WHO must remain a strong global health leader post Ebola The 2014 Ebola outbreak in west Africa has demonstrated again the urgent need for strong leadership and coordination in responding to global health challenges. As members of the global health scholarly community, we call upon all WHO Member States to recommit themselves to strengthening global outbreak alert and response by sustainably investing in the WHO, its departments, and personnel. As members of the WHO secretariat have admitted, mistakes were made in how the organisation initially responded to the 2014 Ebola outbreak. Ahead of the 68th World Health Assembly in May, 2015, the temptation will be to point fingers and use the extreme case of Ebola to justify further erosion of the WHO. The temptation might also be to divert voluntary contributions to other institutions. We firmly believe that any such measures must be approached with extreme care. In international forums, a proposal is being discussed to establish a new “first responder” UN agency, which will provide emergency operational assistance in humanitarian crises by rapidly deploying trained personnel, equipment, and supplies. While an enhanced rapid response would be beneficial, a new agency would be subject to the same vagaries of institutional funding and Member State interests in delivering its mandate. Even more importantly, these are functions that the WHO already fulfils via the Global Outbreak Alert and Response Network (GOARN), which maintains a roster of experts that can be deployed to assist in humanitarian disasters. The resources to create an entirely new agency would therefore be better served by strengthening the WHO’s emergency response division rather than duplicating existing functions. Resources could also be more effectively used to help Member States implement www.thelancet.com Vol 385 January 10, 2015
the International Health Regulations (2005) via health system strengthening. An independent investigation of the WHO’s handling of the 2014 Ebola outbreak is both appropriate and warranted. The investigation should focus on the structural and procedural elements of institutional practice, consider how recent funding cuts affected the WHO’s ability to respond, and identify pathways to sustainable funding of the institution. The WHO can provide global health leadership that is technically informed and representative. The organisation remains a fundamental element of global health governance, and provides an indispensable service as the lead technical agency in global health. While mistakes have been made, rather than engage in the further dismantling of the WHO we call on all Member States and the international community to give the organisation the resources it needs to serve its members and the populations they represent. SH has worked as a consultant for WHO. The other authors declare no competing interests. The views expressed here are those of the authors and not necessarily those of their institutions.
*Adam Kamradt-Scott, Sophie Harman, Joao Nunes, Anne Roemer-Mahler, Clare Wenham, on behalf of 95 signatories
[email protected] University of Sydney, Sydney, NSW, Australia (AK-S); Queen Mary University of London, London, UK (SH); University of York, York, UK (JN); University of Sussex, Brighton, UK (AR-M); and London School of Hygiene & Tropical Medicine, London, UK (CW)
Interventions for intimate partner violence We disagree with Susan Rees and Derrick Silove’s Correspondence 1, which states that primary care interventions do not work for intimate partner violence. Investigators have shown that primary care interventions for women increase identification and referrals to services for intimate partner violence in the UK (IRIS trial)2 and increase safety
discussion and decrease depressive symptoms (WEAVE trial) in Australia.3 One primary care intervention (WEAVE) not having an effect on some outcomes does not justify dismissal of primary care for interventions against intimate partner violence. Rather, more needs to be learned from these trials about how to tailor interventions to the trajectory of abuse and help seeking, perhaps to increase the intensity of a whole-of-practice approach and stronger links with community services for intimate partner violence, as in IRIS.2 A systematic review of primary care interventions for intimate partner violence,4 mostly from reproductive care, reported referrals as the most positively affected outcome. Interventions were brief, involving empowerment, safety discussion, and referral to community resources. In WEAVE, many women identified through primary care screening did not take up referrals as few women wanted this at the point of contact. By contrast, most women disclosing abuse through case finding to IRIS doctors consented to referral to intimate partner violence services. Both trial populations valued the acknowledgment and validation of the abuse, and the understanding by doctors that intimate partner violence is a chronic issue—key responses women say they want from health professionals.5 As Rees and Silove1 suggest, many women experience mental health disorders as a result of recurrent abuse,6 with many WEAVE participants already seeing mental health professionals, and others being referred to mental health interventions when they did attend the doctor, a key pathway to care.3 Rees and Silove1 argue that funding for services for intimate partner violence is inadequate, and that these community services need to be rigorously assessed; points with which we thoroughly agree. They then argue that community services are best placed to care for all survivors, despite the absence of evidence. In Australia and the UK, very few survivors directly
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Correspondence
For the list of signatories see appendix
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seek support from services for intimate partner violence because most are not ready or not able to do so, instead turning first to family and friends and then to health professionals. Although it is very important to assess community services for intimate partner violence and support their increased take-up, it is problematic to argue that primary care support should not be refined. WHO guidelines for intimate partner violence and sexual violence show a key role for primary care in first-line response, particularly in countries where there are no specialised services.7 All individuals involved should support interventions and trials across the health and community sector. As Rees and Silove 1 suggest, the complex problem of intimate partner violence needs creative solutions. The message of the recent trials in primary care2–4 is one of hope for change in supporting women on their journey to safety and healing. KH, AT, and GF were involved in the WEAVE study. GF, DJ-H, and MJ were involved in IRIS study. We declare no competing interests.
