Correspondence
evaluate children newly diagnosed with hypertrophic cardiomyopathy. We declare that we have no competing interests.
*Steven E Lipshultz, E John Orav, James D Wilkinson, on behalf of the Pediatric Cardiomyopathy Registry Study Group [email protected] Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA (SEL); Department of Pediatrics, Leonard M Miller School of Medicine, University of Miami, Miami, FL 33101, USA (SEL, JDW); and Harvard Medical School, Boston, MA, USA (EJO) 1
2
3
4
5
6
Lipshultz SE, Orav EJ, Wilkinson JD, et al. Risk stratification at diagnosis for children with hypertrophic cardiomyopathy: an analysis of data from the Pediatric Cardiomyopathy Registry. Lancet 2013; 382: 1889–97. Schwartz ML, Cox GF, Lin AE, et al. Clinical approach to genetic cardiomyopathy in children. Circulation 1996; 94: 2021–38. Cox GF, Sleeper LA, Lowe AM, et al. Factors associated with establishing a causal diagnosis in children with cardiomyopathy. Pediatrics 2006; 118: 1519–31. Colan SD, Lipshultz SE, Lowe AM, et al. Epidemiology and cause-specific outcome of hypertrophic cardiomyopathy in children: findings from the Pediatric Cardiomyopathy Registry. Circulation 2007; 115: 773–81. Foerster SR, Canter CE, Cinar A, et al. Ventricular remodeling and survival are more favorable for myocarditis than for idiopathic dilated cardiomyopathy in childhood: an outcomes study from the Pediatric Cardiomyopathy Registry. Circ Heart Fail 2010; 3: 689–97. Wilkinson JD, Lowe AM, Salbert BA, et al. Outcomes in children with Noonan syndrome and hypertrophic cardiomyopathy: a study from the Pediatric Cardiomyopathy Registry. Am Heart J 2012; 164: 442–48.
Whether this intense legislative activity during the past 10 years has modified medical education and clinical practices is not known. I evaluated the knowledge in laïcité of 50 medical students from Paris Descartes University, Paris, and of 50 hospital clinicians from 13 different university medical centres in Paris using the questionnaire available in the appendix. Response rate was 99% for both medical students and clinicians. Strikingly, only 2% of medical students and 4% of clinicians stated that they received some teaching on laïcité in public hospitals. Only 31% of clinicians were aware of the differences between public and private hospitals, where rules vary slightly. The percentages of correct answers (about 60%) were quite similar between medical students and clinicians, suggesting that practice in public hospitals does not help to reinforce the academic education. Should we be satisfied with this paradoxal situation—a very detailed legislation but a lack of education in laïcité in the medical field? 70% of medical students are in favour of specific teachings on laïcité in hospitals. I declare that I have no competing interests.
Georgia Malamut [email protected] Université Paris Descartes-Sorbonne and Hôpital Européen Georges Pompidou, Paris 75015, France
Laïcité in medical schools: a French paradox? 10 years ago, in the context of the 2004 law to ban religious symbols in public schools, Sebastien Tassy and colleagues’ Correspondence 1 in The Lancet recalled the French attachment to the principles of laïcité (French secularism) in public hospitals. Since then, several reforms successively contributed to reshape laïcité in France (specifically in health-care facilities in 2005,2 for people admitted to hospitals in 2006,3 in public services in 2007,4 and the prohibition on full-faced covering up in public spaces in 20105). www.thelancet.com Vol 383 March 1, 2014
1 2
3
4
5
Tassy S, Polski L, Banet J, Gorincour G. Laïcité in hospitals. Lancet 2004; 363: 1401–02. Circulaire DHOS/G/2005/57 du 2 Février 2005 relative à la laïcité dans les établissements de santé. http://www.sante.gouv.fr/fichiers/ bo/2005/05-02/a0020035.htm (last accessed Feb 10, 2014). Circulaire DHOS/E1/DGS/SD1B/SD1C/ SD4A/2006/90 du 2 Mars 2006 relative aux droits des personnes hospitalisées et comportant une charte de la personne hospitalisée. http://circulaire.legifrance.gouv. fr/pdf/2009/04/cir_10571.pdf (last accessed Feb 10, 2014). Circulaire 5209/SG du 13 Avril 2007 relative à la charte de laïcité dans les services publics. http:// www.dgdr.cnrs.fr/bo/2007/07-07/521-bo0707cir5209.htm (last accessed Feb 10, 2014). LOI n° 2010-1192 du 11 Octobre 2010 interdisant la dissimulation du visage dans l’espace public. http://www.legifrance.gouv.fr/ affichTexte.do?cidTexte=JORFTEXT000022911 670&categorieLien=id (last accessed Feb 10, 2014).
