Correspondence
With the rapid rate of urbanisation in developing countries across Asia and Africa, about 70% of the world’s population is expected to be living in cities by 2050.1 In their density and complexity, cities often drive national economies, provide a rich array of specialised services, ideas and innovation, with diverse social and cultural populations. However, with an estimated one billion people living in slums—according to UN Habitat, cities are also sites of extreme poverty and environmental degradation with some missing basic infrastructure and services including sanitation, electricity, and health care. In addition to health issues, such as infectious diseases and environmental pollution in urban areas, cities are now confronted with epidemics of non-communicable diseases associated with unhealthy diets, sedentary lifestyles, obesity, and mental health problems—which can be associated with substance misuse, violence, poverty, or unemployment.2 In the next decades, urban populations are estimated to double to 6·3 billion people,1 exacerbating these problems. Although the strengthening of public health and health-care delivery systems are fundamental to any development strategy, action in other sectors is also essential to improve health. There is a pressing need to address the basic needs of urban populations and, at the same time, to change the social, economic, and environmental determinants of health in cities through sustainable development. These changes need integration, coordination, and financial investment. Planning of land-use, food security, creation of jobs, transportation infrastructure, conservation of biodiversity and water, supply of renewable energy sources through waste and recycling management, disaster management, www.thelancet.com Vol 385 February 28, 2015
the provision of education, public health-care services, and housing in urban areas are all important issues that need addressing.3,4 The upcoming 12th International Conference on Urban Health in Dhaka, Bangladesh, is themed Urban Health for a Sustainable Future. This conference will be a forum for scientists, practitioners, policy makers, and community organisations to discuss how to advance research and practice to promote the health of people living in cities. Futhermore, this conference will lead to discussions with people from different geographical areas and from low-income to high-income settings on how to integrate urban health in the post-2015 development framework. Expected outcomes include the promotion of transdisciplinary research, resource mobilisation, and sharing of evidence-based policy reforms and interventions to advance urban health through the proposed sustainable development goals. The transformative approach stated in the post-2015 development agenda necessitates innovative and strong partnerships between civil society and private sectors, institutions that can work in an integrated manner, transfer of technology, capacity building, and greater attention than previously given to information access, monitoring, and reporting for accountability. A worldwide shared ambition should be to bring health to the centre of sustainable urban development. We declare no competing interests.
*Shamim Talukder, Anthony Capon, Dhiraj Nath, Anthony Kolb, Selmin Jahan, Jo Boufford [email protected] Eminence, Dhaka, Bangladesh (ST, SJ); International Institute for Global Health, United Nations, Cheras, Kuala Lumpur, Malaysia (AC); Asian Development Bank, Manila, Philippines (DN); US Agency for International Development, Washington, DC, USA (AK); and New York Academy of Medicine, New York, USA (JB) 1
UN Department of Economic and Social Affairs. World urbanization prospects: the 2014 revision. New York: United Nations, 2014.
2
3
4
WHO, UN-HABITAT. Hidden cities: unmasking and overcoming health inequities in urban settings. Geneva: World Health Organization Centre for Health Development and United Nations Human Settlements Programme, 2010. UN Department of Economic and Social Affairs. World economic and social survey 2013: sustainable development challenges. New York: United Nations, 2013. Rydin Y, Bleahu A, Davies M, et al. Shaping cities for health: complexity and the planning of urban environments in the 21st century. Lancet 2012; 379: 2079–108.
