Comment
Global health security now
www.thelancet.com Vol 385 May 9, 2015
and enhanced human and financial resources. Finally, in a Viewpoint Margaret Kruk and colleagues4 identify and discuss the preconditions for health-system resilience. One consequence of this increased attention to health security is an erosion—it might not be an exaggeration to say collapse—of multilateral approaches to the world’s greatest threats. In Washington, DC, the most influential city determining the future of global health, the political atmosphere is deeply hostile to multilateral solutions to global health challenges. It is, sadly, also deeply hostile to WHO, which, one senior US State Department official told us recently, has been “overwhelmed” by Ebola. The US Government remains fully committed to global health. But another government adviser tells us that the US administration is “furious” about the way existing international health arrangements failed to contain the Ebola outbreak. The USA will now “go it alone”, he said. It will protect its homeland through bilateral responses, such as the announcement of an African Centres for Disease Control and Prevention through a partnership with the African Union, not WHO.5 The USA will no longer be interested in UN, let alone WHO, reform, he suggests. Instead, it will do what it needs to do to protect its own interests— domestically and overseas. If more countries see multilateralism as a failed enterprise, prospects for global health security will be
See Public Policy pages 1884 and 1902 See Viewpoint page 1910
Pete Marovich/epa/Corbis
The concept of security as an important dimension of health divides opinions. To invoke the idea of security risks giving permission to more authoritarian-minded governments to use health crises as justification for sometimes extreme curbs on liberty or the political, economic, and social rights of citizens. During the Ebola virus disease outbreak, photographs appeared in news media of police brutally attacking the public for breaching curfews. Invoking arguments of global health security might further encourage this kind of violent response. Alternatively, security could more constructively mean protecting and empowering people, a view promulgated by the UN’s Commission on Human Security in 2003.1 This week, The Lancet looks at the implications of a security lens applied to health in the aftermath of the Ebola outbreak in west Africa.2–4 Thanks to Ebola, global health security is now a priority, not only for ministers of health but also for heads of state. In a Public Policy paper, David Heymann has brought together a diverse group of experts to reflect on the broad meaning of global health security.2 The central message of this collection of short essays is that there is no simple definition of health security. It can mean, variously, human security, the prevention and control of infectious diseases, attention to non-communicable diseases, revitalising research and development to produce global public goods, dealing with substandard and falsified drugs, considering conflict and disaster settings, addressing international migration, and building stronger health systems through universal health coverage. The complexity of global health security should not induce paralysis. But it should make us pause before we argue for quick solutions. We also publish the first comprehensive analysis of the Ebola crisis by Lawrence Gostin and Eric Friedman.3 Several working groups are already planning and writing reports on the way the international community responded to the epidemic, together with lessons learned. The Public Policy paper by Gostin and Friedman will be hard to better—they offer incisive recommendations for a new global health framework, strengthened national health systems, an empowered WHO, clearer roles and responsibilities for stakeholders, revised International Health Regulations,
1805
Comment
bleak. The papers we publish this week aim to show why withdrawing from multilateralism would be the wrong response to Ebola. It is perfectly understandable why many nations view threats to their citizens and sovereignty as reasons to act alone, on the basis of a narrow concept of strengthened state security. But human beings have many affiliations and interests. We are not defined only as citizens of a single nationstate. To reach a fuller and richer understanding of health security, governments, development agencies, and health organisations might also argue that each of us has an affiliation to the larger world we inhabit—a global identity that demands global solutions through cooperation between nations. Global health security,
we think, is an idea that presses the case in favour of a renaissance in multilateralism, not its demise. Richard Horton, Pamela Das The Lancet, London EC2Y 5AS, UK 1 2
3
4 5
Commission on Human Security. Human security now. New York: Commission on Human Security, 2003. Heymann DL, Chen L, Takemi K, et al. Global health security: the wider lessons from the west African Ebola virus disease epidemic. Lancet 2015; 385: 1884–901. Gostin LO, Friedman EA. A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex. Lancet 2015; 385: 1902–09. Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet 2015; 385: 1910–12. The Lancet. The African CDC and WHO AFRO. Lancet 2015; 385: 1592.
