Comment

at radiation doses lower than amounts traditionally

considered inducible by direct changes in the exposed cells.
Such ndings suggest non-targeted mechanisms could
be associated with the development of radiation-related
health eects.9,10 Atherosclerosis is a multifactorial disease,
resulting from a lifelong interplay between genetic,
environmental, and behavioural factors, which might be
modied by radiation exposure.
The relative risk of cardiovascular disease associated
with radiation dose is much smaller than that of
radiation-associated cancer, which would have substantial public-health implications in view of the high
background rates of cardiovascular disease. Because
of the uncertainty in the magnitude and nature of
cardiovascular disease risk at a low dose of radiation,
estimation of the excess number of patients in an
exposed population is premature. Further investigations are needed to sort out eects of radiation
and confounders in existing and planned studies of
radiation-exposed cohorts, and new laboratory studies
are needed to explore biological mechanisms for
low-dose radiation-related cardiovascular eects. The
low-dose radiation eects on cardiovascular disease risk
are likely to remain challenging and controversialeven
more so than the linear no-threshold arguments for
cancer risk that are debated to this daybut should not
be dismissed.
After writing this Comment, we learned about the
recent death of Dave McGeoghegan. We are saddened
by this news. The scientic community will miss this

thoughtful epidemiologist who brought a new and

valuable insight into this complex issue.
Parveen Bhatti, Alice J Sigurdson, *Kiyohiko Mabuchi
Radiation Epidemiology Branch, Division of Cancer Epidemiology
and Genetics, National Cancer Institute, National Institutes of
Health, Bethesda, MD 20892, USA
mabuchik@mail.nih.gov
The views expressed here are ours, and do not necessarily reect those of the
NCI/NIH. We declare that we have no conict of interest.
1
2
3

10

Adams MJ, Hardenbergh PH, Constine LS, Lipshultz SE. Radiation-associated

cardiovascular disease. Crit Rev Oncol Hematol 2003; 45: 5575.
Senkus-Konefka E, Jassem J. Cardiovascular eects of breast cancer
radiotherapy. Cancer Treat Rev 2007; 33: 57893.
Little MP, Tawn EJ, Tzoulaki I, et al. A systematic review of epidemiological
associations between low and moderate doses of ionizing radiation and
late cardiovascular eects, and their possible mechanisms. Radiat Res 2008;
169: 99109.
McGale P, Darby SC. Low doses of ionizing radiation and circulatory
diseases: a systematic review of the published epidemiological evidence.
Radiat Res 2005; 163: 24757.
Carr ZA, Land CE, Kleinerman RA, et al. Coronary heart disease after
radiotherapy for peptic ulcer disease. Int J Radiat Oncol Biol Phys 2005;
61: 84250.
McGeoghegan D, Binks K, Gillies M, Jones S, Whaley S. The non-cancer
mortality experience of male workers at British Nuclear Fuels plc,
19462005. Int J Epidemiol 2008; 37: 50618.
Vrijheid M, Cardis E, Ashmore P, et al. Mortality from diseases other than
cancer following low doses of ionizing radiation: results from the
15-country study of nuclear industry workers. Int J Epidemiol 2007;
36: 112635.
Hayashi T, Kusunoki Y, Hakoda M, et al. Radiation dose-dependent
increases in inammatory response markers in A-bomb survivors.
Int J Radiat Biol 2003; 79: 12936.
Morgan WF. Non-targeted and delayed eects of exposure to ionizing
radiation II: radiation-induced genomic instability and bystander eects in
vivo, clastogenic factors and transgenerational eects. Radiat Res 2003;
159: 58196.
Morgan WF. Non-targeted and delayed eects of exposure to ionizing
radiation I: radiation-induced genomic instability and bystander eects in
vitro. Radiat Res 2003; 159: 56780.

