Security and should therefore be seen as a way of strengthening existing governance platforms, as the People’s Health Movement recommends. We should also clarify that our call for global solidarity is intended more as peopleto-people solidarity across nations, so that governments and transnational companies that violate the right to health abroad are also held accountable by the people in their home country. We appreciate Pricivel Carrera’s comments and applaud the efforts of the Health in All Policies (HiAP) approach. We agree that it complements the mechanisms we suggest. The challenge is to recognise and confront the political interests, at national but also global level, that sometimes hinder the achievement of HiAP. In a globalised world, nation-states frequently engage in transnational transactions that affect health of other countries’ populations. “Institutions impose rules on the behaviour of social actors—or they are supposed to do so.”2 We declare that we have no competing interests.
Ole Petter Ottersen, Desmond McNeill, Jashodhara Dasgupta, Inger Scheel, *Sidsel Roalkvam [email protected] Centre for Development and the Environment, University of Oslo, Oslo NO-0855, Norway (SR, DM); University President’s Office, University of Oslo, Oslo, Norway (OPO); SAHAYOG, Lucknow, India (JD); and Institute of Health and Society, University of Oslo, Oslo, Norway (IS) 1
2
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Streeck W. Taking capitalism seriously. Socio-Economic Rev 2011; 9: 137–67.
North Korea: a challenge for global solidarity On the basis of the Commission of Inquiry on human rights in the Democratic People’s Republic of Korea, a recent Editorial (March 1, p 756)1 presented evidence of gross violations of human rights in North Korea. The Commission did not call for economic sanctions, which is fortunate, as the side-effects could be violations of the www.thelancet.com Vol 383 April 19, 2014
right to health, and more than 60 years of US sanctions have not led to political change in North Korea. There are no indications that the political origins of health inequities will be solved at national level alone, but rather they may require global political solutions rooted in commitments to global solidarity and shared responsibility.2 The Commission recommended the creation of opportunities for dialogue and contact in science, exchange of information, and exposure of people to the outside world. For the sake of global solidarity and shared responsibility, we urge nations and universities to work together, creating space for research collaboration and capacity building in North Korea. Countries should set aside political differences and give universities academic freedom to collaborate independently of partner countries’ political system, as long as the actual collaboration follows main principles, such as the Declaration of Helsinki. The University of Oslo, Norway, has made the institution available for academic cooperation with Kim Il Sung University, North Korea. Health challenges in North Korea are plethora, and during a visit to North Korea in November, 2010, we noted that officials in the Ministry of Public Health and Kim Il Song University were open about the country’s health challenges, ranging from chronic undernutrition and tuberculosis to non-communicable diseases (NCDs). They wanted advice on how to get the most health benefit out of resources available, cooperation in curriculum development, teaching, laboratory equipment, and medicines. Staff at Kim Il Song University wanted collaboration in publishing of research findings in international journals. North Korea has lots of interesting data and highly motivated researchers, but the dialogue with the outside world through publications is scarce. Estimates of the burden of diseases in North Korea are mainly based on reports from international organisations, including WHO and
UNICEF. Under-5 mortality rates increased from 45 per 1000 livebirths in 1990 to 58 in 2000, and dropped to 33 in 2011.3,4 The peak was probably due to the famines in the mid-1990s; and it is most likely an underestimation, as the famines killed between 600 000 and 1 000 000 people out of a total population of approximately 22 million. The collapse of the Soviet Union in 1991, an important ally of North Korea, contributed to the deterioration of health indicators in the 1990s. The political determinants arising from such changes in transnational interaction may participate in health inequities.2 In 2009, the prevalence of stunting and underweight among North Korean children younger than 5 years was 32% and 19%, respectively, close to the worst-performing African countries.3,5 There are also important regional differences; stunting and underweight are worst in the northeast of the country.3 NCDs are currently responsible for two-thirds of deaths in North Korea, with cardiovascular diseases being the most important disease group.3,6 Tuberculosis has been an important health issue in North Korea for the past 20 years, with one of the highest incidence rates outside sub-Saharan Africa, and by contrast with other countries the occurrence of HIV/AIDS is low. On the basis of WHO estimates, from 1995 to 2011, the incidence of tuberculosis has been stable high at 344 per 100 000, while the prevalence dropped from 738 to 422 per 100 000 in the same period.3,7 The mortality rate of tuberculosis is relatively low and has dropped from 20 to 6 per 100 000 during the same period. If these figures are correct, it may indicate that treatment success rate has increased. However, the spread of multidrug-resistant tuberculosis in North Korea is much more advanced than was previously assumed, which is a threat to North Korea’s population and neighbouring countries—although very few people, at the moment, are allowed to cross the borders.
