Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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First the diagnosis, but soon thereafter the efficacious therapeutic intervention.
- Sergio Stagnaro (12 April 2002)
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Thanks for the memories
- Saty Satya Murti (15 April 2002)
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Limits of Medicine
- Roger E Stephenson (15 April 2002)
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Editorial on "too much medicine" is a little bit non sequitur!
- K.R. Nayar, Oliver Razum (17 April 2002)
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A history lesson
- Ray, N Moynihan (18 April 2002)
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Dr. Knock's village of Saint-Maurice
- Francois MENNERAT (19 April 2002)
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Keep Illich on the Editorial Board
- Ned Hoke (23 April 2002)
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Too much selfishness
- Feroz Dinah, BT12 6BA (27 April 2002)
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NHS reforms will lead to further medicalisation
- ASHIS BANERJEE (9 May 2002)
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Too much medicine?
- Robert Stewart (14 May 2002)
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Too much medicine
- Henning Rohde, none (30 May 2002)
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Consider the earth too.
- Prabha Krishnan (28 October 2002)
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Too many drugs?
- John P Heptonstall (29 October 2002)
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Do medications make patients better or worse?
- Richard G Fiddian-Green (30 October 2002)
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Re: Too much medicine?
- Eileen Orr (9 November 2002)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal and Metabolic Disease. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy
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Sirs, Ray Moynihan and Richard Smith (BMJ 2002;324:859-860, 13 April) state that most doctors believe medicine to be a force for good, as can be clearly seen. I am certainly allowed to pronounce the same statement as regards science in general, of course: even a lancet can be for good or, by contrast, it can become harmful. In reality, we have to think first that the actual “medicine” is ruled unfortunately by economists, politicians, business-men, a.s.o., and secondly confront it with a desirable one, not necessarily ruled as we observe nowadays. I agree, from this point of view, with who says that “The medical establishment has become a major threat to healt” (1), adding, however, for completeness reason, “to medical science”. Certainly, in western countries no one wants to keep cutting back on education, the arts, scientific research, good food a.s.o., but all people would like surely to see their money spent in a better way. For example, there is a bias (or, perhaps, something else)in our actual cancer screening (BMJ.com, Rapid Response, 14 May 2001) and , moreover, an useless waste of money, time, energy follows to it, as a plain consequence of that situation. As a matter of fact, not all individuals can be involved by malignant tumour, solid or liquid, because exclusively 30 % of people (at least, in my little town, Riva Trigoso, near Genoa) are positive for particular abnormality of psycho-neuro-endrocine- immunological system, I termed “Oncological Terrain”, recognizable at the bed-side “quantitatively” by means of a simple stethoscope (See the site HONCode ID N.233736 http://digilander.iol.it/semeioticabiofisica, and the weekly Page, Semeiotica Biofisica, I held on the italian site www.Katamed.it) (1,2). I certainly appreciate (and agree with) the critique of modern, or industrialised, medicine (1), which consider the limits of present health care, but, after the diagnosis it is necessary the proper therapeutic intervention. Therefore, I would be really delighted with a possible, honest discussion about such argument, unavoidable for a successful cancer prevention, i.e., the existence of “Oncological Terrain” with who are responsable for Health Care, including Health Ministers, of course. Sergio Stagnaro MD. Active Member NYAS. 1.Illich I. Limits to medicine. London: Marion Boyars, 1976. 2) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447, 1993. 3) Stagnaro S., Auscultatory percussion of the cerebral tumour: Diagnostic importance of the evoked potentials, Biol. Med., 7, 171-175, 1985. |
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Saty Satya Murti, neurologist Topeka, KS 66610
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Illich's words, but not his teachings, had faded away a bit from my memory over the last 25 years. I thank you for recalling him, and reminding me that I, too, have fashioned large segments of my career based on Illich's inspirational message. |
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Roger E Stephenson, Principal in General Practice The Surgery, Fair Park, Bow, CREDITON, Devon EX17 6EY
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Ray Moynihan and Richard Smith ask whether we might have reached the point where medicine is counterproductive. Their answer, in careful journalese, is short on figures. Here are some which suggest that we have reached that point at least in one field. The Department of Health tell us (1) that there is a risk of more than two per million courses of polio vaccine, of contracting the disease, polio, from the vaccine itself (both vaccinee and contacts being at risk). In the same publication we are told that natural polio infection no longer occurs in the UK. So for a child not travelling to polio infected areas it is safer to remain unimmunised. In fact, a child's only risk of contracting polio in the UK is from his friends' immunisations. Medical Nemesis or what? 1. Polio Vaccine Factsheet; Department of Health: November 1997 |
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K.R. Nayar, Associate Professor in Social Sciences Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru Universi, Oliver Razum
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Editorial on “too much medicine” is a little bit
non
sequitur!
