Response to letter to the editor.No abstract available

Singh, Jerome Amir.

The Lancet

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For personal use. Only reproduce with permission from The Lancet publishing Group.328 THE LANCET • Vol 363 • January 24, 2004 • www.thelancet.comCORRESPONDENCECORRESPONDENCECOMMENTARYwe estimate that there are more than100000 patients presently on statintreatment, and that about 10% of thesepatients will also be on long-termwarfarin therapy. I believe yourEditorial was correct in highlighting theissue of safety, and to suggest that“physicians must tell their patients thetruth about rosuvastatin”. However, Iwould add that physicians themselvesshould be informed of the real risk of aclinically significant interaction betweenrosuvastatin and warfarin. Such acombination should be avoided in myview—alternative statin drugs can besafely co-administered.Michael BarryDepartment of Pharmacology and Therapeutics,Trinity College Dublin, Dublin 2, Ireland(e-mail: mbarry@stjames.ie)1 The Lancet. The statin wars: whyAstraZeneca must retreat. Lancet 2003; 362:1341.Author’s replySir—To extricate politics from medicaljournals—especially in a sectiondedicated to health and human rights—is wrong for at least five reasons. First,medicine has a history of beingmisapplied for politically motivatedends. The human rights abusescommitted by physicians in the employof the Nazi and apartheid regimes speakto this point.Second, medical personnel some-times practise in settings where theinfliction of politically motivated humanrights abuses is common. ApartheidSouth Africa and present-day Zimbabweare examples of such settings.Third, the opinion of medicalprofessionals carries substantial moraland political clout in many quarters. Ifconvinced on an issue, this communitycould use its leverage to lobby forchange in policy at a state level. Thisstrategy on AIDS treatment recentlybore fruit in South Africa.Fourth, medical professionals areinvolved in decision-making at thehighest political levels. South Africa’sForeign Minister, for example, is amedical doctor. Cogent arguments in areputable journal, especially when suchviews are endorsed by WHO,1 couldpotentially influence such people to alteror affirm their state’s foreign policies.Finally, debate is healthy. It usuallyresults in better informed individualsand policies. Medical journals,especially reputable ones, thus have anethical duty to publish works thatconsider the ramifications of politicaldecision-making on health and humanrights; more so if such works canpotentially realise a change in policy-making that results in ameliorations inthese arenas for affected parties.With respect to Jim Whiting’s secondpoint, I concur. Moreover, I believe thatcriticism of such practices—particularlygiven its detrimental effect on health andhuman rights in affected countries—should especially be voiced by those inthe developing world. Although I andother colleagues from the developingworld recently voiced our opinion onthis issue,2 more need to join our call. Aswe argued, corruption and self-servingaggrandisement and oppression (amonge-mail submissions to correspondence@lancet.comRosuvastatin–warfarin drug interactionSir—In your Oct 25 Editorial (p 1341),1you suggest that safety cannot beassured for statin medications, and citethe example of cerivastatin-associatedrhabdomyolysis and the fact that the 80mg dose of rosuvastatin was withdrawnby AstraZeneca because of safetyconcerns. I would like to highlight theclinically significant interaction betweenrosuvastatin and warfarin, which hasreceived little attention to date.The British National Formularysuggests that the effect of warfarin is“possibly enhanced” by rosuvastatin.The summary of product characteristicsfor rosuvastatin in Ireland suggests that concomitant administration ofrosuvastatin and warfarin “may result inan increase in International NormalisedRatio (INR)” and that “appropriatemonitoring of INR is desirable”. Thepossibility of an interaction first came tomy attention from a report on anadverse event from the continuingJUPITER study, in which a 74-year-old female patient on long-term warfarin developed increased bruising,haematuria, and lightheadedness about4 weeks after starting rosuvastatin. HerINR was recorded at 8·0, having beenstable at 2·0 before the introduction ofthe statin. The interaction resulted inhospital admission, and treatmentincluded the discontinuation ofwarfarin, 2 units fresh frozen plasma,and 10 mg vitamin K. Most clinicianswould conclude that this was a clinicallysignificant interaction.AstraZeneca