The

n e w e ng l a n d j o u r na l

inhibitors have been proposed, including transmembrane-mediated reverse signaling, down-regulation of proinflammatory cytokines, complement-mediated cytotoxicity, and activation of regulatory immune cells.5 Altogether, the underlying modes of action of TNF inhibitors are more complex than initially hypothesized. Mehmet Coskun, Ph.D. Ole Haagen Nielsen, M.D., D.M.Sc. Herlev Hospital Copenhagen, Denmark [email protected] Dr. Coskun reports no potential conflict of interest relevant to this letter. Since publication of his article, Dr. Nielsen reports no further potential conflict of interest.

of

m e dic i n e

1. Coury F, Ferraro-Peyret C, Le Cam S, et al. Peripheral blood

lymphocytes from patients with rheumatoid arthritis are differentially sensitive to apoptosis induced by anti-tumour necrosis factor-alpha therapy. Clin Exp Rheumatol 2008;26:234-9. 2. Derer S, Till A, Haesler R, et al. mTNF reverse signalling induced by TNFα antagonists involves a GDF-1 dependent pathway: implications for Crohn’s disease. Gut 2013;62:376-86. 3. Perrier C, de Hertogh G, Cremer J, et al. Neutralization of membrane TNF, but not soluble TNF, is crucial for the treatment of experimental colitis. Inflamm Bowel Dis 2013;19:246-53. 4. Vos AC, Wildenberg ME, Duijvestein M, Verhaar AP, van den Brink GR, Hommes DW. Anti-tumor necrosis factor-α antibodies induce regulatory macrophages in an Fc region-dependent manner. Gastroenterology 2011;140:221-30. 5. Peake ST, Bernardo D, Mann ER, Al-Hassi HO, Knight SC, Hart AL. Mechanisms of action of anti-tumor necrosis factor α agents in Crohn’s disease. Inflamm Bowel Dis 2013;19:1546-55. DOI: 10.1056/NEJMc1312800

Noncommunicable Diseases To the Editor: Hunter and Reddy (Oct. 3 issue)1 outline issues associated with the changing global burden of noncommunicable diseases. The strategies for prevention and control touch on multiple sectors. However, the article does not give a clear sense of what might be most urgent in addressing the problem. This question would be especially relevant for low-income countries that are best served by prioritized utilization of their scarce resources. I would argue that the development of health care facilities that are capable of dealing with noncommunicable diseases should be central to the efforts aimed at addressing these diseases in the developing world. Although evidence of the effectiveness of preventive strategies directed at selected risk factors is quite promising,2 low-income countries will very likely face challenges in their implementation.3 This means that clinical diseases will require care. I am a clinician working in a low-income country with a health care setup that is utterly incapable of caring for patients with chronic illnesses who require screenings, long-term followup, laboratory support, and affordable medications. Effective communication between patients and health care workers is also limited in this clinical setting. I consider the development of health care facilities to be an urgent matter even in my current everyday clinical practice. Subarna M. Dhital, M.D. Biomed Diabetes and Endocrinology Center Kathmandu, Nepal [email protected] No potential conflict of interest relevant to this letter was reported.

2562

1. Hunter DJ, Reddy KS. Noncommunicable diseases. N Engl J

Med 2013;369:1336-43.

2. Capewell S, O’Flaherty M. Rapid mortality falls after risk-

factor changes in populations. Lancet 2011;378:752-3.

3. Justice J. Policies, plans and people: culture and health de-

velopment in Nepal. Berkeley: University of California Press, 1986. DOI: 10.1056/NEJMc1313604

To the Editor: Hunter and Reddy discuss succinctly the importance of noncommunicable diseases in developing countries. International initiatives such as those related to maternal and child deaths, infectious diseases, and the distribution of antiretroviral drugs have turned Africans who once would have died in the villages into patients who are now considered to have potentially curable diseases. Nowadays, mothers do not have “pure” peripartum sepsis, but rather sepsis with human immunodeficiency virus infection and concomitant tuberculosis. Because of well-funded public health programs, more patients require intensive care unit (ICU) services for such conditions, but providers of anesthesia and intensive care do not receive funding from these international programs. The “25 by 25” initiative and the incorporation of noncommunicable diseases into the post2015 Sustainable Development Goals will increase pressure on these ICUs because many cardiovascular and respiratory diseases are not really treatable in a typical African ward. The ongoing fight against communicable diseases and the future one against noncommunicable diseases are jeopardized if there is no

n engl j med 369;26 nejm.org december 26, 2013

The New England Journal of Medicine Downloaded from nejm.org on August 13, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.