Editor - No doubt that there is too much medicine in some parts of the world. There is also too little in other parts. Ray Moynihan and Richard Smith try to homogenise the world by drawing in examples out of their context (1). A case in point is their use of Amartya Sen’s analysis of the health situation in Kerala and Bihar in India (2) to support the much-admired, iconoclastic critique of industrialised medicine by Ivan Illich. Firstly, the two extreme examples of Kerala and Bihar are misleading
when assessing the association between health investment and reported morbidity
or medical action. The table shows data on four states which spend the
highest per capita amount for health in India and the state of Bihar which
spends the least amount (3; 4). The data indicate that investment in health
is not consistently associated with either reported morbidity or health
actions taken. For example, Rajastan has the highest per capita
health expenditure but the lowest prevalence of reported reproductive health
problems.
Table: Health indicators of selected states of India
Secondly, the available data on morbidity in India are generally based on patients reporting to government hospitals. It is difficult to believe that people in Bihar are not taking any action to ameliorate their suffering due to a health problem. They may not go to a government hospital, but approach an indigenous practitioner or any available service instead. The assumption that they do use services is supported by the high proportion of assisted births (table). Finally, we do not think that encapsulating Illich’s suggested preventive and primary care strategies within the so-called “truly modern culture that fostered self-care and autonomy” would help the millions of under-medicalised people of the world. Self-help and self-care are increasingly being instrumentalised in a neo-liberal agenda to replace government support to health care in developing countries. They may or may not help in de-medicalisation and de-professionalisation but they would certainly further reduce access to health care in such populations. We agree that increasing medical inputs will at some point become counterproductive
but it seems populations in many developing countries are drifting farther
away from that point rather than approaching it. As long as there is widespread
death and suffering from diseases such as tuberculosis, malaria, pneumonia,
measles, and polio, people have a right to expect to “get things”, i.e.
effective prevention and care, through a government health system, rather
than being expected to “find their own way”.
K. R. Nayar associate professor in Social Sciences
Oliver Razum epidemiologist
Competing interests: none declared References: 1. Moynihan R, Smith R. Too much medicine? Almost certainly. BMJ 2002;324:859-60.
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Ray, N Moynihan, Journalist Australian Financial Review
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Who better to help us understand contemporary debates about medicalisation than a world class historian. In 1996 the late great Roy Porter wrote ".....an expanding medical establishment, faced with a healthier population of its own creation, is driven to medicating normal life events (such as the menopause), to converting risks into diseases, and to treating trivial complaints with fancy procedures. Doctors and 'consumers' alike are becoming locked within a fantasy that unites the creation of anxiety with gung-ho 'can-do, must- do' technological perfectibilism: everyone has something wrong with them, everyone can be cured." Guest Editor
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Francois MENNERAT, Medical Adviser, FNMF 75015 Paris (France)
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Sir, For those who read French, what humankind is at risk of (at least its "developed" part) has been perfectly described by Jules Romain in its wonderful play "Docteur Knock". Any activity in his rural village progressively becomes second to health care. Any medical student should be given a copy of this book on his or her very first day in a Medical School. Sincerely François Mennerat |
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Ned Hoke, Ecological Medicine/private Calif/USA
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Each issue of BMJ could contain an Illich section wherein stories, proposals, and other evidences of the theme qualities championed by Mr. Illich. Your editorial so lightly passes over the challenges and their meanings it would be easy to move slightly in one's chair and turn to the next page. Nonetheless your direct exposure of the Illich principles for consideration indicates to me you know and do not turn away from their biting illuminations. For physicians to hear time and again reasonable discussion unmasking the unnecessarily shallow or profoundly unwise aspects of their everyday activities is to restore a fundamental integrity within the healthcare dialogue. |