Criminalising homosexuality threatens the fight against HIV/AIDS Homosexuality is criminalised in more than 70 countries,1 with severe implications for the health and wellbeing of the lesbian, gay, bisexual, and transgender (LGBT) community. Recent developments in several countries such as India, Uganda, and Nigeria—where HIV/AIDS remains a pressing public health issue—to reintroduce or strengthen criminalisation of homosexuality holds deep ramifications for patients and health-care workers tackling HIV/AIDS. Although temporarily thwarted in Uganda, the alleged proposal to criminalise a failure to “report” gay persons adds to the alarm.2 The success of the global campaign to reduce HIV transmission, radically improve antiretroviral therapy access, and maintain patient adherence has been rooted in the basis that tackling the heterosexual and homosexual epidemics collectively, through a respect for the rights of all people, including those most vulnerable to HIV, is the optimum approach.3 Criminalising homosexuality might do untold damage to HIV treatment and prevention efforts that have succeeded in engaging with the homosexual community, a feeling recently expressed by HIV/AIDS physicians in Europe.4 LGBT persons might already encounter stigma and discrimination at home and the workplace, making engagement with health-care programmes challenging; the prospect of criminal prosecution could dissuade them from seeking medical help altogether. Will health-care workers be afforded protection to treat homosexual patients in confidence? Or will they be under actual or perceived duress to report members of the homosexual community to authorities? These questions hold implications not only for the HIV/AIDS community, but
See Online for appendix
783
Correspondence
the medical community as a whole. They threaten both the trust placed in health-care professionals and their efforts to achieve universal health coverage. Finally, public attention and advocacy should rightly be invested in campaigning against legislation changes in countries; however, equal attention is needed in settings in which they are already in law. The ambitious goals to tackle HIV by 2015 as outlined by UNAIDS, particularly to halve the number of countries with “punitive laws and practices around HIV transmission, sex work, drug use or homosexuality that block effective responses” 5 cannot be achieved if we are going backwards and not forwards. If homosexual communities are further marginalised or isolated by national policies, the prospect of undoing progress in HIV/AIDS care is real. The international health community, together with those in law, human rights, and equality, can ill-afford to not make this case heard. I declare that I have no competing interest. For more on the International Society of Drug Bulletins see http://www.isdbweb.org/
Ashton Barnett-Vanes [email protected] St George’s University of London, London SW17 0QT, UK 1
2
3
4
5
784
Office of the High Commissioner for Human Rights. Tackling discrimination on grounds of sexual orientation and gender identity. http:// www.ohchr.org/Documents/Issues/ Discrimination/LGBT_discrimination_A4.pdf (accessed Jan 27, 2014). Smith D. Ugandan MPs rush through draconian laws against homosexuality. The Guardian (London), Dec 20, 2013. http:// www.theguardian.com/world/2013/dec/20/ uganda-mps-laws-homosexuality (accessed Jan 27, 2014). UNAIDS. UNAIDS expresses concern over proposed ‘Anti-Homosexuality Bill’ in Uganda. 2011. http://www.unaids.org/en/resources/ presscentre/pressreleaseandstatementarchive/ 2011/may/20110510psuganda/ (accessed Jan 27, 2014). Alcorn K. European physicians condemn impact of Russian anti-gay law on HIV prevention and care. Nam Aidsmap, Oct 16, 2013. http://www.aidsmap.com/Europeanphysicians-condemn-impact-of-Russian-antigay-law-on-HIV-prevention-and-care/ page/2780967/ (accessed Jan 27, 2014). UNAIDS. UNAIDS Strategy 2011–2015. http:// www.unaids.org/en/aboutunaids/ unaidsstrategygoalsby2015/ (accessed Jan 27, 2014).
