Correspondence
by the hospitals in the region, as the worsening of the Venezuelan health-
overall patient survival and survival
patterns for the interval cancer group
and declined screening group were
similar across all regions.
We declare no competing interests.
*Anil Thomas George, Smeer Aggarwal,
Sridhar Dharmavaram,
Achyuth Menon, Mukul Dube,
Mike Vogler, Philip Foden, Andrew Field
anil.george1@nhs.net
Department of Colorectal Surgery, Queen’s Medical
Centre, University Hospitals Nottingham NHS Trust,
Nottingham NG7 2UH, UK (ATG); Department of
Colorectal Surgery, Sherwood Forest Hospitals NHS
Foundation Trust, Mansfield, UK (ATG, SA, SD, AM,
MD); Department of Colorectal Surgery, Royal
Derby Hospitals NHS Trust, Derby, UK (ATG); BCSP
Eastern Hub, Queen’s Medical Centre, Nottingham,
UK (MV, AF); and Department of Medical Statistics,
University Hospital of South Manchester NHS
Foundation Trust, Manchester, UK (PF)
1 George AT, Aggarwal S, Dharmavaram S, et al.
Faecal occult blood testing screening for
colorectal cancer and ‘missed’ interval cancers:
are we ignoring the elephant in the room?
Results of a multicentre study.
Colorectal Dis 2017; 19: O108–O114.
2 Cancer Research UK. Bowel cancer statistics.
2014. http://www.cancerresearchuk.org/health-
professional/cancer-statistics/statistics-by-cancer-
type/bowel-cancer (accessed Jan 10, 2017).
3 National Cancer Intelligence Network.
Colorectal cancer survival by stage—NCIN data
briefing. 2013. http://www.ncin.org.uk/
publications/data_briefings/colorectal_
cancer_survival_by_stage (accessed
Jan 10, 2017).
4 Damery S, Clifford S, Wilson S. Colorectal cancer
screening using the faecal occult blood test
(FOBt): a survey of GP attitudes and practices in
the UK. BMC Fam Pract 2010; 11: 20.
5 Mandel JS, Church TR, Bond JH, et al. The effect
of fecal occult-blood screening on the
incidence of colorectal cancer.
N Engl J Med 2000; 343: 1603–07.
6 NHS Digital. Quality and Outcomes
Framework—2012–13. Oct 29, 2013. https://
digital.nhs.uk/data-and-information/
publications/statistical/quality-and-outcomes-
framework-achievement-data/quality-and-
outcomes-framework-2012-13 (accessed
Jan 15, 2014).
The challenges of
restructuring health
care in Venezuela
I read with great interest The Lancet’s
Editorial (April 7, p 1331) 1 on the
collapse of Venezuela’s health-care
system. However, although the
278 www.thelancet.com Vol 392 July 28, 2018
Solid national data from 2000–20126
care crisis is evident and the newly
released data2 of the Encuesta Nacional
de Hospitales 2018 are calamitous,
the current humanitarian crisis in
Venezuela and the collapse of its health-
care system are actually a consequence
of years of inadequate and weak health
policies, the dismantlement of health-
care institutions, and the reduction in
epidemiological surveillance activities
that started during the period of
Hugo Chavez’s presidency, or even
before. Nevertheless, a steeper decline
in health outcomes over the past
three years is apparent. I find this
information relevant, since a solution
to the humanitarian crisis will probably
not depend solely on macroeconomic
or political reforms, but on a complete
restructuring of the Venezuelan health-
care system.
Data published by WHO and the
World Bank3,4 suggest that health
indicators such as life expectancy at
birth improved between 1998 and
2013. However, these data should be
evaluated with caution because of
the possibility of under-reporting of
health statistics by the Venezuelan
Ministry of Health. For example, in
2011, we did a survey on mortality
in children aged under 5 years in a
representative sample (0·5% of the
state population) of women from
Delta Amacuro state. From these data,
a conservative estimate of the total
number of under-5 deaths for the
studied population was 30% higher
than the actual number reported by
the local Office of Epidemiology during
the same period for the entire state
population (124 067 people). We also
identified more under-5 deaths in
some municipalities than the numbers
officially recorded by the local office.5
Malaria cases have clearly sky­
rocketed in the last 4 years, mainly
because of overall shortages of
essential antimalarial drugs, but also
because of lapses in vector-control
efforts while operating in a context
of increased illegal mining operations
in the southern part of the country.
show that the number of reported
malaria cases in Venezuela had already,
counterintuitively, been increasing
steadily during times of the highest
oil prices in world history, mainly be­
cause of a reduction in epi­demiological
surveillance activities.
