The
n e w e ng l a n d j o u r na l
of
m e dic i n e
of traditional incision and drainage with a lan- David A. Talan, M.D. ceolate incision. Although excision of a thin Olive View–UCLA Medical Center strip of skin overlying the abscess may make Sylmar, CA drainage and packing easier, this is rarely indi- Adam J. Singer, M.D. cated except for very large, multiloculated or Stony Brook University Stony Brook, NY recalcitrant abscesses. For the majority of simple [email protected] abscesses, a small incision and drainage without Since publication of their article, the authors report no furthe need for packing is adequate and minimizes ther potential conflict of interest. DOI: 10.1056/NEJMc1404437 further trauma and patient discomfort.
Global Supply of Health Professionals To the Editor: Contrary to information in the recent review by Crisp and Chen (March 6 issue),1 we would highlight that both Namibia and Botswana have medical schools. The University of Namibia School of Medicine was established in 2010 together with the University of Namibia School of Pharmacy. Timothy Rennie, M.Pharm., Ph.D. University of Namibia School of Pharmacy Windhoek, Namibia [email protected]
Jennifer Marriott, B.Pharm., Ph.D. Monash University Faculty of Pharmacy and Pharmaceutical Sciences Melbourne, VIC, Australia
Tina P. Brock, Ed.D. University of California, San Francisco San Francisco, CA No potential conflict of interest relevant to this letter was reported. 1. Crisp N, Chen L. Global supply of health professionals.
N Engl J Med 2014;370:950-7. [Erratum, N Engl J Med 2014;370: 1668.] DOI: 10.1056/NEJMc1404326
To the Editor: Crisp and Chen give little attention to pharmacists in their assessment of the supply of health professionals. In collaboration with the United Nations Educational, Scientific and Cultural Organization and the World Health Organization, the International Pharmaceutical Federation Education Initiative1 is working to stimulate transformational change in pharmaceutical education and engender global development of pharmacy science and practice. Pharmacy education should be socially accountable while teaching practice and science that are evidence-based; practitioners should have the required competencies to provide needed services to their communities. 2246
Global pharmacy now has a common competency framework2 that provides guidance for foundations of practice at an individual level and for further development into advanced practice. It has been successfully implemented in several countries since its launch in 2012. Andreia Bruno, B.Sc.Pharm., Ph.D. International Pharmaceutical Federation Lisbon, Portugal [email protected]
Kirstie Galbraith, M.Clin.Pharm. Monash University Faculty of Pharmacy and Pharmaceutical Sciences Melbourne, VIC, Australia
Ross McKinnon, B.Pharm., Ph.D. Flinders Centre for Innovation in Cancer Adelaide, SA, Australia No potential conflict of interest relevant to this letter was reported. 1. International Pharmaceutical Federation Education Initia-
tive (FIPEd). 2013 FIPEd global education report. Part 5 — using FIPEd resources and networks to implement educational development change. The Hague, the Netherlands: International Pharmaceutical Federation, 2013 (http://www.fip.org/education reports). 2. Idem. A global competency framework for services provided by pharmacy workforce. The Hague, the Netherlands: International Pharmaceutical Federation, 2012 (http://www.fip.org/pe_ resources). DOI: 10.1056/NEJMc1404326
To the Editor: Crisp and Chen comprehensively analyze global health workforce challenges. However, as in previous articles,1 the entire cadre of 4 million oral health professionals is missing from the analysis. Oral diseases are among the most common maladies worldwide, and dental caries affect 60 to 90% of populations. Members of the global oral health workforce (dentists, auxiliaries, hygienists, therapists, and laboratory
n engl j med 370;23 nejm.org june 5, 2014
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
correspondence
Number of patients per dentist Fewer than 3000 3000–19,999 20,000–49,999 50,000–199,999 200,000 or more No data
Figure 1. Estimated Number of Patients per Dentist Worldwide, 2007. Data are from Beaglehole et al.2
technicians) share the challenges of other health professionals, yet shortages and maldistribution are even more obvious, particularly in low-income and middle-income countries (Fig. 1). For example, whereas the ratio of dentists to the population of Brazil in 2007 was 1:860, it was 1:1,278,000 in Ethiopia.2 Low availability of care contributes to untreated caries being the most common disease among all 291 conditions studied in the Global Burden of Disease project.3 Essential oral care needs to be integrated into primary health care.4 This will happen only if efforts are made to refocus on prevention, develop innovative workforce models, and balance the supply of oral health professionals. The political neglect of oral diseases must be overcome, and equal recognition of the oral health workforce could be a starting point.5 Habib Benzian, D.D.S., Ph.D. University College London London, United Kingdom [email protected]
Lois K. Cohen, Ph.D. Paul G. Rogers Society for Global Health Research Bethesda, MD
Tin C. Wong, M.Sc. Orth. FDI World Dental Federation Geneva, Switzerland No potential conflict of interest relevant to this letter was reported.