have done at least twoclinical studies on the co-administrationof rosuvastatin and warfarin, andpresumably the results of these studiesprovide the basis for the suggestion bythe British National Formulary thatthere might be an interaction betweenrosuvastatin and warfarin. Havingreceived details of the studies fromAstraZeneca, I am unable to outline thefindings here because a confidentialityclause has been added.Just how relevant is all this? We askedmore than 1700 general practitioners in1999 about factors they regarded asimportant in relation to prescription ofstatins. The three most importantpoints according to the clinicians weresafety, efficacy, and drug interactions.From our prescribing data in Ireland,Politics in medical journalsSir—I am dismayed by the appearance,again, of a political tract by JeromeSingh (Nov 15, p 1672),1 this time onthe necessity for rich nations to takecare of poor nations. If this had beenwritten 60 years ago, it would havebeen justly decried as a defence forcolonialism. Justice and fairness wereused as justifications then, too.If The Lancet is justified in devoting asection to health and human rights—acombination that should seem odderthan it does—it would be much morehelpful to elaborate on the plights ofthe nations in reference—here Rwandaand Sierra Leone—so as to addressroot causes rather than pleas for alms.If political issues need to be addressedin a medical journal, surely that shouldstart with a critical description of thecorruption, lawlessness, extortion, andcriminal neglect that characterise thesecountries. I appeal to the editors toexercise the judgment we expect in ajournal of such pedigree.Jim WhitingDepartment of Imaging, Portland VA MedicalCenter, Portland, OR 97207, USA(e-mail: jimmww@yahoo.com)1 Singh JA. Is donor aid allocation to Iraqfair? Lancet 2003; 362: 1672.For personal use. Only reproduce with permission from The Lancet publishing Group.THE LANCET • Vol 363 • January 24, 2004 • www.thelancet.com 329CORRESPONDENCEother practices) on the part of manydeveloping world leaders is having adevastating effect on health services inthose countries. Here again, medicaljournals have an ethical duty to publishsuch opinions.Affluent donor nations are makingnoteworthy attempts to uplift conditionsin the developing world. The FogartyInternational Center of the US NationalInstitutes of Health, for example, is aleading proponent of north-southpartnerships and southern capacity-building in the medical arena. Whitingperhaps missed the point of my paper. Itwas not that rich donor nations areobliged to donate aid to poorer nations;rather, if they choose to do so theyshould disburse their aid fairly so thatthose most in need benefit. Works in reputable medical journalscan potentially influence policy-makingand ultimately affect millions of lives. Iapplaud The Lancet for its boldness andtenacity in covering politically sensitiveissues that concern health and humanrights.Jerome A SinghHoward College School of Law, University ofNatal, Durban 4041, South Africa(e-mail: singhj9@nu.ac.za)1 Nabarro D, Loretti A, Colombo A. Increasedequity in postconflict reconstruction. Lancet2003; 362: 1673.2 Singh JA, Nkala B, Amuah E, Mehta N,Ahmad A. The ethics of nurse-poaching fromthe developing world. Nursing Ethics 2003;10: 667–71.none in fact deal with human rights butinstead with social justice and ethicalconcerns. Those working in the fields ofethics, human rights, and social justiceare learning where our fields converge,overlap, and complement one another,but our differences are also importantbecause they define a powerful synergy,rather than redundancy, among thesefields.Traditionally, human rights issues aremeant in the first instance to guide theactions of governments, whereas ethicsmuch more broadly encompassesconcern for the specific actions andrelationships of individual healthworkers, researchers, and organisations.The ethical principles that guide ourwork are the product of broad-basedconsultation and are presented in theform of guidelines and proposed codesof conduct by professional bodies andorganisations. Human rights norms andstandards tend to be drafted bygovernment representatives, negotiatedin political fora, and incorporated in thebody of international law in the form ofinternational treaties which impose legalobligations on the governments thatratify them. Although each piecepresented is certainly worthy ofpublication, I fear that their placementwithin this section will only serve toconfuse the public health community asto the value of human rights, ethics, andsocial