Correspondence
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Global health security:
a fl awed SDG framework
After the Rio +20 conference in 2012, in Brazil, a series of proposed Sustainable Development Goals (SDGs) were developed.1 This broad vision for the future incorporates a pledge to reduce inequality within and among countries; ensure healthy lives and promote wellbeing for all at all ages; and promote peaceful and inclusive societies for sustainable development, in addition to other goals.1 As with the Millennium Development Goals that they supersede, the SDGs will redefi ne the political and fi nancial commitment to global development during the next 15 years.
In their letter to The Lancet, Ilona Kickbusch and colleagues (March 21, p 1069),2 called for an additional SDG (SDG18) that would recognise global health security as an important stand-alone component of the post-2015 development agenda. The ongoing Ebola virus outbreak in the west African countries of Sierra Leone, Guinea, and Liberia, has reignited global health security debates. Kickbusch and colleagues2 draw on this health emergency to propose their additional goal, “to reduce the vulnerability of people around the world to new, acute, or rapidly spreading risks to health, particularly those threatening to cross international borders”.
Although the present Ebola virus outbreak reveals a clear breakdown of disease surveillance and a subsequent sluggish humanitarian response, health advocates should guard against the endorsement of increasingly robust global health security measures as a solution to such difficulties. WHO’s widely circulated definition of global health security—the “activities required...to minimize vulnerability to acute public health events”—underplays what remains a controversial concept.3 As Simon Rushton argues,4 a framework for global health security should be assessed against empirical evidence, and not solely on the basis of theoretical
composition and carefully crafted defi nitions, to determine whether the concept is a viable model for health development.
The securitisation (ie, depiction of health as a threat to a nation’s security) of health has distilled health issues of international concern largely down to highly virulent infectious diseases and bioterrorist threats.3 For this reason, the agenda for global health security has a skewed priority setting in health, creating a disconnect between perceived threats to health and the leading causes of morbidity and mortality worldwide.3 For example, the predicted spread of malaria in countries affected by the Ebola virus is further evidence of the need to avoid a single disease-specifi c approach in times of crisis.5
Criticisms have been raised about the way in which a predominantly North American and European interpretation of risk and susceptibilty has been used to define health security discourse internationally. With substantial financial and political power, many high-income countries are able to project their own foreign policy priorities and state security interests during the design and implementation of large-scale global health and humanitarian programmes.3,4 UNDP made no eff ort to underplay the way in which the infection of people in the USA and Europe with the Ebola virus coincided with a commitment from the international community to respond to this outbreak, many months after the first case was registered.6 This delay makes a mockery of the shared susceptibility and responsibility discourse championed by advocates of global health security.
With only a few months remaining before member states of the UN convene in New York to finalise the SDGs, health advocates should question the resurgence of global health security and seek to disentangle the perceived vested interests of a minority from the overwhelming needs of the majority. I declare no competing interests.
James Smith
North East Thames Foundation School, London E1 2DR, UK
1 UN. Open working group proposal for sustainable development goals (A/68/970). New York; United Nations, 2014. 2 Kickbusch I, Orbinski J, Winkler T, Schnabel A.
We need a sustainable development goal 18 on global health security. Lancet 2015;
385: 1069.
3 Stevenson MA, Moran M. Health security and the distortion of the global health agenda. In: Rushton S, Youde J, eds. Routledge handbook of global health security. Abingdon; Routledge, 2014.
4 Rushton S. Global health security: security for whom? Security from what? Polit Stud 2011;
59: 779–96.
5 Walker PG, White MT, Griffi n JT, Reynolds A, Ferguson NM, Ghani AC. Malaria morbidity and mortality in Ebola-aff ected countries caused by decreased health-care capacity, and the potential eff ect of mitigation strategies: a modelling analysis. Lancet Infect Dis 2015; published online April 23. DOI:10.1016/ S1473-3099(15)70124-6.
6 UNDP. Assessing the socio-economic impacts of Ebola virus disease in Guinea, Liberia, and Sierra Leone: the road to recovery. New York; United Nations Development Programme, 2014.
For more about the Rio +20 conference see http://www. uncsd2012.org/about.html
Evidence-informed
response to illicit drugs
in Indonesia
To address the serious harm caused by drugs to individuals and the community is an important public health priority and one that all countries, including Indonesia, must tackle.
The Indonesian Government, led by President Joko Widodo, has heralded its commitment to evidence-based policy making. The public health community welcomes this commitment; however, as researchers, scientists, and practitioners, we have grave concerns that the government is missing an opportunity to implement an eff ective response to illicit drugs informed by evidence.
A close examination of the nature and extent of drug use in Indonesia reveals substantial gaps in knowledge and a scarcity of evidence to support forced rehabilitation and the punitive, law-enforcement-led approach favoured by the government.
For WHO’s defi nition of global public health security in the 21st century see http://www. who.int/whr/2007/overview/en/ index.html
Amanda Hall/R
obert Harding
W
Correspondence
2250 www.thelancet.com Vol 385 June 6, 2015
5 Badan Narkotika Nasional bekerjasama dengan Pusat Penelitian Kesehatan Universitas Indonesia. Laporan Survei Penyalahgunaan Narkoba di Indonesia: Studi Kerugian Ekonomi dan Sosial akibat Narkoba, tahun 2008. Jakarta: Badan Narkotika Nasional, 2008.
