Correspondence
See Online for appendix
pelvic CT when a small (5 mitoses per 50 HPFs at these sites are associated with much greater risks, 16%, 73%, 50%, and 52%, respectively.4 These estimations need to be interpreted cautiously, since mitotic counting is challenging to standardise, and the risk of metastases does not increase abruptly when the count exceeds 5 mitoses per 50 HPFs. Such abrupt changes in outcome estimations can be avoided in risk stratification schemes that consider tumour size and mitotic count as continuous variables. For example, using such a scheme, a 3-cm gastric GIST is estimated to have virtually zero rate of metastasis when mitotic count is ≤2, 10–20% risk when the count is 5, and 20–40% risk when 10 mitoses are counted from 50 HPFs.5 Small gastrointestinal tumours judged to be GIST should be biopsied for tissue diagnosis and for estimation of the risk of recurrence. Bleeding tumours and those with risk for metastasis should be excised. Small GISTs with a low mitotic count might be considered for endoscopic surveillance depending on tumour site, patient comorbidities, and risks related to surgery. Most macroscopic non-gastric GISTs should be excised irrespective of size, since even small tumours might give rise to metastases.2,3,5 We declare that we have no conflicts of interest.
1702
*Heikki Joensuu, Peter Hohenberger heikki.joensuu@hus.fi Department of Oncology, Helsinki University Central Hospital, 00029 Helsinki, Finland (HJ); and Division of Surgical Oncology & Thoracic Surgery, Mannheim University Medical Center, Mannheim, Germany (PH) 1
2
3
4
5
Joensuu H, Hohenberger P, Corless CL. Gastrointestinal stromal tumour. Lancet 2013; 382: 973–83. ESMO/ European Sarcoma Network Working Group. Gastrointestinal stromal tumors: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012; 23: vii49–55. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: soft tissue sarcoma (version 1.2013). http:// www.nccn.org/professionals/physician_gls/ pdf/sarcoma.pdf (accessed Oct 15, 2013). Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathology and prognosis at different sites. Semin Diagn Pathol 2006; 23: 70–83. Joensuu H, Vehtari A, Riihimäki J, et al. Risk of recurrence of gastrointestinal stromal tumour after surgery: an analysis of pooled population-based cohorts. Lancet Oncol 2012; 13: 265–74.
Germany and global health: an unfinished agenda? One day before the national elections, a Lancet Editorial (Sept 21, p 999)1 commented on Germany’s role in global health. The Editorial suggests that Germany’s low visibility and engagement does not match its economic and political influence. This has been different in the distant past. Physicians like Rudolf Virchow (1821–1902) had emphasised the social determinants of health. His statement “Medicine is a social science, and politics is nothing else but medicine on a large scale” marked the beginning of the discipline of public health in Germany and echoed in the Declaration on Primary Health Care in 1978, and the Millennium Declaration in 2000.2 After World War 2, public health in Germany was confined to specific prevention services, whereas basic medical research and a rapidly developing curative medicine absorbed most funds. 3 Activities in the field of international health were largely restricted to biomedical
research projects of universities beside bilateral and multilateral monetary contributions. Only few German institutions such as the Public Health Institute, Heidelberg University, had a clear focus on health systems research and capacity building and developed close ties with institutions in developing countries while interacting with German development agencies and international organisations.4 If Germany is to live up to its responsibility in global health, it needs to substantially invest in capacity building, domestically (eg, creating the first Centre of Global Health Research) and internationally (eg, promoting a sustainable Global Health Fund), beside a serious engagement in global health governance. In analogy to a recent Comment from the Prime Minister of Japan,5 we hope to see soon a commentary in The Lancet from the recently elected German Government emphasising its commitment to global health. We declare that we have no conflicts of interest.
