A commentary paper in your journal by Besancon et al. [1] suggests that industry is opposing the Nutri-Score system and hence preferentially publishes papers that support criticism on that front-of-pack label. It is concluded by Besancon et al. [1] that ‘a study is 21 times more likely to show unfavourable results if the authors have a conflict of interest or the study is funded by the food industry’. The figure of ’21 times’ is suggestive because there are too many unscientific assumptions behind this figure. One assumption is that a study is of poor quality or a biased study if it shows unfavourable results to Nutri-Score and/or if there is a mention of a Conflict of Interest, i.e. sponsored by industry. A second assumption is that studies that are carried out by the developers of Nutri-Score are by definition of good quality and unbiased. Moreover, we found out that Besancon et al. [1] did not conduct a comprehensive search of the literature: they just used the literature list on the website of the developers of Nutri-Score (https://nutriscore.blog/author/logonutriscore/ d.d. August 2023). This list was far from complete, i.e. it did not comprise all peer-reviewed papers about Nutri-Score, especially not the papers that are unfavourable for Nutri-Score. Finally, the analysis by Besancon et al. was limited to the outcome of the studies, without considering the detailed content of the pape...
A commentary paper in your journal by Besancon et al. [1] suggests that industry is opposing the Nutri-Score system and hence preferentially publishes papers that support criticism on that front-of-pack label. It is concluded by Besancon et al. [1] that ‘a study is 21 times more likely to show unfavourable results if the authors have a conflict of interest or the study is funded by the food industry’. The figure of ’21 times’ is suggestive because there are too many unscientific assumptions behind this figure. One assumption is that a study is of poor quality or a biased study if it shows unfavourable results to Nutri-Score and/or if there is a mention of a Conflict of Interest, i.e. sponsored by industry. A second assumption is that studies that are carried out by the developers of Nutri-Score are by definition of good quality and unbiased. Moreover, we found out that Besancon et al. [1] did not conduct a comprehensive search of the literature: they just used the literature list on the website of the developers of Nutri-Score (https://nutriscore.blog/author/logonutriscore/ d.d. August 2023). This list was far from complete, i.e. it did not comprise all peer-reviewed papers about Nutri-Score, especially not the papers that are unfavourable for Nutri-Score. Finally, the analysis by Besancon et al. was limited to the outcome of the studies, without considering the detailed content of the papers or their relevance for the validation of Nutri-Score.
In order to present a complete overview of published literature, recently, we published another study on the validation and efficacy of Nutri-Score and found suggestion for a large publication bias (Peters & Verhagen 2024 [2]. in which we report that the large majority of studies that support Nutri-Score are carried out by the developers of Nutri-Score. In contrast, the majority of studies that are carried out independently from the developers of Nutri-Score showed unfavourable results. For our study we have extended the table of Besancon et al. with the missing literature and added columns to show the relevance of the studies for the validation of the effectiveness of Nutri-Score and added remarks when we were not in line with the conclusions of Besancon et al. with respect to whether studies were favourable or unfavourable to Nutri-Score. All details can be found in the supplementary material of our study [2].
Our paper [2] has received a rebuttal by the developers of Nutri-Score [3] challenging our conclusions. Interestingly, this rebuttal to our recent paper by the developers of Nutri-Score, perhaps ironically but essentially, confirms our analysis: there is a publication bias versus affiliation.
Whereas in our comprehensive analysis [2], the publications by the developers of Nutri-Score are nearly all favourable towards Nutri-Score (52 of 56 papers; 93%), in the rebuttal by Touvier et al. [3] it is stated that even 100% of their papers have a favourable outcome. When only considering papers that were published by authors that are not at all affiliated with the developers of Nutri-Score, a similar pattern is visible: we [2] conclude that only 19 out of 49 papers (39%) are in favour, and the developers of Nutri-Score [3] fully confirm this outcome: 20 out of 44 (45%) are in favour of Nutri-Score.
We have published a reply [4] to the rebuttal by team Nutri-Score [3] and concluded that when taking together the rebuttal by Touvier et al. [3] and our study [2], the final conclusion cannot be denied by either party: There is a clear suggestion of publication bias behind the studies about Nutri-Score, coming from either direction.
It is our opinion that the evaluation of the effectiveness of Nutri-Score should be carried out by an independent food authority. We suggest that the European Food Safety Authority (EFSA) should carry out this important job, because we question the current situation that the scientific development, the evaluation of the scientific development and the updating of the errors in the algorithm are all being conducted by the developers of Nutri-Score.
References:
1. Besancon, S.; Beran, D.; Batal, M. A study is 21 times more likely to find unfavourable results about the nutrition label Nutri-Score if the authors declare a conflict of interest or the study is funded by the food industry. BMJ Glob Health 2023, 8, doi:10.1136/bmjgh-2023-011720.
