Comment
Faith-based delivery of science-based care
Faith is too often perceived as a force that divides. In
The Lancet, a new Series1–3 examines the potential of faith-
based health care to unite and heal. The Series is led by
Ed Mills, from Global Evaluative Sciences in Vancouver,
Canada, and supported financially by a grant from Capital
for Good, which connects donors with organisations
working in health and other development areas. This
Lancet Series on faith-based health care draws together
the insights and experiences of authors from several
countries and denominations, academic institutions, and
non-governmental organisations (NGOs). Faith-based
organisations deliver a substantial volume of health care,
and their common visions of stewardship, inclusiveness,
dignity, and justice make many such organisations
ideally suited as key partners for delivering the post-2015
Sustainable Development Goals.
Religions are about more than good deeds; yet they
also inspire behaviours and actions as an expression of
faith, which can benefit others. For instance, respect for
the diversity of the natural world and preservation of
its resources and habitats. Service—particularly care for
the sick—is another characteristic. In that care, faith is
regularly present, even though it may be silent. Faith is
interwoven with local culture and overlaid by personal
beliefs and organised religions that can make the
disentanglement of individual components a challenge.
The purpose of this Series is to examine how faith-based
behaviours influence the delivery of health care at an
organisational level. A vivid example is the response to
the Ebola outbreak, as described in a Comment for this
Series by Katherine Marshall and Sally Smith.4
In the first Series paper, Jill Olivier and colleagues1
analyse the characteristics of faith-based care in Africa. A
particular strength of faith-inspired organisations is the
care they give to populations marginalised by poverty or
stigma. Such faith-based care complements government
facilities and extends the reach of services beyond
traditional populations. Indeed, faith-based organisations
account for about 20% of the total number of agencies
working to combat HIV/AIDS in Africa.5 To maximise the
contributions of faith-based care, it is essential that such
providers are as professional in their organisation and
management of human resources, and as evidence-based
in practice, as any other health-care provider. The faith
moniker does not excuse shortcomings.
www.thelancet.com Vol 386 October 31, 2015
Criticism of the influence of dogma on practice can Published Online
July 7, 2015
arise from an incomplete appreciation of the doctrinal http://dx.doi.org/10.1016/
basis that frames different approaches to health. In the S0140-6736(15)61104-7
second Series paper, Andrew Tomkins and coauthors,2 See Comment pages e22
and e24
who come from several religious traditions, examine the
See Series pages 1765, 1776,
basis for controversies in faith and health, and separate and 1786
myths from messages. They provide faith-based For Capital for Good see
http://www.capitalforgood.org
explanations for different practices that are valuable to
any clinician in a multifaith environment. Appreciation
of spiritual, social, and cultural dimensions of health are
crucial to care.6 Better understanding of the reasons for
different practices provides opportunities to reframe
faith as part of the solution, rather than the problem, in
complex consultations.
Jean Duff and Warren Buckingham III3 conclude
the Series with five recommendations to facilitate
collaboration between governments and NGOs with
faith-based entities, which build on existing strengths to
improve health outcomes. Among these is the need for
improved measurement of the benefits that faith-based
organisations bring to health-care delivery and outcomes.
Faith-based organisations translate beliefs into
action through funding, commissioning, researching,
or providing care. By studying the presence and unique
attributes of faith-based care through the lens of health,
this Series provides a platform for broader engagement
between faith-based groups, medical practitioners,
and policy makers. Such engagement, and better
recognition and utilisation of faith-inspired behaviours,
Philippe Lissac/Godong/Corbis
1709
 Comment
has the potential to accelerate and improve health and
social outcomes.
William Summerskill, Richard Horton
The Lancet, London EC2Y 5AS, UK
1 Olivier J, Tsimpo C, Gemignani R, et al. Understanding the roles of faith-
based health-care providers in Africa: review of the evidence with a focus
on magnitude, reach, cost, and satisfaction. Lancet 2015; published online
July 7. http://dx.doi.org/10.1016/S0140-6736(15)60251-3.