n engl j med 370;23
1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a
new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58. 2. Beaglehole R, Benzian H, Crail J, Mackay J. The Oral Health Atlas: mapping a neglected global health issue. Geneva: FDI World Dental Federation, 2009. 3. Marcenes W, Kassebaum NJ, Bernabé E, et al. Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res 2013;92:592-7. 4. Glick M, Monteiro da Silva O, Seeberger GK, et al. FDI Vision 2020: shaping the future of oral health. Int Dent J 2012;62:27891. 5. Benzian H, Hobdell M, Holmgren C, et al. Political priority of global oral health: an analysis of reasons for international neglect. Int Dent J 2011;61:124-30. DOI: 10.1056/NEJMc1404326
The Authors Reply: Rennie et al. are quite right about the medical schools in Botswana and Namibia. According to the Sub-Saharan African Medical Schools Study (http://samss.org), the University of Botswana School of Medicine was established in 2009, and the University of Namibia School of Medicine started in 2010. These two new schools were not listed in the online directory of medical schools worldwide (AVICENNA), which has been administered since 2007 by the University of Copenhagen (avicenna.ku.dk). Like all ongoing databases, the updating of new medical schools may lag behind actual developments. Nevertheless, even with these corrections, our conclusion that there are enormous global disparities in medical schools among countries still holds true.
nejm.org
june 5, 2014
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
2247
The
n e w e ng l a n d j o u r na l
Similarly, we acknowledge and welcome the point made by Bruno et al. that we made little mention of pharmacists and the point made by Benzian and colleagues that we did not describe the requirement for suitable staffing for oral health. These are very important matters. Equally, we did not have space to cover other important professions and services such as the pressing need for greater mental health capacity and for adequate staffing for eye health care throughout the world. The simple point we would reinforce here is that shortages in the health workforce are the biggest single barrier to improving
of
m e dic i n e
these services. We hope our article helps to raise the profile of the global workforce so that improvements are made in these and other related areas. Nigel Crisp, M.A. House of Lords London, United Kingdom
Lincoln Chen, M.D. China Medical Board Cambridge, MA Since publication of their article, the authors report no further potential conflict of interest. DOI: 10.1056/NEJMc1404326
23andMe and the FDA To the Editor: In their Perspective article (March 13 issue),1 Annas and Elias state that the conflict between the genetic-testing company 23andMe and the Food and Drug Administration (FDA) concerns analytic and clinical validity, clinical utility, and ethical, legal, and social issues. However, their discussion is limited to a domestic U.S. perspective. After a person’s raw genetic data have been determined from a DNA sample, the data are stored remotely and can be accessed easily anywhere in the world. For example, in Japan, maternal blood samples from Japanese mothers undergoing noninvasive prenatal testing are sent to an American company to be analyzed, and their data are sent back to Japan.2 Therefore, genomic digital data are transborder. Any regulatory framework for the genome business should be based not solely on domestic laws but on an international harmonization.3-5 We would be grateful if the authors would comment on this. Koichiro Yuji, M.D., Ph.D. Tetsuya Tanimoto, M.D. Yasuo Oshima, M.D., Ph.D. University of Tokyo Tokyo, Japan [email protected] Dr. Oshima reports having received stipends from Novartis Pharma and Sanofi. No other potential conflict of interest relevant to this letter was reported. 1. Annas GJ, Elias S. 23andMe and the FDA. N Engl J Med
2014;370:985-8.