*Kelsey Hegarty, Angela Taft, Davina James-Hanman, Medina Johnson, Gene Feder
[email protected] University of Melbourne, Carlton, VIC, Australia (KH); La Trobe University, Melbourne, VIC, Australia (AT); AVA—Against Violence and Abuse, London UK (DJ-H); Next Link, Bristol, UK (MJ); and University of Bristol, Bristol, UK (GF) 1
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Rees S, Silove D. Why primary health-care interventions for intimate partner violence do not work. Lancet 2014; 384: 229. Feder G, Davies RA, Baird K, et al. Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011; 378: 1788–95. Hegarty K, O’Doherty L, Taft A, et al. Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial. Lancet 2013; 382: 249–58. Bair-Merritt M, Lewis-O’Connor A, Goel S, et al. Primary Care-Based Intervetnions for intimate partner violence. Am J Prev Med 2014; 46: 188–94. Feder G, Hutson M, Ramsay J, Taket A. Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med 2006; 166: 22–37.
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Hegarty K, O’Doherty L, Chondros P, et al. Effect of type and severity of intimate partner violence on women’s health and service use: findings from a primary care trial of women afraid of their partners. J Interpers Violence 2013; 28: 273–94. WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization, 2013.
Authors’ reply The WEAVE study assessed the effectiveness of family doctors providing brief counselling for women exposed to intimate partner violence.1 Importantly, no case-control differences were shown for any of the three primary outcomes of quality of life, safety planning, and mental health. Therefore, it is reasonable to conclude that there is no empirical evidence to support the effectiveness of counselling by family doctors to address the core problems faced by women experiencing intimate partner violence, which is the the point that we and others have made in previous Correspondence.2,3 Kelsey Hegarty and colleagues confound this important message by referring to studies that differ fundamentally from WEAVE. 1 Specifically, they refer to the success of the IRIS study, which focused solely on training doctors to detect and refer women experiencing intimate partner violence to specialist services.4 In addition, they refer to a meta-analysis that showed positive effects for interventions by non-medical professionals who commonly referred women to specialist services.5 These studies provide no evidence to support family doctors playing a central part as counsellors to address intimate partner violence; instead, the evidence they offer underscores the importance of specialist community services in providing comprehensive assistance for women experiencing intimate partner violence.2 It is always risky to resort to secondary measures when primary outcomes of randomised controlled trials do not show any effects. The authors claim that WEAVE had a beneficial effect on the secondary
outcome of depression. Self-report questionnaires of depression such as the Hospital Anxiety and Depression Scale (HADS) tend to be oversensitive, detecting mild and transient cases that can fluctuate over time, raising doubts about the clinical significance of the slight difference in depression in the intervention group (46% at baseline, 41% at 12 months). Also of concern is that the primary mental health measure, the Short-Form (SF)-12, which is a robust proxy measure of depression, showed no change.6 Finally, controls showed remarkable flux in their HADS depression scores over time (52% positive at baseline, 46% at six months, 58% at 12 months), raising questions about whether that group represented a valid comparator for the intervention group who received counselling. Given these concerns, it is premature to claim that brief counselling by family doctors can have a clinically significant and lasting effect on depression in women experiencing intimate partner violence. To declare unambiguously that a high-quality study has produced a negative finding is of great value to the field because it can provide the impetus to search for and test novel models of intervention.7 By contrast, to obscure this finding and draw inferences from secondary measures will only confuse researchers and practitioners, risking the perpetuation of ineffective practices. We declare no competing interests.
*Susan J Rees, Derrick M Silove
[email protected] University of New South Wales, Sydney, NSW 2052, Australia 1
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Hegarty K, O’Doherty L, Taft A, et al. Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial. Lancet 2013; 382: 249–58. Rees S, Silove D. Why primary health-care interventions for intimate partner violence do not work. Lancet 2014; 384: 229. Jewkes R. Intimate partner violence: the end of routine screening. Lancet 2013; 382: 190–91. Feder G, Davies RA, Baird K, et al. Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011; 378: 1788–95.
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