Despite national health indicators
showing an overall improvement in
health care during the early 2000s,
neglected pockets of poverty have been
a substantial problem in Venezuela for
the past several years. For example,
data from 2011 show that, when
compared with data for 104 developing
countries, only the Nigerian population
had a higher multidimensional poverty
index (0·642) than that of the Warao
indigenous people from Venezuela
(0·564).5
Although Venezuela has been hit
by an unprecedented health crisis,
the roots of this have been gradually
established over several years. Most of
the complexities associated with the
health-care crisis that were present
before the administration of incumbent
President Nicolás Maduro—such as
declining prevention strategies,7 the
dismantling of scientific institutions,8
escalating violence,9 or the intense
exodus of physicians, scientists, and
university professors10—are increasing
steeply. However, with regard to the
epidemiological challenges that could
be faced by bordering countries over
the coming years (such as waves
of migration and the potential for
refugee crises, overwhelming of
health-care systems, and outbreaks of
communicable diseases), the outlook
will remain gloomy unless ex­tensive
and crucial health-care re­forms aimed
at rebuilding Venezuela’s broken health-
care system are put into practice.
I declare no competing interests.
Julian A Villalba
julian.villalba@mgh.harvard.edu
Department of Pathology, Massachusetts General
Hospital, Harvard Medical School, Boston, MA
02114, USA
1 The Lancet. The collapse of the Venezuelan
health system. Lancet 2018; 391: 1331.

2 Encuesta Nacional de Hospitales 2018.
Apr 12, 2018. http://bit.ly/enh2018data
(accessed Jun 21, 2018).
3 The World Bank. Life expectancy at birth,
total (years). https://data.worldbank.org/
indicator/SP.DYN.LE00.IN?locations=VE
(accessed Jun 21, 2018).
4 WHO. Countries: Venezuela (Bolivarian
Republic of). http://www.who.int/countries/
ven/en/ (accessed Jun 21, 2018).
5 Villalba JA, Liu Y, Alvarez MK, et al. Low child
survival index in a multi-dimensionally poor
Amerindian population in Venezuela.
PLoS One 2013; 8: e85638.
6 Rodríguez-Morales AJ, Paniz-Mondolfi AE.
Venezuela’s failure in malaria control.
Lancet 2014; 384: 663–64.
7 Verhagen LM, Warris A, Hermans PW,
del Nogal B, de Groot R, de Waard JH. High
prevalence of acute respiratory tract
infections among Warao Amerindian children
in Venezuela in relation to low immunization
coverage and chronic malnutrition.
Pediatr Infect Dis J 2012; 31: 255–62.
8 Mendoza C, Urbina JA. Venezuelan researchers
call for international help. Nature 2003;
421: 473.
9 Briceño-León R, Villaveces A, Concha-
Eastman A. Understanding the uneven
distribution of the incidence of homicide in
Latin America. Int J Epidemiol 2008;
37: 751–57.
10 Romero S. In Venezuela, a new wave of
foreigners. Nov 6, 2010. The New York Times
(New York). https://www.nytimes.
com/2010/11/07/world/americas/07venez.
html (accessed Jun 21, 2018).
Qualifying the promise
of Universal Health
Coverage
In his recent Comment (April 7,
p 1342),1 Richard Horton underlined
the importance of the Universal
Health Coverage (UHC) campaign,
promoted by WHO on World Health
Day 2018. He also problematised
UHC on two counts: first, by arguing
that, although UHC might sound like
a finite achievable goal, it is not so in
practice, and second, by underlining
that UHC is not sufficient by itself, but
must be coupled to targeted political
actions, including legislation and pro­
grammes that address specific national
health problems, such as diabetes and
safer water.
