Correspondence
whereby benefits and burdens are fairly distributed. Hölldobler and Wilson’s illustration of the ant colony is fitting: just as ants cooperate within their own colony but compete with new colonies when they are introduced, so must individual health-care providers learn to cooperate within a wider setting of competition, without an inherent need for a hierarchy or a market.5 We declare that we have no conflicts of interest.
*Barnabas J Gilbert, Mahiben Maruthappu, Laurence Leaver, Muir Gray [email protected]; University of Oxford, Oxford OX2 6HG, UK (BJG, LL, MG); and Harvard University, Cambridge, MA, USA (MM) 1
2 3 4
5
Davis J. What were you doing while the NHS was being destroyed? Nov 13, 2013. http:// www.theguardian.com/commentisfree/2013/ nov/13/nhs-being-destroyed-labour (accessed Nov 15, 2013). The Lancet. The NHS: free and caring or a market commodity? Lancet 2013; 382: 571. Sullivan R. The Cost Disease. Lancet Oncol 2013; 14: 295. Hellowell M. The role of public-private partnerships in health systems is getting stronger. Commonwealth Health Partnerships, 2012. Hölldobler B, Wilson EO. The ants. Cambridge, MA: Springer-Verlag, 1990.
See Online for appendix
An early warning and response system for Syria The conflict in Syria has continued for more than 2 years: many Syrians have fled to escape the fighting (more than 5 million people have been internally displaced and about 2 million refugees are in neighbouring countries),1 and the Syrian healthcare system has been badly affected by the crisis.2–4 With huge population movements, substantial decreases in vaccination coverage, and deterioration of water and sanitation systems, the risk of epidemic-prone diseases is high. Epidemics pose a threat to health not only within Syria, but also in neighbouring countries. Public health surveillance is crucial 2066
to avert epidemics in emergency situations.5 In September, 2012, with the support of WHO, the Syrian Ministry of Health established an Early Warning Alert and Response System (EWARS) to strengthen the national surveillance system, detect epidemic threats early, respond to and control outbreaks, and monitor epidemic-prone diseases. EWARS is a network of reporting sentinel sites that collect information on a weekly basis. EWARS includes an alert element that signals outbreak at early stages, and it also includes preparedness plans. EWARS is supported by a network of laboratories, a communication network (via mobile phones), and a training component. At the beginning (September, 2012), 104 health centres were designated as sentinel reporting sites for EWARS across 14 governorates in the country. To overcome the problems in centres located in the governorates particularly affected by the conflict, non-governmental organisations’ health facilities and private hospitals and clinics were recruited by WHO in those governorates. By November, 2013, there were 368 reporting sites. Nine diseases were judged to be of high burden and epidemic-prone. A weekly bulletin is produced by EWARS and posted on WHO country office and Ministry of Health websites. EWARS is established and functional. It has succeeded so far in mitigating the consequences of many outbreaks, responding to a nation-wide measles outbreak, a typhoid outbreak in Deir ALZour, and the present polio outbreak. We declare that we have no conflicts of interest.
*Ghada Muhjazi, Hyam Bashour, Nidal Abourshaid, Hani Lahham [email protected] WHO Surveillance of Communicable Diseases, Damascus, Syria (GM); Damascus University, Damascus, Syria (HB); and Ministry of Health Damascus, Syria (NA, HL) 1
The UN Refugee Agency. Syria regional refugee response. http://data.unhcr.org/syrianrefugees/ regional.php (accessed Dec 3, 2013).
2
3 4
5
WHO. Health: Syrian Arab Republic 2013. http://www.who.int/hac/syria_ dashboard_6june2013_final_small_.pdf (accessed Dec 3, 2013). Garfield R. Health professionals in Syria. Lancet 2013; 382: 205–06. Médecins Sans Frontières. Syria two years on: the failure of international aid so far. http:// doctorswithoutborders.tumblr.com/ post/44944097430/syria-two-years-on-thefailure-of-international (accessed Dec 3, 2013). WHO. Outbreak surveillance and response in humanitarian emergencies: WHO guidelines for EWARN implementation. 2012. http:// whqlibdoc.who.int/hq/2012/who_hse_gar_ dce_2012_1_eng.pdf (accessed Dec 3, 2013).
