Correspondence
For the UK Department of Health report, Overseas visitors and migrant use of the NHS: extent and costs see https:// www.gov.uk/government/ publications/overseas-visitorsand-migrant-use-of-the-nhsextent-and-costs
detailed scrutiny of the policy and its underpinning evidence, there is a particular danger that pregnant women might be denied or put off accessing clinically and cost-effective care. The UK already charges visitors and some migrants for maternity care. Although policy is that maternity care should be provided even if a woman is unable to pay, nonetheless women have been refused treatment.2 Hospital trusts have a duty to recover costs but should not go beyond what is reasonable when pursuing charges.3 Imposing any form of charge is out of line with many European countries who exempt pregnancy entirely (eg, France, Belgium, Spain, Italy, Portugal, and the Netherlands), so extending charging even further to primary care is unnecessary and risky. Finally, there is a well established association between disadvantaged women (including recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English) and failure to access care early, or at all, leading to poor outcomes.4,5 Far from being fair, these proposals are liable to lead to worse outcomes for vulnerable women and babies. We declare that we have no conflicts of interest.
*Susan Bewley, Rosalind Bragg, Simon Popay, Abigail Fitzgibbon [email protected] Women’s Health Academic Department, Kings College London, London SE1 7NH, UK (SB); Maternity Action, London, UK (RB); Royal College of Midwives, London, UK (SP); and British Pregnancy Advisory Service, London, UK (AF) 1 2
3
4
124
The Lancet. Immigration and health in the UK. Lancet 2013; 382: 1459. Joint Committee on Human Rights. Tenth Report. Provision of healthcare (135–43). www.publications.parliament.uk/pa/ jt200607/jtselect/jtrights/81/8107.htm (accessed Nov 15, 2013). Department of Health. Guidance on implementing the overseas visitors hospital charging regulations, 2012 (pp 43, 48). https:// www.gov.uk/government/uploads/system/ uploads/attachment_data/file/213015/ GUIDANCE-October-2012-FINAL.pdf (accessed Nov 8, 2013). National Institute for Health and Care Excellence. Pregnancy and complex social factors, 2010. http://www.nice.org.uk/ nicemedia/live/13167/50822/50822.pdf (accessed Nov 8, 2013).
5
Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118: 1–203.
Does take-home naloxone reduce non-fatal overdose? After a 1 year assessment of community or prison-based prescription of take-home naloxone (THN) to opiate users in Wales,1 the Welsh Government rolled out nationally the prescription of THN later in 2011. The main aim was to reduce opiaterelated overdose deaths from about 85 per year (for 2006–09). In 2010, there were 68 opiate-related deaths in Wales, but an 18% reduction was also reported in England (from 1065 opiate-related deaths per year in 2006–09, to 873 in 2010). Because of delays in death-registration in England and Wales,2 the data for 2011 and 2012 are still incomplete. National data on the prevalence of non-fatal overdose in Wales are lacking. We designed a national survey of non-fatal overdose among injecting opiate users who attended needleexchange schemes to create a baseline measure of the prevalence of nonfatal overdose that could be useful to monitor the impact of THN and other harm-reduction interventions. The survey, done in February and March 2013, included 661 respondents (48% of the 1380 opiate users registered in the needle exchange organisation’s database). Among these 661 injecting opiate users, 308 had overdosed and 100 had overdosed in the past 12 months (similar to the 12% [39 out of 313] reported by Gossop and colleagues,3 in 1994). Of those who had overdosed in the past year, 85 disclosed how many times: once (44), two times (26), three (seven), four (two), five (two), six (one), seven (one), eight (one), and 12 times (one):
a total of 168 survived overdoses. The mean was thus 2·0 (standard error 0·2) survived overdoses per respondent who had overdosed in the past year. For the 308 most recently survived opiate overdoses, naloxone was given by paramedics (58), by nonparamedics (49), or by both (6)—ie, in 113 out of 308 (37%, 95% CI 31–42%) overdoses. 97 of 661 respondents were registered by a city-centre hostel, which accommodated opiate users. Excluding the hostel site, 58 administrations of naloxone were done by paramedics, 15 by someone else, and six by both; the ratio of paramedical to other administrations was 3:1. This ratio is likely to change over time and should continue to be monitored. 284 of 308 respondents disclosed whether they were alone at the time of their most recent overdose: 245 were with someone else (86%, 95% CI 82–90%). Such surveys are a minimally biased way of obtaining information on non-fatal overdoses, but at least 60% response rate and good geographical representation are desirable. The main challenge here was managing trust in data entry as respondents’ answers were entered onto a research-only part of a database that is otherwise used to log client attendances. If individuals are not persuaded about the integrity of the survey database, they might be unwilling to take part or give honest answers. Valid estimates of the prevalence of non-fatal overdoses across locations and times could assist in targeting and assessment of overdose prevention strategies. TB and KH declare that they have no conflicts of interest. SMB is co-principal investigator for the prison-based N-ALIVE pilot trial of naloxone-onrelease and serves on Scotland’s National Naloxone Advisory Group.