KCNA/Xinhua Press/Corbis
Correspondence
For the UN’s Human Rights Council’s Commission of Inquiry on human rights in the Democratic People’s Republic of Korea see http://www.ohchr. org/EN/HRBodies/HRC/CoIDPRK/ Pages/Reportofthe CommissionofInquiryDPRK.aspx
1381
Correspondence
Several international organisations have been engaged in North Korea for many years, and still there are grave, morally unacceptable, health inequities in the country. To ensure the right to health for all people of North Korea, increased academic collaboration could be a small step on the way to success. Reliable knowledge of a state’s health challenges and health system could help planning of health services, interventions, and humanitarian aid programmes.
Department of Community Medicine, Institute of Health and Society, University of Oslo, 0318 Oslo, Norway
more responsible and positive part in dealing with this issue instead of simply rejecting this accusation or opposing the politicisation of such issues.3 First, it is necessary to distinguish refugees from citizens who have entered China illegally for economic reasons. China must protect refugees’ basic rights, treat them with dignity, and stop repatriating them too easily. Second, China should take the comments and suggestions from the international community more seriously, working together, not only to contribute to humanitarian relief, but also to work to end the undeniable and unacceptable suffering of North Korea’s people. It is China’s responsibility and duty.
1
We declare that we have no competing interests.
We declare that we have no competing interests.
*Espen Bjertness, Ahmed Ali Madar [email protected]
2
3
4
5
6
7
The Lancet. North Korea: evidence of intolerable human rights violations. Lancet 2014; 383: 756. Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Yo Han Lee, Seok-Jun Yoon, Young Ae Kim, Ji Won Yeom, In-Hwan Oh. Overview of the burden of diseases in North Korea. J Prev Med Public Health 2013; 46: 111–17. United Nations Children’s Fund. Levels and trends in child mortality: report 2012. http:// www.childinfo.org/files/Child_Mortality_ Report_2012.pdf (accessed March 13, 2014). WHO. Levels and trends in child malnutrition: UNICEF-WHO-The World Bank joint child malnutrition estimates. http://www.who.int/ nutgrowthdb/jme_unicef_who_wb.pdf (accessed March 13, 2014). WHO. Noncommunicable disease country profiles: Democratic People’s Republic of Korea. http://www.who.int/nmh/countries/ prk_en.pdf?ua=1 (accessed March 13, 2014). WHO. Tuberculosis county profiles: Democratic People’s Republic of Korea. http://www.who. int/tb/country/en/index.html (accessed March 13, 2014).