Hormone therapy: short-term relief, long-term consequences Published Online February 13, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)62458-2 See Articles page 1835
1806
The decline of a woman’s natural hormones during menopause is associated with various symptoms, including hot flashes, night sweats, mood swings, and trouble concentrating. Long-term effects can include bone loss, risk of fractures, and cardiovascular disease. To ameliorate short-term and long-term consequences of menopause, hormone replacement with oestrogen was introduced in the 1940s. The biological mechanisms underlying the associations between hormone use and various conditions are not well understood. Evidence for benefits and adverse effects of menopausal hormone therapy has come from many observational studies and a few clinical trials. In the 1970s, observational studies showed a strong increase in endometrial cancer risk related to postmenopausal oestrogen use.1 As a result, oestrogen-progestagen regimens were developed to mitigate the increased risk. During the 1990s, epidemiological studies showed evidence for an increase in breast cancer risk related to oestrogenprogestagen use.2 In 2002, the Women’s Health Initiative randomised trial of oestrogen-progestagen versus placebo was stopped early because it confirmed this increased breast cancer risk and, somewhat unexpectedly, showed an increase in cardiovascular disease among hormone users.3 Oestrogen-progestagen sales decreased precipitously in the following year. Additional analyses from the
trial showed increased risk of myocardial infarction restricted to women who used oestrogen-progestagen beyond menopause; furthermore, several adverse effects increased with hormone therapy use after menopause in extended follow-up.4 Currently recommended indications for hormone therapy use are restricted to treatment of menopausal symptoms, not for prevention of chronic disease.5 Regulatory decisions and public health recommendations related to hormone therapy use were based mostly on findings from the Women’s Health Initiative trial. However, reliance on one trial alone has limitations; this trial was not powered to assess rare endpoints such as ovarian cancer, and, furthermore, the trial was mainly designed to assess short-term use and short-term health effects. Since early 2000, findings from observational studies have suggested that long-duration hormone therapy use is associated with ovarian cancer risk.6 In The Lancet, the Collaborative Group on Epidemiological Studies of Ovarian Cancer7 reports findings from a meta-analysis of individual participant data from 52 epidemiological studies assessing hormone therapy use and ovarian cancer risk. The principal analyses involved data from 17 prospective studies. The investigators report increased risk with current hormone therapy use (for duration
Global health security now
www.thelancet.com Vol 385 May 9, 2015
and enhanced human and financial resources. Finally, in a Viewpoint Margaret Kruk and colleagues4 identify and discuss the preconditions for health-system resilience. One consequence of this increased attention to health security is an erosion—it might not be an exaggeration to say collapse—of multilateral approaches to the world’s greatest threats. In Washington, DC, the most influential city determining the future of global health, the political atmosphere is deeply hostile to multilateral solutions to global health challenges. It is, sadly, also deeply hostile to WHO, which, one senior US State Department official told us recently, has been “overwhelmed” by Ebola. The US Government remains fully committed to global health. But another government adviser tells us that the US administration is “furious” about the way existing international health arrangements failed to contain the Ebola outbreak. The USA will now “go it alone”, he said. It will protect its homeland through bilateral responses, such as the announcement of an African Centres for Disease Control and Prevention through a partnership with the African Union, not WHO.5 The USA will no longer be interested in UN, let alone WHO, reform, he suggests. Instead, it will do what it needs to do to protect its own interests— domestically and overseas. If more countries see multilateralism as a failed enterprise, prospects for global health security will be
See Public Policy pages 1884 and 1902 See Viewpoint page 1910
Pete Marovich/epa/Corbis
The concept of security as an important dimension of health divides opinions. To invoke the idea of security risks giving permission to more authoritarian-minded governments to use health crises as justification for sometimes extreme curbs on liberty or the political, economic, and social rights of citizens. During the Ebola virus disease outbreak, photographs appeared in news media of police brutally attacking the public for breaching curfews. Invoking arguments of global health security might further encourage this kind of violent response. Alternatively, security could more constructively mean protecting and empowering people, a view promulgated by the UN’s Commission on Human Security in 2003.1 This week, The Lancet looks at the implications of a security lens applied to health in the aftermath of the Ebola outbreak in west Africa.2–4 Thanks to Ebola, global health security is now a priority, not only for ministers of health but also for heads of state. In a Public Policy paper, David Heymann has brought together a diverse group of experts to reflect on the broad meaning