Boulle, P

Fernandez, G

MSF Field Research

Correspondence
www.thelancet.com   Vol 381   March 16, 2013 901
Submissions should be 
made via our electronic 
submission system at 
http://ees.elsevier.com/
thelancet/
northwest of England. We followed 
up almost 15 000 patients over an 
8-year period using a district-wide 
diabetes register encompassing both 
primary and secondary care. Our 
ﬁ ndings indicate a falling mortality 
rate in type 2 diabetes.2
Simmons and colleagues recruited 
a large number of individuals in the 
screening and control practices, but 
a relatively small number of patients 
with diabetes was followed up. The 
intraclass correlation coeﬃ  cient, 
which can only be indirectly estimated 
owing to the confounding eﬀ ects in 
the two paired clusters, is unreliable. 
It is also possible to overestimate 
the stability of a trial of less than 
40 clusters owing to the probability of 
large standard errors.3
Furthermore, the validity of permu-
tation tests becomes unreliable 
since there are imbalances in the 
cohort cluster size and consequently 
distortion in the paired matching 
results.4 The assumptions of the 
Cox proportional hazard modelling, 
which tests the mortality risks in the 
screened and controlled cohorts, is 
normally based on error variations 
in the cohort groups and not within 
matched pairs.5
Finally, Simmons and colleagues 
have not revealed whether there were 
adjustments for other covariates in the 
all-cause mortality in both cohorts. We 
suggest that Simmons and colleagues 
present their hazard ratios alongside 
a measure of time such as median 
time to death in comparison with the 
screened and controlled cohorts.
We declare that we have no conﬂ icts of interest.
*Chukwuemeka Nwaneri, 
David Bowen-Jones, Helen Cooper
c.nwaneri@chester.ac.uk
Department of Community & Child Health, 
University of Chester, Chester CH1 1SL, UK (CN, HC); 
and Centre for Diabetes and Endocrinology, The 
Wirral University Teaching Hospital NH S Foundation 
Trust, Arrowe Park Hospital, Upton, UK (CN, DB-J)
1 Simmons RK, Echouﬀ o-Tceugui JB, Sharp SJ, 
et al. Screening for type 2 diabetes and 
population mortality over 10 years 
(ADDITION-Cambridge): a cluster-randomised 
controlled trial. Lancet 2012; 380: 1741–48.
Where conﬂ ict’s medical 
consequences remain 
unchanged 
In the aftermath of the 2003 war in 
Iraq, much attention was focused on 
state reconstruction and development 
eﬀ orts. However, many remote areas 
were excluded from these develop-
ments, leaving thousands of Iraqis 
without access to essential health care 
to this day.
The explanation for this situation 
can be found in the conditions that 
aﬀ ected the develop ment of health 
provision during and after the conﬂ ict. 
Substantial and ongoing security 
constraints prevented humanitarian 
actors from accessing and properly 
assessing the medical needs in many 
parts of Iraq. Aid was mainly limited 
to the provision of supplies and 
training from abroad, without direct 
popu lation contact and the ability 
to provide prompt and targeted 
adjustment to the support.1,2
With an estimated population of half 
a million people, Hawijah district of 
Kirkuk Governorate is a vivid example of 
where the medical consequences of the 
conﬂ ict continue. As a result of the well 
documented exodus of Iraqi medical 
doctors ﬂ eeing the country’s violence,3 
and by the much less described internal 
migration of professionals towards 
safer areas within Iraq, it is extremely 
diﬃ  cult to ﬁ nd Iraqi medical doctors 
willing to work in Hawijah, because 
they fear for their security. Rural 
primary health-care centres continue to 
report shortages of medical personnel, 
drugs, and services. Basic components 
of hospital medical care, including 
infection control and nursing skills, 
are sorely lacking and still in need of 
external support. The 116-bed district 
hospital remains without adequate 
human resource capacity to sustain 
the availability of emergency surgical 
services 24 h per day. With more than 
3300 consultations in September 
and October, 2012 (Médecins Sans 
Frontières [MSF], unpublished data), 
the hospital’s busy emergency room 
remains highly dependent on three 
newly graduated doctors, often 
working alone since senior profes-
sionals are scarce. After almost 3 years 
of continuous support, MSF staﬀ  are 
still responsible for half of the hospital’s 
anaesthetic procedures. 
This situation in remote areas is 
not often portrayed in the media or 
medical literature, but MSF is witness 
to the struggle faced by health services 
in Hawijah to provide adequate care 
to the population. Development and 
state-building eﬀ orts need to reach 
every citizen, and to do so much more 
attention needs to be given to remote 
areas where the reality for Iraqis has 
not substantially improved over the 
past 10 years.
We declare that we have no conﬂ icts of interest.
*Gustavo Fernandez, Philippa Boulle
gustavo.fernandez@geneva.msf.org
Médecins Sans Frontières Switzerland, 
1211 Geneva 21, Switzerland
1 Burkle F. Measuring humanitarian assistance in 
conﬂ icts. Lancet 2008;  371: 189–90.
2 Humanitarian Policy Group. Humanitarian 
action in Iraq: putting the pieces together. 
March 2008. http://www.odi.org.uk/sites/odi.
org.uk/ﬁ les/odi-assets/publications-opinion-
ﬁ les/1716.pdf (accessed Dec 13, 2012).
3 Webster P. Iraq’s health system yet to heal 
from ravages of war. Lancet 2011;  
378: 863–66.
Screening for type 2 
diabetes and population 
mortality over 10 years
The study by Rebecca Simmons 
and colleagues (Nov 17, p 1741)1 is 
interpreted as showing little or no 
mortality beneﬁ t from screening for 
type 2 diabetes mellitus in general 
practices in eastern England. In our 
view the results should be treated 
with caution because they depend on 
low patient numbers and notoriously 
unreliable death certiﬁ cation as a 
means of identifying cause of death.
The ﬁ ndings contrast with our own 
data on a large district population of 
patients with type 2 diabetes in the 
Co
rb
is


Where conflict's medical consequences remain unchanged [letter]

Gustavo Fernandez

Philippa Boulle

Crossref

The Lancet