Improving medical research in the Arab world Arab nations’ medical research output and broad impact are weak according to the 2013 Scimago Institutions Rankings report 1 (of the 2740 universities and research institutions worldwide, only 60 were from Arab countries), which echoes the Scimago Journal and Country Rank (1996–2012), 2 and the 2013 Shanghai Ranking (appendix).3 Arab institutions were linked with 76 417 reports published between 1996 and 2012, which is only 4% of medical research reports by US-based institutions (table). Medical research publication from institutions from all Arab countries is almost half of that from Turkey, almost the same as that from Israel, and double that from Iran, but with a lower H index4 average (table). Promotion of medical research in Arab countries needs serious efforts and several strategic goals must be agreed on by all stakeholders— scientists and decision makers. The strategy should include upgrading research infrastructure and equipment, providing sufficient funds and high-quality training, as well as promoting excellence. Additionally, Arab scientists working abroad should be seen as an asset. China has already shown the way by recruiting qualified www.thelancet.com Vol 382 December 21/28, 2013
Correspondence
USA
Documents Citable documents
Citations
Selfcitations
Citations per H index4 document
1 875 195
1 652 683
37 441 209
18 437 180
22·36
904
Turkey
120 954
109 240
648 234
128 711
6·71
142
Israel
59 894
54 409
953 440
104 365
16·89
255
Iran
38 147
35 492
131 537
43 207
7·82
82
Arab nations*
76 417†
69 753†
444 281†
49 680†
7·67‡
39‡
*22 Arab nations (Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, Yemen). †Cumulative values for the 22 Arab nations. ‡Average value of the 22 Arab nations.
Table: Medical research output from the USA, Turkey, Israel, Iran, and Arab nations (1996–2012)
Chinese academics, mainly from USA, so that by 2018, China’s research output will be growing by 330%, according to forecast.5 We believe that an Arab medical research council—inspired from the US National Institutes of Health, the Medical Reasearch Council in the UK, and INSERM in France—is necessary to establish strategies that promote medical and health research in the Arab world in collaboration with international institutions. Historically pioneers in several sciencific domains, Arab scientists have an obligation to initiate a scientific Arab spring to promote medical research and subsequently participate in the development of their nations. We declare that we have no conflicts of interest.
*Mohammed El-Azami-El-Idrissi, Mounia Lakhdar-Idrissi, Karim Ouldim, Wafaa Bono, Afaf Amarti-Riffi, Moustapha Hida, Chakib Nejjari [email protected] Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University of Fez and Hassan II University Hospital of Fez, Fez 30000, Morocco 1
2
3
4
Scimago Institutions Rankings. SIR World Report 2013. http://www.scimagoir.com/pdf/ SIR Global 2013 O.pdf (accessed Sept 3, 2013). Scimago Journal and Country Rank. Country rankings. http://www.scimagojr.com/ countryrank.php?area=2700&category=0®i on=all&year=all&order=it&min=0&min_ type=it (accessed Sept 3, 2013). Shangai Ranking. Academic ranking of world universities. http://www.shanghairanking.com/ ARWU2013.html (accessed Sept 3, 2013). Hirsch JE. An index to quantify an individual’s scientific research output. Proc Natl Acad Sci USA 2005; 102: 16569–72.
www.thelancet.com Vol 382 December 21/28, 2013
5
ScimagoLab. Forecasting exercise: how world scientific output will be in 2018. http://www. scimagolab.com/blog/2012/forecastingexercise-how-world-scientific-output-will-bein-2018/ (accessed Sept 3, 2013).
