Correspondence
6
Vollmer T, Key L, Durkalski V, et al. Oral simvastatin treatment in relapsing-remitting multiple sclerosis. Lancet 2004; 363: 1607–08. Cuzick J, Thorat M, Bosetti C, et al. Estimates of benefits and harms of prophylactic use of aspirin in the general population. Ann Oncol 2014; published online Aug 5. DOI:10.1093/annonc/ mdu225.
3
4
5
Can dementia be lessened by statins? The Lancet Editorial of June 281 states that Prime Minister David Cameron has taken the lead in the attempt to lessen the global epidemic of dementia by identifying a cure or disease modifying therapy by 2025. 1 Yet in the same issue of The Lancet, we read that statins have anti-inflammatory properties and inhibit leucocyte migration through the blood–brain barrier, thereby lessening atrophy of the brain. 2 Possible additional brain protective mechanisms are endothelial protection via action on the nitric oxide synthase system and as well as antioxidant and anti-inflammatory and anti-platelet effects.3–5 Thus there are several pointers that together make a case for the wider use of statins with the aim of lessening the effect of dementia. Although we will undoubtedly have more information by 2025, the currently available data suggest the use of high-dose statins as relatively simple therapy to lessen the severity of developing dementia. Ultimately a large-scale definitive study would be required fully to prove this concept. I declare no competing interests.
Lionel H Opie [email protected] Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town 7925, South Africa 1 2
The Lancet. Addressing global dementia. Lancet 2014; 383: 2185. Chataway J, Schuerer N, Alsanousi A, et al. Effect of high-dose simvastatin on brain atrophy and disability in secondary progressive multiple sclerosis (MS-STAT): a randomised, placebo-controlled, phase 2 trial. Lancet 2014; 383: 2213–21.
www.thelancet.com Vol 384 September 13, 2014
Vaughan CJ, Delanty N. Neuroprotective properties of statins in cerebral ischemia and stroke. Stroke 1999; 30: 1969–73. Ma M, Uekawa K, Hasegawa Y, et al. Pretreatment with rosuvastatin protects against focal cerebral ischemia/reperfusion injury in rats through attenuation of oxidative stress and inflammation. Brain Res 2013; 1519: 87–94. Moon GJ, Kim SJ, Cho YH, Ryoo S, Bang OY. Antioxidant effects of statins in patients with atherosclerotic cerebrovascular disease. J Clin Neurol 2014; 10: 140–47.
The US Centers for Disease Control: a crucial actor in global health The Lancet’s Health of Americans Series rightly acknowledges the contribution made by US Centers for Disease Control and Prevention to global health.1 Yet, all great leadership should allow space to reflect on challenges. A great success in public health— the Presidential Emergency Plan for AIDS Relief (PEPFAR) evolved. Initially it was criticised for the health systems effect of vertical programming and for its conditionalities. 2 For example, organisations receiving funding were required to adhere to the Global Gag Rule. No funding could be given to organisations providing comprehensive sexual and reproductive health (SRH) services, which included safe abortion or information on abortion. 3 It also required recipients of funding to sign an anti-prostitution pledge. This requirement was rejected by human rights and sex worker activists as demonising activities and ignoring principles of empowerment and autonomy, which have been shown as essential to addressing the health needs of these communities. Similarly, the programmes’ initial emphasis of abstinence over condoms was criticised as a so-called moral agenda flying in the face of evidence-based HIV prevention.4 At the heart of US engagement is a tension between an agency accountable to domestic policy audiences—the US Congress and
through it the people of the USA— while shaping the health and services of people abroad with little say in setting these agendas. Overcoming this tension holds the most important lesson of US engagement in global health: the need for more open and crucial dialogue about what works, to adapt, to evolve, and allow learning from implementation rather than a one-size-fits-all approach to reaching targets.
James King-Holmes/Science Photo Library
5
I declare no competing interests.