Trevor Bennett, Katy Holloway, *Sheila M Bird [email protected] University of South Wales, Centre for Criminology, Pontypridd, UK (TB, KH); and MRC Biostatistics Unit, Cambridge CB2 0SR, UK (SMB)
www.thelancet.com Vol 383 January 11, 2014
Correspondence
2 3
Bennett TH, Holloway K. The impact of takehome naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN project in Wales. Drugs Educ Prevent Policy 2012; 19: 320–28. Bird SM. Counting the dead properly and promptly. J R Stat Soc 2013; 176: 815–817. Gossop M, Griffiths P, Powis B, Williamson S, Strang J. Frequency of non-fatal heroin overdose; survey of heroin users recruited in non-clinical settings. BMJ 1996; 313: 402.
Webcast the World Health Assembly Once a year, delegates of WHO member states gather in Geneva for the World Health Assembly (WHA) to establish WHO’s priorities and programmes for the coming year. Those health practitioners, scholars, advocates, and journalists who are brave (or foolish) enough to come to the event jostle for credentials and queue for security, after spending thousands of dollars and burning tanks of jet fuel, with no guarantee of having a seat in the small public gallery. The expense and bother of attending the WHA have many negative consequences for international health governance. Many civil society organisations, especially those from low-income and middle-income countries for whom foreign travel is prohibitively expensive, are excluded, as are the vulnerable populations they represent. Few journalists have the resources to attend the WHA, so even important global health stories go unreported. Transparency, debate, and accountability all suffer as a result. We believe that a substantial improvement would be made by webcasting the WHA and, in due course, all WHO regional committee and member state meetings. This would allow many more people to observe and even to comment on the proceedings in real time with social media. Wider debate and extra publicity would also establish the WHA as an annual event of importance, and thereby reinforce the public perception of WHO. www.thelancet.com Vol 383 January 11, 2014
WHO is the untransparent exception in the UN for not webcasting its meetings. The UN Security Council and General Assembly webcast many proceedings; and so do most UN agencies (such as the Food and Agriculture Organization, the International Atomic Energy Agency, or the World Intellectual Property Organization, among others). Possibly the most enthusiastic is the International Telecommunications Union, which webcasts even its preparatory meetings and provides an open forum for public input.1 Plainly, WHO must catch up. Currently, some of WHO’s regional committees webcast parts of their proceedings.2 For a comprehensive webcasting as soon as the 2014 WHA, technical, legal, and political challenges need to be discussed. Technically, the WHA is already carried on closed-circuit video with simultaneous interpretation in the six UN languages. Live streaming these audio and video channels is easily done with a conventional internet connection, and need not be expensive, especially if the other UN organisations in Geneva share their technical facilities. Legally, there is nothing secret or proprietary about WHA proceedings (excluding closed-door diplomatic sessions). Observers range freely over the meeting hall, and there is no reasonable expectation of privacy over anything said or done. WHO has already taken the liberty of webcasting selected speeches and sights from the scene.3,4 Nothing would be transgressed by comprehensive webcasting in real time. Politically, many UN forums are webcast, so the WHA should be no different. A difficulty is that the WHO Secretariat has as recently as this year refused to enforce the organisation’s transparency rules when faced with opposition from some member states. A WHA Resolution passed by member states in 1987 gives officially recognised NGOs the “right...to participate” in committee