of global health security.2 The central message of this collection of short essays is that there is no simple definition of health security. It can mean, variously, human security, the prevention and control of infectious diseases, attention to non-communicable diseases, revitalising research and development to produce global public goods, dealing with substandard and falsified drugs, considering conflict and disaster settings, addressing international migration, and building stronger health systems through universal health coverage. The complexity of global health security should not induce paralysis. But it should make us pause before we argue for quick solutions. We also publish the first comprehensive analysis of the Ebola crisis by Lawrence Gostin and Eric Friedman.3 Several working groups are already planning and writing reports on the way the international community responded to the epidemic, together with lessons learned. The Public Policy paper by Gostin and Friedman will be hard to better—they offer incisive recommendations for a new global health framework, strengthened national health systems, an empowered WHO, clearer roles and responsibilities for stakeholders, revised International Health Regulations,
1805
Comment
bleak. The papers we publish this week aim to show why withdrawing from multilateralism would be the wrong response to Ebola. It is perfectly understandable why many nations view threats to their citizens and sovereignty as reasons to act alone, on the basis of a narrow concept of strengthened state security. But human beings have many affiliations and interests. We are not defined only as citizens of a single nationstate. To reach a fuller and richer understanding of health security, governments, development agencies, and health organisations might also argue that each of us has an affiliation to the larger world we inhabit—a global identity that demands global solutions through cooperation between nations. Global health security,
we think, is an idea that presses the case in favour of a renaissance in multilateralism, not its demise. Richard Horton, Pamela Das The Lancet, London EC2Y 5AS, UK 1 2
3
4 5
Commission on Human Security. Human security now. New York: Commission on Human Security, 2003. Heymann DL, Chen L, Takemi K, et al. Global health security: the wider lessons from the west African Ebola virus disease epidemic. Lancet 2015; 385: 1884–901. Gostin LO, Friedman EA. A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex. Lancet 2015; 385: 1902–09. Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet 2015; 385: 1910–12. The Lancet. The African CDC and WHO AFRO. Lancet 2015; 385: 1592.
Hormone therapy: short-term relief, long-term consequences Published Online February 13, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)62458-2 See Articles page 1835
1806
The decline of a woman’s natural hormones during menopause is associated with various symptoms, including hot flashes, night sweats, mood swings, and trouble concentrating. Long-term effects can include bone loss, risk of fractures, and cardiovascular disease. To ameliorate short-term and long-term consequences of menopause, hormone replacement with oestrogen was introduced in the 1940s. The biological mechanisms underlying the associations between hormone use and various conditions are not well understood. Evidence for benefits and adverse effects of menopausal hormone therapy has come from many observational studies and a few clinical trials. In the 1970s, observational studies showed a strong increase in endometrial cancer risk related to postmenopausal oestrogen use.1 As a result, oestrogen-progestagen regimens were developed to mitigate the increased risk. During the 1990s, epidemiological studies showed evidence for an increase in breast cancer risk related to oestrogenprogestagen use.2 In 2002, the Women’s Health Initiative randomised trial of oestrogen-progestagen versus placebo was stopped early because it confirmed this increased breast cancer risk and, somewhat unexpectedly, showed an increase in cardiovascular disease among hormone users.3 Oestrogen-progestagen sales decreased precipitously in the following year. Additional analyses from the
trial showed increased risk of myocardial infarction restricted to women who used oestrogen-progestagen beyond menopause; furthermore, several adverse effects increased with hormone therapy use after menopause in extended follow-up.4 Currently recommended indications for hormone therapy use are restricted to treatment of menopausal symptoms, not for prevention of chronic disease.5 Regulatory decisions and public health recommendations related to hormone therapy use were based mostly on findings from the Women’s Health Initiative trial. However, reliance on one trial alone has limitations; this trial was not powered to assess rare endpoints such as ovarian cancer, and, furthermore, the trial was mainly designed to assess short-term use and short-term health effects. Since early 2000, findings from observational studies have suggested that long-duration hormone therapy use is associated with ovarian cancer risk.6 In The Lancet, the Collaborative Group on Epidemiological Studies of Ovarian Cancer7 reports findings from a meta-analysis of individual participant data from 52 epidemiological studies assessing hormone therapy use and ovarian cancer risk. The principal analyses involved data from 17 prospective studies. The investigators report increased risk with current hormone therapy use (for duration