2. Peters, S.; Verhagen, H. Publication bias and Nutri-Score: A complete literature review of the substantiation of the effectiveness of the front-of-pack logo Nutri-Score. PharmaNutrition 2024, 27, 100380, doi:10.1016/j.phanu.2024.100380.
3. Touvier, M.; P., G.; Julia, C.; Deschasaux-Tanguy, M.; Srour, B.; Kesse-Guyot, E.; Andreeva, E.; Hercberg, C. Rebuttal to the (pre-proof) paper published by S. Peters and H. Verhagen. PharmaNutrition 2024, 24, 100386.
4. Peters, S.; Verhagen, H. Coming from opposite parts of the spectrum of interpreting studies about Nutri-Score: Suggestion of publication bias cannot be denied. PharmaNutrition 2024, 28, 100387.
Congratulations on this well-designed study. I carefully read your study with great interest. I decided to write a commentary on your study as it discusses a field I am most passionate about.
- Introduction:
The introduction provides a comprehensive background on the use of herbal medicine (HM) during pregnancy, the potential risks, and the importance of effective patient-physician communication. The rationale for conducting this systematic review is well-justified.
- Methods:
The search strategy is well-described and comprehensive, covering multiple relevant databases and using appropriate keywords and search terms.
The eligibility criteria for study inclusion are clearly stated and reasonable.
The process of study selection, data extraction, and risk of bias assessment is described in detail and appears to be rigorous.
The methods for data synthesis and statistical analysis, including the use of subgroup analyses and correlation analyses, are appropriate and well-explained.
- Results:
The results are presented systematically and clearly, with the use of tables, figures, and forest plots to effectively visualize the findings.
The findings related to the prevalence of HM use during pregnancy, the rates of disclosure to healthcare providers, and the factors associated with disclosure are insightful and well-supported by the data.
The subgroup analyses based on geographical regio...
Congratulations on this well-designed study. I carefully read your study with great interest. I decided to write a commentary on your study as it discusses a field I am most passionate about.
- Introduction:
The introduction provides a comprehensive background on the use of herbal medicine (HM) during pregnancy, the potential risks, and the importance of effective patient-physician communication. The rationale for conducting this systematic review is well-justified.
- Methods:
The search strategy is well-described and comprehensive, covering multiple relevant databases and using appropriate keywords and search terms.
The eligibility criteria for study inclusion are clearly stated and reasonable.
The process of study selection, data extraction, and risk of bias assessment is described in detail and appears to be rigorous.
The methods for data synthesis and statistical analysis, including the use of subgroup analyses and correlation analyses, are appropriate and well-explained.
- Results:
The results are presented systematically and clearly, with the use of tables, figures, and forest plots to effectively visualize the findings.
The findings related to the prevalence of HM use during pregnancy, the rates of disclosure to healthcare providers, and the factors associated with disclosure are insightful and well-supported by the data.
The subgroup analyses based on geographical region, study year, and various maternal and child health (MCH) indicators provide valuable insights into the variations and potential determinants of HM use and disclosure.
The additional findings related to patient-physician communication on HM use, such as the lack of inquiry from physicians and the reasons for non-disclosure, are informative and contribute to a better understanding of the problem.
- Discussion:
The discussion section provides a comprehensive interpretation of the findings, drawing upon relevant literature and theories to support the interpretations.
The authors effectively highlight the potential consequences of inappropriate HM use and the importance of open patient-physician communication in preventing adverse MCH outcomes.
The discussion of the study's limitations is appropriate and acknowledges the potential impact of factors such as language restrictions, non-random sampling, and variations in study characteristics.
- Conclusion:
The conclusion summarizes the key findings and provides practical recommendations for promoting effective patient-physician communication on HM use during antenatal care, such as training healthcare professionals, implementing community outreach programs, and integrating inquiries about HM use into routine antenatal care.
Overall, this systematic review and meta-analysis is well-designed, well-executed, and provides valuable insights into the use of HM during pregnancy and the importance of patient-physician communication. The authors have addressed the research questions comprehensively and have employed rigorous methods for data synthesis and analysis. The study findings have important implications for healthcare practice and policy and can inform efforts to promote safe and appropriate HM use during pregnancy.
Suggestions for improvement:
- The authors could consider discussing the potential impact of cultural and socioeconomic factors on HM use and disclosure, as these factors may vary across different geographical regions and influence patient-physician communication.
- Additional subgroup analyses based on specific types of HM or indications for use could provide further insights into the patterns of HM use and disclosure, although the authors acknowledge the limitations in data availability.
- The authors could explore the potential for publication bias in more detail, as this may influence the overall prevalence estimates.