Johanna Hanefeld [email protected] London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK 1
2
3
4
Schuchat A, Tappero J, Blandford J. Global health and the US Centers for Disease Control and Prevention. Lancet 2014; 384: 98–101. Hanefeld J. The impact of Global Health Initiatives at national and sub-national level—a policy analysis of their role in implementation processes of antiretroviral treatment (ART) roll-out in Zambia and South Africa. AIDS Care 2010; 22: 93–102. Ghanotakis E, Mayhew S, Watts C. Tackling HIV and gender-based violence in South Africa: how has PEPFAR responded and what are the implications for implementing organizations? Health Policy Plann 2009; 24: 357–66. Cohen J, Schleifer R, Tate T. AIDS in Uganda: the human-rights dimension. Lancet 2005; 365: 2075–76.
For the Series see http://www. thelancet.com/series/health-ofamericans-2014
Health of Americans I commend Ursula Bauer and colleagues1 for drawing attention to the need to address the non-communicable disease (NCD) burden as part of a series on the health of Americans.2 However, their work has three vital limitations. First, a deeper analysis of why only 3% of public spend on health care and less than 2% of employer spend goes to prevention is needed for sustained change. Underinvestment in prevention science—including the use of behavioral economics and innovative personalised technologies —is one key reason.3 This funding gap, starting with the National Institutes of Health, has led to less actionable knowledge by health authorities and the Congressional Budget Office. Sceptical attitudes 953
Correspondence
towards the value of prevention alongside mandates that restrict analyses to a 10-year window have also lead to suboptimal investments by the Centers for Disease Control and Prevention and other government agencies. The underdevelopment of academic, political, and corporate leaders, and low media interest in prevention can also be attributed to this funding issue. Second, the classic government-led (infectious) disease-control paradigm that Harold Jaffe recommends4 needs substantial adaptation to tackle the complexity of NCD prevention. The recently completed Report on Investing in Prevention3 highlights the importance of collaborating with industry, investors, and government to make markets work for progress. Corporate interest in NCD prevention from sectors ranging from IT, retail, sports and leisure to healthy food should be harnessed as prevention partners.3 They would counterbalance the dominant voices of treatment and care that have distorted US health-care priorities for decades. Third, workplaces must be utilised more effectively for key prevention for the 155 million working-age adults. This change starts with Chief Executives leadership supported by health being reported as a key indicator alongside financial metrics in annual reports. In their report,5 the commissioners further mention the value of better public sector prevention programmes for employers but neglect to highlight the opposite need: workplace programmes that reach into communities for business and community benefit.5 I am Executive Director at Vitality Institute.
Derek Yach [email protected] See World Report page 943
The Vitality Institute, New York, NY 10019, USA 1
2
954
Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet 2014; 384: 45–52. The Lancet. Life, liberty, and the pursuit of healthiness. Lancet 2014; 384: 1.
3
4
5
Vitality Institute Commissioners. Investing in Prevention: A National Imperative. The Vitality Institute, 2014. http://thevitalityinstitute.org/ site/wp-content/uploads/2014/06/Vitality_ Recommendations2014.pdf (accessed Aug 22, 2014). Jaffe HW, Frieden TR. Improving health in the USA: progress and challenges. Lancet 2014; 384: 3–5. HERO Employer-Community Collaboration Committee. Environmental Scan: The Role of Corporate America in Community Health and Wellness. HERO, 2014. http://the-hero.org/ Research/HERO_EnvScanFinaltoIOMa.pdf (accessed Aug 22, 2014).
