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Pediaclic: Toda la pediatria a un click
Lancet, Volume 378, Issue 9809, Pages 2062 – 2063, 17 December 2011
doi:10.1016/S0140-6736(11)61889-8Cite or Link Using DOI
This year had a heady mix of health reforms, revolutions, groundbreaking research in HIV and spinal cord medicine, and a world population milestone. Udani Samarasekera reports.
On Jan 19, UK Health Secretary Andrew Lansley unveiled the Health and Social Care Bill. The legislation dictated a massive shake-up of the National Health Service (NHS), which included putting general practioners in charge of commissioning health services and allowing price competition between state and private health-care providers. Many health professionals felt reforms of the speed and scale outlined in the bill were unnecessary, damaging, and tantamount to privatisation of the NHS. The hugely unpopular bill united health-care professionals in England in protest, with many taking to the streets throughout the year. Minor changes were made to the draft legislation after a public “listening exercise” in June. In October, in a letter in The Telegraphrepublished in The Lancet, more than 400 of the country’s leading public health experts urged the House of Lords to reject the legislation. As The Lancet went to press, the bill continued its passage through parliament.
The fallout from France’s Mediator (benfluorex) scandal continued this year, with the publication of a damning report in January by accountability organisation Inspection Générale des Affaires Sociales. The report criticises drug manufacturer Servier for deceptive marketing of Mediator and the French drug regulator for being an ineffective and overworked bureaucracy. Mediator, used as an adjuvant for diabetes, might have contributed to the deaths of 500 people from valvular heart disease in its 33 years on the market by conservative estimates. France pulled the drug in November, 2009, years after other countries had made the move. From March to May this year, a national consultation about the regulation of prescription drugs culminated in a bill by French Health Minister Xavier Bertrand in August to overhaul the drug regulatory system. The legislation called for a crackdown on conflicts of interest, restructuring of the French drug regulator, and improvements in drug licensing processes and post-approval monitoring.
Starting on Dec 18, 2010, the wave of uprisings across the Arab world has been a defining event of 2011. This year has seen revolutions in Tunisia and Egypt, civil war in Libya, and major uprisings in Bahrain, Syria, and Yemen. Smaller protests have also occurred in other Arab countries. Health and humanitarian concerns remain high in the region. According to WHO, at least 50 000 people are thought to have been wounded during the Libya conflict, 20 000 of them seriously. Conflict-related injuries remain the country’s main health priority, followed by non-communicable diseases—due to lack of health staff, drugs, and medical supplies—and mental health. In Bahrain, health professionals have been targeted in crackdowns by government forces whereas hospitals have become places of torture in Syria, according to a recent report by Amnesty.
At 05:46 GMT on March 11 a magnitude 9·0 earthquake struck off the coast of northeast Japan—the country’s most powerful earthquake in recorded history. The large tsunami that followed caused widespread destruction to buildings and communications and transport infrastructure. The Fukushima Daiichi nuclear power plant, 240 km north of Tokyo, was damaged and all six reactors had failures of their cooling systems, releasing radioactive material into the area. Several hospitals were also destroyed and other health services faced challenging circumstances such as loss of electricity and lack of essential supplies. The disaster killed more than 16 000 people, and displaced more than 100 000 others. Many of the displaced survivors were elderly people who were housed in temporary accommodation as temperatures plummeted during the Japanese winter.
In May, results from the phase 3 HPTN052 trial provided definitive proof that highly active antitretroviral therapy (HAART) can prevent the sexual transmission of HIV in serodiscordant couples when one is HIV positive and the other negative. The study involved 1763 couples at 13 sites in nine countries in Africa, the USA, and Asia. The trial was stopped early by the international data and safety monitoring board after it showed that immediate HAART given to the HIV- infected partners at a CD4 cell count between 350 and 550 cells per μL could reduce the sexual transmission of HIV by 96%—the primary endpoint. Immediate HAART was also associated with a 30% decrease in the combined endpoint of disease progression and death and an 83% reduction in incidence of pulmonary tuberculosis.
