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Correspondence

by the hospitals in the region, as the worsening of the Venezuelan health- Solid national data from 2000–20126
overall patient survival and survival care crisis is evident and the newly show that the number of reported
patterns for the interval cancer group released data2 of the Encuesta Nacional malaria cases in Venezuela had already,
and declined screening group were de Hospitales 2018 are calamitous, counterintuitively, been increasing
similar across all regions. the current humanitarian crisis in steadily during times of the highest
We declare no competing interests. Venezuela and the collapse of its health- oil prices in world history, mainly be­
care system are actually a consequence cause of a reduction in epi­demiological
*Anil Thomas George, Smeer Aggarwal,
Sridhar Dharmavaram, of years of inadequate and weak health surveillance activities.
Achyuth Menon, Mukul Dube, policies, the dismantlement of health- Despite national health indicators
Mike Vogler, Philip Foden, Andrew Field care institutions, and the reduction in showing an overall improvement in
anil.george1@nhs.net epidemiological surveillance activities health care during the early 2000s,
Department of Colorectal Surgery, Queen’s Medical
that started during the period of neglected pockets of poverty have been
Centre, University Hospitals Nottingham NHS Trust, Hugo Chavez’s presidency, or even a substantial problem in Venezuela for
Nottingham NG7 2UH, UK (ATG); Department of before. Nevertheless, a steeper decline the past several years. For example,
Colorectal Surgery, Sherwood Forest Hospitals NHS
in health outcomes over the past data from 2011 show that, when
Foundation Trust, Mansfield, UK (ATG, SA, SD, AM,
MD); Department of Colorectal Surgery, Royal three years is apparent. I find this compared with data for 104 developing
Derby Hospitals NHS Trust, Derby, UK (ATG); BCSP information relevant, since a solution countries, only the Nigerian population
Eastern Hub, Queen’s Medical Centre, Nottingham, to the humanitarian crisis will probably had a higher multidimensional poverty
UK (MV, AF); and Department of Medical Statistics,
University Hospital of South Manchester NHS not depend solely on macroeconomic index (0·642) than that of the Warao
Foundation Trust, Manchester, UK (PF) or political reforms, but on a complete indigenous people from Venezuela
1 George AT, Aggarwal S, Dharmavaram S, et al. restructuring of the Venezuelan health- (0·564).5
Faecal occult blood testing screening for care system. Although Venezuela has been hit
colorectal cancer and ‘missed’ interval cancers:
are we ignoring the elephant in the room? Data published by WHO and the by an unprecedented health crisis,
Results of a multicentre study. World Bank3,4 suggest that health the roots of this have been gradually
Colorectal Dis 2017; 19: O108–O114.
2 Cancer Research UK. Bowel cancer statistics.
indicators such as life expectancy at established over several years. Most of
2014. http://www.cancerresearchuk.org/health- birth improved between 1998 and the complexities associated with the
professional/cancer-statistics/statistics-by-cancer- 2013. However, these data should be health-care crisis that were present
type/bowel-cancer (accessed Jan 10, 2017).
3 National Cancer Intelligence Network. evaluated with caution because of before the administration of incumbent
Colorectal cancer survival by stage—NCIN data the possibility of under-reporting of President Nicolás Maduro—such as
briefing. 2013. http://www.ncin.org.uk/
publications/data_briefings/colorectal_
health statistics by the Venezuelan declining prevention strategies,7 the
cancer_survival_by_stage (accessed Ministry of Health. For example, in dismantling of scientific institutions,8
Jan 10, 2017). 2011, we did a survey on mortality escalating violence,9 or the intense
4 Damery S, Clifford S, Wilson S. Colorectal cancer
screening using the faecal occult blood test in children aged under 5 years in a exodus of physicians, scientists, and
(FOBt): a survey of GP attitudes and practices in representative sample (0·5% of the university professors10—are increasing
the UK. BMC Fam Pract 2010; 11: 20.
state population) of women from steeply. However, with regard to the
5 Mandel JS, Church TR, Bond JH, et al. The effect
of fecal occult-blood screening on the Delta Amacuro state. From these data, epidemiological challenges that could
incidence of colorectal cancer. a conservative estimate of the total be faced by bordering countries over
N Engl J Med 2000; 343: 1603–07.
6 NHS Digital. Quality and Outcomes
number of under-5 deaths for the the coming years (such as waves
Framework—2012–13. Oct 29, 2013. https:// studied population was 30% higher of migration and the potential for
digital.nhs.uk/data-and-information/ than the actual number reported by refugee crises, overwhelming of
publications/statistical/quality-and-outcomes-
framework-achievement-data/quality-and- the local Office of Epidemiology during health-care systems, and outbreaks of
outcomes-framework-2012-13 (accessed the same period for the entire state communicable diseases), the outlook
Jan 15, 2014).
population (124 067 people). We also will remain gloomy unless ex­tensive
identified more under-5 deaths in and crucial health-care re­forms aimed
some municipalities than the numbers at rebuilding Venezuela’s broken health-
The challenges of officially recorded by the local office.5 care system are put into practice.
Malaria cases have clearly sky­
restructuring health rocketed in the last 4 years, mainly
I declare no competing interests.