Overall, this is a well-conducted systematic review and meta-analysis that contributes valuable knowledge to the field of maternal and child health.
We would like to thank Professor Holst for taking the time to read and respond to our article. Indeed, in developing the piece, we read with great interest Professor Holst’s 2020 article on emergence, hegemonic trends and biomedical reductionism in global health. We acknowledge that global health is a broad and complex field, and ongoing discourse around terminology is welcome and encouraged.
As Professor Holst himself states, “the predominant Global Health concept reflects the inherited hegemony of the Global North”.(1) With this is mind, we sought in our paper to articulate a practical interpretation of global health that emphasises the critical barriers to universal health coverage and optimal health outcomes. The challenges of access, resource and context limitation are global in nature, and do not relate exclusively to the provision of “humanitarian aid”. We agree with Professor Holst that addressing these issues requires trans-national solutions and multi-sectoral engagement.
In articulating the ARC-H principle, we acknowledge that we have applied a “clinical-biomedical” frame. This reflects our work as emergency physicians who have borne witness to the direct and indirect consequences of access-, resource- and context-limited healthcare. Our interpretation is pragmatic, and deliberately serves to emphasise the expertise and lived experience of ARC-H populations.
In no way do we seek to minimise the social, environmental, political and commer...
We would like to thank Professor Holst for taking the time to read and respond to our article. Indeed, in developing the piece, we read with great interest Professor Holst’s 2020 article on emergence, hegemonic trends and biomedical reductionism in global health. We acknowledge that global health is a broad and complex field, and ongoing discourse around terminology is welcome and encouraged.
As Professor Holst himself states, “the predominant Global Health concept reflects the inherited hegemony of the Global North”.(1) With this is mind, we sought in our paper to articulate a practical interpretation of global health that emphasises the critical barriers to universal health coverage and optimal health outcomes. The challenges of access, resource and context limitation are global in nature, and do not relate exclusively to the provision of “humanitarian aid”. We agree with Professor Holst that addressing these issues requires trans-national solutions and multi-sectoral engagement.
In articulating the ARC-H principle, we acknowledge that we have applied a “clinical-biomedical” frame. This reflects our work as emergency physicians who have borne witness to the direct and indirect consequences of access-, resource- and context-limited healthcare. Our interpretation is pragmatic, and deliberately serves to emphasise the expertise and lived experience of ARC-H populations.
In no way do we seek to minimise the social, environmental, political and commercial determinants of health, or the inequalities and power imbalances that contribute to sub-optimal health outcomes. Rather, we have endeavoured to highlight the practical, downstream consequences of these factors. Healthcare that is access- or resource-limited is invariably a manifestation of the broader social, environmental and political context.
As articulated in our article, our intent is not to replace established terminology and definitions, but rather emphasise the importance of clarity and precision when referring to global health activities and programmes. We hope to have encouraged those who use the term ‘global health’ to think critically about what they actually mean. In writing his response, Professor Holst has applied the exact type of reflexive approach that we were hoping to stimulate.
In a February correspondence to BMJ, Greenland et al opined that an end to violence in Palestine “can only occur when Hamas ends its war to destroy the state of Israel...”.[1] The Israeli offensive, the authors argued, is legitimised by the support of “the governments of the UK, the USA, Germany, France, Italy and other sovereign states”[1] and purported “evidence” contained within predominantly North American news outlets including the New York Times, CNN, and the Washington Post.
What the article glaringly omits are the evidence-based analyses and unified first-hand accounts of global health, humanitarian, and human rights organisations operating in Gaza – organisations borne in direct response to war atrocities and mandated to alleviate suffering, protect rights, uphold international law, and maintain neutrality, peace, security, and diplomacy. How far we have fallen if the experiences of such organisations are no longer considered valid and worthy of reference, but violence and oppression are legitimised through citing unreliable sources at best, and biased standpoints of political and vested interest at worst. Disappointingly, such citations undermine the high ethical standards of journals like the BMJ. In the interests of respecting evidence and facts, we highlight experiences from global bodies to refute Greenland et al’s baseless claims.
First, the authors dispute the occupation of Gaza itself, claiming – using a misquoted Wikipedia reference[2] – “t...
In a February correspondence to BMJ, Greenland et al opined that an end to violence in Palestine “can only occur when Hamas ends its war to destroy the state of Israel...”.[1] The Israeli offensive, the authors argued, is legitimised by the support of “the governments of the UK, the USA, Germany, France, Italy and other sovereign states”[1] and purported “evidence” contained within predominantly North American news outlets including the New York Times, CNN, and the Washington Post.