*Olaf Müller, Claudia Beiersmann, Hans Jochen Diesfeld, Albrecht Jahn [email protected] Ruprecht-Karls-University, Medical School, Institute of Public Health, INF 324, 69120 Heidelberg, Germany 1 2
3
4
5
Lancet. A new German Government: leadership for health? Lancet 2013; 382: 999. Diesfeld HJ. Von Rudolf Virchow zu den Millenniums-Entwicklungszielen 2000. In: Razum O, Zeeb H, Laaser U, eds. Globalisierung, gerechtigkeit, gesundheit – einführung in International Public Health. Bern, Switzerland: EVerlag Hans Huber, 2006 (in German). Müller O, Razum O. 30 Jahre Primary Health Care: Neuauflage einer revolutionären Idee. Deutsches Ärzteblatt 2008; 9: 407–09 (in German). Becher H, Kouyaté B. Health research in developing countries. Heidelberg: SpringerVerlag Berlin, 2005 (in German). Abe S. Japan’s strategy for global health diplomacy: why it matters. Lancet 2013; 382: 915–16.
After years of subordinating global health, the German Government recently released a concept note for global health (for a summary of the concept note, see appendix).1 This effort is highly appreciated. The major strengths of the concept are a clear commitment to Universal www.thelancet.com Vol 382 November 23, 2013
Correspondence
KB, WB, MK, and PT are founding members of the Global Health Alliance, a network of academic institutions to promote education in global health. WB, PT, WH, and RK were invited participants of an official “public dialogue” event between civil-society and the Federal Ministries of Health (BMG), Foreign Affairs (AA), and Development Cooperation (BMZ) before the formulation of the strategy. RK is an external consultant of the Gesellschaft für Internationale Zusammenarbeit (GIZ).
*Kayvan Bozorgmehr, Walter Bruchhausen, Wolfgang Hein, Michael Knipper, Rolf Korte, Peter Tinnemann, Oliver Razum [email protected] www.thelancet.com Vol 382 November 23, 2013
Department of General Practice and Health Services Research, University of Heidelberg, Heidelberg 69115, Germany (KB); Institute of History, Theory and Ethics in Medicine, Aachen University, Aachen, Germany (WB); German Institute of Global and Area Studies (GIGA), Institute of Latin American Studies, Hamburg, Germany (WH); Institute of the History of Medicine, Faculty of Medicine, University Giessen, Giessen, Germany (MK); Institute of Hygiene and Environmental Health, Faculty of Medicine, University Giessen, Giessen, Germany (RK); Department of International Health Sciences, Institute for Social Medicine, Epidemiology and Health Economics, Charité-University Medical Centre, Berlin, Germany (PT); and Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany (OR) 1 2
3
4
5
Lancet. A new German Government: leadership for health? Lancet 2013; 382: 999. European Union Council. Council conclusions on the EU role in Global Health. https://www. consilium.europa.eu/uedocs/cms_Data/docs/ pressdata/EN/foraff/114352.pdf (accessed Nov 9, 2013). Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013; 381: 1323–31. WHO Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008. www.who.int/social_determinants/ final_report/ (accessed Nov 9, 2013). Rechel B, Mladovsky P, Devillé W, Rijks B, Petrova-Benedict R, McKee M. Migration and Health in the European Union. European Observatory on Health Systems and Policies Series. Maidenhead, Berkshire: McGraw-Hill, Open-University Press, 2011.
Appeal from Chinese doctors to end violence Within only 10 days in October, seven consecutive incidents of violence against medical personnel took place in Chinese hospitals, three doctors were killed and ten medical staff were injured.1 This recent wave of assaults on medical staff has led to widespread discussions on Chinese social media. Anger, fear, despair, and even hatred are common among doctors. Chinese doctors are under tremendous stress. The growing problem of violence in hospitals in China can certainly be attributed to the worsening of the doctor–patient relationship, but more importantly, it is probably due to the fact that China’s health-care system lacks regulations to protect
medical staff from intended violence.2 There is no comprehensive legislation in China to specifically address medical disputes and violence, with the exception of so-called guiding opinions without legal effects. On Oct 24, the Chinese Ministry of Health and the Ministry of Public Security announced new guidelines to provide better security at hospitals: the number of security guards in each hospital should be at least one per 20 patient beds or no less than 3% of medical staff.3 This announcement has provoked the ire of medical professionals and Internet users, stressing the government’s hypocrisy because it will not address the fundamental issue of protection of doctors and might even further intensify the doctor–patient conflicts.4 This deteriorated medical environment has led many to question what will be the future of doctors in China— this is a collective concern for the entire Chinese society.5 As doctors in China, we call for a zero-tolerance attitude toward violence in hospital. The Chinese Government should drive the momentum of health-care reform to bring fundamental relief in this tense situation. Legislation should be strengthened to tackle crimes hampering the safety of medical staff. Only with effective and prompt actions will we be able to rebuild confidence.