correspondence

possibility of admission of patients to an ICU. We are unable to treat children who are saved from death by means of vaccination and oral rehydration therapy when they return as adults with ketoacidosis as well as pneumonia and chronic obstructive pulmonary disease. High-dependency units and ICUs should be incorporated into all considerations of managing the burden of noncommunicable diseases. Gregor Pollach, M.D. University of Malawi Blantyre, Malawi [email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1313604

noncommunicable diseases should extend from policy measures that have a population-wide impact to clinical services for persons who have these diseases. The Global Action Plan for the Prevention and Control of Noncommunicable Diseases, approved by the World Health Assembly in May 2013, provides a judicious combination of such interventions.4 There is also no dissonance between the priority afforded to communicable diseases and maternal and child health and the call for attention to noncommunicable diseases. A life-course approach to health and adoption of universal health coverage as the vehicle for delivering efficient and equitable health care will ensure that all essential health needs are met at each stage of a person’s life.5 Although some ICUs will be needed and must be provided, they cannot become the overriding priority for a health system that must ensure a wide range of promotive, preventive, diagnostic, therapeutic, palliative, and rehabilitative services. At each level of available national resources, we must prioritize the right mix of these services.

The Authors Reply: Both Dhital and Pollach call for prioritizing the provision of clinical care to persons in whom any noncommunicable disease develops. A comprehensive strategy for the prevention and control of noncommunicable diseases should indeed incorporate cost-effective clinical care. However, it is incorrect to portray K. Srinath Reddy, M.D., D.M. prevention and clinical care as conflicting agenPublic Health Foundation of India das competing for scarce resources. Many policy New Delhi, India interventions that reduce the risk of noncommunicable diseases in the population do not cost David J. Hunter, M.B., B.S., M.P.H. money. Basu et al.1 estimate that tobacco-control Harvard School of Public Health Boston, MA measures would prevent 25% of deaths from Since publication of their article, the authors report no furmyocardial infarction and stroke in India. Higher ther potential conflict of interest. taxes on tobacco and alcohol raise revenue, some Basu S, Glantz S, Bitton A, Millett C. The effect of tobacco of which can be used for providing essential 1. control measures during a period of rising cardiovascular dishealth services. In the Philippines, for example, ease risk in India: a mathematical model of myocardial infarcthe tax on tobacco has been raised to fund uni- tion and stroke. PLoS Med 2013;10(7):e1001480. 2. Philippines attacks ‘vices’ with tobacco, alcohol tax raise. versal health coverage.2,3 Australia Network News. December 20, 2012 (http://www.abc Neglect of prevention and primary health care .net.au/news/2012-12-20/an-phils-raises-tobacco2c-alcohol-taxes/ could result in ever-increasing numbers of per- 4438954). Sin Tax. Official Gazette. 2012 (http://www.gov.ph/sin-tax). sons requiring technology-intensive and costly 3. 4. Global action plan for the prevention and control of nontertiary care. No health system in the world, communicable diseases 2013-2020. Geneva: World Health Orgaespecially those in low- and middle-income coun- nization, 2013 (http://apps.who.int/iris/bitstream/10665/94384/1/ tries, can afford the escalating costs of clinical 9789241506236_eng.pdf). 5. The world health report: health systems financing: the path care for patients with noncommunicable diseases to universal coverage. Geneva: World Health Organization, 2010 if the demand for such services is not contained. (http://whqlibdoc.who.int/whr/2010/9789241564021_eng.pdf). The spectrum of the strategic response to DOI: 10.1056/NEJMc1313604

Cochlear Implants To the Editor: In his Perspective article (Sept. the machinery of human communication.” He 26 issue),1 O’Donoghue states that “[d]eafness highlights cochlear implants as a panacea for impairs quality of life by relentlessly dismantling persons with hearing loss, without discussing n engl j med 369;26 nejm.org december 26, 2013

The New England Journal of Medicine Downloaded from nejm.org on August 13, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.

2563

Noncommunicable diseases.

Noncommunicable diseases. - PDF Download Free
293KB Sizes 0 Downloads 0 Views