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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: How much should we spend on healthcare? Fiona Godlee. 358:doi 10.1136/bmj.j3714

Dear Dr Godlee,

In response to your editorial this week, about Rachel’s article. I think it is appalling

But I personally feel the hours imposed by the European working time directive did enormous harm to medicine in this country. I sense it destroyed the team spirit. In our day if you worked hard your consultant looked after you. If you did not you were left to your own devices. The consultant got to know their junior staff and it worked both ways as regards loyalty.

I am aged (84). As a JHO I was appointed to the Royal Victoria hospital, Belfast, in 1956-7. I was told right at the start my rotations for the year. Three months in general surgery, then neurosurgery, Casualty and finally general medicine. We knew our salary from the BMJ. We were in residence so we did not get any official time off. When we were quiet I got cover from the JHO next door (he later became Professor of Surgery and I still keep in touch with him). There was great bonding in that year’s residence. When I was in general medicine I was invited to a girl friend’s graduation dinner in Edinburgh. I was able to go because the team looked after each other and the senior registrar covered for the 48 hours. I do not remember any SHOs or registrar but we must have had them. (I remember very well that July in 1957 because I developed a pilonidal sinus abscess which burst while I was in Edinburgh and I was injecting myself with penicillin. One does not forget those sort of things!)

In 1956-7 HR got the 24-26 of us (JHOs) to decide on 2 weeks' holiday. I was allocated, and had some choice, of 2 weeks' holiday and went to Geilo in Norway in March. I think we had a JHO, or 2, who covered holidays and that was organised at the beginning of our year.

I recently was at a meeting of the Leicester Medical Society and the administrators have insisted on a joint waiting list for gynaecology. I said to the consultant who was speaking that I thought that was not only crazy but very dangerous. I asked why did the consultants not unite and throw it out? She said “unite” and laughed. That is another problem.

Apologies but you did ask for comments and well done to Rachel.

Yours sincerely

C. A. Jeremy Macafee, MD FRCOG FRCS (Glas)
(Very much retired)

Competing interests: No competing interests

08 August 2017
C. A. Jeremy Macafee
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Re: Electrical injury Victor Waldmann, Kumar Narayanan, Nicolas Combes, Eloi Marijon. 357:doi 10.1136/bmj.j1418

On initial publication, a number of references in this Clinical Update were published with incorrect volume numbers. These references have now been amended and all references now show correct volume numbers.

Competing interests: No competing interests

08 August 2017
Sharon Davies
letters editor
The BMJ, London WC1H 9JR
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Re: The antibiotic course has had its day Cliff Gorton, John Paul, Tim E A Peto, Lucy Yardley, et al. 358:doi 10.1136/bmj.j3418

What I learnt at university about bacterial infections was quite simple, because I thought I understood the key-message: The host versus microbe interaction decided whether or not to prescribe antibiotics, including for how many days.

What I learnt from this BMJ Analysis article is only that the BMJ is a platform which causes a lot of discussion amongst doctors and a lot of confusion amongst patients. The former is welcome, the latter not, especially because the confusion of the public on ‘stopping the antibiotic course when feeling better’ will augment the global threat of antibiotic resistance. Two reasons:

a) The doctor versus patient interaction. Doctors, claiming to be experts, tell other doctors to change their policy. Patients in the Netherlands, readers of highly rated daily newspapers such as De Volkskrant and Trouw, read the message of stopping any antibiotic course when feeling better. These readers are not aware of the fact that the authors advocate patient centred decision making, which is a dangerous concept when the issue is still under medical debate. My patients want information on diagnosis and prognosis of an expert, being their doctor. Only on this condition, shared decision making may follow. Now however, my patients might think that the antibiotic course I prescribed is not that important, and may preserve half of the course for the next time they will have similar complaints. Thus, courses shortened by patients will result in more frequent use of antibiotics and in more antibiotic resistance. In this way, the public’s incomplete understanding of antibiotic resistance (1) will be further undermined.