XiXinXing/Corbis
Health Coverage (UHC) based on the human rights to health approach and an unequivocal commitment to strengthening the leadership of WHO, by strengthening the core mandate of WHO for setting binding norms and standards for member countries. However, important gaps in policy and implementation aspects need to be addressed. We have identified the following gaps: intellectual property rights and access to medicines; 2 structural determinants such as trade, economic crises,3 and global inequity;4 serious limitations of the right to the highest attainable state of health for migrants, refugees, and asylum seekers in the European Union, including Germany;5 funding mechanisms for WHO; strategies to foster global health research and education; and an effective and transparent interministerial institutionalisation of German global health policies. Moreover, the stated aim of exporting the products of the strong German health-care industry for the benefit of global health ( appendix appendix)) w will divert scarce resources in low-income countries from urgently needed social interventions promoting equity to costly technologies of doubtful appropriateness. The new German Government should aim to fill the gaps outlined above and develop a concrete global health strategy, including a timescale and measurable goals. Only then can the intentions of the concept note be fulfilled.
We declare that we have no conflicts of interest.
Tian Yang, Han Zhang, Feng Shen, Jie-Wei Li, Meng-Chao Wu* [email protected] Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China 1
2 3
Reuters. Chinese doctor stabbed to death in latest hospital attack. Oct 25, 2013. http:// www.reuters.com/article/2013/10/25/uschina-health-idUSBRE99O08X20131025 (accessed Oct 30, 2013). The Lancet. Ending violence against doctors in China. Lancet 2012; 379: 1764. MacLeod C. China trying to stop patients from killing doctors. USA Today, Oct 24, 2013. http://www.usatoday.com/story/news/ world/2013/10/24/china-hospitalattacks/3178633 (accessed Oct 30, 2013).
1703
See Online for appendix
pelvic CT when a small (5 mitoses per 50 HPFs at these sites are associated with much greater risks, 16%, 73%, 50%, and 52%, respectively.4 These estimations need to be interpreted cautiously, since mitotic counting is challenging to standardise, and the risk of metastases does not increase abruptly when the count exceeds 5 mitoses per 50 HPFs. Such abrupt changes in outcome estimations can be avoided in risk stratification schemes that consider tumour size and mitotic count as continuous variables. For example, using such a scheme, a 3-cm gastric GIST is estimated to have virtually zero rate of metastasis when mitotic count is ≤2, 10–20% risk when the count is 5, and 20–40% risk when 10 mitoses are counted from 50 HPFs.5 Small gastrointestinal tumours judged to be GIST should be biopsied for tissue diagnosis and for estimation of the risk of recurrence. Bleeding tumours and those with risk for metastasis should be excised. Small GISTs with a low mitotic count might be considered for endoscopic surveillance depending on tumour site, patient comorbidities, and risks related to surgery. Most macroscopic non-gastric GISTs should be excised irrespective of size, since even small tumours might give rise to metastases.2,3,5 We declare that we have no conflicts of interest.
1702
*Heikki Joensuu, Peter Hohenberger heikki.joensuu@hus.fi Department of Oncology, Helsinki University Central Hospital, 00029 Helsinki, Finland (HJ); and Division of Surgical Oncology & Thoracic Surgery, Mannheim University Medical Center, Mannheim, Germany (PH) 1
2
3
4
5
Joensuu H, Hohenberger P, Corless CL. Gastrointestinal stromal tumour. Lancet 2013; 382: 973–83. ESMO/ European Sarcoma Network Working Group. Gastrointestinal stromal tumors: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012; 23: vii49–55. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: soft tissue sarcoma (version 1.2013). http:// www.nccn.org/professionals/physician_gls/ pdf/sarcoma.pdf (accessed Oct 15, 2013). Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathology and prognosis at different sites. Semin Diagn Pathol 2006; 23: 70–83. Joensuu H, Vehtari A, Riihimäki J, et al. Risk of recurrence of gastrointestinal stromal tumour after surgery: an analysis of pooled population-based cohorts. Lancet Oncol 2012; 13: 265–74.