Independent drug information in Burkina Faso is key to improving public health It is a quiet morning at the Centre for Documentation and Information on Medicines (CEDIM) in Burkina Faso. Someone knocks on the door: a drug industry representative barges in complaining. She has visited several hospitals and to her dismay, physicians are challenging use of her company’s drug. They continue to prescribe the reference treatment with a favourable benefit–risk balance, as recommended in the latest issue of the local drug bulletin La Lettre du CEDIM. Such visits occur often. CEDIM was established 25 years ago with the support of WHO. CEDIM provides local doctors and community health workers with tailored and evidence-based information about medicines and health strategies and publishes La Lettre du CEDIM—a quarterly 16-page drug bulletin. La Lettre du CEDIM is part of the International Society of Drug Bulletins, a worldwide network of publications on drugs and therapeutics founded in 1986. Despite CEDIM’s impressive track record and international recognition, the only independent drug bulletin in francophone sub-Saharan Africa is now threatened. After recent reorganisations at the Ministry of Health, CEDIM’s autonomy in the use of its €30 000 annual budget covering, among other items, publication costs, is jeopardised—putting CEDIM’s independence and sustainability at risk. In a resource-constrained setting, where reliable information is scarce, internet access is difficult, and libraries are few and ill-equipped, CEDIM’s role is even more remarkable. Independent high-quality drug information is key to improvements in public health, particularly when health workers will otherwise rely on advertising materials
from pharmaceutical companies as sources of information about new drugs.1 We call upon the Burkina Faso Government and the international scientific community to ensure that CEDIM can continue to deliver its valuable, necessary, and independent input for better care in Burkina Faso and beyond. We declare that we have no competing interests.
Gianni Tognoni, Bruno Toussaint, *Andrew Herxheimer, Jörg Schaaber [email protected] Clinical Pharmacology Laboratory, Mario Negri Institute, Milan, Italy (GT); Prescrire, Paris, France (BT); UK Cochrane Centre, Oxford OX2 7LG, UK (AH), and International Society of Drug Bulletins, Bielefeld, Germany (JS) 1
Burnand B. Independent drug bulletins to promote the prescription of appropriate drugs: a necessary but difficult task. Bull World Health Organ 2013. http://www.who. int/bulletin/volumes/91/6/13-122762/en/ (accessed Feb 17, 2014).
www.thelancet.com Vol 383 March 1, 2014
evaluate children newly diagnosed with hypertrophic cardiomyopathy. We declare that we have no competing interests.
*Steven E Lipshultz, E John Orav, James D Wilkinson, on behalf of the Pediatric Cardiomyopathy Registry Study Group [email protected] Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA (SEL); Department of Pediatrics, Leonard M Miller School of Medicine, University of Miami, Miami, FL 33101, USA (SEL, JDW); and Harvard Medical School, Boston, MA, USA (EJO) 1
2
3
4
5
6
Lipshultz SE, Orav EJ, Wilkinson JD, et al. Risk stratification at diagnosis for children with hypertrophic cardiomyopathy: an analysis of data from the Pediatric Cardiomyopathy Registry. Lancet 2013; 382: 1889–97. Schwartz ML, Cox GF, Lin AE, et al. Clinical approach to genetic cardiomyopathy in children. Circulation 1996; 94: 2021–38. Cox GF, Sleeper LA, Lowe AM, et al. Factors associated with establishing a causal diagnosis in children with cardiomyopathy. Pediatrics 2006; 118: 1519–31. Colan SD, Lipshultz SE, Lowe AM, et al. Epidemiology and cause-specific outcome of hypertrophic cardiomyopathy in children: findings from the Pediatric Cardiomyopathy Registry. Circulation 2007; 115: 773–81. Foerster SR, Canter CE, Cinar A, et al. Ventricular remodeling and survival are more favorable for myocarditis than for idiopathic dilated cardiomyopathy in childhood: an outcomes study from the Pediatric Cardiomyopathy Registry. Circ Heart Fail 2010; 3: 689–97. Wilkinson JD, Lowe AM, Salbert BA, et al. Outcomes in children with Noonan syndrome and hypertrophic cardiomyopathy: a study from the Pediatric Cardiomyopathy Registry. Am Heart J 2012; 164: 442–48.