In May, Susan Harkema and colleagues reported in The Lancet that electrostimulation of the spinal cord of a patient with paraplegia along with task-specific training led to several minutes of standing and fairly coordinated stepping without any input from the brain. 23-year-old Rob Summers became paraplegic after being hit by a motor vehicle in 2006 and showed no spine-controlled leg movement despite 2 years of rehabilitation. However, continual direct electrical stimulation from a surgically implanted epidural array in his lower spinal cord was able to mimic signals that the brain normally transmits to initiate movement. As noted in an accompanying Comment, the level of recovery achieved in this case study was “unprecedented”.
The European summer was seriously disrupted this year by a novel strain of Shiga-toxin-producing Escherichia coli. On May 22, Germany first reported a substantial increase in patients with haemolytic uraemic syndrome and bloody diarrhoea caused by enterohaemorrhagic E coli O1O4:H4. Between May 22 and July 21, the virulent strain caused 4075 cases of infection and led to the deaths of 50 people, mainly in Germany with some cases elsewhere in Europe and in North America. The source of the outbreak was eventually traced to bean sprouts produced at a German farm but only after several vegetables were erroneously blamed, including raw tomatoes, lettuce, and Spanish cucumbers. As an Editorial in The Lancet put it: “communication surrounding the outbreak has been haphazard at best, dismal at worst.”
There was good news for the GAVI Alliance in June when donors committed substantial new funds to the organisation during apledging meeting in London, UK. The meeting, attended by UK Prime Minister David Cameron, raised US$4·3 billion, exceeding the $3·7 billion target. The funds will allow GAVI to expand its portfolio to include vaccines such as those against the human papillomavirus that causes cervical cancer. Meanwhile, for other multilaterals, it was a disappointing year: the Global Fund to Fight AIDS, Tuberculosis and Malaria announced suspension of its latest funding round because of a lack of donor support.
The worst drought in 60 years in the Horn of Africa, coupled with conflict in Somalia, left more than 13 million people in need of food or humanitarian assistance in July. On July 20, the UN declared famine in two regions of Somalia, southern Bakool and Lower Shabelle. It was the first time that the UN had declared famine in a part of Somalia since 1991—92. Across the country, nearly half the Somali population—3·7 million people—remain in crisis. In October, the UN Office for the Coordination of Humanitarian Affairs stated: “The famine in the Horn of Africa remains the biggest crisis in the world today…The regional aid effort will need to continue well into 2012, both to meet immediate needs and—in the longer-term—to tackle the underlying problems and vulnerabilities which have put so many people in danger.”
On Sept 20, heads of state and governments made progress on global efforts to tackle non-communicable diseases (NCDs) at the UN High-Level Meeting of the General Assembly of the UN in New York, NY, USA. Countries approved the Political Declaration on the Prevention and Control of Non-communicable Diseases. However, many health experts and observers were disappointed that no time-bound targets appeared in the final document, not even the very broad one proposed by the NCD Alliance, of a 25% decrease in NCD deaths by 2025. WHO is now charged with developing voluntary targets for member states to reduce the burden of NCDs and for establishing a process to monitor progress by the end of 2012.
Promising interim results from a phase 3 trial of GlaxoSmithKline’s experimental vaccine against malaria were published in theNew England Journal of Medicine in October. The study showed that the RTS,S/AS01 vaccine roughly halved the risk of clinical and severe malaria in African infants aged 5—17 months a year after vaccination. However, meningitis and generalised convulsive seizures occurred more frequently in those receiving the RTS,S/AS01 vaccine than in the control group, and the vaccine did not reduce deaths from malaria. The data for 6—12-week-old infants are due to be reported next year, and the full trial results in 2014.
The end of October saw the world’s population hit 7 billion people, according to the UN Population Fund (UNFPA). The planet’s human population has almost doubled during the past 50 years. Average life expectancy has increased from about 48 years in the early 1950s to about 68 years in the first decade of the new century. Infant deaths have decreased from about 133 in 1000 births in the 1950s to 46 per 1000 between 2005 to 2010. The number of children a woman has also fell from about 6·0 to 2·5. But despite these successes, UNFPA note that poverty gaps between rich and poor people are widening everywhere. Things are only set to get bigger (and hopefully better): the UN foresees a global population of 9·3 billion people in 2050, and more than 10 billion by the end of this century.