b) The host versus microbe interaction. Table 1 suggests a balanced overview of trials assessing the effects of duration of treatment. For my specialty, streptococcal pharyngitis, the cited Cochrane review does not show any effect of duration, because the trials compare 10 days penicillin with 3-6 days of other antibiotics: The classic comparison between apples and pears. Our research-group compared 7 days penicillin with 3 days and with placebo (2), (3). We found for penicillin given for 3 days a tendency to prolong the period of sore throat in the first week and to increase the recurrence rate in the following 6 months. We hypothesized that the short duration of penicillin treatment only suppressed the pathogenic streptococci without eradicating them. Thus, another interaction between host and microbe than antibiotic resistance was possibly harmful to the patients receiving a too-short course.

I was happy to read in today’s newspaper a comment of a Dutch expert, professor of infectious dieases, on the headlines ‘Completing antibiotic course? Nonsense’. He advised the public to ask the GP for advice (4). My conclusion: Patient centred decision making is an illusion when the medical debate is still ongoing.

1) McNulty CA, Nichols T, French DP, Joshi P, Butler CC. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. The British Journal of General Practice. 2013;63(612):e429-e436. doi:10.3399/bjgp13X669149.
2) Zwart S, Sachs APE, Ruijs GJHM, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. BMJ : British Medical Journal. 2000;320(7228):150-154.
3) Zwart S, Rovers MM, de Melker RA, Hoes AW. Penicillin for acute sore throat in children: randomised, double blind trial. BMJ : British Medical Journal. 2003;327(7427):1324.
4) Marc Bonten. Maak dat kuurtje toch maar af. Dagblad Trouw, August 8th 2017.

Competing interests: No competing interests

08 August 2017
Sjoerd Zwart
General Practitioner
GP-trainer at University Medical Centre Utrecht
Vloeddijk 40, 8261 GC Kampen, The Netherlands
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Re: Ernest George Knox Vivien Drake. 358:doi 10.1136/bmj.j3556

George and I were on the Epidemiology Advisory Committee to the European Union. He took great pleasure in discussing any subject whatever. Alcohol-free beer still has a minute amount of ethanol left and we tried to calculate the number of these drinks that would give the same amount as one "normal" beer. We discussed the technique often used in committee debates when an uncontroversial point is presented as a problem and attacked as such (Lambasting a straw man). He asked me could I find the height of the Slieve Donard mountain in County Down because he had found that at a spot in Wales the tip was visible only every three years.

There was never a dull moment with George, and I am very sad at his passing.

Competing interests: No competing interests

08 August 2017
Roger Blaney
retired senior lecturer in social & preventive medicine
Holywood County Down
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Re: E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys Gary J Tedeschi, et al. 358:doi 10.1136/bmj.j3262

I completely disagree with the very premise of these findings. If people switched from cigarettes to chewing tobacco would we say they've quit? No. Trading one tobacco product for another isn't cessation, anymore than switching from beer to wine is quitting drinking.

Competing interests: No competing interests

08 August 2017
Bruce A Baldwin
cessation coordinator
Chico CA
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Re: A new drug strategy for the UK Adam R Winstock, Niamh Eastwood, Alex Stevens. 358:doi 10.1136/bmj.j3643

The Drug Strategy 2017(1) adopts a directed approach to tackle the threats of new types of drug misuse. Those new threats include psychoactive substances, image and performance-enhancing drugs, ‘chemsex’ drugs and misuse of prescribed medicines. The Government’s novel approach brings the police, health and local partners together to support those high priority groups at risk of misusing drugs(2). At the same time, there is little or no provision for resources(3) to implement this kind of partnership, nor sufficient funding for harm reduction, drug education, and mental health to help those at risk with these new types of drug misuse.