2 Tomkins A, Duff J, Fitzgibbon A, et al. Controversies in faith and health
care. Lancet 2015; published online July 7. http://dx.doi.org/10.1016/
S0140-6736(15)60252-5.
Long working hours: an avoidable cause of stroke?
Published Online William Osler, in an article about atherosclerosis
August 20, 2015
http://dx.doi.org/10.1016/
published 100 years ago, wrote that the main cause
S0140-6736(15)61000-5 of myocardial infarction was “wear and tear of life”.1
See Articles page 1739 Although we now have more detailed theories regarding
the causal mechanisms, there is still some kinship
between modern studies of work-related determinants
of cardiovascular diseases and Osler’s broad approach to
the cause of disease.2
One important aspect of work environment is working
time. Long working hours correlate with increased
incidence of cardiovascular diseases and their risk
factors.3,4 However, contradictory results show that
long working hours are not associated with increased
risk of metabolic syndrome.5 In a working paper from
2003, White and Beswick reviewed 66 studies from
1920 to 2002 with a guarded conclusion that there are
“…potentially negative effects of working long hours
on physical health. The strongest evidence probably
concerns the links with cardiovascular disorder…”.6
In The Lancet, Miki Kivimäki and colleagues7 present
findings from a meta-analysis of long working
hours and risk of cardiovascular disease, based on
both published and unpublished data, for up to
603 838 men and women from 24 cohorts in Europe,
the USA, and Australia. The investigators conclude
that, compared with standard working hours of
35–40 h per week, long working hours (defined as
working ≥55 h per week) are a risk factor mainly for
stroke (relative risk [RR] 1·33, 95% CI 1·11–1·61), with
estimates showing a dose–response association (RR
1·10 [95% CI 0·94–1·28] for 41–48 h, 1·27 [1·03–1·56]
for 49–54 h, and 1·33 [1·11–1·61] for ≥55 h per week).
The study is a pioneering one because of its large scale,
1710
3 Duff JF, Buckingham WW III. Strengthening of partnerships between the
public sector and faith-based groups. Lancet 2015; published online July 7.
http://dx.doi.org/10.1016/S0140-6736(15)60250-1.
4 Marshall K, Smith S. Religion and Ebola: learning from experience.
Lancet 2015; published online July 7. http://dx.doi.org/10.1016/
S0140-6736(15)61082-0.
5 WHO. The world health report 2004: changing history, community
participation in public health. Geneva: World Health Organization, 2004.
6 General Medical Council. Good clinical practice. Manchester: General
Medical Council, 2014. http://www.gmc-uk.org/static/documents/
content/Good_medical_practice_-_English_0914.pdf (accessed June 13,
2015).
comprising more than 5 million person-years of follow-
up, including not only myocardial infarction but also
stroke as endpoints. So far, Kivimäki and colleagues’
results provide the strongest indication of a causal
association between long working hours and an aspect
of cardiovascular disease—namely, stroke. On the other
hand, the authors report a less convincing association
between long working hours and coronary heart
disease (RR 1·13, 95% CI 1·02–1·26). Because coronary
heart disease is more prevalent than stroke in people
of working age,8 this finding is an interesting one
that has probably been missed because of the smaller
populations studied previously.
In the present study, the investigators were able to
adjust for various confounding factors (ie, age, sex,
socioeconomic status, smoking, body-mass index,
physical activity, and alcohol consumption). But, as in
many epidemiological studies, outcome is measured
with better accuracy than exposure—working time
is self-assessed and measured just once. And, as in
all observational studies, there could be selection
effects (eg, work involvement—the degree to which an
employee is engaged in and enthusiastic about doing
his or her work) and confounding factors (eg, workload
or sleeping hours) that are not controlled for.
Prevention of cardiovascular diseases almost
exclusively focuses on medical and individual preventive
measures.9 Findings from other studies have shown
that this approach is not always simple and tends to
increase inequities in health, because individuals with
the most favourable socioeconomic situation are often
the most successful in implementing these preventive
activities.10
www.thelancet.com Vol 386 October 31, 2015