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Feroz Dinah, SpR Trauma & Orthopaedics Royal Victoria Hospital, Belfast, BT12 6BA
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26th April 2002 Dear Editor, I read with interest the editorial ‘Too much medicine?’1, with which I agree wholeheartedly. However, I believe there is a further dimension to the problem, and hence to the solution. Another way of looking at it is that we are trying to make our existence perfect. Indeed any kind of imperfection – e.g. illness, baldness, infertility, ageing and even death – is looked upon with embarrassment or disdain. While no-one is prepared for the unexpected, we have the ability to reflect, seek help appropriately and then adapt. Unfortunately, post-modern medicine has strayed from its noble humanitarian origins into the commercial arena of demand and supply. The medical and pharmaceutical establishments, lay people and academics all shoulder a part of the blame for perpetuating the myths of the ‘magic bullet’. No biological system is perfect, and even less so the current social, commercial or information networks. The basic needs of food, shelter, clothing (and love) are unchanged, but are no longer sufficient for happiness and contentment. With affluence has come greater expectations, with the most well-off seemingly the most ill, and the poorest people rating their health the highest2. We have developed ourselves mentally, physically – and some would add morally, too – but have forgotten our spiritual dimension. We have forgotten how to be ‘mere mortals’, and little can be said about the virtues of self-control, altruism and humility. While denying responsibility for our health, we abhor the concept of fate, and have become ungrateful for small mercies. We have even begun to think that the whole universe revolves around us: in fact, we are but a lowly life-form, on a speck of dust in the vastness of the Cosmos. The authors refer to the works of Illich from the last century as having clinched the diagnosis. The cure, however, might lie in the wisdom from religious texts of the last millennium, or earlier. Life’s not fair, but what will happen after death. There is definitely life after death: about 6 billion lives, actually, after your death … and what can they look forward to if you squander precious resources on ‘non-diseases’ ? Feroz Dinah Specialist Registrar in Orthopaedics Royal Victoria Hospital, Belfast BT12 6BA feroz72@hotmail.com Competing interests: None. References 1. Moynihan R, Smith R. Too much medicine? BMJ 2002; 324: 859-60 (13 April). 2. Sen A. Health: perception versus observation. BMJ 2002; 324: 860-1 (13 April). |
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ASHIS BANERJEE, Specialist Registrar Public Health South Worcestershire PCT, Isaac Maddox House, Shrub Hill Road, Worcester WR4 9RW
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Editor, At the heart of the current government reforms of the NHS is the belief that the main problems to be addressed are chronic underfunding and inconsistent quality of care(i). As society has become more consumerist and less satisfied by a paternalistic approach, policies of evidence based medicine, clinical governance, risk management and revalidation of doctors have been implemented to regain the public’s trust. These reforms however do not address many of the wider issues regarding the role of medicine in society discussed in Moynihan and Smith’s editorial in the BMJ(ii). The danger is that the present political climate is stoking unattainable public expectations of the ongoing reforms. The general public needs to be told that medicine has limitations even with proper funding and a well-trained professional workforce. Many rationing decisions ultimately rest on difficult ethical debates that the general population must become fully engaged in. Clinical evidence can help inform the decision-making process in some cases but has a number of limitations inherent within it. For example, the structure of trials means it is difficult to provide conclusive evidence on interventions that are complex or heterogeneous such as many complementary therapies and some forms of psychotherapy. With the medicalisation of life, medicine is being drawn into areas it does not have a right or capacity to adjudicate over. The present health reforms heavily promote the authority of medicine as a science that can always provide answers. Whereas in the 16th century Copernicus’ heliocentric view of astronomy was attacked for being blasphemous, we now accuse schoolteachers who advocate creationist theories of being unscientific(iii). To promote medicine as king is to avoid recognising its limitations. Society needs to face its fear of mortality and discuss the importance of rights, responsibilities and equity in the modern NHS. i Check against delivery [Prime Minister's speech on the NHS]. 