Putting health first in universal health coverage The Lancet’s Editorial on universal health coverage (UHC; Dec 13, p 2083)1 states “putting people first” in its title. Yet, ironically, the entire UHC initiative really puts process ahead of people and their actual health—as shown by Robert Marten and colleagues’ Health Policy paper.2 Their descriptions of UHC in Brazil, Russia, India, China, and South Africa (BRICS) focus entirely on the process of health-care services. Of course, clinical services are important. But by jumping to focus on factors such as providers, health plans, and insurance, UHC projects only the clinical model of promotion of health. If the objective is actual health, where is the discussion of the effect of alcohol on health in Russia and the role of taxation? For China, where is the discussion of the immense effect of tobacco and air pollution on health, and how to address these? For any of the BRICs countries considered, where is the discussion on water and sanitation, nutrition, or injury prevention? Health interventions are more than just clinical health-care services. And clinical services can be a huge drain with little effect. Health-care advocate Donald Berwick noted “No relationship exists between health-care expenditures and health outcomes, either internationally among developed nations or nationally among the states with the highest income levels.”3 Sadly, the term universal health coverage is Orwellianly misleading in
Michael Runkel/Robert Harding World Imagery/Corbis
Urban health in the post-2015 agenda
See Editorial page 745 For more about the 12th International Conference on Urban Health see http:// icuh2015.org/ For UN Habitat see http:// unhabitat.org/
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
769
Correspondence
two ways. It focuses on clinical health services rather than on health itself, and, the terms universal and coverage imply that virtually everything can be covered. Particularly in resource-constrained countries, the priority should be low-cost, high-effect interventions, both clinical and non-clinical. I declare no competing interests. The views expressed are the author’s and not necessarily those of the US Agency for International Development.
James D Shelton [email protected] US Agency for International Development, Washington, DC 20523, USA 1 2
3
Lancet. Universal health coverage post-2015: putting people first. Lancet 2014; 384: 2083. Marten R, McIntyre D, Travassos C, et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). Lancet 2014; 384: 2164–71. Berwick DM. Reshaping US health care. From competition and confiscation to cooperation and mobilization. JAMA 2014; 312: 2099–100.
Alemtuzumab induction therapy in kidney transplantation We read with interest the results of the 3C Study (Nov 8, p 1684)1 that compares alemtuzumab induction treatment with basiliximab, followed by sirolimus versus tacrolimus maintenance treatment for long-term preservation of kidney transplant function. The results of this study will be of substantial clinical importance as the number of kidney transplants done annually—alongside their immunological complexity—is increasing. However, we wish to raise several points. Alemtuzumab is a promising new treatment for multiple sclerosis.2 Investigators of recent clinical trials have highlighted the issue of autoimmunity; in particular, thyroid dysfunction after treatment with this drug. This autoimmunity might need medium-term treatment with corticosteroids, avoidance of which is one of the goals of alemtuzumab 770
induction. Did the 3C investigators find any evidence of clinically problematic autoimmune disorders in the alemtuzumab group? In view of the fact that onset of autoimmunity can be delayed more than a year after treatment, vigilance for this autoimmunity is advisable during the 3C Study follow-up period. Cardiovascular disease remains the commonest cause of death with a functioning graft and is therefore also the commonest cause of graft failure.3 Hypertension and proteinuria are important cardiovascular risk factors often present in kidney transplant recipients. Their reduction is the main strategy for reduction of cardiovascular risk. Interest in immunomodulatory treatments that might lower blood pressure4 and proteinuria is increasing.5 Whether there were any differences in these variables at 6 months between those given alemtuzumab (a potent lymphocyte-depleting agent) and basiliximab (a non-depleting interleukin 2 receptor antagonist) would be interesting to know. We declare no competing interests.
*Neeraj Dhaun, David C Kluth [email protected] Centres for Cardiovascular Sciences (ND), and Inflammation Research (DCK), University of Edinburgh, Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK 1
2
3
4
5
3C Study Collaborative Group, Haynes R, Harden P, et al. Alemtuzumab-base induction treatment versus basilixmab-base induction treatment in kidney transplantation (the 3C Study): a randomised trial. Lancet 2014; 384: 1684–90. Cohen JA, Coles AJ, Arnold DL, et al. Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial. Lancet 2012; 380: 1819–28. Stoumpos S, Jardine AG, Mark PB. Cardiovascular morbidity and mortality after kidney transplantation. Transpl Int 2014; 28: 10–21. Idris-Khodja N, Mian MO, Paradis P, Schiffrin EL. Dual opposing roles of adaptive immunity in hypertension. Eur Heart J 2014; 35: 1238–44. Yu CC, Fornoni A, Weins A, et al. Abatacept in B7-1-positive proteinuric kidney disease. N Engl J Med 2013; 369: 2416–23.
