Migration, health, and care in French overseas territories

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Correspondence
www.thelancet.com Vol 376 November 27, 2010
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Funk and colleagues’ study under-
scores the urgent need for resources to
implement and assess interventions
that reduce global disparities in access
to essential surgical care, which should
be seen as a basic human right.5
We declare that we have no confl icts of interest.
*Doruk Ozgediz,
Jacqueline Mabweijano,
Cephas Mijumbi, Sudha Jayaraman,
Michael Lipnick
dozgediz@hotmail.com
University of Toronto, Toronto, ON M5G 2J8,
Canada (DO); Makerere University, Kampala,
Uganda (JM, CM); University of California at San
Francisco, San Francisco, CA, USA (SJ); and Global
Partners in Anesthesia and Surgery, San Francisco,
CA, USA (DO, JM, CM, SJ, ML)
1 Funk L, Weiser TG, Berry WR, et al. Global
operating theatre distribution and pulse
oximetry supply: an estimation from reported
data. Lancet 2010; 376: 1055–61.
2 Myles PS, Haller G. Global distribution of access
to surgical services. Lancet 2010; 376: 1027–28.
3 Mock CN, Jurkovic GJ, Nii-Amon Kotei D, et al.
Trauma mortality patterns in three nations of
diff erent economic levels: implications for
global trauma system development. J Trauma
1998; 44: 804–14.
4 Jayaraman S, Mabweijano JR, Lipnick M, et al.
First things fi rst: eff ectiveness and scalability
of a basic prehopital program for lay fi rst
responders in Kampala, Uganda. PLoS One
2010; 4: 1–7.
5 McQueen KA, Ozgediz D, Riviello R, et al.
Essential surgery: integral to the right to health.
Health Human Rights J 2010; 12: 137–52.
Cancer funding in
developing countries:
the next health-care
crisis?
We welcome the call to expand
cancer control in low-income and
middle-income countries (LMIC) by
Paul Farmer and colleagues (Oct 2,
p 1186).1 The Global Fund to fi ght
AIDS, Tuberculosis and Malaria was
formed in 2002 after a call in The
Lancet by Amir Attaran and Jeff rey
Sachs2 for a special funding stream for
HIV/AIDS. Can we expect the same for
cancer?
In less developed countries alone,
more people develop (7·1 million) and
die from cancer (4·8 million) each year3
than are infected or die from HIV/AIDS
throughout the world (an estimated
2·7 million and 2 million, respectively,
in 2008).4 Cancer, unlike HIV/AIDS,
is also often curable, particularly if
diagnosed early.
Although there is much to be
learned from the achievements of the
focused approaches to AIDS, malaria,
and tuberculosis, cancer care requires
a much more individualised approach,
based on the type and stage of cancer—
both of which require expertise to
determine. Notwith standing the
mention by Farmer and colleagues of
the provision of cancer chemotherapy
in rural regions in Rwanda and Malawi
by non-specialists, successful cancer
treatment mostly requires a team
of skilled specialists to ensure good
diagnosis and the availability of
appropriate surgery, radiotherapy,
systemic therapy, and supportive care.
Doubtless, the complexities and cost
of cancer care have much to do with
the low priority assigned to cancer
control, which has created a kind of
“triple penalty” in which poor access
to care results in patients presenting
with advanced disease, greatly
increasing both the cost5 and toxicity
of treatment (including more surgical
mutilation) and resulting in much
lower survival rates. In turn, the poor
results back up the assumption that
poor countries—and wealthy donors—
cannot aff ord to include cancer care on
their health agendas.
Funding will initially be required
to generate evidence on what
works and what doesn’t in low-
resource settings, coupled with
the development of sustainable
cancer control program mes and
an improvement in the results of
existing cancer treatment centres
through education of all stakeholders
with respect to what is possible when
diagnosis is early and basic cancer
care is accessible. This should lead
to an increase in available funding
from a wide range of sources, and a
gradual amelioration of the situation,
although the challenges involved
should not be underestimated, nor
too much expected as a result of the
successes achieved with HIV/AIDS.
We declare that we have no confl icts of interest.
