 441/1/9789241565394-eng.pdf (accessed Oct 14, 2016).
Department of Error Loewenberg S. Treating and preventing cholera in Bangladesh. Lancet 2017; 390: 637–38—This World Report benefited from external funding from the European Journalism Centre via its Innovation in Development Reporting Grant Programme, which should have been declared. This information was added to the online version as of Aug 17, 2017.
www.thelancet.com Vol 390 September 2, 2017