The 3C Study Collaborative Group report a reduction of biopsy-proven acute rejection (BPAR) from 16% with
basiliximab to 7% with alemtuzumab in a randomised trial of 852 renal transplant recipients. 1 Despite its rather high rate and standardised detection, BPAR nowadays should no longer guide treatment decisions. Early BPAR without effect on graft function is well known to have no effect on long-term outcomes.2 Hence, for trials of renal transplantation, both the European Medicines Agency and US Food and Drug Administration have suggested use of combined primary endpoints that include patient and graft survival, and graft function besides acute rejection. In this trial, despite the reported advantage of BPAR, graft loss summed to 4% and patient death summed to 3% with alemtuzumab, with graft loss summing to 3% and patient death summing to 1% with basiliximab at 1 year. Therefore, the authors should provide numbers of non-death-censored graft loss (sum of death and graft loss) in both groups (these would theoretically sum to 6·3% [alemtuzumab] vs 4·5% [basiliximab] if only one event is assumed to occur in any given patient). Furthermore, BK virus infection occurred twice as often with alemtuzumab than with basiliximab, and leucopenia was 3·6 times more frequent, both of which might reduce graft survival long term. Some evidence suggests that long-term outcomes might be inferior with alemtuzumab compared with conventional induction treatment.3 Finally, clinical use of alemtuzumab might be severely hampered because the drug (MabCampath) has been withdrawn from the market in the European Union since Aug 8, 2012. BKK reports personal fees from Astellas, Bristol-Myers Squibb, Novartis, Chiesi, and Roche outside the submitted work. The other authors declare no competing interests.
Andrea Berghofen, Thomas Singer, Bernd Krüger, *Bernhard K Krämer, Urs Benck [email protected] University Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany
www.thelancet.com Vol 385 February 28, 2015
With the rapid rate of urbanisation in developing countries across Asia and Africa, about 70% of the world’s population is expected to be living in cities by 2050.1 In their density and complexity, cities often drive national economies, provide a rich array of specialised services, ideas and innovation, with diverse social and cultural populations. However, with an estimated one billion people living in slums—according to UN Habitat, cities are also sites of extreme poverty and environmental degradation with some missing basic infrastructure and services including sanitation, electricity, and health care. In addition to health issues, such as infectious diseases and environmental pollution in urban areas, cities are now confronted with epidemics of non-communicable diseases associated with unhealthy diets, sedentary lifestyles, obesity, and mental health problems—which can be associated with substance misuse, violence, poverty, or unemployment.2 In the next decades, urban populations are estimated to double to 6·3 billion people,1 exacerbating these problems. Although the strengthening of public health and health-care delivery systems are fundamental to any development strategy, action in other sectors is also essential to improve health. There is a pressing need to address the basic needs of urban populations and, at the same time, to change the social, economic, and environmental determinants of health in cities through sustainable development. These changes need integration, coordination, and financial investment. Planning of land-use, food security, creation of jobs, transportation infrastructure, conservation of biodiversity and water, supply of renewable energy sources through waste and recycling management, disaster management, www.thelancet.com Vol 385 February 28, 2015
the provision of education, public health-care services, and housing in urban areas are all important issues that need addressing.3,4 The upcoming 12th International Conference on Urban Health in Dhaka, Bangladesh, is themed Urban Health for a Sustainable Future. This conference will be a forum for scientists, practitioners, policy makers, and community organisations to discuss how to advance research and practice to promote the health of people living in cities. Futhermore, this conference will lead to discussions with people from different geographical areas and from low-income to high-income settings on how to integrate urban health in the post-2015 development framework. Expected outcomes include the promotion of transdisciplinary research, resource mobilisation, and sharing of evidence-based policy reforms and interventions to advance urban health through the proposed sustainable development goals. The transformative approach stated in the post-2015 development agenda necessitates innovative and strong partnerships between civil society and private sectors, institutions that can work in an integrated manner, transfer of technology, capacity building, and greater attention than previously given to information access, monitoring, and reporting for accountability. A worldwide shared ambition should be to bring health to the centre of sustainable urban development. We declare no competing interests.