Britain developed one of the harshest drug regimes in the world after the introduction of the Psychoactive Substances Act(4), yet it still hosts one of Europe’s largest illicit drug markets(5). Drug-related deaths in the UK are nearly three times higher than the European average(6). This contradiction lends considerable weight to the thesis that criminalisation and enforcement response do not resolve the problem of drug use. Criminalisation simply transforms market and consumer habits, further as David Nutt argues “limiting availability of a relatively low-harm drug can lead to greater harm from alternatives”(7).

More than ever, then, we must recognise that demand for illicit drugs is not going away, criminalisation does not work as it never worked in the past. Prohibition of drug use actually increases “exposure to violence and fosters stigma, discrimination, and social exclusion”(8, 9). We are also aware that criminalisation increases the health risks of drug use, particularly injection drug use(10).

The report from the Office for National Statistics on drug poisoning in England and Wales in 2016(11) states that the number of deaths from drug misuse reached record levels, higher than in any year since 1993. More than half the deaths were linked to an opiate. This data points to the problems and paradoxes of the British society. Consumption of psychoactive substances is likely to occur to enhance pleasure and fun. Opioid utilisation is likely a form of self-medication adopted by people who have undergone stressful lives or traumatic experiences.

The Government’s drug strategy is at best, based on a misdiagnosis of the root of the problem. The document focuses on vulnerable groups but ignores socio-economic causes that generate exposure to harm and misuse among those specific groups. Drug consumption needs to be contextualised in a social unit, but also in psychological frame to identify the reasons why some groups are more vulnerable and use drugs to deal with difficulties as society antagonises them(12).

What the plan misses is an alternative way of thinking and acting on drug-related issues. What is necessary is reconsidering existing responses to the problems associated with people's drug risk through understanding the cultural differences of these consumption behaviours(13). Closer consideration of the cultures and social contexts of vulnerable groups can improve future debate on drug education and reflection on the effectiveness of harm minimisation strategies.

Research is thus needed on how social, economic and health policies, or a lack thereof, create conditions that increase vulnerability, risk and harm. What is clear is that the human appeal for intoxication, both in the pursuit of pleasure or to reduce sufferance, remains a constant in any societies at the cost of individual health.

The approach of the new drug strategy helps, at best, mask the causes of risk and vulnerability of the target groups. It also suggests that if anyone or anything should be targeted, it is the lack of a proper drug policy, not the users most at risk.

2. Commons Library debate pack - Drugs Policy
3. A new drug strategy for the UK.
4. Psychoactive Substances Act 2016
5. European Drug Report 2017: Trends and Developments.
6. Deaths related to drug poisoning in England and Wales: 2016 registrations
7. Stories about ‘legal high’ deaths are bound up in media hysteria
8. Collateral damage and the criminalisation of drug use
9. Effect of drug law enforcement on drug market violence: A systematic review
10. HIV and risk environment for injecting drug users: the past, present, and future
11. Deaths related to drug poisoning in England and Wales
12. Sociopharmacology of drug use: initial thoughts
13. Party drugs and party people: examining the ‘normalization’ of recreational drug use in Melbourne, Australia

Competing interests: No competing interests

08 August 2017
Marco Scalvini
Houghton St, London WC2A 2AE, UK
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Re: Judging the benefits and harms of medicines Joe Freer, Fiona Godlee. 357:doi 10.1136/bmj.j3129

Re: Judging the benefits and harms of medicines

I congratulate Joe Freer, Fiona Godlee [1] and Kamran Abbasi [2] for encouraging discussion on medicines and vaccines side-effects. Could the unmasked international fraud that caused untold harm in Ghana [3] not be occurring worldwide?