Violence and the role of illness narratives

Although statistical associations conrm that violence
affects health, the mechanisms are less well understood.13 Whilst they constitute the invisibility of
war,4 the complex social, economic, historical, and
political forces in conflict settings obscure the precise
pathways through which conflict affects disease
patterns. How, for instance, is the transmission,
course, and outcome of HIV infection affected by
war? How can we best respond to disease amid cycles
of poverty and violence?
Understanding local context requires critical examination of the dynamic social and biological processes in
conicts, and how they become embodied as individual
www.thelancet.com Vol 372 August 30, 2008

disease and suering. One technique for this task is the

illness narrative.5 Dened as a story the patient tells,
and signicant others retell, to give coherence to the
distinctive events and long-term course of suering,
illness narratives have gained recognition mainly in
hospitals and clinics in auent countries as a means to
improve patients lives.6,7
Much less work has focused on the usefulness of
illness narratives in resource-poor conict settings.
As clinicians in such settings, we have noted that
illness narratives hold deep analytical and therapeutic
potential to understand and interrupt cycles of violence
and disease. Illness narratives are elicited orally through
699

Comment

Panos Pictures

The printed
journal includes
an image merely
for illustration

Surviver of violence in Darfur

open-ended, often semistructured, interviews during

clinic and home visits and ward rounds. Narratives
are collected in the patients native language, often
translated into English, analysed by the clinical team
with methods of social analysis, and presented as case
studies or ethnography.
Methodologically, illness narratives oer several advantages in war settings. Insecurity, geographical restrictions,
and the demise of health-care facilities often present
weighty obstacles in large resource-intensive quantitative
studies. For example, in the Democratic Republic of the
Congo, the number of quantitative HIV/AIDS studies fell
to nearly zero as violent conict rose in the early 1990s.8
Illness narratives oer a practical alternative, since they
can be collected with fewer resources and a smaller
number of research participants but retain powerful
analytical capacity.9 Limitations do exist though: a smaller
sample size and selection bias might lead to erroneous
ndings. Thus conclusions should be interpreted with
care and when possible should be complemented by
quantitative studies.
700

In our experience, the landscape of local context

unveiled by illness narratives can clarify salient issues in
global-health debates and serve to design strategies to
improve the health of poor people. In northern Uganda,
patients narratives have rened debates on eective
HIV prevention.10 Insights gleaned from these narratives
show the inadequacy of generalised HIV-prevention
measures, such as condom promotion, partner reduction,
or abstinence, and show the indispensability of human
rights for successful HIV prevention.
Beyond their revelatory power, illness narratives
can inform the design of equitable health-care interventions. In Liberia, narratives focused on eliciting
barriers to HIV-treatment adherence revealed that
direct and indirect costs associated with travelling
long distances to collect medicines led to treatment
interruption. From this analysis, a community-based
treatment programme, the HIV Equity Initiative, was
developed to administer directly observed antiretroviral treatment and organise transportation and food
assistance, which led to retention and survival of
patients.11
In Haiti, illness narratives informed Partners In Health
and Zanmi Lasantes sustainable community-based
responses to poverty, violence, and disease.12 In response
to the voices of patients, home and school construction,
provision of food, micronance programmes, and paid
community health workers have been key components
of this work in Haiti. During Haitis 2004 coup, the
network of community health workers ensured that no
drug doses were missed by more than 1100 patients
with AIDS and 1500 with tuberculosis.13 This feat
shows the capacity that illness narratives have for rst
understanding the links between violence and disease
and then forging solutions that protect health in the
face of violence.
Our experiences have taught us that listening to illness
narratives can revolutionise the provision of medical
care in conict and postconict settings. Incorporation
of local and global context on the basis of patients
experiences leads to the design of powerful health
interventions, with the potential to reverse trends in
disease and violence. Giving primacy to patients voices
is an age-old premise of medicine with even greater
salience in conict settings.
*Michael Westerhaus, Rajesh Panjabi, Joia Mukherjee
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Comment

Brigham and Womens Hospital, Boston, MA 02115, USA (MW);

Department of Medicine, Massachusetts General Hospital, Boston,
MA, USA (RP); and Division of Social Medicine and Health
Inequalities, Brigham and Womens Hospital, Boston, MA, USA (JM)
mwesterhaus@partners.org
We thank Yoti Zabulon, Arachu Castro, Paul Farmer, Alan Cross, and
Robert Lawrence for guidance and mentorship. RP is Executive Director of
Tiyatien Health Inc, a non-prot organisation that was involved in reference 11.
JM is Medical Director of Partners In Health, a non-prot organisation. MW
declares that he has no conict of interest.
1

2
3

Burnham G, Lafta R, Doocy S, Roberts L. Mortality after the 2003

invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006;
368: 142128.
Coghlan B, Brennan RJ, Ngoy P, et al. Mortality in the Democratic Republic
of Congo: a nationwide survey. Lancet 2006; 367: 4451.
Ranson K, Poletti T, Bornemisza O, Sondorp E. Promoting health equity in
conict-aected fragile states. Feb 3, 2007. http://www.who.int/social_
determinants/resources/csdh_media/promoting_equity_conict_2007_
en.pdf (accessed June 30, 2008).
Nordstrom C. Shadows of war: violence, power, and international
proteering in the twenty-rst century. Berkeley, CA: University of
California Press, 2004.