*Shamim Talukder, Anthony Capon, Dhiraj Nath, Anthony Kolb, Selmin Jahan, Jo Boufford [email protected] Eminence, Dhaka, Bangladesh (ST, SJ); International Institute for Global Health, United Nations, Cheras, Kuala Lumpur, Malaysia (AC); Asian Development Bank, Manila, Philippines (DN); US Agency for International Development, Washington, DC, USA (AK); and New York Academy of Medicine, New York, USA (JB) 1
UN Department of Economic and Social Affairs. World urbanization prospects: the 2014 revision. New York: United Nations, 2014.
2
3
4
WHO, UN-HABITAT. Hidden cities: unmasking and overcoming health inequities in urban settings. Geneva: World Health Organization Centre for Health Development and United Nations Human Settlements Programme, 2010. UN Department of Economic and Social Affairs. World economic and social survey 2013: sustainable development challenges. New York: United Nations, 2013. Rydin Y, Bleahu A, Davies M, et al. Shaping cities for health: complexity and the planning of urban environments in the 21st century. Lancet 2012; 379: 2079–108.
Putting health first in universal health coverage The Lancet’s Editorial on universal health coverage (UHC; Dec 13, p 2083)1 states “putting people first” in its title. Yet, ironically, the entire UHC initiative really puts process ahead of people and their actual health—as shown by Robert Marten and colleagues’ Health Policy paper.2 Their descriptions of UHC in Brazil, Russia, India, China, and South Africa (BRICS) focus entirely on the process of health-care services. Of course, clinical services are important. But by jumping to focus on factors such as providers, health plans, and insurance, UHC projects only the clinical model of promotion of health. If the objective is actual health, where is the discussion of the effect of alcohol on health in Russia and the role of taxation? For China, where is the discussion of the immense effect of tobacco and air pollution on health, and how to address these? For any of the BRICs countries considered, where is the discussion on water and sanitation, nutrition, or injury prevention? Health interventions are more than just clinical health-care services. And clinical services can be a huge drain with little effect. Health-care advocate Donald Berwick noted “No relationship exists between health-care expenditures and health outcomes, either internationally among developed nations or nationally among the states with the highest income levels.”3 Sadly, the term universal health coverage is Orwellianly misleading in
Michael Runkel/Robert Harding World Imagery/Corbis
Urban health in the post-2015 agenda
See Editorial page 745 For more about the 12th International Conference on Urban Health see http:// icuh2015.org/ For UN Habitat see http:// unhabitat.org/
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
769
Correspondence
two ways. It focuses on clinical health services rather than on health itself, and, the terms universal and coverage imply that virtually everything can be covered. Particularly in resource-constrained countries, the priority should be low-cost, high-effect interventions, both clinical and non-clinical. I declare no competing interests. The views expressed are the author’s and not necessarily those of the US Agency for International Development.
James D Shelton [email protected] US Agency for International Development, Washington, DC 20523, USA 1 2
3
Lancet. Universal health coverage post-2015: putting people first. Lancet 2014; 384: 2083. Marten R, McIntyre D, Travassos C, et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). Lancet 2014; 384: 2164–71. Berwick DM. Reshaping US health care. From competition and confiscation to cooperation and mobilization. JAMA 2014; 312: 2099–100.