*Ian Magrath, Pierre Bey, Aziza Shad,
Simon Sutcliff e
International Network for Cancer Treatment and
Research (INCTR), 1180 Brussels, Belgium (IM);
Alliance Mondiale Contre le Cancer (INCTR France),
Paris, France (PB); INCTR USA, Chevy Chase, MD,
USA (AS); and INCTR Canada, Vancouver, BC,
Canada (SS)
1 Farmer P, Frenk J, Knaul FM, et al. Expansion of
cancer care and control in countries of low and
middle income: a call to action. Lancet 2010;
376: 1186–93.
2 Attaran A, Sachs J. Defi ning and refi ning
international donor support for combating the
AIDS pandemic. Lancet 2001; 357: 57–61.
3 International Agency for Research on Cancer.
Globocan database. http://globocan.iarc.fr
(accessed Nov 17, 2010).
4 Avert. Global HIV/AIDS estimates, end of
2008. http://www.avert.org/worldstats.htm
(accessed Nov 9, 2010).
5 Kerr DJ, Midgley R. Can we treat cancer for a
dollar a day? Guidelines for low income
countries. N Engl J Med 2010; 363: 9.
Migration, health, and
care in French overseas
territories
France was recently reprimanded by
a UN human rights body1 concerned
about discriminatory political dis-
course and an increase in acts and
expressions of racism and xenophobia
in this country. The report also called
attention to “the increasing diffi culties
faced by certain inhabitants of [French]
overseas territories in accessing health
care without discrimination”.
In Mayotte, especially, access to
health care is very precarious, and it
is further hampered by security and
fi nancial concerns. Located in the
Comoros Archipelago, this French
island, with a population of 200 000,
of whom nearly a third do not have
regular residence status, holds
the record for a policy of expelling
undocumented foreigners. During the
fi rst quarter of 2010, there were 12 300
expulsions from Mayotte compared
with 14 700 from mainland France,
Reuters
The printed
journal
includes an
image merely
for illustration

Correspondence
1828
www.thelancet.com Vol 376 November 27, 2010
metastatic cancer would be much
more likely. Such an attitude can lead to
erroneous treatment decisions.
Physicians need to be aware of
this all too human tendency towards
compassionate optimism and aim to
correct it by means of a more bal anced,
bias-free interpretation of the facts.
I declare that we have no confl icts of interest.
Ami Schattner
amiMD@clalit.org.il
Department of Medicine, Kaplan Medical Center,
POB 1, Rehovot 76100, Israel
1 Eisenberg JM. Sociologic infl uences on
decision-making by clinicians. Ann Intern Med
1979; 90: 957–64.
2 Landon BE, Reschovsky J, Reed M,
Blumenthal D. Personal, organizational, and
market level infl uences on physicians’ practice
patterns: results of a national survey of
primary care physicians. Med Care 2001;
39: 889–905.
3 Logan RL, Scott PJ. Uncertainty in clinical
practice: implications for quality and costs of
health care. Lancet 1996; 347: 595–98.
4 Nanda S, Prakash Bhatt S, Steinberg D,
Volk SA. Unusual cause of generalized
osteolytic vertebral lesions: a case report.
J Med Case Reports 2007; 1: 33.
*Inserm, U707, Research Team on Social
Determinants of Health and Health Care,
75012 Paris, France (AJ, SF, JL, PC); Université
Pierre-et-Marie-Curie Paris-6, UMR S 707, Paris,
France (AJ, SF, JL, PC); and AP-HP, Hôpital Saint-
Antoine, Paris, France (JL, PC)
1 Committee on the Elimination of Racial
Discrimination. France: concluding
observations. Geneva: Offi ce of the United
Nations High Commissioner for Human
Rights, 77th session, 2010, report CERD/C/
FRA/CO/17-19.
2 République Francaise, Préfecture de Mayotte.
Résultats de la lutte contre l’immigration
clandestine et la travail illégal: premiere
semestre, 2010. Dzaoudzi: Préfecture de
Mayotte, 2010.
3 Florence S, Lebas J, Parizot I, et al. Migration,
health and access to care in Mayotte Island in
2007: lessons learned from a representative
survey. Rev Epidemiol Sante Publique 2010;
58: 237–44.