6 Badan Narkotika Nasional bekerjasama dengan Pusat Penelitian Kesehatan Universitas Indonesia. Ringkasan Eksekutif Survei Penyalahgunaan Narkoba di Indonesia: Studi Kerugian Ekonomi dan Sosial akibat Narkoba, tahun 2011. Jakarta: Badan Narkotika Nasional, 2011.
We call on the Indonesian Government to scale back punitive strategies that are ineffective and counterproductive and instead expand evidence-based interventions, such as opioid substitution therapy, needle and syringe programmes, HIV treatment, and care for people who use drugs; invest in the collection of better quality data on the scale and nature of drug use in Indonesia, without which an eff ective and appropriately targeted response cannot be developed; and form a national committee on drug use, comprising the National Narcotics Board, Ministry of Health, Ministry of Social Aff airs, Ministry of Law and Human Rights, service providers, and community representatives, to review drug-related data, set priorities, recommend evidence-informed actions, and monitor progress. We support a transparent, peer-reviewed process for collecting data on drug-use indicators, and a commensurate evidence-based policy response. We declare no competing interests.
*Irwanto, Dewa N Wirawan, Ignatius Praptoraharjo,
Sulistyowati Irianto, Siti Musdah Mulia, on behalf of 11 signatories
Irwant [email protected]
HIV/AIDS Research Centre, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia (I); Public Health Postgraduate Program, Udayana University, Denpasar, Indonesia (DNW); Center for Health Policy and Management, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia (IP); Faculty of Law, Universitas Indonesia, Jakarta, Indonesia (SI); and Indonesian Conference on Religion for Peace, Jakarta, Indonesia (SMM)
1 Degenhardt L, Whiteford HA, Ferrari AJ, et al. Global burden of disease attributable to illicit drug use and dependence: fi ndings from the Global Burden of Disease Study 2010. Lancet 2013; 382: 1564–74.
2 Tilson H, Aramrattana A, Bozzette S. Preventing HIV infection among injecting drug users in high-risk countries: an assessment of the evidence. Washington, DC: Institute of Medicine, 2007.
3 Reuter P. Ten years after the United Nations General Assembly Special Session (UNGASS): assessing drug problems, policies and reform proposals. Addiction 2009; 104: 510–17. 4 WHO Regional Offi ce for the Western Pacifi c.
Assessment of compulsory treatment of people who use drugs in Cambodia, China, Malaysia and Viet Nam: an application of selected human rights principles. Manila: WHO Regional Offi ce for the Western Pacifi c, 2009. Opioid overdose and infectious
diseases, including HIV transmitted through unsafe injecting practices, are the primary causes of drug-related deaths worldwide.1 In the past 10 years, Indonesia has taken positive steps forward by introducing strategies such as opioid substitution therapy, needle and syringe programmes, and increased access to HIV treatment. Substantial evidence2 supports the eff ectiveness of these interventions in reducing fatal overdose and HIV transmission, morbidity, and mortality. However, these interventions have yet to be implemented to scale in Indonesia, and this delay is preventing the realisation of their potential benefi t.
Meanwhile, there is evidence that criminalisation of people who use drugs and punitive law-enforcement approaches have failed to reduce the prevalence of drug use and are fuelling
the HIV epidemic.3 Compulsory
detention and rehabilitation of drug users has been shown to be ineff ective in sustaining reductions in drug use.4
The Indonesian Government has frequently cited National Narcotics Board studies from 20085 and 2011,6 which estimate drug-use prevalence to be 2·6% in the general population (equivalent to 4·5 million people) and as many as 50 deaths per day from drug-related causes. We have serious concerns about the validity of these estimates for the following reasons: the details and methods of these studies are not publicly accessible; from information that is available, the recruitment methods appear to have been inappropriate, resulting in an unrepresentative sample and results that are not generalisable; differentiation between different types of drugs and frequency and patterns of their use were inadequate to identify problematic drug use; definitions of addiction were inconsistent with accepted criteria for drug dependence; and the unorthodox method used to indirectly estimate drug-related mortality is unreliable.
ISAT: end of the debate
on coiling versus
clipping?
In the International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling by Andrew Molyneux and colleagues,1 the study design was optimal for a short-term follow-up. The primary objective of this study was to establish outcomes at 1 year after surgery, and the secondary objective was to assess differences in the rebleeding rate. Since surgery has a high success rate in eliminating the lifelong risk of rebleeding,1 the establishment of new treatments should be based on at least a similar success rate or superior safety.
The 10 year ISAT results (Feb 21, p 691)2 suggest that endovascular coiling is perhaps safer than neuro-surgical clipping in treating ruptured intra cranial aneurysms (table). However, with respect to the secondary objective, overall rebleeding rate was higher after endovascular treatment (table). The estimated 1 year rerupture rate of 2·6–2·8%1 of target intracranial aneurysms corresponds to the reported natural course of 7–12 mm unruptured intracranial aneurysms in the anterior circulation and is more than 20 times higher than the reported rupture rate of small (<7 mm) unruptured intracranial aneurysms.3 In view of the suboptimum long-term follow-up protocol (questionnaire-based, no systematic autopsies for sudden deaths) and exclusion of the