“Crime of obtaining money or some other benefit by deliberate deception” [4]. It is by this definition that this [3] and other events need to be assessed. An Italian, a Lebanese, and a Ghanaian arranged to supply Ampicillin to Ghana’s Ministry of Health. The Italian flew in tens of thousands of empty red/black capsules labelled 500 mg. The two expatriates used the Ghanaian’s factory to put just 10 mg of the antibiotic in each capsule, adding enough chalk and kokonte (cassava powder) to fill it up. How I discovered the names of the culprits, how the Lebanese promised to build me 2 houses in Accra if I kept quiet, how I reported them to the then Commissioner for Health, how when he began to investigate he was moved to the Ministry of Agriculture - all described in BMJ [3]. Ward rounds made me distrust Ministry of Health antibiotics. Front-page splash in GHANAIAN TIMES Friday March 16 1984 read “POWDERED MAIZE IN AMPICILLIN CAPSULES: Five arrested in Kumasi and Accra”. [5]

Fraud details in countries differ. Dr J K Anand made the correct diagnosis: “A fraud has been perpetuated by one or more individuals …” [6] looking at the “Missing data at a cost of $2 bn” [2 7]. What happened in Ghana was “crude fraud” [3] but what BMJ Editors highlight is “smooth fraud” whose global effect exceeds my country’s monstrosity by far. This CORRUPTION stinks Tafracher! [8].


Describe something as “scientific” and probity is assumed. Are we right in that assumption? [9 10 11]. How many of Professor John Tooke’s 12000 Academy of Medical Sciences Fellows [12] have read that remarkable article by Professor Lord S Zuckerman OM FRS MA DSc LLD MD FRCP FRCS, entitled “Pride and Prejudice in Science”? [13] Reading that convinced me scientific liars and lying scientists exist.

BMJ Editor Richard Smith in his book The Trouble with Medical Journals [14] states that medical journals have become "creatures of the drug industry", rife with fraudulent research and packed with articles ghost written by pharmaceutical companies. In a 2014 interview with New Scientist he suggested criminalization of research fraud [15].


Take the frequent use of phrases like “reputation of science is at stake”, and “poor science”, and “imperfections in the evidence base”, and “inadequate evidence”, and “gaps in vaccine science”. How, O how do I identify from these phrases the kind of fraudulent researcher Lord Zuckerman describes whether regarding Statins, or Thalidomide, or Tamiflu, or Tranquilizers in pregnancy, or Opiates, or Hydroxyurea? Is there no way of identifying researchers who give science a bad name? Must scientists making mistakes take refuge in something called “poor science” that “will correct itself” [16]?


Has minority opinion (the tail) not sometimes worked its way into Global bodies like WHO, UNESCO, WORLD BANK, CDC to prescribe “Official Policy” for the majority (the dog) resulting in disaster? How else do we explain WHO Director-General apologising for Sierra Leone losing 11,000 people to Ebola? [17] Or reversing earlier endorsement of Tamiflu (Oseltamivir)? [7]. Why did experts differ so much that Dr Fiona Godlee demanded “an independent review” on Statins? [18] Front page Daily Telegraph August 1 “Statins ‘needlessly doled out to millions’” [19], and DAILY EXPRESS July 14 2017 “STATINS: NEW HEALTH ALERT – Study says heart pills do you more harm than good” [20].


“The Lancet”, wrote Sarah Knapton, “argued that thousands of people had been misled into stopping their medication after two articles appeared in the BMJ questioning their use and warning of side-effects” [21]. Two editorial giants disagreeing on Statins? There was no suggestion that any editorial palms had been greased. Indeed, one Lancet Editorial “Corruption in health care costs lives” criticised “aggressive marketing strategy by pharmaceutical companies” [22]. We know that equally brilliant experts can look at facts differently, and I gave the example of Dr Jeffrey Sachs and Professor C J Peters whose emphases on tropical public health priorities differ. [3 23. 24].