What the article glaringly omits are the evidence-based analyses and unified first-hand accounts of global health, humanitarian, and human rights organisations operating in Gaza – organisations borne in direct response to war atrocities and mandated to alleviate suffering, protect rights, uphold international law, and maintain neutrality, peace, security, and diplomacy. How far we have fallen if the experiences of such organisations are no longer considered valid and worthy of reference, but violence and oppression are legitimised through citing unreliable sources at best, and biased standpoints of political and vested interest at worst. Disappointingly, such citations undermine the high ethical standards of journals like the BMJ. In the interests of respecting evidence and facts, we highlight experiences from global bodies to refute Greenland et al’s baseless claims.
First, the authors dispute the occupation of Gaza itself, claiming – using a misquoted Wikipedia reference[2] – “there are no ‘occupying Jews’”.[1] Not only is this confused and irrelevant, but the “belligerent”[3] military occupation of the Palestinian territories, including Gaza, is an irrefutable fact under international law, recognised by United Nations (UN) bodies and international organisations since 1967 and enduring today.[3–5]
Second, the authors blame Hamas for the current conflict – again, with historical reference drawn from Wikipedia – without acknowledging Israel’s culpability in the decades prior to October 7, and their attacks on civilians since. As António Guterres, UN Secretary-General, stated: “the attacks by Hamas did not happen in a vacuum, with the Palestinian people being subjected to 56 years of suffocating occupation… and those appalling attacks cannot justify the collective punishment of the Palestinian people.”[6]
Furthermore, the authors’ claim that Israel declared war against Hamas, not civilians, is farcical given the astronomical civilian death toll exceeding 31,700 people.[7] At least 12,300 Gazan children have been killed over four months.[8] UN human rights experts have issued multiple warnings of the risk of genocide.[9] 2.3 million Gazans face impending famine due to Israel’s “total siege”[9,10] despite Israel’s obligation to provide basic supplies to the Gazan population under international law.[11] All these facts have been confirmed by credible global organisations with presence in Gaza.
Third, the authors draw focus to the undetermined origin of attack on Al-Ahli Hospital on October 17,[12] yet omit reference to Israel’s well documented and verified attacks on the Indonesian hospital and near Al-Shifa and Al-Quds hospitals[13] days prior to article submission. Christopher Lockyear, Secretary-General of Médecins Sans Frontières (MSF), reported: “Israeli forces have attacked our convoys, detained our staff, and bulldozed our vehicles, and hospitals have been bombed and raided.”[14] In January, the World Health Organisation (WHO) reported almost 600 attacks on health infrastructure since October 7.[15]
The authors then use the unfounded claim, a so-called “fact known for years”, that Hamas has used hospitals for military purposes to justify attacks on health infrastructure, citing CNN and the Washington Post.(1) “[W]e have seen zero independently verified evidence of this,” declared Lockyear.[14] The ICRC emphasises that in cases of doubt, health establishments should be presumed not to be used as accessories to war.[16] On March 18, Israeli attacks on Al-Shifa resumed, with MSF reporting mass arrests and loss of contact with staff.[17]
Gazans are facing an “unparalleled humanitarian crisis”.[9] We reiterate the calls of WHO Director-General Dr Tedros Adhanom Ghebreyesus, Guterres, Lockyear, and every global organisation witnessing the atrocities in Gaza, for an immediate ceasefire.[14,18–20] These are the voices that must be taken seriously, unified in their outrage and disbelief at a politics and propaganda taking unjustifiable and unconscionable positions in denial of reality, and in denial of humanity.
The authors are to be commended on an important article which makes a compelling point.
Out of interest, where authors are appropriately credited as joint first and joint last, should their names then be listed alphabetically? In the example of this paper, this would place authors based in more resource-poor countries as the first and last listed authors, and would also seem the more rational ordering if authorship is jointly shared. There is some evidence that the ordering of 'joint first' authors does involve some implicit biasing in terms of gender balance - might this not also be an issue in work published as part of an global partnership? Attributing authorship can be genuinely difficult, but where equivalence is recognised it then seems concerning that the chosen (but not explained) order still places the high-income authors in the traditional positions of distinction.
Recently, in BMJ Global Health, Nasir Jafar and colleagues made another attempt to redefine 'global health'. They aim for 'greater clarity and precision' in a pragmatic and more inclusive sense, with the noble objective '‘to offload colonial vestiges present within the field and terminology of ‘global health’.‘ While this goal is undoubtedly right, important and overdue, the argument is alarmingly unconvincing and narrow. In their attempt to redefine, or rather reinterpret, global health, the authors make two important restrictions. Their proposal is based on an understanding of global health that is limited not only to a single country, but also to the field of humanitarian aid. Health emergencies and relief are only part of global health, so reducing the latter to humanitarian aid is absolutely unacceptable. It blatantly neglects both the meaning of "global" as "universal" and the complexity of global health as an explicitly political concept.