Whether this intense legislative activity during the past 10 years has modified medical education and clinical practices is not known. I evaluated the knowledge in laïcité of 50 medical students from Paris Descartes University, Paris, and of 50 hospital clinicians from 13 different university medical centres in Paris using the questionnaire available in the appendix. Response rate was 99% for both medical students and clinicians. Strikingly, only 2% of medical students and 4% of clinicians stated that they received some teaching on laïcité in public hospitals. Only 31% of clinicians were aware of the differences between public and private hospitals, where rules vary slightly. The percentages of correct answers (about 60%) were quite similar between medical students and clinicians, suggesting that practice in public hospitals does not help to reinforce the academic education. Should we be satisfied with this paradoxal situation—a very detailed legislation but a lack of education in laïcité in the medical field? 70% of medical students are in favour of specific teachings on laïcité in hospitals. I declare that I have no competing interests.
Georgia Malamut [email protected] Université Paris Descartes-Sorbonne and Hôpital Européen Georges Pompidou, Paris 75015, France
Laïcité in medical schools: a French paradox? 10 years ago, in the context of the 2004 law to ban religious symbols in public schools, Sebastien Tassy and colleagues’ Correspondence 1 in The Lancet recalled the French attachment to the principles of laïcité (French secularism) in public hospitals. Since then, several reforms successively contributed to reshape laïcité in France (specifically in health-care facilities in 2005,2 for people admitted to hospitals in 2006,3 in public services in 2007,4 and the prohibition on full-faced covering up in public spaces in 20105). www.thelancet.com Vol 383 March 1, 2014
1 2
3
4
5
Tassy S, Polski L, Banet J, Gorincour G. Laïcité in hospitals. Lancet 2004; 363: 1401–02. Circulaire DHOS/G/2005/57 du 2 Février 2005 relative à la laïcité dans les établissements de santé. http://www.sante.gouv.fr/fichiers/ bo/2005/05-02/a0020035.htm (last accessed Feb 10, 2014). Circulaire DHOS/E1/DGS/SD1B/SD1C/ SD4A/2006/90 du 2 Mars 2006 relative aux droits des personnes hospitalisées et comportant une charte de la personne hospitalisée. http://circulaire.legifrance.gouv. fr/pdf/2009/04/cir_10571.pdf (last accessed Feb 10, 2014). Circulaire 5209/SG du 13 Avril 2007 relative à la charte de laïcité dans les services publics. http:// www.dgdr.cnrs.fr/bo/2007/07-07/521-bo0707cir5209.htm (last accessed Feb 10, 2014). LOI n° 2010-1192 du 11 Octobre 2010 interdisant la dissimulation du visage dans l’espace public. http://www.legifrance.gouv.fr/ affichTexte.do?cidTexte=JORFTEXT000022911 670&categorieLien=id (last accessed Feb 10, 2014).
Criminalising homosexuality threatens the fight against HIV/AIDS Homosexuality is criminalised in more than 70 countries,1 with severe implications for the health and wellbeing of the lesbian, gay, bisexual, and transgender (LGBT) community. Recent developments in several countries such as India, Uganda, and Nigeria—where HIV/AIDS remains a pressing public health issue—to reintroduce or strengthen criminalisation of homosexuality holds deep ramifications for patients and health-care workers tackling HIV/AIDS. Although temporarily thwarted in Uganda, the alleged proposal to criminalise a failure to “report” gay persons adds to the alarm.2 The success of the global campaign to reduce HIV transmission, radically improve antiretroviral therapy access, and maintain patient adherence has been rooted in the basis that tackling the heterosexual and homosexual epidemics collectively, through a respect for the rights of all people, including those most vulnerable to HIV, is the optimum approach.3 Criminalising homosexuality might do untold damage to HIV treatment and prevention efforts that have succeeded in engaging with the homosexual community, a feeling recently expressed by HIV/AIDS physicians in Europe.4 LGBT persons might already encounter stigma and discrimination at home and the workplace, making engagement with health-care programmes challenging; the prospect of criminal prosecution could dissuade them from seeking medical help altogether. Will health-care workers be afforded protection to treat homosexual patients in confidence? Or will they be under actual or perceived duress to report members of the homosexual community to authorities? These questions hold implications not only for the HIV/AIDS community, but
See Online for appendix
783
Correspondence