Electronic health records in the UK and USA Aziz Sheikh and colleagues’ Comment (July 5, p 8)1 entitled “Adoption of electronic health records in UK hospitals: lessons from the USA” emphasises the greater success in adoption in the USA and stresses the top-down decision-making processes in the UK as the key issue. The article makes a number of important points, but does not fully acknowledge the major achievement of the UK in getting almost 100% coverage of electronic health records (EHR) in primary care2 at a time when the US rate of adoption was 10–30%.3 These general practice systems maintain longitudinal, lifelong EHR and are therefore arguably more significant than episodic EHRs within individual hospitals. Hospital EHRs cover a much shorter, albeit more intense portion, of a patient’s care. The primary-care achievement also runs counter to the claim that the key factor in the UK failure was that it “pursued a top-down implementation strategy, in which central Government signed substantial contracts with a handful of EHR vendors” since it was a top-down government policy and funding that was associated with the successful primary care rollout. Jha and colleagues important study4 likely shows the true problem. A decade ago British officials leading the Connecting for Health project believed that the so-called hospital EHR problem had been solved and that they just needed to buy US EHR
systems. But in a survey4 of US hospitals half a decade later, Jha and colleagues showed that less than 10% had a basic EHR and 2·9% had a comprehensive EHR system in all departments. Half of those comprehensive systems were in Veterans Administration hospitals running the open-source VistA system and others were large so-called one-off EHR systems in academic medical centres. The commercial systems covered perhaps 1%, and had been developed to match the US insurance-based health-care processes. Now major UK primary care EHR vendors (such as TPP SystmOne and EMIS) are expanding to integrate hospital, community, and long-term care systems offering British solutions that bridge primary and secondary care. One lesson from the UK should surely be that implementation of EHRs can only happen when appropriate, well tested EHR systems actually exist. OAJ is a director of the health informatics software company X-Lab. HSFF is a cofounder and leader of OpenMRS an open source, non-profit EHR project. The other authors declare no competing interests.
Owen A Johnson, Hamish S F Fraser, Jeremy C Wyatt, *John D Walley [email protected] Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9PL, UK 1
2
3
4
Sheikh A, Jha A, Cresswell K, Greaves F, Bates DW. Adoption of electronic health records in UK hospitals: lessons from the USA. Lancet 2014; 384: 8–9. Payne TH, Detmer DE, Wyatt JC, Buchan IE. National-scale clinical information exchange in the United Kingdom: lessons for the United States. J Am Med Inform Assoc 2011; 18: 91–98. Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int J Med Inform 2008; 77: 848–54. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009; 360: 1628–38.
Violence against doctors in Iraq While violence against healthcare workers, as reported by Roxanne Nelson (April 19, p 1373),1 is a global problem, health-care workers in war zones are even more prone to these violent acts with bigger www.thelancet.com Vol 384 September 13, 2014
6
Vollmer T, Key L, Durkalski V, et al. Oral simvastatin treatment in relapsing-remitting multiple sclerosis. Lancet 2004; 363: 1607–08. Cuzick J, Thorat M, Bosetti C, et al. Estimates of benefits and harms of prophylactic use of aspirin in the general population. Ann Oncol 2014; published online Aug 5. DOI:10.1093/annonc/ mdu225.
3
4
5
Can dementia be lessened by statins? The Lancet Editorial of June 281 states that Prime Minister David Cameron has taken the lead in the attempt to lessen the global epidemic of dementia by identifying a cure or disease modifying therapy by 2025. 1 Yet in the same issue of The Lancet, we read that statins have anti-inflammatory properties and inhibit leucocyte migration through the blood–brain barrier, thereby lessening atrophy of the brain. 2 Possible additional brain protective mechanisms are endothelial protection via action on the nitric oxide synthase system and as well as antioxidant and anti-inflammatory and anti-platelet effects.3–5 Thus there are several pointers that together make a case for the wider use of statins with the aim of lessening the effect of dementia. Although we will undoubtedly have more information by 2025, the currently available data suggest the use of high-dose statins as relatively simple therapy to lessen the severity of developing dementia. Ultimately a large-scale definitive study would be required fully to prove this concept. I declare no competing interests.
Lionel H Opie [email protected] Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town 7925, South Africa 1 2
The Lancet. Addressing global dementia. Lancet 2014; 383: 2185. Chataway J, Schuerer N, Alsanousi A, et al. Effect of high-dose simvastatin on brain atrophy and disability in secondary progressive multiple sclerosis (MS-STAT): a randomised, placebo-controlled, phase 2 trial. Lancet 2014; 383: 2213–21.
www.thelancet.com Vol 384 September 13, 2014
Vaughan CJ, Delanty N. Neuroprotective properties of statins in cerebral ischemia and stroke. Stroke 1999; 30: 1969–73. Ma M, Uekawa K, Hasegawa Y, et al. Pretreatment with rosuvastatin protects against focal cerebral ischemia/reperfusion injury in rats through attenuation of oxidative stress and inflammation. Brain Res 2013; 1519: 87–94. Moon GJ, Kim SJ, Cho YH, Ryoo S, Bang OY. Antioxidant effects of statins in patients with atherosclerotic cerebrovascular disease. J Clin Neurol 2014; 10: 140–47.