The second, unacceptable limitation is the authors' narrowing of global health to healthcare and healthcare systems. It may be that a clinical-biomedical understanding dominates the theory and practice of global health, but the call for an a posteriori recognition of pragmatic development should not distract from the fact that global health is much more complex, encompassing the social, environmental, political and commercial determination of health, as well as inequalities...
Recently, in BMJ Global Health, Nasir Jafar and colleagues made another attempt to redefine 'global health'. They aim for 'greater clarity and precision' in a pragmatic and more inclusive sense, with the noble objective '‘to offload colonial vestiges present within the field and terminology of ‘global health’.‘ While this goal is undoubtedly right, important and overdue, the argument is alarmingly unconvincing and narrow. In their attempt to redefine, or rather reinterpret, global health, the authors make two important restrictions. Their proposal is based on an understanding of global health that is limited not only to a single country, but also to the field of humanitarian aid. Health emergencies and relief are only part of global health, so reducing the latter to humanitarian aid is absolutely unacceptable. It blatantly neglects both the meaning of "global" as "universal" and the complexity of global health as an explicitly political concept.
The second, unacceptable limitation is the authors' narrowing of global health to healthcare and healthcare systems. It may be that a clinical-biomedical understanding dominates the theory and practice of global health, but the call for an a posteriori recognition of pragmatic development should not distract from the fact that global health is much more complex, encompassing the social, environmental, political and commercial determination of health, as well as inequalities and power imbalances between and within countries. Against this backdrop, the attempt by Nasir Jafar et al. to redefine global health proves to be inadequate and misleading. Due to the fundamental reductionism reflected in their commentary, the approach is unlikely to make a relevant contribution to decolonising global health, as it diverts the attention from the far more relevant upstream determinants of global health and health inequalities.
A recently published article addresses the worrysome connections existing between the progressively increasing Arctic Sea ice melting and the chronic starvation experienced by polar bears (Ursus maritimus) (1). Indeed, the progressively declining Arctic Sea ice thickness represents a leading cause of the profound ecological, behavioural, feeding and dietary pattern modifications reported with an increased frequency in this highly threatened apex predator (1).
Within such an alarming context, the animals' chronic stress deriving from prolonged starvation is an additional matter of concern. Indeed, besides being a powerful and efficient machinery allowing us and all the other living organisms to cope with a huge number of environmental stressors, chronic stress responses are invariably characterized by immunosuppression, originating from enhanced cortisol production (2). Therefore, while increased cortisol levels should be reasonably expected to occur in the blood of polar bears experiencing chronic starvation (1), it should be emphasized they may also become, at the same time, much more susceptible to microbial pathogens impacting their health and conservation status.
This could be especially true for Toxoplasma gondii, a cosmopolitan and zoonotic protozoan parasite infecting humans and a large number of terrestrial and aquatic mammal species, including polar bears. In this respect, anti-T. gondii antibodies were previously reported in almost half of the p...
A recently published article addresses the worrysome connections existing between the progressively increasing Arctic Sea ice melting and the chronic starvation experienced by polar bears (Ursus maritimus) (1). Indeed, the progressively declining Arctic Sea ice thickness represents a leading cause of the profound ecological, behavioural, feeding and dietary pattern modifications reported with an increased frequency in this highly threatened apex predator (1).
Within such an alarming context, the animals' chronic stress deriving from prolonged starvation is an additional matter of concern. Indeed, besides being a powerful and efficient machinery allowing us and all the other living organisms to cope with a huge number of environmental stressors, chronic stress responses are invariably characterized by immunosuppression, originating from enhanced cortisol production (2). Therefore, while increased cortisol levels should be reasonably expected to occur in the blood of polar bears experiencing chronic starvation (1), it should be emphasized they may also become, at the same time, much more susceptible to microbial pathogens impacting their health and conservation status.
This could be especially true for Toxoplasma gondii, a cosmopolitan and zoonotic protozoan parasite infecting humans and a large number of terrestrial and aquatic mammal species, including polar bears. In this respect, anti-T. gondii antibodies were previously reported in almost half of the polar bears from Svalbard, Norway, with males showing higher seroprevalence values than females and with the infection's frequency turning out to have doubled in comparison to an earlier investigation carried out in the same area (3).
Furthermore, the well-known top predator position occupied by polar bears within the marine food chain makes these animals prone to bioaccumulate and biomagnify a huge number of persistent environmental pollutants within their body tissues, including immunotoxic heavy metals like methyl mercury (methyl Hg) (4).
Summarizing, the immunosuppression synergistically induced by the chronic stress response deriving from prolonged starvation as well as by the high tissue concentrations of immunotoxic environmental xenobiotics, may render polar bears much more susceptible toward the acquirement and subsequent development of various infectious disease processes, of both viral and non-viral nature, impacting their already threatened health and conservation status, including SARS-CoV-2 infection, which has shown a progressively expanding wild and domestic animal host range (5).