Threats immediately provoke rumours as when on July 8 2002 one UN Official at the Barcelona AIDS Conference said (BBC’s WORLD AT ONE) that any country’s Leader failing to heed “Official Policy” should be “kicked out” [31], rumours intensified: POPULATION CONTROL is what most “Official Policy” is about - mandatory vaccinations [26], use of Artesunate-Amodiaquine for malaria [32], medicated bed nets (“What’s wrong with present nets? These Imperialists are killing babies with chest problems from medicated nets”), azoospermia in African young men caused by “spermicidal vitamins” [25 26], “Pressure from UK to legislate that men marry men and women marry women is for population control”. When vaccination for HIV was mooted people exclaimed: “Are they going to prick us with needles so we can do what we like?” [26]. Speak Tribal Language to collect grassroots opinion and you will find “Official Policy”-Vaccinology perceived as big business to kill many birds with one spicule-stone for POPULATION CONTROL. [25 26 33-36]


“Intelligent Openness” [37] does not exist in a post-truth world [38-40]. Deception requires “Intelligent Coverup”. The serious concerns of parents and doctors who have seen damage caused by medicines and vaccines must prevail over “Official Policy” from WHO, NICE, NIH, CDC, EUROPEAN COMMUNITY. Vigilance is required as when Ghana Academy of Arts & Sciences advised Parliament NOT to allow Ebola Virus Vaccine Trials in our Ebola-free country. [41 42]. Protest is mounting against mandatory vaccinations worldwide [43 44]. Why should coercive tails continue to wag docile dogs?

Competing Interests: Self-Appointed Spokesman for Africa on Clinical Epidemiology [45 46], Public Health [47 48], and African Anthropogenetics [49 50 51].

Email: Twitter@profkonoteayhul

Felix I D Konotey-Ahulu FGA MD(Lond) FRCP(Lond) FRCP(Glasg) DTMH(L’;pool) FGCP

Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana and Former Consultant Physician Genetic Counsellor in Sickle Cell and Other Haemoglobinopathies, Korle Bu Teaching Hospital, Accra, Ghana and 9 Harley Street London W1G 9AL.


1 Freer Joe, Godlee Fiona. Judging the benefits and harms of medicines. BMJ 2017; 357: j3129 (30 June 2017)

2 Abbasi Kamran. The missing data that cost $20 bn. BMJ 2014: 358

3 Konotey-Ahulu FID. Who should pharmacovigilate in developing countries? Rapid Response 14 September 2007 to BMJ Editorial by Pirmohamed M, Atuah KN, Dodoo ANO, Winstanley P. Pharmacovigilance in developing countries. BMJ 2007; 335: 462

4 ENCARTA World English Dictionary. Fraud is the crime of obtaining money or some other benefit by deliberate deception. A BLOOMSBURY REFERENCE BOOK. Bloomsbury Publishing Plc 1999, London page 741.

5 GHANAIAN TIMES. Powdered Maize in Ampicillin Capsules. In Konotey-Ahulu FID What Is AIDS? Tetteh-A’Domeno Company, Watford, England 1989, Figure 5.6, page 75. ISBN: 0 9515442 0 9

6 Anand JK. “A fraud has been perpetuated …” Rapid Response 14 July 2017 to Mark H Ebell’s “deliberately withheld data” in WHO downgrades status of Oseltamivir BMJ 2017: 358: j3266 (12 July 2017) [Reference 7] and Kamran Abbasi’s “Missing billions” [Reference 2].

7 Ebell Mark H. WHO downgrades status of Oseltamivir: Important lessons from the Tamiflu story. BMJ 12 July 2017; 358:doi.10.1136/bmj.j3266

8 Konotey-Ahulu FID. Tafracher – Invaluable Ghanaian devulgarizing word. BMJ Personal View 1(5953): 329 8 February 1975.

9 Dyer Clare. Journal agrees to retract paper after university found study was never done. BMJ 2013; 347:155
September 5 2013

10 Eales L-J, Nye KE, Pinching AJ. Group specific component and AIDS. Erroneous data. Lancet 1988; i: 936

11 Konotey-Ahulu FID. Sickle Cell and Altitude. BMJ 1972; 2: 231-232
“If evidence obtained from my country cannot be scientific it should at least be true”

12 Tooke J. Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines. Academy of Medical Science Report. 2017

13 Zuckerman, S. Pride and Prejudice in Science. Aerospace Medicine 1974; 45: 638-647. [Also republished in Ghana Medical Journal 1975; 14: 52-60]

14 Smith Richard. The Trouble with Medical Journals. Royal Society of Medicine Press, London, 266 pages. ISBN 1-85315-5673-6

15 Smith Richard "It's time to criminalize serious scientific misconduct", in Interview with Nuwer R. New Scientist, 2986: 27 (15 September 2014).