The US Centers for Disease Control: a crucial actor in global health The Lancet’s Health of Americans Series rightly acknowledges the contribution made by US Centers for Disease Control and Prevention to global health.1 Yet, all great leadership should allow space to reflect on challenges. A great success in public health— the Presidential Emergency Plan for AIDS Relief (PEPFAR) evolved. Initially it was criticised for the health systems effect of vertical programming and for its conditionalities. 2 For example, organisations receiving funding were required to adhere to the Global Gag Rule. No funding could be given to organisations providing comprehensive sexual and reproductive health (SRH) services, which included safe abortion or information on abortion. 3 It also required recipients of funding to sign an anti-prostitution pledge. This requirement was rejected by human rights and sex worker activists as demonising activities and ignoring principles of empowerment and autonomy, which have been shown as essential to addressing the health needs of these communities. Similarly, the programmes’ initial emphasis of abstinence over condoms was criticised as a so-called moral agenda flying in the face of evidence-based HIV prevention.4 At the heart of US engagement is a tension between an agency accountable to domestic policy audiences—the US Congress and
through it the people of the USA— while shaping the health and services of people abroad with little say in setting these agendas. Overcoming this tension holds the most important lesson of US engagement in global health: the need for more open and crucial dialogue about what works, to adapt, to evolve, and allow learning from implementation rather than a one-size-fits-all approach to reaching targets.
James King-Holmes/Science Photo Library
5
I declare no competing interests.
Johanna Hanefeld [email protected] London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK 1
2
3
4
Schuchat A, Tappero J, Blandford J. Global health and the US Centers for Disease Control and Prevention. Lancet 2014; 384: 98–101. Hanefeld J. The impact of Global Health Initiatives at national and sub-national level—a policy analysis of their role in implementation processes of antiretroviral treatment (ART) roll-out in Zambia and South Africa. AIDS Care 2010; 22: 93–102. Ghanotakis E, Mayhew S, Watts C. Tackling HIV and gender-based violence in South Africa: how has PEPFAR responded and what are the implications for implementing organizations? Health Policy Plann 2009; 24: 357–66. Cohen J, Schleifer R, Tate T. AIDS in Uganda: the human-rights dimension. Lancet 2005; 365: 2075–76.
For the Series see http://www. thelancet.com/series/health-ofamericans-2014
Health of Americans I commend Ursula Bauer and colleagues1 for drawing attention to the need to address the non-communicable disease (NCD) burden as part of a series on the health of Americans.2 However, their work has three vital limitations. First, a deeper analysis of why only 3% of public spend on health care and less than 2% of employer spend goes to prevention is needed for sustained change. Underinvestment in prevention science—including the use of behavioral economics and innovative personalised technologies —is one key reason.3 This funding gap, starting with the National Institutes of Health, has led to less actionable knowledge by health authorities and the Congressional Budget Office. Sceptical attitudes 953
Correspondence
towards the value of prevention alongside mandates that restrict analyses to a 10-year window have also lead to suboptimal investments by the Centers for Disease Control and Prevention and other government agencies. The underdevelopment of academic, political, and corporate leaders, and low media interest in prevention can also be attributed to this funding issue. Second, the classic government-led (infectious) disease-control paradigm that Harold Jaffe recommends4 needs substantial adaptation to tackle the complexity of NCD prevention. The recently completed Report on Investing in Prevention3 highlights the importance of collaborating with industry, investors, and government to make markets work for progress. Corporate interest in NCD prevention from sectors ranging from IT, retail, sports and leisure to healthy food should be harnessed as prevention partners.3 They would counterbalance the dominant voices of treatment and care that have distorted US health-care priorities for decades. Third, workplaces must be utilised more effectively for key prevention for the 155 million working-age adults. This change starts with Chief Executives leadership supported by health being reported as a key indicator alongside financial metrics in annual reports. In their report,5 the commissioners further mention the value of better public sector prevention programmes for employers but neglect to highlight the opposite need: workplace programmes that reach into communities for business and community benefit.5 I am Executive Director at Vitality Institute.
