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
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