We read with interest The Lancet’s Editorial on North Korea and evidence of intolerable human rights violations.1 As Chinese health-care professionals, we share The Lancet’s concerns about the situation in our neighbouring country, North Korea. Only a few people know what exactly happens there due to extremely limited news coverage. Since the evidence is solid after a year-long investigation into systematic human rights violations in North Korea,2 it is urgent that China plays a 1382
Cai-Yue Liu, An-Tang Liu, Hua-Peng Guan, *Hua Jiang [email protected] Department of Plastic and Reconstructive Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China (C-YL, A-TL, HJ); and Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, China (H-PG) 1
2
3
The Lancet. North Korea: evidence of intolerable human rights violations. Lancet 2014; 383: 756. UN’s Human Rights Council. Commission of Inquiry on human rights in the Democratic People’s Republic of Korea, UN’s Human Rights Council. http://www.ohchr.org/EN/HRBodies/ HRC/CoIDPRK/Pages/Reportofthe CommissionofInquiryDPRK.aspx (accessed Feb 17, 2014). Agence France-Press. China rejects complicity in North Korea human rights violations. The Globalpost, Feb 18, 2014. http://www. globalpost.com/dispatch/news/regions/asiapacific/china/140218/china-rejectscomplicity-north-korea-human-rights-vi (accessed Feb 18, 2014).
Treatment of paracetamol overdose We read with interest David Bateman and colleagues’ report (Feb 22, p 697)1 regarding reduction of adverse effects during treatment with intravenous acetylcysteine for paracetamol poisoning. Acute ingestions of para cetamol are common and consequently it has become one of
the most frequent causes of acute liver failure in the USA. As such, efforts to reduce treatment-related adverse events and the overall costs of care are greatly needed. However, we are concerned about the generalisability of the protocol used by Bateman and colleagues. A new acetylcysteine protocol that reduces the minimum duration of treatment from 21 h to 12 h is appealing in the common setting of hospital overcrowding. While deserving of investigation, this justification alone is insufficient to advocate for the widespread adoption of this protocol. Although the present study effectively evaluates adverse events related to treatment, it was not powered for efficacy. We are specifically concerned about the use of shortened protocols in patients who either present later than 8 h after ingestion or with very high paracetamol concentrations such that substantial amounts of paracetamol would remain at the end of 12 h of therapy. We commend the authors for their elegant first step but caution that without efficacy data the risks of reducing care might outweigh the benefits. We agree that shortened therapeutic courses seem reasonable in patients who present early with paracetamol concentrations minimally above the treatment threshold, but strongly caution against abandonment of a treatment protocol that has been proven to be largely safe and effective until sound efficacy data are obtained. We declare that we have no competing interests.
*Benjamin Kessler, Robert Hoffman [email protected] Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA (BK); and Division of Medical Toxicology, Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA (RH) 1
Bateman DN, Dear DW, Thanacoody HKR, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial. Lancet 2014; 383: 697–704.
www.thelancet.com Vol 383 April 19, 2014
Ole Petter Ottersen, Desmond McNeill, Jashodhara Dasgupta, Inger Scheel, *Sidsel Roalkvam [email protected] Centre for Development and the Environment, University of Oslo, Oslo NO-0855, Norway (SR, DM); University President’s Office, University of Oslo, Oslo, Norway (OPO); SAHAYOG, Lucknow, India (JD); and Institute of Health and Society, University of Oslo, Oslo, Norway (IS) 1
2
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Streeck W. Taking capitalism seriously. Socio-Economic Rev 2011; 9: 137–67.