Germany and global health: an unfinished agenda? One day before the national elections, a Lancet Editorial (Sept 21, p 999)1 commented on Germany’s role in global health. The Editorial suggests that Germany’s low visibility and engagement does not match its economic and political influence. This has been different in the distant past. Physicians like Rudolf Virchow (1821–1902) had emphasised the social determinants of health. His statement “Medicine is a social science, and politics is nothing else but medicine on a large scale” marked the beginning of the discipline of public health in Germany and echoed in the Declaration on Primary Health Care in 1978, and the Millennium Declaration in 2000.2 After World War 2, public health in Germany was confined to specific prevention services, whereas basic medical research and a rapidly developing curative medicine absorbed most funds. 3 Activities in the field of international health were largely restricted to biomedical
research projects of universities beside bilateral and multilateral monetary contributions. Only few German institutions such as the Public Health Institute, Heidelberg University, had a clear focus on health systems research and capacity building and developed close ties with institutions in developing countries while interacting with German development agencies and international organisations.4 If Germany is to live up to its responsibility in global health, it needs to substantially invest in capacity building, domestically (eg, creating the first Centre of Global Health Research) and internationally (eg, promoting a sustainable Global Health Fund), beside a serious engagement in global health governance. In analogy to a recent Comment from the Prime Minister of Japan,5 we hope to see soon a commentary in The Lancet from the recently elected German Government emphasising its commitment to global health. We declare that we have no conflicts of interest.
*Olaf Müller, Claudia Beiersmann, Hans Jochen Diesfeld, Albrecht Jahn [email protected] Ruprecht-Karls-University, Medical School, Institute of Public Health, INF 324, 69120 Heidelberg, Germany 1 2
3
4
5
Lancet. A new German Government: leadership for health? Lancet 2013; 382: 999. Diesfeld HJ. Von Rudolf Virchow zu den Millenniums-Entwicklungszielen 2000. In: Razum O, Zeeb H, Laaser U, eds. Globalisierung, gerechtigkeit, gesundheit – einführung in International Public Health. Bern, Switzerland: EVerlag Hans Huber, 2006 (in German). Müller O, Razum O. 30 Jahre Primary Health Care: Neuauflage einer revolutionären Idee. Deutsches Ärzteblatt 2008; 9: 407–09 (in German). Becher H, Kouyaté B. Health research in developing countries. Heidelberg: SpringerVerlag Berlin, 2005 (in German). Abe S. Japan’s strategy for global health diplomacy: why it matters. Lancet 2013; 382: 915–16.
After years of subordinating global health, the German Government recently released a concept note for global health (for a summary of the concept note, see appendix).1 This effort is highly appreciated. The major strengths of the concept are a clear commitment to Universal www.thelancet.com Vol 382 November 23, 2013
Correspondence
KB, WB, MK, and PT are founding members of the Global Health Alliance, a network of academic institutions to promote education in global health. WB, PT, WH, and RK were invited participants of an official “public dialogue” event between civil-society and the Federal Ministries of Health (BMG), Foreign Affairs (AA), and Development Cooperation (BMZ) before the formulation of the strategy. RK is an external consultant of the Gesellschaft für Internationale Zusammenarbeit (GIZ).