2001 Dec 6. Available from: URL: http://www.number- 10.gov.uk/news.asp?NewsId=3233&SectionId=32 ii Moynihan R, Smith R. Too much medicine? BMJ 2002; 324: 859-860 iii McKie R. Bishop warns Blair over danger of creationism. Observer 2002 Apr 7. |
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Robert Stewart, Lecturer Institute of Psychiatry, De Crespigny Park, London SE5 8AF
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Is there really too much medicine? [1] It certainly seems to be a convenient 'get out' for an overburdened medical service. But who gets to lose out if services are 'reoriented' (withdrawn)? The 'effort' of medical care does not only arise from providing the care itself but also from providing it equitably. Surely there is a fine line between 'resisting the categorisation of life's problems as medical' [1] and ignoring increased morbidity in those who are more burdened by life's problems? So if you are rich you shouldn't be depressed and your depression gets treated. If you are poor (or old), your depression is a product of your disadvantage - and of course it would be completely inappropriate to 'medicalise' poverty or 'understandable' unhappiness. 1. Moynihan R, Smith R. Too much medicine? BMJ 2002;324:859-60. |
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Henning Rohde, Prof.endoscopy and proctology Friesenplatz 17a, 50672 Cologne (Germany), none
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EDITOR- to me the anus is one part of our body where "medicine's power to harm individual patients and whole populations"( 1 ) is evident. There is a lot of money to be made from telling people "haemorrhoids and their symptoms are on of the most common afflictions in the Western world".( 2 ) Unfortunately and tragically, patientes suffering from any symptoms related to the lower bowel and anus assume all too frequently and often incorrectly that their symptoms are due to haemorrhoids. In my proctological clinic various types of anal dermatitis were found more frequently than haemorrhoids in patients examined for rectal bleeding.( 3 ) Additionally doctor's advice for anal cleansing like "Keep the area clean by washing after every bowel action and night and morning"( 4 ) or "If you are away from home or good toilet facilities when you have to pass a motion ase medicated wipes such as Wet Ones or Baby Wipes"( 4 ) is causing harm to thousands of individual patiens according to what I see at my proctologic clinic.( 5 ) But much more important, this advice has never been tested by randomised controlled trials. Anal dermatitis heals if patients stop with anal cleansing, and avoid showers, baths,swims, moist tissue, Sitz baths until healing.( 5 ) |
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Prabha Krishnan, health activist 402, West Wind II, Gandhigram Road,Juhu, Mumbai- 49, INDIA
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The earth too is being over-drugged. In India this is particularly sad since we still have large pools of native wisdom that tell us how to live in creative equilibrium with the environment. Our health policies are fuelling the devastation of the earth and people alike. I have documented this in my book, Health Care, Earth Care, published by Earthcare Books, Mumbai and Kolkatta. The two major sections are Drugging the Body and Drugging the Earth. My submission is that we err seriously when we fail to consider ourselves as an extension of the environment we occupy. This alienation is the basis of our Conquer-the Earth, Conquer-Disease outlook. |
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John P Heptonstall, Director of The Morley Acupuncture Clinic and Complementary Therapy Centre Leeds LS27 8EG