Haze, air pollution, and health in China In January, 2013, a hazardous dense haze covered 1·4 million km² of China and affected more than 800 million people.1 This winter, again, northern China is being hit by a heavy haze. According to the Global Burden of Disease Study, 2 a frightening 3·2 million people died from air pollution in 2010—2·1 million were from Asia. Meanwhile, the number of paediatric patients with pneumonia dramatically increased in China. Experts warned that China’s haze could be “more horrible than the SARs epidemic”.1 “Haze weather is more carcinogenic than cigarettes”, declared Zhong Nanshan (Director of the Chinese Academy of Engineering and Guangzhou Institute of Respiratory Diseases). While smoking has fallen in China, the prevalence of lung cancer has increased, most probably due to air pollution. In addition to respiratory diseases and cancer, the haze also substantially affects prevalence of cardiovascular and cerebrovascular diseases. Air pollution in China is mainly caused by coal, motor vehicles, and industrial dust, and is linked with the rapid economic development. Although this rapid economic
development has improved living conditions, it also threatens people’s health, which is a dilemma for China. It is time to do something to solve the air pollution problem in China. It has been caused by accumulation over time of both natural factors and an unhealthy economic growth model. As Prime Minister Li Keqiang acknowledged, it will be a long process, but we have to act.1 Monitoring of PM2·5 has been introduced and the Chinese Government has committed to spend ¥3·4 trillion on environmental protection in the 12th Five Year Plan. The air pollution prevention action plan, published in September, 2013, calls for strict controls on pollution, industry production, coal consumption; implementation of clean production processes; and promotion of clean vehicles, among other measures.3 The results of these policies are still to be seen; it will be a very long process, requiring a balance between various regions’ interests and implementation of economic and structural adjustments. Quality of the environment and people’s health should not be the victims of the economic development. We declare that we have no conflicts of interest.
Peng Xu, Yongfen Chen, *Xiaojian Ye [email protected] Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China (PX, XY); and Department of Paediatric Cardiology, Shanghai Children’s Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China (YC) 1
2
3
Caijing. China’s haze “more horrible” than SARs epidemic, expert warns. http://english. caijing.com.cn/2013-01-31/112478574.html (accessed Jan 31, 2013). Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224–60. Chinese Government. The State Council issued the “Air Pollution Prevention Action Plan” Ten measures (in Chinese). http://www.gov.cn/ jrzg/2013-09/12/content_2486918.htm (accessed Oct 12, 2013).
2067
whereby benefits and burdens are fairly distributed. Hölldobler and Wilson’s illustration of the ant colony is fitting: just as ants cooperate within their own colony but compete with new colonies when they are introduced, so must individual health-care providers learn to cooperate within a wider setting of competition, without an inherent need for a hierarchy or a market.5 We declare that we have no conflicts of interest.
*Barnabas J Gilbert, Mahiben Maruthappu, Laurence Leaver, Muir Gray [email protected]; University of Oxford, Oxford OX2 6HG, UK (BJG, LL, MG); and Harvard University, Cambridge, MA, USA (MM) 1
2 3 4
5
Davis J. What were you doing while the NHS was being destroyed? Nov 13, 2013. http:// www.theguardian.com/commentisfree/2013/ nov/13/nhs-being-destroyed-labour (accessed Nov 15, 2013). The Lancet. The NHS: free and caring or a market commodity? Lancet 2013; 382: 571. Sullivan R. The Cost Disease. Lancet Oncol 2013; 14: 295. Hellowell M. The role of public-private partnerships in health systems is getting stronger. Commonwealth Health Partnerships, 2012. Hölldobler B, Wilson EO. The ants. Cambridge, MA: Springer-Verlag, 1990.