Alemtuzumab induction therapy in kidney transplantation We read with interest the results of the 3C Study (Nov 8, p 1684)1 that compares alemtuzumab induction treatment with basiliximab, followed by sirolimus versus tacrolimus maintenance treatment for long-term preservation of kidney transplant function. The results of this study will be of substantial clinical importance as the number of kidney transplants done annually—alongside their immunological complexity—is increasing. However, we wish to raise several points. Alemtuzumab is a promising new treatment for multiple sclerosis.2 Investigators of recent clinical trials have highlighted the issue of autoimmunity; in particular, thyroid dysfunction after treatment with this drug. This autoimmunity might need medium-term treatment with corticosteroids, avoidance of which is one of the goals of alemtuzumab 770
induction. Did the 3C investigators find any evidence of clinically problematic autoimmune disorders in the alemtuzumab group? In view of the fact that onset of autoimmunity can be delayed more than a year after treatment, vigilance for this autoimmunity is advisable during the 3C Study follow-up period. Cardiovascular disease remains the commonest cause of death with a functioning graft and is therefore also the commonest cause of graft failure.3 Hypertension and proteinuria are important cardiovascular risk factors often present in kidney transplant recipients. Their reduction is the main strategy for reduction of cardiovascular risk. Interest in immunomodulatory treatments that might lower blood pressure4 and proteinuria is increasing.5 Whether there were any differences in these variables at 6 months between those given alemtuzumab (a potent lymphocyte-depleting agent) and basiliximab (a non-depleting interleukin 2 receptor antagonist) would be interesting to know. We declare no competing interests.
*Neeraj Dhaun, David C Kluth [email protected] Centres for Cardiovascular Sciences (ND), and Inflammation Research (DCK), University of Edinburgh, Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK 1
2
3
4
5
3C Study Collaborative Group, Haynes R, Harden P, et al. Alemtuzumab-base induction treatment versus basilixmab-base induction treatment in kidney transplantation (the 3C Study): a randomised trial. Lancet 2014; 384: 1684–90. Cohen JA, Coles AJ, Arnold DL, et al. Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial. Lancet 2012; 380: 1819–28. Stoumpos S, Jardine AG, Mark PB. Cardiovascular morbidity and mortality after kidney transplantation. Transpl Int 2014; 28: 10–21. Idris-Khodja N, Mian MO, Paradis P, Schiffrin EL. Dual opposing roles of adaptive immunity in hypertension. Eur Heart J 2014; 35: 1238–44. Yu CC, Fornoni A, Weins A, et al. Abatacept in B7-1-positive proteinuric kidney disease. N Engl J Med 2013; 369: 2416–23.
The 3C Study Collaborative Group report a reduction of biopsy-proven acute rejection (BPAR) from 16% with
basiliximab to 7% with alemtuzumab in a randomised trial of 852 renal transplant recipients. 1 Despite its rather high rate and standardised detection, BPAR nowadays should no longer guide treatment decisions. Early BPAR without effect on graft function is well known to have no effect on long-term outcomes.2 Hence, for trials of renal transplantation, both the European Medicines Agency and US Food and Drug Administration have suggested use of combined primary endpoints that include patient and graft survival, and graft function besides acute rejection. In this trial, despite the reported advantage of BPAR, graft loss summed to 4% and patient death summed to 3% with alemtuzumab, with graft loss summing to 3% and patient death summing to 1% with basiliximab at 1 year. Therefore, the authors should provide numbers of non-death-censored graft loss (sum of death and graft loss) in both groups (these would theoretically sum to 6·3% [alemtuzumab] vs 4·5% [basiliximab] if only one event is assumed to occur in any given patient). Furthermore, BK virus infection occurred twice as often with alemtuzumab than with basiliximab, and leucopenia was 3·6 times more frequent, both of which might reduce graft survival long term. Some evidence suggests that long-term outcomes might be inferior with alemtuzumab compared with conventional induction treatment.3 Finally, clinical use of alemtuzumab might be severely hampered because the drug (MabCampath) has been withdrawn from the market in the European Union since Aug 8, 2012. BKK reports personal fees from Astellas, Bristol-Myers Squibb, Novartis, Chiesi, and Roche outside the submitted work. The other authors declare no competing interests.
Andrea Berghofen, Thomas Singer, Bernd Krüger, *Bernhard K Krämer, Urs Benck [email protected] University Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany
www.thelancet.com Vol 385 February 28, 2015