Once again, a multidisciplinary, One Health-based approach would be strongly recommended in order to get proper insight into, and adequately counteracT, the alarming risk of getting another "piece of biodiversity" irreversibly lost!
References
1) Pagano, A.M., Rode, K.D., Lunn, N.J., et al. Polar bear energetic and behavioral strategies on land with implications for surviving the ice-free period. Nat Commun 15, 947 (2024). https://doi.org/10.1038/s41467-023-44682-1.
2) O'Leary, A. Stress, emotion, and human immune function. Psychol. Bull.108, 363-382 (1990). doi: 10.1037/0033-2909.108.3.363.
3) Jensen, S.K., Aars, J., Lydersen, C., et al. The prevalence of Toxoplasma gondii in polar bears and their marine mammal prey: evidence for a marine transmission pathway?. Polar. Biol 33, 599–606 (2010). https://doi.org/10.1007/s00300-009-0735-x
4) St Louis, V.L., Derocher, A.E., Stirling, I., et al. Differences in mercury bioaccumulation between polar bears (Ursus maritimus) from the Canadian high- and sub-Arctic. Environ. Sci. Technol. 45, 922-928 (2011). doi: 10.1021/es2000672.
5) Di Guardo, G. The SARS-CoV-2 pandemic at the wildlife-domestic animal-human interface. Pathogens 12(2), 222 (2023). doi: 10.3390/pathogens12020222.
I would like to register my strong support for this viewpoint. I am part of a large group of >200 physicians, researchers, and academics who endorsed and contributed to this article. Unfortunately, as part of a highly disappointing series of editorial decisions, BMJ Global did not allow the authors to publish our names and information as a supplement to this article (which was the original plan). I therefore would like to register a rapid response documenting that I was one of the extremely large group of academics who endorsed this article.
An excellent comprehensive, thoughtful review. Until such time as Israel-- a Jewish homeland and liberal democracy-- is accepted as a reality there can be no peace. To paraphrase Golda Meir, ",,,,,,, if the Arab world put down their weapons, there would be peace.,,,,,,, if Israel put down their weapons there would be no Israel".
Both this commentary and the previous one by Smith et al are both misleading and political attacks on the right for Israel to exist as a free and democratic nation. The Palestinian people of Gaza have been victims of Hamas since they took over in 2005/2006. To dismiss the horrendous terrorist attack of Oct 7 where children and women mutilated and raped, which was actually documented by the terrorists themselves is abhorrent and totally irresponsible of BMJ Global health. In fact prior to Oct 7, thousands of Palestinian Gazans were getting health care in Israel, including family members of Gaza leadership. Thousands of Gazans were crossing the border daily to work in Israeli Farms/Kibbutzim who paid them, fed them and at times housed them, only for them to map out each farm and houses to provide to the terrorists so they know how to attack them. In addition, many of those who worked in those farms/kibbutzim participated in the attacks. Finally, Gaza built an underground network/city under the hospitals and schools to plana and stage their attack on Israel, knowing using the Palestinian/Gazan residents as human shields to they can get sympathy from the world. In addition the communities that were attacked in the Negev, that were formed in the 1920s, were predominantly Jewish, with very few Muslims or "Palestinians" living there. Israel has every right to defend itself against this barbaric attack, as would any country. Health justice and publication of thi...
Both this commentary and the previous one by Smith et al are both misleading and political attacks on the right for Israel to exist as a free and democratic nation. The Palestinian people of Gaza have been victims of Hamas since they took over in 2005/2006. To dismiss the horrendous terrorist attack of Oct 7 where children and women mutilated and raped, which was actually documented by the terrorists themselves is abhorrent and totally irresponsible of BMJ Global health. In fact prior to Oct 7, thousands of Palestinian Gazans were getting health care in Israel, including family members of Gaza leadership. Thousands of Gazans were crossing the border daily to work in Israeli Farms/Kibbutzim who paid them, fed them and at times housed them, only for them to map out each farm and houses to provide to the terrorists so they know how to attack them. In addition, many of those who worked in those farms/kibbutzim participated in the attacks. Finally, Gaza built an underground network/city under the hospitals and schools to plana and stage their attack on Israel, knowing using the Palestinian/Gazan residents as human shields to they can get sympathy from the world. In addition the communities that were attacked in the Negev, that were formed in the 1920s, were predominantly Jewish, with very few Muslims or "Palestinians" living there. Israel has every right to defend itself against this barbaric attack, as would any country. Health justice and publication of this information is not something that should be published in Medical Journals, it is political and with much misinformation.