16 Krumholz Harlan M. Statins evidence: when answers also raise questions. Sharing data is more likely to settle the debate than another review. BMJ 2016; 354:i1463 (doi:10.1136/bmj.i4963)

17 WHO Apology: Maria Cheng – The Associated Press: “WHO admits it botched early attempt to stop disease. Health Agency says response to recognize potential Ebola’s explosive spread too slow”. October 17 2014.

18 Godlee F. Statins: We need an independent review. BMJ 2016; 354: j4992

19 Bodkin Henry. Statins “needlessly doled out to millions”. Daily Telegraph Front Page August 1 2017

20 Sheldrick Giles. Statins: New Health Alert. Daily Express Front Page July 14 2007.

21 Knapton Sarah. End statins controversy with government review. Daily Telegraph. Friday September 2015, page 1

22 Lancet Editorial. Corruption in health care costs lives. Lancet 2006, February 11-17, page 447.

23 Sachs JD. A new global effort to control malaria. Science 2002; 298: 112-124.

24 Peters CJ. Hurrying towards disaster? Special Centennial Edition of PAHO, Washington DC, pp 14-20. [1902-2002]

25 Konotey-Ahulu, FID. What is AIDS? Tetteh-A'Domeno Company, Watford, England, 1989, 227 pages ISBN: 0 9515442 Reprinted 1996.

26 Konotey-Ahulu FID. AIDS in Africa: Wake-up call and need for paradigm shift. BMJ Rapid Response (3 April 2003) to Didier Fassin and Helen Schneider on Politics of AIDS in South Africa, beyond the controversies BMJ 2003; 326: 295-297

27 Clinton President W J. Apology on behalf of the American Government to survivors of the Tuskegee Syphilis Experiment victims. Worldwide Radio & Television. May 16 1997.

28 Konotey-Ahulu FID. President Obama apologizes over Guatemala syphilis study: International cooperative research in jeopardy. BMJ Rapid response October 17 2010.

29 Muller-Hill Berno. Murderous Science: Elimination by Scientific Selection of Jews, Gypsies, and Others – Germany 1933-1945 [Translated from German by G R Fraser] Oxford University Press, 1988.

30 Thairu Kihumbu. The African & The AIDS Holocaust: A Historical and Medical Perspective. Phoenix Publishers Ltd. Nairobi, Kenya 2003. ISBN 9966 47 1847.

31 BBC July 8 2002 WORLD AT ONE names UN Official who said any country’s leader who failed to obey “Official Policy” should be “kicked out”.

32 Amofah G. Furore over Artesunate-Amodiaquine. Daily Graphic Accra 2006, Monday May 15, page 23.

33 Konotey-Ahulu FID. AIDS in Africa. Lancet 2002; 360 (9343): 1424 Nov 2. In response to “vaccine development in the developing world” in Weidle PJ, Mastro TD, Alison DG, Nkengasong J, Machara D.HIV/AIDS treatment and HIV vaccines for Africa.

34 Konotey-Ahulu FID. Konotey-Ahulu FID. Averting a malaria disaster. Lancet 1999; 354: 258. July 17.

35 Konotey-Ahulu FID. Ebola viewed through HIV/AIDS spectacles – What Africans think. BMJ Rapid Response. August 7 2015 to Zosia Kmietowicz: Ebola vaccine trial results “extremely promising” says WHO. BMJ 351: h4192 July 31 2015.

36 Lancet Annotations. The Biological Bomb. Lancet 1968 March 20; 1: 465 Lord Ritchie-Calder - “Public health in reverse: While one group of scientists is devoting its energies to prevent diseases, another is devising man-made epidemics”.