5
6
7
8

9
10

11

12
13

Charon R, Wyer P for the NEBM Working Group. Narrative evidence based
medicine. Lancet 2008; 371: 29697.
Kleinman A. The illness narratives: suering, healing, and the human
condition. USA: Basic Books, 1988.
McLellan F. Literature and medicine: narratives of physical illness.
Lancet 1997; 349: 161820.
Beyrer C. Civil conict and health information: the impact of social
disruption and war on HIV/AIDS and Malaria research in the Democratic
Republic of Congo, 19802004. In: Beyrer C, Pizer HP, eds. Public health
and human rights: evidence-based approaches. Baltimore, MD: Johns
Hopkins University Press, 2007: 26885.
Charon R. Narrative medicine: honoring the stories of illness. New York:
Oxford University Press, 2006.
Westerhaus M, Finnegan A, Zabulon Y, Mukherjee J. Framing HIV
prevention discourse to encompass the complexities of war in northern
Uganda. Am J Public Health 2007; 97: 118486.
Panjabi R, Aderibigbe O, Quitoe W. Towards universal outcomes: a
community-based approach to improve HIV care in post-conict Liberia.
XVII International AIDS Conference, Mexico City, Mexico; Aug 38, 2008:
CDB030 (abstr).
Farmer P, Landre F, Mukherjee JS, et al. Community-based approaches to
HIV treatment in resource-poor settings. Lancet 2001; 358: 40409.
Lyon E, Farmer P. Inequality, infections, and community-based healthcare.
Yale J Health Policy Law Ethics 2004; 1: 43947.

Using taxes to curb drinking in Australia

In April, 2008, the Australian Government brought
the excise duty on premixed spirits in line with the
excise on unmixed spiritsa 70% increase from
AU$3936/L to $6667/L. This action has raised the
question as to whether such a one-o manipulation of
tax can reasonably be expected to improve public-health
outcomes related to alcohol consumption.
In Australia, alcohol consumption is generally dened
in two ways: usual consumption and its eect on
long-term risk, such as disease; and episodic excessive
drinking on one occasion (binge drinking) and its
eect on short-term risk, such as injury. Rates of usual
consumption and at least one binge occasion per month
in Australia have increased marginally (99% and 203%,
respectively, in 2001 compared with 103% and 204%,
respectively, in 2007).1,2 In addition to self-reported
use, sales data provide an opportunity to investigate
market trends, especially in relation to premixed spirits,
and consider the likely eect of the tax increase on the
demand for such spirits.
Alcohol sales in Australia (in current terms) in 2006
were $288 billion, a 47% increase from $196 billion
in 1997.3 Per-capita expenditure on alcohol increased
by 34% during the same period, from $1058 to $1414
in 2006.3 The table shows that premixed spirits have
increased by more than 450%, increasing from 3% of
total sales or 38 L per capita in 1997 to 15% of total
www.thelancet.com Vol 372 August 30, 2008

sales or 193 L per capita in 2006. Per-capita expenditure

on premixed spirits increased by 394% from $51 in 1997
to $252 in 2006.3
Bringing the excise on premixed spirits into line with
that of unmixed spirits has two implications. First, it
does not make excise rates on alcohol uniform across
the board. Excise rates are still applied dierentially
in Australia, creating the opportunity for the industry
to exploit those beverage types for which their
prot margins are greatest. For example, in 2007,
manufacturers share of the selling price of a typical
domestically produced wine (the product with lowest
excise) was 43%, compared with 23% for a domestically
produced spirit (product with the highest excise).
Although marketing campaigns have almost certainly
helped substantially increase market share for premixed
spirits, the real value to manufacturers when promoting
such spirits is that they have been able to recoup a greater
proportion of the returns on sales than the marginal
returns on higher taxed beverages. While the obvious
solution is to have a standard tax on all beverages sold
in Australia (commonly referred to as a volumetric tax),
this tax would probably increase the price of beer which,
because it has by far the greatest market share, would be
politically sensitive.
Second, the excise increase raises the question about
whether consumers of premixed spirits will simply
701