2. As I see it: now is the time to address problems in non-inva-
sive prenatal testing. Mainichi Shimbun. January 18, 2014 (http://mainichi.jp/english/english/perspectives/news/ 20140118p2a00m0na007000c.html).
2248
3. Organization for Economic Co-operation and Development.
The 2013 OECD privacy guidelines: the recommendation of the OECD Council concerning Guidelines governing the protection of privacy and transborder f low of personal data. Paris: OECD, July 2013 (http://www.oecd.org/sti/ieconomy/privacy .htm#newguidelines). 4. European Commission. Proposal for a regulation of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data and on the free movement of such data (General Data Protection Regulation). Brussels: European Commission, January 25, 2012 (http://ec.europa.eu/justice/data-protection/document/review2012/ com_2012_11_en.pdf). 5. The Asia-Pacific Economic Cooperation. Cross-border privacy rules (CBPR) (http://www.apec.org/Groups/Committee-on-Trade -and-Investment/Electronic-Commerce-Steering-Group.aspx). DOI: 10.1056/NEJMc1404692
The authors reply: Yuji and colleagues are correct that neither the FDA nor any individual country can set international norms for clinical genetics, including noninvasive prenatal testing. They are also correct in noting that even if individual DNA samples could be restricted from traveling between countries, genomic digitalized data cannot be geographically confined. International harmonization of standards remains a major challenge. It is always tempting to adopt a lowest-common-denominator approach and permit individual countries to adopt higher standards if they wish. There is no global approach to international standard setting (with the possible exception of pharmaceutical patent law) that has demonstrated efficacy. Nonetheless, recognition that the lack of international standards is a problem for the development of clinical genetics provides at least some reason to hope that the coun-
n engl j med 370;23 nejm.org june 5, 2014
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
n e w e ng l a n d j o u r na l
of
m e dic i n e
of traditional incision and drainage with a lan- David A. Talan, M.D. ceolate incision. Although excision of a thin Olive View–UCLA Medical Center strip of skin overlying the abscess may make Sylmar, CA drainage and packing easier, this is rarely indi- Adam J. Singer, M.D. cated except for very large, multiloculated or Stony Brook University Stony Brook, NY recalcitrant abscesses. For the majority of simple [email protected] abscesses, a small incision and drainage without Since publication of their article, the authors report no furthe need for packing is adequate and minimizes ther potential conflict of interest. DOI: 10.1056/NEJMc1404437 further trauma and patient discomfort.
Global Supply of Health Professionals To the Editor: Contrary to information in the recent review by Crisp and Chen (March 6 issue),1 we would highlight that both Namibia and Botswana have medical schools. The University of Namibia School of Medicine was established in 2010 together with the University of Namibia School of Pharmacy. Timothy Rennie, M.Pharm., Ph.D. University of Namibia School of Pharmacy Windhoek, Namibia [email protected]
Jennifer Marriott, B.Pharm., Ph.D. Monash University Faculty of Pharmacy and Pharmaceutical Sciences Melbourne, VIC, Australia
Tina P. Brock, Ed.D. University of California, San Francisco San Francisco, CA No potential conflict of interest relevant to this letter was reported. 1. Crisp N, Chen L. Global supply of health professionals.