4 Jolivet A, Cadot E, Carde E, et al. Migration,
santé et soins en Guyane. Paris: Agence
Française de Développement, 2010 (in press).
5 HALDE. Délibération relative aux conditions
d’accès aux soins des étrangers en situation
irrégulière et de leurs enfants ainsi que des
mineurs étrangers isolés, résidant à Mayotte.
Paris: Haute Autorité de Lutte contre les
Discriminations et pour l’Egalité, 2010,
délibération n°2010-87 du 01/03/2010.
or about 62 and 0·2 expulsions,
respectively, per 1000 population.2
Since 2005, so as not to create an
open invitation for illegal immigration,
these people have been denied health
coverage and, with the exception of
rare emergency situations, access to
free health care. Yet, a study that we
did among a representative sample
of the island’s inhabitants3 found that
the proportion of foreign migrants
who had emigrated for health reasons
(8·8%) was low compared with the
proportion of those who had done
so for other reasons (the main one
being economic: 49·4%). A similar
study in French Guiana,4 bordering
Brazil and Surinam and, like Mayotte,
a destination of signifi cant migratory
movements, shows that despite more
favourable legislation (people without
regular residence status can theor-
etically obtain medical coverage under
the same conditions as in mainland
France), the rate of immigration for
health reasons is even lower (1%).
The fact that there is no public
medical assistance for people without
regular residence status in Mayotte
constitutes an impediment to the
right to health protection guaranteed
by the French constitution and several
international treaties ratifi ed by
France. This situation was condemned
by an independent French public
authority, the Haute Autorité de
Lutte contre les Discriminations
(HALDE), on March 1, 2010,5 after
pressure from several organisations,
but so far to no avail. It has also
asked the government to make social
security available to unaccompanied
minors and children of persons
without regular residence status. We,
too, urge the French national and
local authorities to distinguish—in
overseas territories particularly—
health and health-care policies from
immigration policy.
We declare that we have no confl icts of interest.
Anne Jolivet, Sophie Florence,
Jacques Lebas, *Pierre Chauvin
chauvin@u707.jussieu.fr
Compassionate
optimism
Many non-clinical factors can interfere
with the pure, evidence-based process
of physicians’ decision making.1
They include diverse personal factors
such as physicians’ reactions to fear
of litigation and poor tolerance of
common clinical uncertainty, but also
overconfi dence and hidden fi nancial
incentives.2,3 A previously unreported
personal factor aff ecting objective
evidence-based decision making
by physicians might be termed
“compassionate optimism”.
Compassionate optimism might
occur when a physician’s empathy and
compassion towards his or her patient
causes erroneous interpretation of
clinical data to favour a more benign, less
ominous diagnosis, contrary to the facts
and clinical probability. For example,
a clinician who strongly sympathises
with a young mother who has osteo-
lytic spine lesions might adhere to a
false belief that they represent a treat-
able granulomatous disease,4 whereas
Department of Error
Alwan A, MacLean DR, Riley LM, et al. Monitoring
and surveillance of chronic non-communicable
diseases: progress and capacity in high-burden
countries. Lancet 2010; 376: 1861–68—In the
Summary and line 7 of the Mortality section of
this Series (Nov 27), the proportion of deaths
occurring in people younger than 70 years
should have been 47%. This correction has
been made to the online version as of Nov 15,
2010, and to the printed version.
Fernald LCH, Gertler PJ, Neufeld LM. 10-year
eff ect of Oportunidades, Mexico’s conditional
cash transfer programme, on child growth,
cognition, language, and behaviour: a
longitudinal follow-up study. Lancet 2009;
374: 1997–2005—In this Article (Dec 12,
2009), the last sentence of the Findings
section in the Summary should have read: “An
additional 18 months of the programme
before age 3 years for children aged 8–10 years
whose mothers had no education resulted in
improved child growth of about 1·5 cm
assessed as height-for-age Z score (β 0·23
[0·023–0·44] p=0·029), independently of cash
received.” This correction has been made to
the online version as of Nov 26, 2010.
Published Online
November 15, 2010
DOI:10.1016/S0140-
6736(10)62108-3
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