37 Tooke J. Judging the benefits and harms of medicines. Rapid Response 14 July 2017 to Joe Freer and Fiona Godlee

38 Konotey-Ahulu FID. AIDS in Africa: Misinformation and Disinformation. Lancet 1987; 2(8552): 206-208 July 25

39 McCartney Margaret. Evidence in a post-truth world. BMJ 2016: 355: i6363 (Nov 28 2016)

40 Konotey-Ahulu FID Evidence in a post-truth world: Scientists' Misinformation and Disinformation 19 December 2016

41 Konotey-Ahulu FID. Ebola and Ethics: “Are vaccine trials going on somewhere in Africa?” BMJ Rapid Response June 2 2015

42 Konotey-Ahulu FID. Ebola and Ethics: Ghana Academy of Arts and Sciences and Ghana Government Suspend Ebola Virus Vaccine Trials. BMJ Rapid Response

43 Day Michael. Doctor and MPs in Italy are assaulted after vaccination law is passed. 358:doi 10.1136/bmj.j3721

44 Scheibner Viera. “Presently, vaccination proponents are pushing for more and more mandatory vaccinations in many countries. Re: Peter Doshi “US Government ..” (Rapid Response July 13 2017)

45 Konotey-Ahulu FID. An African on AIDS in Africa. (Guest Editorial). The AIDS Letter - Royal Society of Medicine 1989, No 11, Feb/March 1989, pp 1-3.

46 Konotey-Ahulu FID. Clinical epidemiology, not sero-epidemiology is the answer to Africa’s AIDS problem. BMJ 1987; 294: 1593-1594. June 20.

47 Konotey-Ahulu FID. Public Health in less developed countries. Lancet 356 (9243): 1769-1770

48 Konotey-Ahulu FID. Combating malaria: Try public health measures in Africa too. BMJ 2009; 338: b 1971

49 Konotey-Ahulu FID. The Human Diversity Project: Cogitations of an African Native. In POLITICS AND THE LIFE SCIENCES, September 1999, Vol 18(2), pp 317-322.

50 Konotey-Ahulu FID. Sequencing genome of 1000 volunteers: Why do this anonymously? African J Health Sciences 2011; 18:37-52

51 Konotey-Ahulu FID. Male procreative superiority index (MPSI): The missing co-efficient in African anthropogenetics. BMJ 1980; 281(6256): 1700-1702 doi:10.1136/bmj.281.6256.

Competing interests: Self-Appointed Spokesman for Africa on Clinical Epidemiology [45 46], Public Health [47 48], and African Anthropogenetics [49 50 51].

08 August 2017
Felix ID Konotey-Ahulu
Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana
Former Consultant Physician Genetic Counsellor in Sickle Cell and Other Haemoglobinopathies, Korle Bu Teaching Hospital, Accra Ghana and 9 Harley Street, London W1G 1AA
14 Imperial Way Hemel Hempstead, Herts, HP3 9FJ.
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Re: Should doctors work 24 hour shifts? Steven C Stain, Michael Farquhar. 358:doi 10.1136/bmj.j3522

Notwithstanding the assertion that "the NHS was created in order to free citizens from the constraints of the market place"(1), the reality is that part time private practice has always cast a long shadow over the practices and ethics of the NHS workplace.

Firstly, private practice has created the cult of the "superhuman" doctor who combines a full time NHS workload with the gruelling demands of the market-driven private sector. The financial rewards generated by the private sector have, in turn, skewed career choices in favour of specialties which generate a "fast buck", at the expense of less profitable specialties such as general practice, paediatrics, and geriatrics, for example. Although what is moot is the safety of the work practices of these superhuman doctors, the reality is that many trainees aspire to superhuman status because that is what generates high profit margins.

Secondly, thanks to the fact that the intellectual elites of the medical profession have always experienced the identity crisis of loyalty to the NHS vs loyalty to the private sector, the NHS has, since its inception, been deprived of the single-minded intellectual input that would have enabled it to evolve into a more efficient and cost-effective organisation. The consequences of the missed opportunity for single-minded intellectual input remain incalculable to this day.