N Engl J Med 2014;370:950-7. [Erratum, N Engl J Med 2014;370: 1668.] DOI: 10.1056/NEJMc1404326
To the Editor: Crisp and Chen give little attention to pharmacists in their assessment of the supply of health professionals. In collaboration with the United Nations Educational, Scientific and Cultural Organization and the World Health Organization, the International Pharmaceutical Federation Education Initiative1 is working to stimulate transformational change in pharmaceutical education and engender global development of pharmacy science and practice. Pharmacy education should be socially accountable while teaching practice and science that are evidence-based; practitioners should have the required competencies to provide needed services to their communities. 2246
Global pharmacy now has a common competency framework2 that provides guidance for foundations of practice at an individual level and for further development into advanced practice. It has been successfully implemented in several countries since its launch in 2012. Andreia Bruno, B.Sc.Pharm., Ph.D. International Pharmaceutical Federation Lisbon, Portugal [email protected]
Kirstie Galbraith, M.Clin.Pharm. Monash University Faculty of Pharmacy and Pharmaceutical Sciences Melbourne, VIC, Australia
Ross McKinnon, B.Pharm., Ph.D. Flinders Centre for Innovation in Cancer Adelaide, SA, Australia No potential conflict of interest relevant to this letter was reported. 1. International Pharmaceutical Federation Education Initia-
tive (FIPEd). 2013 FIPEd global education report. Part 5 — using FIPEd resources and networks to implement educational development change. The Hague, the Netherlands: International Pharmaceutical Federation, 2013 (http://www.fip.org/education reports). 2. Idem. A global competency framework for services provided by pharmacy workforce. The Hague, the Netherlands: International Pharmaceutical Federation, 2012 (http://www.fip.org/pe_ resources). DOI: 10.1056/NEJMc1404326
To the Editor: Crisp and Chen comprehensively analyze global health workforce challenges. However, as in previous articles,1 the entire cadre of 4 million oral health professionals is missing from the analysis. Oral diseases are among the most common maladies worldwide, and dental caries affect 60 to 90% of populations. Members of the global oral health workforce (dentists, auxiliaries, hygienists, therapists, and laboratory
n engl j med 370;23 nejm.org june 5, 2014
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
correspondence
Number of patients per dentist Fewer than 3000 3000–19,999 20,000–49,999 50,000–199,999 200,000 or more No data
Figure 1. Estimated Number of Patients per Dentist Worldwide, 2007. Data are from Beaglehole et al.2
technicians) share the challenges of other health professionals, yet shortages and maldistribution are even more obvious, particularly in low-income and middle-income countries (Fig. 1). For example, whereas the ratio of dentists to the population of Brazil in 2007 was 1:860, it was 1:1,278,000 in Ethiopia.2 Low availability of care contributes to untreated caries being the most common disease among all 291 conditions studied in the Global Burden of Disease project.3 Essential oral care needs to be integrated into primary health care.4 This will happen only if efforts are made to refocus on prevention, develop innovative workforce models, and balance the supply of oral health professionals. The political neglect of oral diseases must be overcome, and equal recognition of the oral health workforce could be a starting point.5 Habib Benzian, D.D.S., Ph.D. University College London London, United Kingdom [email protected]
Lois K. Cohen, Ph.D. Paul G. Rogers Society for Global Health Research Bethesda, MD
Tin C. Wong, M.Sc. Orth. FDI World Dental Federation Geneva, Switzerland No potential conflict of interest relevant to this letter was reported.
n engl j med 370;23
1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a
new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58. 2. Beaglehole R, Benzian H, Crail J, Mackay J. The Oral Health Atlas: mapping a neglected global health issue. Geneva: FDI World Dental Federation, 2009. 3. Marcenes W, Kassebaum NJ, Bernabé E, et al. Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res 2013;92:592-7. 4. Glick M, Monteiro da Silva O, Seeberger GK, et al. FDI Vision 2020: shaping the future of oral health. Int Dent J 2012;62:27891. 5. Benzian H, Hobdell M, Holmgren C, et al. Political priority of global oral health: an analysis of reasons for international neglect. Int Dent J 2011;61:124-30. DOI: 10.1056/NEJMc1404326
The Authors Reply: Rennie et al. are quite right about the medical schools in Botswana and Namibia. According to the Sub-Saharan African Medical Schools Study (http://samss.org), the University of Botswana School of Medicine was established in 2009, and the University of Namibia School of Medicine started in 2010. These two new schools were not listed in the online directory of medical schools worldwide (AVICENNA), which has been administered since 2007 by the University of Copenhagen (avicenna.ku.dk). Like all ongoing databases, the updating of new medical schools may lag behind actual developments. Nevertheless, even with these corrections, our conclusion that there are enormous global disparities in medical schools among countries still holds true.