See Online for appendix
An early warning and response system for Syria The conflict in Syria has continued for more than 2 years: many Syrians have fled to escape the fighting (more than 5 million people have been internally displaced and about 2 million refugees are in neighbouring countries),1 and the Syrian healthcare system has been badly affected by the crisis.2–4 With huge population movements, substantial decreases in vaccination coverage, and deterioration of water and sanitation systems, the risk of epidemic-prone diseases is high. Epidemics pose a threat to health not only within Syria, but also in neighbouring countries. Public health surveillance is crucial 2066
to avert epidemics in emergency situations.5 In September, 2012, with the support of WHO, the Syrian Ministry of Health established an Early Warning Alert and Response System (EWARS) to strengthen the national surveillance system, detect epidemic threats early, respond to and control outbreaks, and monitor epidemic-prone diseases. EWARS is a network of reporting sentinel sites that collect information on a weekly basis. EWARS includes an alert element that signals outbreak at early stages, and it also includes preparedness plans. EWARS is supported by a network of laboratories, a communication network (via mobile phones), and a training component. At the beginning (September, 2012), 104 health centres were designated as sentinel reporting sites for EWARS across 14 governorates in the country. To overcome the problems in centres located in the governorates particularly affected by the conflict, non-governmental organisations’ health facilities and private hospitals and clinics were recruited by WHO in those governorates. By November, 2013, there were 368 reporting sites. Nine diseases were judged to be of high burden and epidemic-prone. A weekly bulletin is produced by EWARS and posted on WHO country office and Ministry of Health websites. EWARS is established and functional. It has succeeded so far in mitigating the consequences of many outbreaks, responding to a nation-wide measles outbreak, a typhoid outbreak in Deir ALZour, and the present polio outbreak. We declare that we have no conflicts of interest.
*Ghada Muhjazi, Hyam Bashour, Nidal Abourshaid, Hani Lahham [email protected] WHO Surveillance of Communicable Diseases, Damascus, Syria (GM); Damascus University, Damascus, Syria (HB); and Ministry of Health Damascus, Syria (NA, HL) 1
The UN Refugee Agency. Syria regional refugee response. http://data.unhcr.org/syrianrefugees/ regional.php (accessed Dec 3, 2013).
2
3 4
5
WHO. Health: Syrian Arab Republic 2013. http://www.who.int/hac/syria_ dashboard_6june2013_final_small_.pdf (accessed Dec 3, 2013). Garfield R. Health professionals in Syria. Lancet 2013; 382: 205–06. Médecins Sans Frontières. Syria two years on: the failure of international aid so far. http:// doctorswithoutborders.tumblr.com/ post/44944097430/syria-two-years-on-thefailure-of-international (accessed Dec 3, 2013). WHO. Outbreak surveillance and response in humanitarian emergencies: WHO guidelines for EWARN implementation. 2012. http:// whqlibdoc.who.int/hq/2012/who_hse_gar_ dce_2012_1_eng.pdf (accessed Dec 3, 2013).
Improving medical research in the Arab world Arab nations’ medical research output and broad impact are weak according to the 2013 Scimago Institutions Rankings report 1 (of the 2740 universities and research institutions worldwide, only 60 were from Arab countries), which echoes the Scimago Journal and Country Rank (1996–2012), 2 and the 2013 Shanghai Ranking (appendix).3 Arab institutions were linked with 76 417 reports published between 1996 and 2012, which is only 4% of medical research reports by US-based institutions (table). Medical research publication from institutions from all Arab countries is almost half of that from Turkey, almost the same as that from Israel, and double that from Iran, but with a lower H index4 average (table). Promotion of medical research in Arab countries needs serious efforts and several strategic goals must be agreed on by all stakeholders— scientists and decision makers. The strategy should include upgrading research infrastructure and equipment, providing sufficient funds and high-quality training, as well as promoting excellence. Additionally, Arab scientists working abroad should be seen as an asset. China has already shown the way by recruiting qualified www.thelancet.com Vol 382 December 21/28, 2013
Correspondence
USA
Documents Citable documents
Citations
Selfcitations
Citations per H index4 document
1 875 195
1 652 683
37 441 209
18 437 180
22·36
904
Turkey
120 954
109 240
648 234
128 711
6·71
142
Israel
59 894
54 409
953 440
104 365
16·89
255
Iran
38 147
35 492
131 537
43 207
7·82
82
Arab nations*
76 417†
69 753†
444 281†
49 680†
7·67‡
39‡
*22 Arab nations (Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, Yemen). †Cumulative values for the 22 Arab nations. ‡Average value of the 22 Arab nations.
