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global health vulnerability to more powerful agendas.

Canada recently offered a striking example of this vulnerability. The conservative government of Canada offi cially announced on Nov 27, 2013, a new strategic direction for Canada’s foreign service called economic diplomacy, a plan designed to put commerce at the heart of foreign policy.3 To critics, this will come at the expense of aid and human rights and as a natural complement to the government’s stated view that multilateralism is a “weak-nation policy”.4

Without a global health strategy and a strong sense that more can be achieved by working together than by going it alone, Canada has inevitably faltered as a global citizen. Its stance on the asbestos export to poor countries, global warming, and human rights (as they relate to reproductive health care and child wellbeing) have drawn international scorn. The Climate Change Performance Index 2013 in its comparison of the 58 top CO2 emitting nations ranked Canada 55 in tackling greenhouse-gas emissions. Its muzzling of government scientists and cancellation of the Statistics Canada long-form census has led many observers to ask whether the government is anti-science and lacks the essential openness needed in a modern democratic society.5

However, this government could benefit from the flow of knowledge and experience and from lessons learned in the South. The 2013 UNICEF report Child Well-being in Rich Countries ranked Canada 27 of 29 countries for health and safety, 28 of 29 for childhood immunisation, and 22 of 29 for infants mortality rates. With 63% coverage for early child education, Canada has the worst record of all Organisation for Economic Co-operation and Development countries. In all instances, the cause is government failure to target and reach poor and vulnerable populations with adequate and eff ective services. In these circumstances, the term neocolonial

Drug policy in China: progress and challengesChina has recently changed its drug policy dramatically. The 2008 Anti-Drug Law—which abolished the modality of re-education through labour (REL)—was a milestone. It called for a boost in community treatment, encouraged drug users to seek treatment voluntarily, and set compulsory isolated rehabilitation as the only government-ordered treatment modality.1 China has also rapidly expanded methadone maintenance treatment programmes.2 These policies are good attempts to shift the penalty-oriented management of drug users to one that is health-oriented. However, in practice, problems remain.

First, although the law did end the practice of REL, the newly named compulsory isolated rehabilitation is still delivered by judicial staff , in the same settings as former REL camps, with an average stay of 2 years. According to Human Rights Watch, residents in these rehabilitation camps were forced to do manual work or other tasks, and access to medical treatment was very limited3—showing little difference from the rescinded REL. Second, although the new policy specifies the important role of community treatment, professionals working and training in the community are scarce. Often individuals without qualifications were appointed by local officials to deliver community treatment, fi lling the position but not doing the job.4 Third, although methadone maintenance treatment programmes have been scaled up in China, their benefits are undermined by police enforcement. The threat of being tested and arrested in the vicinity of a clinic has seriously deterred drug users from accessing and continuing methadone therapy.5 Low coverage and poor quality services are also challenging methadone treatment in China.

It is urgent that China optimises the limited resources allocated to drug users treatment and increases funding and staff training for community and methadone maintenance treatment programmes. Evidence-based treat-ments should be introduced into the existing compulsory isolated rehabilitation programmes. Moreover, because drug addiction has been recognised as a chronic relapsing disease, police should allow drug-dependent patients to receive substitution treatment during relapses. Forced treatment would only exacerbate patients’ stigmatisation.We declare that we have no confl icts of interest.

Mei Yang, Liang Zhou, Wei Hao, *Shui-Yuan Xiao xiaosy@csu.edu.cn

Department of Social Medicine, School of Public Health, Central South University, Changsha 410078, China (MY, LZ, S-YX); and Mental Health Institute, Second Xiangya Hospital, Central South University, Changsha, China (MY, WH)

1 Standing Committee of the National People’s Congress. Narcotics Control Law of the People’s Republic of China. 2007. http://en.pkulaw.cn/display.aspx?cgid=100676&lib=law# (accessed Jan 7, 2014).

2 Yin W, Hao Y, Sun X, et al. Scaling up the national methadone maintenance treatment program in China: achievements and challenges. Int J Epidemiol 2010; 39: ii29–37.

3 Human Rights Watch. “Where darkness knows no limits”. Incarceration, ill-treatment and forced labor as drug rehabilitation in China. 2010. http://www.hrw.org/reports/2010/ 01/07/where-darkness-knows-no-limits-0 (accessed Jan 9, 2014).

4 Zeng YX . Implementation of community rehabilitation and thinking of its improvement [in Chinese]. http://news.jinghua.cn/351/c/201306/27/n3877696.shtml (accessed Jan 7, 2014).