Julian A Villalba
care in Venezuela because of overall shortages of julian.villalba@mgh.harvard.edu
essential antimalarial drugs, but also
Department of Pathology, Massachusetts General
I read with great interest The Lancet’s because of lapses in vector-control Hospital, Harvard Medical School, Boston, MA
Editorial (April 7, p 1331) 1 on the efforts while operating in a context 02114, USA
collapse of Venezuela’s health-care of increased illegal mining operations 1 The Lancet. The collapse of the Venezuelan
system. However, although the in the southern part of the country. health system. Lancet 2018; 391: 1331.

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Correspondence

2 Encuesta Nacional de Hospitales 2018. described as a means of promoting Republic of the Congo (DRC) and the
Apr 12, 2018. http://bit.ly/enh2018data
(accessed Jun 21, 2018).
health equity.2,3 However, although 2014–15 outbreak in Liberia. The DRC
3 The World Bank. Life expectancy at birth, Denmark’s health-care system is an has vast historical experience from
total (years). https://data.worldbank.org/ exemplification of UHC, Denmark has containing eight prior outbreaks, but
indicator/SP.DYN.LE00.IN?locations=VE
(accessed Jun 21, 2018). one of the steepest gradients in health the country has not previously had to
4 WHO. Countries: Venezuela (Bolivarian inequality across socioeconomic groups respond to urban Ebola spread.
Republic of). http://www.who.int/countries/ among European countries, and social The current and ninth DRC outbreak
ven/en/ (accessed Jun 21, 2018).
5 Villalba JA, Liu Y, Alvarez MK, et al. Low child
inequalities in life expectancy are was declared by the Ministry of Health
survival index in a multi-dimensionally poor increasing, particularly for men of lower on May 8, 2018.1 By May 14, Ebola
Amerindian population in Venezuela. socioeconomic status.4 These disparities virus had escaped the rural epicentre
PLoS One 2013; 8: e85638.
6 Rodríguez-Morales AJ, Paniz-Mondolfi AE. provoke uneasy questions about the of Bikoro and travelled 150 km into
Venezuela’s failure in malaria control. coexistence of UHC and health inequity. Mbandaka, an urban centre populated
Lancet 2014; 384: 663–64.
At the very least, the case of by 1·2 million people.1 In a similar
7 Verhagen LM, Warris A, Hermans PW,
del Nogal B, de Groot R, de Waard JH. High Denmark reveals the importance of manner, during late June, 2014, Ebola
prevalence of acute respiratory tract problematising the accepted associ­ virus disease escaped rural Sierra
infections among Warao Amerindian children
in Venezuela in relation to low immunization ations between UHC and health equity, Leone into Foya District of rural Liberia
coverage and chronic malnutrition. as well as the relationship between and proceeded to enter the densely
Pediatr Infect Dis J 2012; 31: 255–62.
access and health outcomes. It also populated New Kru Town community
8 Mendoza C, Urbina JA. Venezuelan researchers
call for international help. Nature 2003; suggests that, if WHO’s UHC cam­ of Monrovia, a city of over 1 million
421: 473. paign were combined with national inhabitants.2 The unprecedented case
9 Briceño-León R, Villaveces A, Concha-
Eastman A. Understanding the uneven
attempts to understand and address counts of the west African epidemic
distribution of the incidence of homicide in the socioeconomic and sociocultural were largely due to this unprecedented
Latin America. Int J Epidemiol 2008; determinants of health, the campaign migration into unprepared urban
37: 751–57.
10 Romero S. In Venezuela, a new wave of would be better placed to meet its aim centres. At the height of the outbreak
foreigners. Nov 6, 2010. The New York Times of securing health for all.5 in September, 2014, Monrovia alone
(New York). https://www.nytimes.
com/2010/11/07/world/americas/07venez. I declare no competing interests. was accounting for 51% of all the
html (accessed Jun 21, 2018). Ebola cases in Liberia. Given the
Antoinette Fage-Butler
fage-butler@cc.au.dk
parallel scenario of cases emerging
in Mbandaka, the response in the
Qualifying the promise Department of English, School of Communication
and Culture, Aarhus University, Aarhus C DK-8000, upcoming weeks and its sensitivity
to the local context will be critical in
of Universal Health Denmark
informing the final outbreak size in
1 Horton R. Offline: UHC—one promise and two
Coverage misunderstandings. Lancet 2018; 391: 1342. the DRC.
2 Singh PK. World Health Day 2018. http://www.
searo.who.int/mediacentre/features/2018/rd-
Understanding the cause of spread in
In his recent Comment (April 7, message-world-health-day-2018/en/ (accessed Liberia provides important lessons for
p 1342),1 Richard Horton underlined April 10, 2018). the DRC. Why did the index urban case