*Kayvan Bozorgmehr, Walter Bruchhausen, Wolfgang Hein, Michael Knipper, Rolf Korte, Peter Tinnemann, Oliver Razum [email protected] www.thelancet.com Vol 382 November 23, 2013
Department of General Practice and Health Services Research, University of Heidelberg, Heidelberg 69115, Germany (KB); Institute of History, Theory and Ethics in Medicine, Aachen University, Aachen, Germany (WB); German Institute of Global and Area Studies (GIGA), Institute of Latin American Studies, Hamburg, Germany (WH); Institute of the History of Medicine, Faculty of Medicine, University Giessen, Giessen, Germany (MK); Institute of Hygiene and Environmental Health, Faculty of Medicine, University Giessen, Giessen, Germany (RK); Department of International Health Sciences, Institute for Social Medicine, Epidemiology and Health Economics, Charité-University Medical Centre, Berlin, Germany (PT); and Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany (OR) 1 2
3
4
5
Lancet. A new German Government: leadership for health? Lancet 2013; 382: 999. European Union Council. Council conclusions on the EU role in Global Health. https://www. consilium.europa.eu/uedocs/cms_Data/docs/ pressdata/EN/foraff/114352.pdf (accessed Nov 9, 2013). Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013; 381: 1323–31. WHO Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008. www.who.int/social_determinants/ final_report/ (accessed Nov 9, 2013). Rechel B, Mladovsky P, Devillé W, Rijks B, Petrova-Benedict R, McKee M. Migration and Health in the European Union. European Observatory on Health Systems and Policies Series. Maidenhead, Berkshire: McGraw-Hill, Open-University Press, 2011.
Appeal from Chinese doctors to end violence Within only 10 days in October, seven consecutive incidents of violence against medical personnel took place in Chinese hospitals, three doctors were killed and ten medical staff were injured.1 This recent wave of assaults on medical staff has led to widespread discussions on Chinese social media. Anger, fear, despair, and even hatred are common among doctors. Chinese doctors are under tremendous stress. The growing problem of violence in hospitals in China can certainly be attributed to the worsening of the doctor–patient relationship, but more importantly, it is probably due to the fact that China’s health-care system lacks regulations to protect
medical staff from intended violence.2 There is no comprehensive legislation in China to specifically address medical disputes and violence, with the exception of so-called guiding opinions without legal effects. On Oct 24, the Chinese Ministry of Health and the Ministry of Public Security announced new guidelines to provide better security at hospitals: the number of security guards in each hospital should be at least one per 20 patient beds or no less than 3% of medical staff.3 This announcement has provoked the ire of medical professionals and Internet users, stressing the government’s hypocrisy because it will not address the fundamental issue of protection of doctors and might even further intensify the doctor–patient conflicts.4 This deteriorated medical environment has led many to question what will be the future of doctors in China— this is a collective concern for the entire Chinese society.5 As doctors in China, we call for a zero-tolerance attitude toward violence in hospital. The Chinese Government should drive the momentum of health-care reform to bring fundamental relief in this tense situation. Legislation should be strengthened to tackle crimes hampering the safety of medical staff. Only with effective and prompt actions will we be able to rebuild confidence.
XiXinXing/Corbis
Health Coverage (UHC) based on the human rights to health approach and an unequivocal commitment to strengthening the leadership of WHO, by strengthening the core mandate of WHO for setting binding norms and standards for member countries. However, important gaps in policy and implementation aspects need to be addressed. We have identified the following gaps: intellectual property rights and access to medicines; 2 structural determinants such as trade, economic crises,3 and global inequity;4 serious limitations of the right to the highest attainable state of health for migrants, refugees, and asylum seekers in the European Union, including Germany;5 funding mechanisms for WHO; strategies to foster global health research and education; and an effective and transparent interministerial institutionalisation of German global health policies. Moreover, the stated aim of exporting the products of the strong German health-care industry for the benefit of global health ( appendix appendix)) w will divert scarce resources in low-income countries from urgently needed social interventions promoting equity to costly technologies of doubtful appropriateness. The new German Government should aim to fill the gaps outlined above and develop a concrete global health strategy, including a timescale and measurable goals. Only then can the intentions of the concept note be fulfilled.
We declare that we have no conflicts of interest.
Tian Yang, Han Zhang, Feng Shen, Jie-Wei Li, Meng-Chao Wu* [email protected] Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China 1
2 3
Reuters. Chinese doctor stabbed to death in latest hospital attack. Oct 25, 2013. http:// www.reuters.com/article/2013/10/25/uschina-health-idUSBRE99O08X20131025 (accessed Oct 30, 2013). The Lancet. Ending violence against doctors in China. Lancet 2012; 379: 1764. MacLeod C. China trying to stop patients from killing doctors. USA Today, Oct 24, 2013. http://www.usatoday.com/story/news/ world/2013/10/24/china-hospitalattacks/3178633 (accessed Oct 30, 2013).
1703