nejm.org
june 5, 2014
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
2247
The
n e w e ng l a n d j o u r na l
Similarly, we acknowledge and welcome the point made by Bruno et al. that we made little mention of pharmacists and the point made by Benzian and colleagues that we did not describe the requirement for suitable staffing for oral health. These are very important matters. Equally, we did not have space to cover other important professions and services such as the pressing need for greater mental health capacity and for adequate staffing for eye health care throughout the world. The simple point we would reinforce here is that shortages in the health workforce are the biggest single barrier to improving
of
m e dic i n e
these services. We hope our article helps to raise the profile of the global workforce so that improvements are made in these and other related areas. Nigel Crisp, M.A. House of Lords London, United Kingdom
Lincoln Chen, M.D. China Medical Board Cambridge, MA Since publication of their article, the authors report no further potential conflict of interest. DOI: 10.1056/NEJMc1404326
23andMe and the FDA To the Editor: In their Perspective article (March 13 issue),1 Annas and Elias state that the conflict between the genetic-testing company 23andMe and the Food and Drug Administration (FDA) concerns analytic and clinical validity, clinical utility, and ethical, legal, and social issues. However, their discussion is limited to a domestic U.S. perspective. After a person’s raw genetic data have been determined from a DNA sample, the data are stored remotely and can be accessed easily anywhere in the world. For example, in Japan, maternal blood samples from Japanese mothers undergoing noninvasive prenatal testing are sent to an American company to be analyzed, and their data are sent back to Japan.2 Therefore, genomic digital data are transborder. Any regulatory framework for the genome business should be based not solely on domestic laws but on an international harmonization.3-5 We would be grateful if the authors would comment on this. Koichiro Yuji, M.D., Ph.D. Tetsuya Tanimoto, M.D. Yasuo Oshima, M.D., Ph.D. University of Tokyo Tokyo, Japan [email protected] Dr. Oshima reports having received stipends from Novartis Pharma and Sanofi. No other potential conflict of interest relevant to this letter was reported. 1. Annas GJ, Elias S. 23andMe and the FDA. N Engl J Med
2014;370:985-8.
2. As I see it: now is the time to address problems in non-inva-
sive prenatal testing. Mainichi Shimbun. January 18, 2014 (http://mainichi.jp/english/english/perspectives/news/ 20140118p2a00m0na007000c.html).
2248
3. Organization for Economic Co-operation and Development.
The 2013 OECD privacy guidelines: the recommendation of the OECD Council concerning Guidelines governing the protection of privacy and transborder f low of personal data. Paris: OECD, July 2013 (http://www.oecd.org/sti/ieconomy/privacy .htm#newguidelines). 4. European Commission. Proposal for a regulation of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data and on the free movement of such data (General Data Protection Regulation). Brussels: European Commission, January 25, 2012 (http://ec.europa.eu/justice/data-protection/document/review2012/ com_2012_11_en.pdf). 5. The Asia-Pacific Economic Cooperation. Cross-border privacy rules (CBPR) (http://www.apec.org/Groups/Committee-on-Trade -and-Investment/Electronic-Commerce-Steering-Group.aspx). DOI: 10.1056/NEJMc1404692
The authors reply: Yuji and colleagues are correct that neither the FDA nor any individual country can set international norms for clinical genetics, including noninvasive prenatal testing. They are also correct in noting that even if individual DNA samples could be restricted from traveling between countries, genomic digitalized data cannot be geographically confined. International harmonization of standards remains a major challenge. It is always tempting to adopt a lowest-common-denominator approach and permit individual countries to adopt higher standards if they wish. There is no global approach to international standard setting (with the possible exception of pharmaceutical patent law) that has demonstrated efficacy. Nonetheless, recognition that the lack of international standards is a problem for the development of clinical genetics provides at least some reason to hope that the coun-
n engl j med 370;23 nejm.org june 5, 2014
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