Francis Dean/GettyImages
3 WHO. Universal health coverage (UHC).
the importance of the Universal Dec 31, 2017. http://www.who.int/mediacentre/ decide to leave Bikoro for Mbandaka?
Health Coverage (UHC) campaign, factsheets/fs395/en/ (accessed April 10, 2018). First, to seek care. She may have
promoted by WHO on World Health 4 Brønnum-Hansen H. Socially disparate trends in come to the city to seek medical care
lifespan variation: a trend study on income and
Day 2018. He also problematised mortality based on nationwide Danish register since care in her village was inadequate
UHC on two counts: first, by arguing data. BMJ Open 2017; 7: e014489. and she was observing others die
5 WHO. Campaign essentials for World Health Day
that, although UHC might sound like 2018. http://www.who.int/campaigns/world-
in spite of the treatment they were
a finite achievable goal, it is not so in health-day/2018/campaign-essentials/en/ receiving. Given this root cause of
practice, and second, by underlining (accessed April 10, 2018). movement, case investigation should
that UHC is not sufficient by itself, but hone in on hospitals and clinics visited
must be coupled to targeted political for treatment to identify highest risk
actions, including legislation and pro­ Preventing rural to contacts. In Liberia, Monrovia’s case
grammes that address specific national zero in 2014 visited Redemption
health problems, such as diabetes and
urban spread of Ebola: Hospital and exposed nurses and
safer water. lessons from Liberia a doctor. Some of those exposed
Experiences with UHC in Denmark at Redemption Hospital went to a
Published Online
prompt yet another problematisation. There has been an eerie mirroring of clinic in a neigh­bouring community
June 25, 2018,
In the WHO campaign on UHC and events between the ongoing outbreak and infected two nurses, who them­ http://dx.doi.org/10.1016/
in existing understanding, UHC is of Ebola virus disease in the Democratic selves sought treatment in another S0140-6736(18)31435-1

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