Derek Yach [email protected] See World Report page 943
The Vitality Institute, New York, NY 10019, USA 1
2
954
Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet 2014; 384: 45–52. The Lancet. Life, liberty, and the pursuit of healthiness. Lancet 2014; 384: 1.
3
4
5
Vitality Institute Commissioners. Investing in Prevention: A National Imperative. The Vitality Institute, 2014. http://thevitalityinstitute.org/ site/wp-content/uploads/2014/06/Vitality_ Recommendations2014.pdf (accessed Aug 22, 2014). Jaffe HW, Frieden TR. Improving health in the USA: progress and challenges. Lancet 2014; 384: 3–5. HERO Employer-Community Collaboration Committee. Environmental Scan: The Role of Corporate America in Community Health and Wellness. HERO, 2014. http://the-hero.org/ Research/HERO_EnvScanFinaltoIOMa.pdf (accessed Aug 22, 2014).
Electronic health records in the UK and USA Aziz Sheikh and colleagues’ Comment (July 5, p 8)1 entitled “Adoption of electronic health records in UK hospitals: lessons from the USA” emphasises the greater success in adoption in the USA and stresses the top-down decision-making processes in the UK as the key issue. The article makes a number of important points, but does not fully acknowledge the major achievement of the UK in getting almost 100% coverage of electronic health records (EHR) in primary care2 at a time when the US rate of adoption was 10–30%.3 These general practice systems maintain longitudinal, lifelong EHR and are therefore arguably more significant than episodic EHRs within individual hospitals. Hospital EHRs cover a much shorter, albeit more intense portion, of a patient’s care. The primary-care achievement also runs counter to the claim that the key factor in the UK failure was that it “pursued a top-down implementation strategy, in which central Government signed substantial contracts with a handful of EHR vendors” since it was a top-down government policy and funding that was associated with the successful primary care rollout. Jha and colleagues important study4 likely shows the true problem. A decade ago British officials leading the Connecting for Health project believed that the so-called hospital EHR problem had been solved and that they just needed to buy US EHR
systems. But in a survey4 of US hospitals half a decade later, Jha and colleagues showed that less than 10% had a basic EHR and 2·9% had a comprehensive EHR system in all departments. Half of those comprehensive systems were in Veterans Administration hospitals running the open-source VistA system and others were large so-called one-off EHR systems in academic medical centres. The commercial systems covered perhaps 1%, and had been developed to match the US insurance-based health-care processes. Now major UK primary care EHR vendors (such as TPP SystmOne and EMIS) are expanding to integrate hospital, community, and long-term care systems offering British solutions that bridge primary and secondary care. One lesson from the UK should surely be that implementation of EHRs can only happen when appropriate, well tested EHR systems actually exist. OAJ is a director of the health informatics software company X-Lab. HSFF is a cofounder and leader of OpenMRS an open source, non-profit EHR project. The other authors declare no competing interests.
Owen A Johnson, Hamish S F Fraser, Jeremy C Wyatt, *John D Walley [email protected] Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9PL, UK 1
2
3
4
Sheikh A, Jha A, Cresswell K, Greaves F, Bates DW. Adoption of electronic health records in UK hospitals: lessons from the USA. Lancet 2014; 384: 8–9. Payne TH, Detmer DE, Wyatt JC, Buchan IE. National-scale clinical information exchange in the United Kingdom: lessons for the United States. J Am Med Inform Assoc 2011; 18: 91–98. Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int J Med Inform 2008; 77: 848–54. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009; 360: 1628–38.
Violence against doctors in Iraq While violence against healthcare workers, as reported by Roxanne Nelson (April 19, p 1373),1 is a global problem, health-care workers in war zones are even more prone to these violent acts with bigger www.thelancet.com Vol 384 September 13, 2014