Dear Editor,
A commentary paper in your journal by Besancon et al. [1] suggests that industry is opposing the Nutri-Score system and hence preferentially publishes papers that support criticism on that front-of-pack label. It is concluded by Besancon et al. [1] that ‘a study is 21 times more likely to show unfavourable results if the authors have a conflict of interest or the study is funded by the food industry’. The figure of ’21 times’ is suggestive because there are too many unscientific assumptions behind this figure. One assumption is that a study is of poor quality or a biased study if it shows unfavourable results to Nutri-Score and/or if there is a mention of a Conflict of Interest, i.e. sponsored by industry. A second assumption is that studies that are carried out by the developers of Nutri-Score are by definition of good quality and unbiased. Moreover, we found out that Besancon et al. [1] did not conduct a comprehensive search of the literature: they just used the literature list on the website of the developers of Nutri-Score (https://nutriscore.blog/author/logonutriscore/ d.d. August 2023). This list was far from complete, i.e. it did not comprise all peer-reviewed papers about Nutri-Score, especially not the papers that are unfavourable for Nutri-Score. Finally, the analysis by Besancon et al. was limited to the outcome of the studies, without considering the detailed content of the pape...
Show MoreDear esteemed authors,
Congratulations on this well-designed study. I carefully read your study with great interest. I decided to write a commentary on your study as it discusses a field I am most passionate about.
- Introduction:
Show MoreThe introduction provides a comprehensive background on the use of herbal medicine (HM) during pregnancy, the potential risks, and the importance of effective patient-physician communication. The rationale for conducting this systematic review is well-justified.
- Methods:
The search strategy is well-described and comprehensive, covering multiple relevant databases and using appropriate keywords and search terms.
The eligibility criteria for study inclusion are clearly stated and reasonable.
The process of study selection, data extraction, and risk of bias assessment is described in detail and appears to be rigorous.
The methods for data synthesis and statistical analysis, including the use of subgroup analyses and correlation analyses, are appropriate and well-explained.
- Results:
The results are presented systematically and clearly, with the use of tables, figures, and forest plots to effectively visualize the findings.
The findings related to the prevalence of HM use during pregnancy, the rates of disclosure to healthcare providers, and the factors associated with disclosure are insightful and well-supported by the data.
The subgroup analyses based on geographical regio...
We would like to thank Professor Holst for taking the time to read and respond to our article. Indeed, in developing the piece, we read with great interest Professor Holst’s 2020 article on emergence, hegemonic trends and biomedical reductionism in global health. We acknowledge that global health is a broad and complex field, and ongoing discourse around terminology is welcome and encouraged.
As Professor Holst himself states, “the predominant Global Health concept reflects the inherited hegemony of the Global North”.(1) With this is mind, we sought in our paper to articulate a practical interpretation of global health that emphasises the critical barriers to universal health coverage and optimal health outcomes. The challenges of access, resource and context limitation are global in nature, and do not relate exclusively to the provision of “humanitarian aid”. We agree with Professor Holst that addressing these issues requires trans-national solutions and multi-sectoral engagement.
In articulating the ARC-H principle, we acknowledge that we have applied a “clinical-biomedical” frame. This reflects our work as emergency physicians who have borne witness to the direct and indirect consequences of access-, resource- and context-limited healthcare. Our interpretation is pragmatic, and deliberately serves to emphasise the expertise and lived experience of ARC-H populations.
In no way do we seek to minimise the social, environmental, political and commer...
Show MoreIn a February correspondence to BMJ, Greenland et al opined that an end to violence in Palestine “can only occur when Hamas ends its war to destroy the state of Israel...”.[1] The Israeli offensive, the authors argued, is legitimised by the support of “the governments of the UK, the USA, Germany, France, Italy and other sovereign states”[1] and purported “evidence” contained within predominantly North American news outlets including the New York Times, CNN, and the Washington Post.
What the article glaringly omits are the evidence-based analyses and unified first-hand accounts of global health, humanitarian, and human rights organisations operating in Gaza – organisations borne in direct response to war atrocities and mandated to alleviate suffering, protect rights, uphold international law, and maintain neutrality, peace, security, and diplomacy. How far we have fallen if the experiences of such organisations are no longer considered valid and worthy of reference, but violence and oppression are legitimised through citing unreliable sources at best, and biased standpoints of political and vested interest at worst. Disappointingly, such citations undermine the high ethical standards of journals like the BMJ. In the interests of respecting evidence and facts, we highlight experiences from global bodies to refute Greenland et al’s baseless claims.
First, the authors dispute the occupation of Gaza itself, claiming – using a misquoted Wikipedia reference[2] – “t...
Show MoreThe authors are to be commended on an important article which makes a compelling point.