Table: Medical research output from the USA, Turkey, Israel, Iran, and Arab nations (1996–2012)
Chinese academics, mainly from USA, so that by 2018, China’s research output will be growing by 330%, according to forecast.5 We believe that an Arab medical research council—inspired from the US National Institutes of Health, the Medical Reasearch Council in the UK, and INSERM in France—is necessary to establish strategies that promote medical and health research in the Arab world in collaboration with international institutions. Historically pioneers in several sciencific domains, Arab scientists have an obligation to initiate a scientific Arab spring to promote medical research and subsequently participate in the development of their nations. We declare that we have no conflicts of interest.
*Mohammed El-Azami-El-Idrissi, Mounia Lakhdar-Idrissi, Karim Ouldim, Wafaa Bono, Afaf Amarti-Riffi, Moustapha Hida, Chakib Nejjari [email protected] Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University of Fez and Hassan II University Hospital of Fez, Fez 30000, Morocco 1
2
3
4
Scimago Institutions Rankings. SIR World Report 2013. http://www.scimagoir.com/pdf/ SIR Global 2013 O.pdf (accessed Sept 3, 2013). Scimago Journal and Country Rank. Country rankings. http://www.scimagojr.com/ countryrank.php?area=2700&category=0®i on=all&year=all&order=it&min=0&min_ type=it (accessed Sept 3, 2013). Shangai Ranking. Academic ranking of world universities. http://www.shanghairanking.com/ ARWU2013.html (accessed Sept 3, 2013). Hirsch JE. An index to quantify an individual’s scientific research output. Proc Natl Acad Sci USA 2005; 102: 16569–72.
www.thelancet.com Vol 382 December 21/28, 2013
5
ScimagoLab. Forecasting exercise: how world scientific output will be in 2018. http://www. scimagolab.com/blog/2012/forecastingexercise-how-world-scientific-output-will-bein-2018/ (accessed Sept 3, 2013).
Haze, air pollution, and health in China In January, 2013, a hazardous dense haze covered 1·4 million km² of China and affected more than 800 million people.1 This winter, again, northern China is being hit by a heavy haze. According to the Global Burden of Disease Study, 2 a frightening 3·2 million people died from air pollution in 2010—2·1 million were from Asia. Meanwhile, the number of paediatric patients with pneumonia dramatically increased in China. Experts warned that China’s haze could be “more horrible than the SARs epidemic”.1 “Haze weather is more carcinogenic than cigarettes”, declared Zhong Nanshan (Director of the Chinese Academy of Engineering and Guangzhou Institute of Respiratory Diseases). While smoking has fallen in China, the prevalence of lung cancer has increased, most probably due to air pollution. In addition to respiratory diseases and cancer, the haze also substantially affects prevalence of cardiovascular and cerebrovascular diseases. Air pollution in China is mainly caused by coal, motor vehicles, and industrial dust, and is linked with the rapid economic development. Although this rapid economic
development has improved living conditions, it also threatens people’s health, which is a dilemma for China. It is time to do something to solve the air pollution problem in China. It has been caused by accumulation over time of both natural factors and an unhealthy economic growth model. As Prime Minister Li Keqiang acknowledged, it will be a long process, but we have to act.1 Monitoring of PM2·5 has been introduced and the Chinese Government has committed to spend ¥3·4 trillion on environmental protection in the 12th Five Year Plan. The air pollution prevention action plan, published in September, 2013, calls for strict controls on pollution, industry production, coal consumption; implementation of clean production processes; and promotion of clean vehicles, among other measures.3 The results of these policies are still to be seen; it will be a very long process, requiring a balance between various regions’ interests and implementation of economic and structural adjustments. Quality of the environment and people’s health should not be the victims of the economic development. We declare that we have no conflicts of interest.
Peng Xu, Yongfen Chen, *Xiaojian Ye [email protected] Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China (PX, XY); and Department of Paediatric Cardiology, Shanghai Children’s Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China (YC) 1
2
3
Caijing. China’s haze “more horrible” than SARs epidemic, expert warns. http://english. caijing.com.cn/2013-01-31/112478574.html (accessed Jan 31, 2013). Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224–60. Chinese Government. The State Council issued the “Air Pollution Prevention Action Plan” Ten measures (in Chinese). http://www.gov.cn/ jrzg/2013-09/12/content_2486918.htm (accessed Oct 12, 2013).
2067