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Sir Surely the more drugs available the better....newer drugs, drugs with fewer side effects, drugs for fatness, drugs for thinness, drugs for appetite, drugs for sleep, drugs for energy, drugs for conception, drugs for contraception, uppers, downers, drugs that cause dependence, drugs to treat dependence, drugs for constipation, drugs for diarrhoea, where would we be without them, a pill for every ill? Perhaps the most unfortunate outcome of our 'drug culture' is that children can no longer tell the difference between 'good' drugs and 'bad' drugs, especially when the massively successful 'corporations' - distributing coffee, chocolate, cola, tobacco, pharmaceuticals, heroin, cocaine are self-evidently drug-based - show one the road to riches. What did we do before the institutionalisation of drugs? Regards John H. |
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Richard G Fiddian-Green, None None
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A large number of drugs, including antibiotics, aspirin, NSAIDS, antidepressants, statins, cannabis, amphetamines, cocaine, heroin, morphine, and antidepressants may impair mitochondrial oxidative phosphorylation (1-14). It is very likely that the effects of many of theses substances are additive when administered together, the most serious damage likely to be inflicted not only by individual substances taken in abnormally large amounts but also by the mixing of different substances taken in normal amounts (15). Different doses have different effects. In the case of alcohol, the most extensively studied, a binge may induce massive mitochondrial damage (16). Chronic consumption in moderate amounts, on the other hand, may increase the efficiency of oxidative phosphorylation (17) and abstinence may reverse the mitochondrial damage done (18). An impairment of mitochondrial oxidative phosphorylation appears to be the cause of most organ dysfunctions and failures in the acutely ill (19,20) and probably in the chronically ill (21-28). It is very likely, therefore, that many of the medications that are being administered for the management of chronic illnesses and taken for recreational purposes increase the risk of developing organ dysfunctions and failures in acute illnesses and the risk of developing chronic illnesses such as neurodegenerative disorders and chronic heart failure. 1. Fosslien E. Mitochondrial medicine--molecular pathology of defective oxidative phosphorylation. Ann Clin Lab Sci. 2001 Jan;31(1):25- 67. Review 2. Yamanouchi H, Imataka G. Mitochondrial diseases due to drug toxicity Nippon Rinsho. 2002 Apr;60 Suppl 4:473-7. Review. 3. Szewczyk A, Wojtczak L. Mitochondria as a pharmacological target. Pharmacol Rev. 2002 Mar;54(1):101-27. Review. 4. Cormier A, Morin C, Zini R, Tillement JP, Lagrue G. In vitro effects of nicotine on mitochondrial respiration and superoxide anion generation. Brain Res. 2001 May 4;900(1):72-9. 5. Berson A, Fau D, Fornacciari R, Degove-Goddard P, Sutton A, Descatoire V, Haouzi D, Letteron P, Moreau A, Feldmann G, Pessayre D. Mechanisms for experimental buprenorphine hepatotoxicity: major role of mitochondrial dysfunction versus metabolic activation. J Hepatol. 2001 Feb;34(2):261-9. 6. Boess F, Ndikum-Moffor FM, Boelsterli UA, Roberts SM. Effects of cocaine and its oxidative metabolites on mitochondrial respiration and generation of reactive oxygen species. Biochem Pharmacol. 2000 Sep 1;60(5):615-23. 7. Muscari C, Bastagli L, Ventura C, Bernardi P, Caldarera CM. Reduction of the rate of mitochondrial respiration in the rat heart perfused with opioids and naloxone Cardiologia. 1988 Apr;33(4):353-7. 8. Das NP, Ratty AK. Studies on the effects of the narcotic alkaloids, cocaine, morphine, and codeine on nonenzymatic lipid peroxidation in rat brain mitochondria. Biochem Med Metab Biol. 1987 Apr;37(2):258-64. 9. Chari-Briton A. Proceedings: Swelling of rat liver mitochondria induced by delta1-tetrahydrocannabinol. Isr J Med Sci. 1975 Nov;11(11):1189. 10. Bailey SM, Cunningham CC. Contribution of mitochondria to oxidative stress associated with alcoholic liver disease. Free Radic Biol Med. 2002 Jan 1;32(1):11-6. Review. 11. Cunningham CC, Bailey SM. Ethanol consumption and liver mitochondria function. Biol Signals Recept. 2001 May-Aug;10(3-4):271-82. Review 12. Goodlett CR, Horn KH. Mechanisms of alcohol-induced damage to the developing nervous system. Alcohol Res Health. 2001;25(3):175-84. Review. 13. Burrows KB, Gudelsky G, Yamamoto BK. Rapid and transient inhibition of mitochondrial function following methamphetamine or 3,4- methylenedioxymethamphetamine administration. Eur J Pharmacol. 2000 Jun 9;398(1):11-8. 14. Fiddian-Green RG. Concerns about prescribing antidepressants bmj.com/cgi/eletters/325/7366/701#25874, 28 Sep 2002 15. Fiddian-Green RG. The real danger is in the mixing? bmj.com/cgi/eletters/325/7367/736/c#26113, 7 Oct 2002 16. Mansouri A, Gaou I, De Kerguenec C, Amsellem S, Haouzi D, Berson A, Moreau A, Feldmann G, Letteron P, Pessayre D, Fromenty B. An alcoholic binge causes massive degradation of hepatic mitochondrial DNA in mice. Gastroenterology. 