Out of interest, where authors are appropriately credited as joint first and joint last, should their names then be listed alphabetically? In the example of this paper, this would place authors based in more resource-poor countries as the first and last listed authors, and would also seem the more rational ordering if authorship is jointly shared. There is some evidence that the ordering of 'joint first' authors does involve some implicit biasing in terms of gender balance - might this not also be an issue in work published as part of an global partnership? Attributing authorship can be genuinely difficult, but where equivalence is recognised it then seems concerning that the chosen (but not explained) order still places the high-income authors in the traditional positions of distinction.
Recently, in BMJ Global Health, Nasir Jafar and colleagues made another attempt to redefine 'global health'. They aim for 'greater clarity and precision' in a pragmatic and more inclusive sense, with the noble objective '‘to offload colonial vestiges present within the field and terminology of ‘global health’.‘ While this goal is undoubtedly right, important and overdue, the argument is alarmingly unconvincing and narrow. In their attempt to redefine, or rather reinterpret, global health, the authors make two important restrictions. Their proposal is based on an understanding of global health that is limited not only to a single country, but also to the field of humanitarian aid. Health emergencies and relief are only part of global health, so reducing the latter to humanitarian aid is absolutely unacceptable. It blatantly neglects both the meaning of "global" as "universal" and the complexity of global health as an explicitly political concept.
The second, unacceptable limitation is the authors' narrowing of global health to healthcare and healthcare systems. It may be that a clinical-biomedical understanding dominates the theory and practice of global health, but the call for an a posteriori recognition of pragmatic development should not distract from the fact that global health is much more complex, encompassing the social, environmental, political and commercial determination of health, as well as inequalities...
Show MoreA recently published article addresses the worrysome connections existing between the progressively increasing Arctic Sea ice melting and the chronic starvation experienced by polar bears (Ursus maritimus) (1). Indeed, the progressively declining Arctic Sea ice thickness represents a leading cause of the profound ecological, behavioural, feeding and dietary pattern modifications reported with an increased frequency in this highly threatened apex predator (1).
Show MoreWithin such an alarming context, the animals' chronic stress deriving from prolonged starvation is an additional matter of concern. Indeed, besides being a powerful and efficient machinery allowing us and all the other living organisms to cope with a huge number of environmental stressors, chronic stress responses are invariably characterized by immunosuppression, originating from enhanced cortisol production (2). Therefore, while increased cortisol levels should be reasonably expected to occur in the blood of polar bears experiencing chronic starvation (1), it should be emphasized they may also become, at the same time, much more susceptible to microbial pathogens impacting their health and conservation status.
This could be especially true for Toxoplasma gondii, a cosmopolitan and zoonotic protozoan parasite infecting humans and a large number of terrestrial and aquatic mammal species, including polar bears. In this respect, anti-T. gondii antibodies were previously reported in almost half of the p...
I would like to register my strong support for this viewpoint. I am part of a large group of >200 physicians, researchers, and academics who endorsed and contributed to this article. Unfortunately, as part of a highly disappointing series of editorial decisions, BMJ Global did not allow the authors to publish our names and information as a supplement to this article (which was the original plan). I therefore would like to register a rapid response documenting that I was one of the extremely large group of academics who endorsed this article.
An excellent comprehensive, thoughtful review. Until such time as Israel-- a Jewish homeland and liberal democracy-- is accepted as a reality there can be no peace. To paraphrase Golda Meir, ",,,,,,, if the Arab world put down their weapons, there would be peace.,,,,,,, if Israel put down their weapons there would be no Israel".
Both this commentary and the previous one by Smith et al are both misleading and political attacks on the right for Israel to exist as a free and democratic nation. The Palestinian people of Gaza have been victims of Hamas since they took over in 2005/2006. To dismiss the horrendous terrorist attack of Oct 7 where children and women mutilated and raped, which was actually documented by the terrorists themselves is abhorrent and totally irresponsible of BMJ Global health. In fact prior to Oct 7, thousands of Palestinian Gazans were getting health care in Israel, including family members of Gaza leadership. Thousands of Gazans were crossing the border daily to work in Israeli Farms/Kibbutzim who paid them, fed them and at times housed them, only for them to map out each farm and houses to provide to the terrorists so they know how to attack them. In addition, many of those who worked in those farms/kibbutzim participated in the attacks. Finally, Gaza built an underground network/city under the hospitals and schools to plana and stage their attack on Israel, knowing using the Palestinian/Gazan residents as human shields to they can get sympathy from the world. In addition the communities that were attacked in the Negev, that were formed in the 1920s, were predominantly Jewish, with very few Muslims or "Palestinians" living there. Israel has every right to defend itself against this barbaric attack, as would any country. Health justice and publication of thi...
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