North Korea: a challenge for global solidarity On the basis of the Commission of Inquiry on human rights in the Democratic People’s Republic of Korea, a recent Editorial (March 1, p 756)1 presented evidence of gross violations of human rights in North Korea. The Commission did not call for economic sanctions, which is fortunate, as the side-effects could be violations of the www.thelancet.com Vol 383 April 19, 2014
right to health, and more than 60 years of US sanctions have not led to political change in North Korea. There are no indications that the political origins of health inequities will be solved at national level alone, but rather they may require global political solutions rooted in commitments to global solidarity and shared responsibility.2 The Commission recommended the creation of opportunities for dialogue and contact in science, exchange of information, and exposure of people to the outside world. For the sake of global solidarity and shared responsibility, we urge nations and universities to work together, creating space for research collaboration and capacity building in North Korea. Countries should set aside political differences and give universities academic freedom to collaborate independently of partner countries’ political system, as long as the actual collaboration follows main principles, such as the Declaration of Helsinki. The University of Oslo, Norway, has made the institution available for academic cooperation with Kim Il Sung University, North Korea. Health challenges in North Korea are plethora, and during a visit to North Korea in November, 2010, we noted that officials in the Ministry of Public Health and Kim Il Song University were open about the country’s health challenges, ranging from chronic undernutrition and tuberculosis to non-communicable diseases (NCDs). They wanted advice on how to get the most health benefit out of resources available, cooperation in curriculum development, teaching, laboratory equipment, and medicines. Staff at Kim Il Song University wanted collaboration in publishing of research findings in international journals. North Korea has lots of interesting data and highly motivated researchers, but the dialogue with the outside world through publications is scarce. Estimates of the burden of diseases in North Korea are mainly based on reports from international organisations, including WHO and
UNICEF. Under-5 mortality rates increased from 45 per 1000 livebirths in 1990 to 58 in 2000, and dropped to 33 in 2011.3,4 The peak was probably due to the famines in the mid-1990s; and it is most likely an underestimation, as the famines killed between 600 000 and 1 000 000 people out of a total population of approximately 22 million. The collapse of the Soviet Union in 1991, an important ally of North Korea, contributed to the deterioration of health indicators in the 1990s. The political determinants arising from such changes in transnational interaction may participate in health inequities.2 In 2009, the prevalence of stunting and underweight among North Korean children younger than 5 years was 32% and 19%, respectively, close to the worst-performing African countries.3,5 There are also important regional differences; stunting and underweight are worst in the northeast of the country.3 NCDs are currently responsible for two-thirds of deaths in North Korea, with cardiovascular diseases being the most important disease group.3,6 Tuberculosis has been an important health issue in North Korea for the past 20 years, with one of the highest incidence rates outside sub-Saharan Africa, and by contrast with other countries the occurrence of HIV/AIDS is low. On the basis of WHO estimates, from 1995 to 2011, the incidence of tuberculosis has been stable high at 344 per 100 000, while the prevalence dropped from 738 to 422 per 100 000 in the same period.3,7 The mortality rate of tuberculosis is relatively low and has dropped from 20 to 6 per 100 000 during the same period. If these figures are correct, it may indicate that treatment success rate has increased. However, the spread of multidrug-resistant tuberculosis in North Korea is much more advanced than was previously assumed, which is a threat to North Korea’s population and neighbouring countries—although very few people, at the moment, are allowed to cross the borders.
KCNA/Xinhua Press/Corbis
Correspondence
For the UN’s Human Rights Council’s Commission of Inquiry on human rights in the Democratic People’s Republic of Korea see http://www.ohchr. org/EN/HRBodies/HRC/CoIDPRK/ Pages/Reportofthe CommissionofInquiryDPRK.aspx
1381
Correspondence
Several international organisations have been engaged in North Korea for many years, and still there are grave, morally unacceptable, health inequities in the country. To ensure the right to health for all people of North Korea, increased academic collaboration could be a small step on the way to success. Reliable knowledge of a state’s health challenges and health system could help planning of health services, interventions, and humanitarian aid programmes.
Department of Community Medicine, Institute of Health and Society, University of Oslo, 0318 Oslo, Norway
more responsible and positive part in dealing with this issue instead of simply rejecting this accusation or opposing the politicisation of such issues.3 First, it is necessary to distinguish refugees from citizens who have entered China illegally for economic reasons. China must protect refugees’ basic rights, treat them with dignity, and stop repatriating them too easily. Second, China should take the comments and suggestions from the international community more seriously, working together, not only to contribute to humanitarian relief, but also to work to end the undeniable and unacceptable suffering of North Korea’s people. It is China’s responsibility and duty.
1
We declare that we have no competing interests.
We declare that we have no competing interests.