(1) Guiseppe Vetrugno. 24 hours a slave Rapid response 2/8/2017

Competing interests: No competing interests

08 August 2017
Oscar M Jolobe
retired geriatrician
manchester medical society
simon building, brunswick street, manchester M 13 9PL
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Re: A growth reference for mid upper arm circumference for age among school age children and adolescents, and validation for mortality: growth curve construction and longitudinal cohort study Evasius Bauni, A Sarah Walker, Diana M Gibb, Gregory Fegan, et al. 358:doi 10.1136/bmj.j3423

The authors have made a good start in constructing curves for MUAC for age, boys and girls separately for -19 years. This will make it easier to classify nutritional status by primary health care workers at the community level. They have taken the references values based on the US national surveys -- viz. The Health Examination Survey (HES)/National Health and Nutrition Examination Survey (NHANES), US population datasets (age 5-25 years) -- which were used for 2007 World Health Organization growth reference for BMI. The findings suggest the sensitivity for death at cut off less than -2 z scores as 72% (95% confidence interval: 57% to 84%) for MUAC –for –age z score. The sensitivity seems to be on the lower side for correlation with mortality, probably due to lesser number of deaths. Further, the validation study done on HIV infected children might not actually reflect the children in the general population and this might not be representative for children at large. The findings need more validation studies with children of varied malnourished states/grades and that too in different populations including South Asia.

Competing interests: No competing interests

08 August 2017
Mongjam Meghachandra Singh
Reeta Devi
Department of Community Medicine, Maulana Azad Medical College, New Delhi & co-author: School of Health Sciences, Indira Gandhi National Open University, New Delhi (India)
Department of Community Medicine, Maulana Azad Medical College, New Delhi & co-author: School of Health Sciences, IGNOU, New Delhi (India)
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Re: Acne Sarah Purdy, David de Berker. 333:doi 10.1136/bmj.38987.606701.80

Giving oestrogenic progestogens for acne (.BMJ 2006;333:949 ) increases the risk of venous thrombosis.

In 2011 Lidegaard et al confirmed that OCs containing newer progestins (desogestrel, gestodene, or drospirenone) caused at least twice the risk of venous thromboembolism (VTE) than older progestins.1 Thomson et al found that desogestrel 150ug and drospirenone 3 mg increased endothelium-dependent vasodilation in large and small peripheral microvasculature, which further confirmed vasodilation in the aetiology of OC induced thrombosis.2 Acne-treating oestrogenic drospirenone and desogestrel caused more thrombosis than acne-causing androgenic levonorgestrel.

In 2015, Vinogradova et al collected 10,500 cases of VTE and 42,000 matched controls in UK general practice databases. 68% of cases and 57% of controls were analysed following exclusions mostly for pregnancy or hysterectomy. Any current use of combined OCs gave a 3-fold increased risk of idiopathic venous thromboembolism compared with no use in the past year. Newer third generation progestins doubled the risk compared with older progestins. Risks for desogestrel (x4.28), gestodene (x4.27), drospirenone (4.12) and cyproterone (4.27) were compared with levonorgestrel (2.38), norethisterone (2.56) and norgestimate (2.53).3

1. Lidegaard O, Nielson LH, Skovlund CW, Skjeldestad FE, Lokkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study 2001-9. BMJ 2011;343:d6423.
2. Thomson AK, Przemska A, Vasiloupou D, Newens KJ, Williams CM. Combined oral contraceptive pills containing desogestrel or drospirenone enhance large vessel and microvasculature vasodilation in healthy premenopausal women. Microcirculation. 2011 Mar 7. doi: 10.1111/j.1549-8719.2011.00094.x.
3. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of combined oral contraceptives and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ 2015;350:h2135

Competing interests: No competing interests

08 August 2017
Ellen C G Grant
Physician and medical gynaecologist
Kingston-upon-Thames KT2 7JU, UK
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