meetings convened under WHO’s authority.5 That this express legal right is sometimes being breached suggests that the WHO Secretariat is less committed to transparency than it might be. When the WHO’s Executive Board meets in January, 2014, we urge that it (and not the Secretariat) decide to webcast the comprehensive WHA 2014 proceedings. The Executive Board already makes all the basic decisions about convening the WHA, such as choosing the time and place, so it could easily stipulate webcasting too. It would then be up to WHO’s Director General, acting at the Executive Board’s request, to inform member states and to make the necessary arrangements. We expect these proposals to be popular all around. Although poor countries and smaller NGOs have the most to gain, in times of austerity all member states can save money by bringing fewer officials to the WHA. For health professionals, scholars, and activists, webcasts will often make the difference between being au courant with the WHA and global health governance or not at all. Indeed, the reasons are so compelling that it is surprising that the WHA has not already been webcast by public health “hacktivists” with camera phones. That might be the eventual outcome, although it would be better for WHO to do so first.
UIG via Getty Images
1
We declare that we have no conflicts of interest.
*Amir Attaran, David Benton, James Chauvin, Martin McKee, Valerie Percival [email protected] University of Ottawa, Faculty of Law, Ottawa, ON, Canada (AA); International Council of Nurses, Geneva, Switzerland (DB); World Federation of Public Health Associations, Geneva, Switzerland (JC); London School of Hygiene and Tropical Medicine, London, UK (MM); and Norman Patterson School of International Affairs, Carleton University, Ottawa, Canada (VP) 1
International Telecommunications Union. World Conference on International Telecommunications (WCIT-12); Dubai, United Arab Emirates Dec 3–14, 2012. http://www.itu. int/en/wcit-12/Pages/default.aspx (accessed Sept 11, 2013).
125
For the UK Department of Health report, Overseas visitors and migrant use of the NHS: extent and costs see https:// www.gov.uk/government/ publications/overseas-visitorsand-migrant-use-of-the-nhsextent-and-costs
detailed scrutiny of the policy and its underpinning evidence, there is a particular danger that pregnant women might be denied or put off accessing clinically and cost-effective care. The UK already charges visitors and some migrants for maternity care. Although policy is that maternity care should be provided even if a woman is unable to pay, nonetheless women have been refused treatment.2 Hospital trusts have a duty to recover costs but should not go beyond what is reasonable when pursuing charges.3 Imposing any form of charge is out of line with many European countries who exempt pregnancy entirely (eg, France, Belgium, Spain, Italy, Portugal, and the Netherlands), so extending charging even further to primary care is unnecessary and risky. Finally, there is a well established association between disadvantaged women (including recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English) and failure to access care early, or at all, leading to poor outcomes.4,5 Far from being fair, these proposals are liable to lead to worse outcomes for vulnerable women and babies. We declare that we have no conflicts of interest.
*Susan Bewley, Rosalind Bragg, Simon Popay, Abigail Fitzgibbon [email protected] Women’s Health Academic Department, Kings College London, London SE1 7NH, UK (SB); Maternity Action, London, UK (RB); Royal College of Midwives, London, UK (SP); and British Pregnancy Advisory Service, London, UK (AF) 1 2
3
4
124
The Lancet. Immigration and health in the UK. Lancet 2013; 382: 1459. Joint Committee on Human Rights. Tenth Report. Provision of healthcare (135–43). www.publications.parliament.uk/pa/ jt200607/jtselect/jtrights/81/8107.htm (accessed Nov 15, 2013). Department of Health. Guidance on implementing the overseas visitors hospital charging regulations, 2012 (pp 43, 48). https:// www.gov.uk/government/uploads/system/ uploads/attachment_data/file/213015/ GUIDANCE-October-2012-FINAL.pdf (accessed Nov 8, 2013). National Institute for Health and Care Excellence. Pregnancy and complex social factors, 2010. http://www.nice.org.uk/ nicemedia/live/13167/50822/50822.pdf (accessed Nov 8, 2013).