Experiences with UHC in Denmark
prompt yet another problematisation.
In the WHO campaign on UHC and
in existing understanding, UHC is
www.thelancet.com Vol 392 July 28, 2018 279
described as a means of promoting
health equity.2,3 However, although
Denmark’s health-care system is an
exemplification of UHC, Denmark has
one of the steepest gradients in health
inequality across socioeconomic groups
among European countries, and social
inequalities in life expectancy are
increasing, particularly for men of lower
socioeconomic status.4 These disparities
provoke uneasy questions about the
coexistence of UHC and health inequity.
At the very least, the case of
Denmark reveals the importance of
problematising the accepted associ­
ations between UHC and health equity,
as well as the relationship between
access and health outcomes. It also
suggests that, if WHO’s UHC cam­
paign were combined with national
attempts to understand and address
the socioeconomic and sociocultural
determinants of health, the campaign
would be better placed to meet its aim
of securing health for all.5
I declare no competing interests.
Antoinette Fage-Butler
fage-butler@cc.au.dk
Department of English, School of Communication
and Culture, Aarhus University, Aarhus C DK-8000,
Denmark
1 Horton R. Offline: UHC—one promise and two
misunderstandings. Lancet 2018; 391: 1342.
2 Singh PK. World Health Day 2018. http://www.
searo.who.int/mediacentre/features/2018/rd-
message-world-health-day-2018/en/ (accessed
April 10, 2018).
3 WHO. Universal health coverage (UHC).
Dec 31, 2017. http://www.who.int/mediacentre/
factsheets/fs395/en/ (accessed April 10, 2018).
4 Brønnum-Hansen H. Socially disparate trends in
lifespan variation: a trend study on income and
mortality based on nationwide Danish register
data. BMJ Open 2017; 7: e014489.
5 WHO. Campaign essentials for World Health Day
2018. http://www.who.int/campaigns/world-
health-day/2018/campaign-essentials/en/
(accessed April 10, 2018).
Preventing rural to
urban spread of Ebola:
lessons from Liberia
There has been an eerie mirroring of
events between the ongoing outbreak
of Ebola virus disease in the Democratic
Correspondence
Republic of the Congo (DRC) and the
2014–15 outbreak in Liberia. The DRC
has vast historical experience from
containing eight prior outbreaks, but
the country has not previously had to
respond to urban Ebola spread.
The current and ninth DRC outbreak
was declared by the Ministry of Health
on May 8, 2018.1 By May 14, Ebola
virus had escaped the rural epicentre
of Bikoro and travelled 150 km into
Mbandaka, an urban centre populated
by 1·2 million people.1 In a similar
manner, during late June, 2014, Ebola
virus disease escaped rural Sierra
Leone into Foya District of rural Liberia
and proceeded to enter the densely
populated New Kru Town community
of Monrovia, a city of over 1 million
inhabitants.2 The unprecedented case
counts of the west African epidemic
were largely due to this unprecedented
migration into unprepared urban
centres. At the height of the outbreak
in September, 2014, Monrovia alone
was accounting for 51% of all the
Ebola cases in Liberia. Given the
parallel scenario of cases emerging
in Mbandaka, the response in the
upcoming weeks and its sensitivity
to the local context will be critical in
informing the final outbreak size in
the DRC.
Understanding the cause of spread in
Liberia provides important lessons for
the DRC. Why did the index urban case
Francis Dean/GettyImages
decide to leave Bikoro for Mbandaka?
First, to seek care. She may have
come to the city to seek medical care
since care in her village was inadequate
and she was observing others die
in spite of the treatment they were
receiving. Given this root cause of
movement, case investigation should
hone in on hospitals and clinics visited
for treatment to identify highest risk
contacts. In Liberia, Monrovia’s case
zero in 2014 visited Redemption
Hospital and exposed nurses and
a doctor. Some of those exposed
at Redemption Hospital went to a
Published Online
clinic in a neigh­bouring community
June 25, 2018,
and infected two nurses, who them­ http://dx.doi.org/10.1016/
selves sought treatment in another S0140-6736(18)31435-1