1999 Jul;117(1):181-90. 17. Piquet MA, Nogueira V, Devin A, Sibille B, Filippi C, Fontaine E, Roulet M, Rigoulet M, Leverve XM. Chronic ethanol ingestion increases efficiency of oxidative phosphorylation in rat liver mitochondria. FEBS Lett. 2000 Feb 25;468(2-3):239-42. 18. Addolorato G, Capristo E, Greco AV, Caputo F, Stefanini GF, Gasbarrini G. Three months of abstinence from alcohol normalizes energy expenditure and substrate oxidation in alcoholics: a longitudinal study. Am J Gastroenterol. 1998 Dec;93(12):2476-81. 19. Fiddian-Green RG. Gastric intramucosal pH, tissue oxygenation and acid-base balance. Br J Anaesth. 1995 May;74(5):591-606. Review. 20. Fiddian-Green RG. Monitoring of tissue pH: the critical measurement. Chest. 1999 Dec;116(6):1839-41. 21. Fiddian-Green RG. Haemodynamic and/or tonometric monitoring in cardiac surgery. Br J Anaesth. 2000 Jan;84(1):128. 22. Iatrogenic diseases with a common cause? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7370/913#26512, 25 Oct 2002 23. Depression: a metabolic perspective. Richard G Fiddian-Green bmj.com/cgi/eletters/325/7370/934#26529, 26 Oct 2002 24. Beta blockers and the risk of neurodegenerative disorders Richard G Fiddian-Green bmj.com/cgi/eletters/325/7369/873#26451, 22 Oct 2002 25. Coenzyme Q vs levodopa for Parkinson's Richard G Fiddian-Green bmj.com/cgi/eletters/325/7369/851#26420, 21 Oct 2002 26. Headaches and cerebral tissue oxygenation Richard G Fiddian-Green bmj.com/cgi/eletters/325/7369/881#26368, 18 Oct 2002 27. Might statins cause Parkinsons? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7369/851#26356, 18 Oct 2002 28. Fiddian-Green RG. Iatrogenic diseases with a common cause? bmj.com, 25 Oct 2002 Competing interests: None declared |
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Eileen Orr, Patient Retired
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Is there any interest in a patient's point of view? These medications are more serious to patients than to doctors. Ten years after single bypass surgery, working with a fourth different doctor, and on a third different medication for high blood pressure, my left leg was swollen and covered with a rash once again. The Home Blood Pressure Monitor showed 90/57. I weaned myself off the calcium channel blocker without a by-your-leave. BP elevated to 116/64 and stayed. A lifelong smoker, absent tests of any kind, my wheezing prompted a diagnosis of COPD and I was prescribed Flovent, Serevent and Nasonex. Bone density tests showed osteopoenia prompting a prescription for Fosamax. And I remained on the daily aspirin. I was offered Evista. Internet research showed a possible side effect of deep-seated thrombosis. My mother died of strokes at age 52. I refused the Evista and decided to carefully research all the prescriptions. And I found mention of "weakened immune system". That research led me to a variety of internet sites on nutrition most of which seem to be based on the writings of Weston A. Price, DDS, who advocated the Paleolithic Diet after his worldwide research. Suffice it to say, that over the last six months I've made my own choices among the suggestions of these doctors and nutritionists, basically giving up most sugar and grains, eating organic whole fat dairy and eggs and grass-fed beef. With all the fertilizers and pesticides prevalent in agri-industry in the United States, fresh fruits and vegetables are questionable and sparsely eaten. My theory is that frozen fruits and vegetables at least are not sprayed to remove the enzymes that preserve their fresh look and destroy all their value. I drink steam-distilled water and ingest absolutely no transfatty acids. I've added a variety of vitamins and supplements but avoid herbs because of my own ignorance. I have given up all my prescriptions and all the wheezing. I read also that aspirin promotes wheezing. In fact, research showed that each prescription I was taking prompted a condition that required a new prescription. My blood pressure now averages 120/70. A wide variety of scar tissue begins to fade. What shall I say to the doctor when I see her next week? It was she who told me: "You are responsible for your own health. I am just the consultant." But what of the worldwide economic uproar if the entire medical profession relied on the intelligence and common sense of the patients? Competing interests: None declared |
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