5
Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118: 1–203.
Does take-home naloxone reduce non-fatal overdose? After a 1 year assessment of community or prison-based prescription of take-home naloxone (THN) to opiate users in Wales,1 the Welsh Government rolled out nationally the prescription of THN later in 2011. The main aim was to reduce opiaterelated overdose deaths from about 85 per year (for 2006–09). In 2010, there were 68 opiate-related deaths in Wales, but an 18% reduction was also reported in England (from 1065 opiate-related deaths per year in 2006–09, to 873 in 2010). Because of delays in death-registration in England and Wales,2 the data for 2011 and 2012 are still incomplete. National data on the prevalence of non-fatal overdose in Wales are lacking. We designed a national survey of non-fatal overdose among injecting opiate users who attended needleexchange schemes to create a baseline measure of the prevalence of nonfatal overdose that could be useful to monitor the impact of THN and other harm-reduction interventions. The survey, done in February and March 2013, included 661 respondents (48% of the 1380 opiate users registered in the needle exchange organisation’s database). Among these 661 injecting opiate users, 308 had overdosed and 100 had overdosed in the past 12 months (similar to the 12% [39 out of 313] reported by Gossop and colleagues,3 in 1994). Of those who had overdosed in the past year, 85 disclosed how many times: once (44), two times (26), three (seven), four (two), five (two), six (one), seven (one), eight (one), and 12 times (one):
a total of 168 survived overdoses. The mean was thus 2·0 (standard error 0·2) survived overdoses per respondent who had overdosed in the past year. For the 308 most recently survived opiate overdoses, naloxone was given by paramedics (58), by nonparamedics (49), or by both (6)—ie, in 113 out of 308 (37%, 95% CI 31–42%) overdoses. 97 of 661 respondents were registered by a city-centre hostel, which accommodated opiate users. Excluding the hostel site, 58 administrations of naloxone were done by paramedics, 15 by someone else, and six by both; the ratio of paramedical to other administrations was 3:1. This ratio is likely to change over time and should continue to be monitored. 284 of 308 respondents disclosed whether they were alone at the time of their most recent overdose: 245 were with someone else (86%, 95% CI 82–90%). Such surveys are a minimally biased way of obtaining information on non-fatal overdoses, but at least 60% response rate and good geographical representation are desirable. The main challenge here was managing trust in data entry as respondents’ answers were entered onto a research-only part of a database that is otherwise used to log client attendances. If individuals are not persuaded about the integrity of the survey database, they might be unwilling to take part or give honest answers. Valid estimates of the prevalence of non-fatal overdoses across locations and times could assist in targeting and assessment of overdose prevention strategies. TB and KH declare that they have no conflicts of interest. SMB is co-principal investigator for the prison-based N-ALIVE pilot trial of naloxone-onrelease and serves on Scotland’s National Naloxone Advisory Group.
Trevor Bennett, Katy Holloway, *Sheila M Bird [email protected] University of South Wales, Centre for Criminology, Pontypridd, UK (TB, KH); and MRC Biostatistics Unit, Cambridge CB2 0SR, UK (SMB)
www.thelancet.com Vol 383 January 11, 2014
Correspondence
2 3
Bennett TH, Holloway K. The impact of takehome naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN project in Wales. Drugs Educ Prevent Policy 2012; 19: 320–28. Bird SM. Counting the dead properly and promptly. J R Stat Soc 2013; 176: 815–817. Gossop M, Griffiths P, Powis B, Williamson S, Strang J. Frequency of non-fatal heroin overdose; survey of heroin users recruited in non-clinical settings. BMJ 1996; 313: 402.