*Espen Bjertness, Ahmed Ali Madar [email protected]
2
3
4
5
6
7
The Lancet. North Korea: evidence of intolerable human rights violations. Lancet 2014; 383: 756. Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Yo Han Lee, Seok-Jun Yoon, Young Ae Kim, Ji Won Yeom, In-Hwan Oh. Overview of the burden of diseases in North Korea. J Prev Med Public Health 2013; 46: 111–17. United Nations Children’s Fund. Levels and trends in child mortality: report 2012. http:// www.childinfo.org/files/Child_Mortality_ Report_2012.pdf (accessed March 13, 2014). WHO. Levels and trends in child malnutrition: UNICEF-WHO-The World Bank joint child malnutrition estimates. http://www.who.int/ nutgrowthdb/jme_unicef_who_wb.pdf (accessed March 13, 2014). WHO. Noncommunicable disease country profiles: Democratic People’s Republic of Korea. http://www.who.int/nmh/countries/ prk_en.pdf?ua=1 (accessed March 13, 2014). WHO. Tuberculosis county profiles: Democratic People’s Republic of Korea. http://www.who. int/tb/country/en/index.html (accessed March 13, 2014).
We read with interest The Lancet’s Editorial on North Korea and evidence of intolerable human rights violations.1 As Chinese health-care professionals, we share The Lancet’s concerns about the situation in our neighbouring country, North Korea. Only a few people know what exactly happens there due to extremely limited news coverage. Since the evidence is solid after a year-long investigation into systematic human rights violations in North Korea,2 it is urgent that China plays a 1382
Cai-Yue Liu, An-Tang Liu, Hua-Peng Guan, *Hua Jiang [email protected] Department of Plastic and Reconstructive Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China (C-YL, A-TL, HJ); and Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, China (H-PG) 1
2
3
The Lancet. North Korea: evidence of intolerable human rights violations. Lancet 2014; 383: 756. UN’s Human Rights Council. Commission of Inquiry on human rights in the Democratic People’s Republic of Korea, UN’s Human Rights Council. http://www.ohchr.org/EN/HRBodies/ HRC/CoIDPRK/Pages/Reportofthe CommissionofInquiryDPRK.aspx (accessed Feb 17, 2014). Agence France-Press. China rejects complicity in North Korea human rights violations. The Globalpost, Feb 18, 2014. http://www. globalpost.com/dispatch/news/regions/asiapacific/china/140218/china-rejectscomplicity-north-korea-human-rights-vi (accessed Feb 18, 2014).
Treatment of paracetamol overdose We read with interest David Bateman and colleagues’ report (Feb 22, p 697)1 regarding reduction of adverse effects during treatment with intravenous acetylcysteine for paracetamol poisoning. Acute ingestions of para cetamol are common and consequently it has become one of
the most frequent causes of acute liver failure in the USA. As such, efforts to reduce treatment-related adverse events and the overall costs of care are greatly needed. However, we are concerned about the generalisability of the protocol used by Bateman and colleagues. A new acetylcysteine protocol that reduces the minimum duration of treatment from 21 h to 12 h is appealing in the common setting of hospital overcrowding. While deserving of investigation, this justification alone is insufficient to advocate for the widespread adoption of this protocol. Although the present study effectively evaluates adverse events related to treatment, it was not powered for efficacy. We are specifically concerned about the use of shortened protocols in patients who either present later than 8 h after ingestion or with very high paracetamol concentrations such that substantial amounts of paracetamol would remain at the end of 12 h of therapy. We commend the authors for their elegant first step but caution that without efficacy data the risks of reducing care might outweigh the benefits. We agree that shortened therapeutic courses seem reasonable in patients who present early with paracetamol concentrations minimally above the treatment threshold, but strongly caution against abandonment of a treatment protocol that has been proven to be largely safe and effective until sound efficacy data are obtained. We declare that we have no competing interests.
*Benjamin Kessler, Robert Hoffman [email protected] Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA (BK); and Division of Medical Toxicology, Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA (RH) 1
Bateman DN, Dear DW, Thanacoody HKR, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial. Lancet 2014; 383: 697–704.
www.thelancet.com Vol 383 April 19, 2014