justice for public health work. Ourwork requires attention to the distinctvalue of each and the differences in theparadigms they represent. We shouldsupport these differences, but we alsoshould not obscure them. The Lancet, bypromoting a section entitled Health andHuman Rights, also has a responsibilityin this regard.Sofia GruskinProgram on International Health and HumanRights, François-Xavier Bagnoud Center forHealth and Human Rights, Harvard School ofPublic Health, 651 Huntington Avenue, Boston,MA 02115, USA(e-mail: sgruskin@hsph.harvard.edu)What are health and humanrights?Sir—The inclusion in The Lancet overthe past several years of a regular sectionentitled Health and Human Rights hasbrought useful and timely pieces to adiverse audience, and has helped signalwider recognition of this field.Until recently, all the pieces have inone way or another drawn out thehuman rights implications of healthpolicy and practice. Although some ofthese pieces have been skewed towardsthe health effects of civil and politicalrights violation—in particular torture—with insufficient attention to theimplication of economic and socialrights for health, or the effects ofattention to human rights on publichealth programming, all have displayedunderstanding of human rightsprinciples, methods, or instruments.All the more disappointing, therefore,to be confronted with the Health andHuman Rights section in your Sept 20and Nov 15 issues. Although the piecesare to be commended on their ownmerit, and each is timely and interesting,Quality of medicaleducation in MexicoSir—We agree with Julio Frenk andcolleagues (Nov 15, p 1667),1 thatsubstantial advancements have beenmade in the Mexican health system. Webelieve that the proposed structure ofthe National Health Program willimprove the health of the Mexicanpeople, especially the most vulnerable.Frenk and colleagues mention thatthe National Crusade of the Quality ofHealth Services was launched toincrease the effectiveness andresponsiveness of health services bypromoting the certification of healthprofessionals and the use of clinicalguidelines, and by improving access toevidenced-based resources. To achievethis end, we think that changing the wayphysicians are trained and taught isparamount.According to the WHO, Mexico has56 medical schools, from which about7800 physicians graduate each year.This term, 21 235 physicians competedfor 4625 residency spots by undergoingan examination. Results of thisexamination are kept private, and thegeneral public are not informed of howmedical schools rank in terms ofoutcome in this test. Those who aresuccessful must apply to their hospital ofpreference, which then keeps theirpapers and makes a decision on whetheror not they are accepted. This processlimits the physician to applying to onlyone or two institutions, and needless tosay benefits the institutions more thanthe trainees.Residency training in Mexico is doneby following a very strict hierarchicalpattern, teaching is scarce, and residentslearn mostly by imitation rather thanevidence-based medicine. Training isdone under conditions of stress, longhours of work, and poor pay.Evidence2 suggests that Mexicanphysicians in training are poor atcritically reading clinical research. Inone report, 572 residents from differentspecialties were assessed on theirabilities to judge and interpret clinicalresearch. Scores were low, withmedians of less than 34%. 17–28% ofexaminees scored less than they wouldhave if they had answered randomly.2,3In another report, the level of trainingresidents received did not affect theirperformance in this test.4 Clearly thesefindings cannot be applied to allMexican medical residents, but the lackof research in this area leads us tobelieve that they could be a goodindicator.Furthermore, Villasis-Keever andcolleagues5 analysed the seroprevalenceof hepatitis B in residents in oneinstitution, and concluded that only80% had been vaccinated, of whom only41·6% had completed the course. Ifthese physicians do not understand theimportance of preventive medicine, howcan they possibly teach and practise iton their patients?Although the main focus of Frenk andcolleagues’ article is based on healthpolicies rather than education, webelieve that medical education inMexico has to be reformed, and thatteaching in institutions, medical schools,and residency programmes must bestandardised and certified. Thisstandardisation will greatly improve the

Politics in medical journals.

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Politics in medical journals.

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