Webcast the World Health Assembly Once a year, delegates of WHO member states gather in Geneva for the World Health Assembly (WHA) to establish WHO’s priorities and programmes for the coming year. Those health practitioners, scholars, advocates, and journalists who are brave (or foolish) enough to come to the event jostle for credentials and queue for security, after spending thousands of dollars and burning tanks of jet fuel, with no guarantee of having a seat in the small public gallery. The expense and bother of attending the WHA have many negative consequences for international health governance. Many civil society organisations, especially those from low-income and middle-income countries for whom foreign travel is prohibitively expensive, are excluded, as are the vulnerable populations they represent. Few journalists have the resources to attend the WHA, so even important global health stories go unreported. Transparency, debate, and accountability all suffer as a result. We believe that a substantial improvement would be made by webcasting the WHA and, in due course, all WHO regional committee and member state meetings. This would allow many more people to observe and even to comment on the proceedings in real time with social media. Wider debate and extra publicity would also establish the WHA as an annual event of importance, and thereby reinforce the public perception of WHO. www.thelancet.com Vol 383 January 11, 2014
WHO is the untransparent exception in the UN for not webcasting its meetings. The UN Security Council and General Assembly webcast many proceedings; and so do most UN agencies (such as the Food and Agriculture Organization, the International Atomic Energy Agency, or the World Intellectual Property Organization, among others). Possibly the most enthusiastic is the International Telecommunications Union, which webcasts even its preparatory meetings and provides an open forum for public input.1 Plainly, WHO must catch up. Currently, some of WHO’s regional committees webcast parts of their proceedings.2 For a comprehensive webcasting as soon as the 2014 WHA, technical, legal, and political challenges need to be discussed. Technically, the WHA is already carried on closed-circuit video with simultaneous interpretation in the six UN languages. Live streaming these audio and video channels is easily done with a conventional internet connection, and need not be expensive, especially if the other UN organisations in Geneva share their technical facilities. Legally, there is nothing secret or proprietary about WHA proceedings (excluding closed-door diplomatic sessions). Observers range freely over the meeting hall, and there is no reasonable expectation of privacy over anything said or done. WHO has already taken the liberty of webcasting selected speeches and sights from the scene.3,4 Nothing would be transgressed by comprehensive webcasting in real time. Politically, many UN forums are webcast, so the WHA should be no different. A difficulty is that the WHO Secretariat has as recently as this year refused to enforce the organisation’s transparency rules when faced with opposition from some member states. A WHA Resolution passed by member states in 1987 gives officially recognised NGOs the “right...to participate” in committee
meetings convened under WHO’s authority.5 That this express legal right is sometimes being breached suggests that the WHO Secretariat is less committed to transparency than it might be. When the WHO’s Executive Board meets in January, 2014, we urge that it (and not the Secretariat) decide to webcast the comprehensive WHA 2014 proceedings. The Executive Board already makes all the basic decisions about convening the WHA, such as choosing the time and place, so it could easily stipulate webcasting too. It would then be up to WHO’s Director General, acting at the Executive Board’s request, to inform member states and to make the necessary arrangements. We expect these proposals to be popular all around. Although poor countries and smaller NGOs have the most to gain, in times of austerity all member states can save money by bringing fewer officials to the WHA. For health professionals, scholars, and activists, webcasts will often make the difference between being au courant with the WHA and global health governance or not at all. Indeed, the reasons are so compelling that it is surprising that the WHA has not already been webcast by public health “hacktivists” with camera phones. That might be the eventual outcome, although it would be better for WHO to do so first.
UIG via Getty Images
1
We declare that we have no conflicts of interest.
*Amir Attaran, David Benton, James Chauvin, Martin McKee, Valerie Percival [email protected] University of Ottawa, Faculty of Law, Ottawa, ON, Canada (AA); International Council of Nurses, Geneva, Switzerland (DB); World Federation of Public Health Associations, Geneva, Switzerland (JC); London School of Hygiene and Tropical Medicine, London, UK (MM); and Norman Patterson School of International Affairs, Carleton University, Ottawa, Canada (VP) 1
International Telecommunications Union. World Conference on International Telecommunications (WCIT-12); Dubai, United Arab Emirates Dec 3–14, 2012. http://www.itu. int/en/wcit-12/Pages/default.aspx (accessed Sept 11, 2013).
125