the medical community as a whole. They threaten both the trust placed in health-care professionals and their efforts to achieve universal health coverage. Finally, public attention and advocacy should rightly be invested in campaigning against legislation changes in countries; however, equal attention is needed in settings in which they are already in law. The ambitious goals to tackle HIV by 2015 as outlined by UNAIDS, particularly to halve the number of countries with “punitive laws and practices around HIV transmission, sex work, drug use or homosexuality that block effective responses” 5 cannot be achieved if we are going backwards and not forwards. If homosexual communities are further marginalised or isolated by national policies, the prospect of undoing progress in HIV/AIDS care is real. The international health community, together with those in law, human rights, and equality, can ill-afford to not make this case heard. I declare that I have no competing interest. For more on the International Society of Drug Bulletins see http://www.isdbweb.org/
Ashton Barnett-Vanes [email protected] St George’s University of London, London SW17 0QT, UK 1
2
3
4
5
784
Office of the High Commissioner for Human Rights. Tackling discrimination on grounds of sexual orientation and gender identity. http:// www.ohchr.org/Documents/Issues/ Discrimination/LGBT_discrimination_A4.pdf (accessed Jan 27, 2014). Smith D. Ugandan MPs rush through draconian laws against homosexuality. The Guardian (London), Dec 20, 2013. http:// www.theguardian.com/world/2013/dec/20/ uganda-mps-laws-homosexuality (accessed Jan 27, 2014). UNAIDS. UNAIDS expresses concern over proposed ‘Anti-Homosexuality Bill’ in Uganda. 2011. http://www.unaids.org/en/resources/ presscentre/pressreleaseandstatementarchive/ 2011/may/20110510psuganda/ (accessed Jan 27, 2014). Alcorn K. European physicians condemn impact of Russian anti-gay law on HIV prevention and care. Nam Aidsmap, Oct 16, 2013. http://www.aidsmap.com/Europeanphysicians-condemn-impact-of-Russian-antigay-law-on-HIV-prevention-and-care/ page/2780967/ (accessed Jan 27, 2014). UNAIDS. UNAIDS Strategy 2011–2015. http:// www.unaids.org/en/aboutunaids/ unaidsstrategygoalsby2015/ (accessed Jan 27, 2014).
Independent drug information in Burkina Faso is key to improving public health It is a quiet morning at the Centre for Documentation and Information on Medicines (CEDIM) in Burkina Faso. Someone knocks on the door: a drug industry representative barges in complaining. She has visited several hospitals and to her dismay, physicians are challenging use of her company’s drug. They continue to prescribe the reference treatment with a favourable benefit–risk balance, as recommended in the latest issue of the local drug bulletin La Lettre du CEDIM. Such visits occur often. CEDIM was established 25 years ago with the support of WHO. CEDIM provides local doctors and community health workers with tailored and evidence-based information about medicines and health strategies and publishes La Lettre du CEDIM—a quarterly 16-page drug bulletin. La Lettre du CEDIM is part of the International Society of Drug Bulletins, a worldwide network of publications on drugs and therapeutics founded in 1986. Despite CEDIM’s impressive track record and international recognition, the only independent drug bulletin in francophone sub-Saharan Africa is now threatened. After recent reorganisations at the Ministry of Health, CEDIM’s autonomy in the use of its €30 000 annual budget covering, among other items, publication costs, is jeopardised—putting CEDIM’s independence and sustainability at risk. In a resource-constrained setting, where reliable information is scarce, internet access is difficult, and libraries are few and ill-equipped, CEDIM’s role is even more remarkable. Independent high-quality drug information is key to improvements in public health, particularly when health workers will otherwise rely on advertising materials
from pharmaceutical companies as sources of information about new drugs.1 We call upon the Burkina Faso Government and the international scientific community to ensure that CEDIM can continue to deliver its valuable, necessary, and independent input for better care in Burkina Faso and beyond. We declare that we have no competing interests.
Gianni Tognoni, Bruno Toussaint, *Andrew Herxheimer, Jörg Schaaber [email protected] Clinical Pharmacology Laboratory, Mario Negri Institute, Milan, Italy (GT); Prescrire, Paris, France (BT); UK Cochrane Centre, Oxford OX2 7LG, UK (AH), and International Society of Drug Bulletins, Bielefeld, Germany (JS) 1
Burnand B. Independent drug bulletins to promote the prescription of appropriate drugs: a necessary but difficult task. Bull World Health Organ 2013. http://www.who. int/bulletin/volumes/91/6/13-122762/en/ (accessed Feb 17, 2014).
www.thelancet.com Vol 383 March 1, 2014