5 Meng J, Burris S. The role of the Chinese police in methadone maintenance therapy: a literature review. Int J Drug Policy 2013; 24: e25–34.

Global health and global citizenshipGiven that global health envisions “a pooling of experience and knowledge, and a two-way fl ow between developed and developing countries”,1 the notion that it is instead neocolonialist—as Richard Horton asked in his Offline (Nov 23, p 1690)2—is a reminder of

For more on the UNICEF report see http://www.unicef-irc.org/publications/pdf/rc11_eng.pdf

For the Climate Change Performance Index 2013 see http://germanwatch.org/en/download/7158.pdf

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mortality, related to the underlying cause.3,4 It would be interesting to know the proportion of cases with status epilepticus in Fazel and colleagues’ cohort and whether their exclusion would alter mortality estimates.

Fazel and colleagues1 found that compared with controls without epilepsy or psychiatric disorders, psychiatric comorbidity in epilepsy was associated with an increased mortality overall and specifi cally for suicide and accidents. The presence of multiplicative or additive interaction between epilepsy and psychiatric disorder was not addressed. Our calculations find synergy between substance misuse and epilepsy for external causes of death, suicide, and vehicle accidents, but not for other accidents. Negative multiplicative interaction was noted for all other associations. On the additive scale most associations between epilepsy and any psychiatric disorder, depression and substance misuse showed positive additive interactions for external causes of death, suicide, and vehicle accidents. This suggests that public health interventions are needed to reduce these specific deaths. We declare that we have no confl icts of interest.

*Torbjörn Tomson, Dale C Hesdorff ertorbjorn.tomson@karolinska.se

Department of Clinical Neuroscience, Karolinska Institutet, SE 171 76 Stockholm, Sweden (TT); and Gertrude H Sergievksy Center and Department of Epidemiology, Columbia University, New York, NY, USA (DCH)

1 Fazel S, Wolf A, Långström N, Newton CR, Lichtenstein P. Premature mortality in epilepsy and the role of psychiatric comorbidity: a total population study. Lancet 2013; 382: 1646–54.

2 Nilsson L, Tomson T, Farahmand BY, Diwan V, Persson PG. Cause-specifi c mortality in epilepsy: a cohort study of more than 9 000 patients once hospitalized for epilepsy. Epilepsia 1997; 38: 1062–68.

3 Neligan A, Shorvon S. Frequency and prognosis of convulsive status epilepticus of diff erent causes. Arch Neurol 2010; 67: 931–40.

4 Logroscino G, Hesdorff er DC, Cascino G, Annegers JF, Hauser WA. Short-term mortality after a fi rst episode of status epilepticus. Epilepsia 1997; 38: 1344–49.

mechanistic origin.5 Therefore, we wonder whether Fazel and colleagues1 have collected data about sleep disturbances in their sample. Furthermore, functional imaging of the brain (eg, PET) could help us to understand suicidal behaviour in more detail. Maybe there is a suicidal brain independent of concomitant diseases or a specifi c disease (eg, epilepsy) that triggers a pattern of suicidal brain dysfunction.We declare that we have no confl icts of interest.

*Andreas Otte, Dieter Riemannandreas.otte@hs-off enburg.de

Biomedical Engineering, University of Applied Sciences, D-77652 Off enburg, Germany (AO); and Department of Clinical Psychophysiology, Hospital for Psychiatry and Psychotherapy, University Medical Center, Freiburg, Germany (DR)

1 Fazel S, Wolf A, Långström N, Newton CR, Lichtenstein P. Premature mortality in epilepsy and the role of psychiatric comorbidity: a total population study. Lancet 2013; 382: 1646–54.

2 De Weerd A, De Haas S, Otte A, et al. Subjective sleep disturbance in patients with partial seizures and impact on quality of life: a questionnaire-based study. Epilepsia 2004; 45: 1397–404.

3 Baglioni C, Battagliese G, Feige B, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Aff ect Disord 2011; 135: 10–19.

4 Bjørngaard JH, Bjerkeset O, Romundstad P, Gunnell D. Sleeping problems and suicide in 75 000 Norwegian adults: a 20 year follow-up of the HUNT I study. Sleep 2011; 34: 1155–59.

5 Wulff K, Gatti S, Wettstein JG, Foster RG. Sleep and circadian rhythm disruption in psychiatric and neurodegenerative disease. Nat Rev Neurosci 2010; 11: 589–99.

would be misplaced unless it is meant to describe the central government’s treatment of its exploitable citizens living at the periphery.I declare that I have no confl icts of interest.

Chris David Simmschristopher.simms@dal.ca

Dalhousie University, Halifax, Nova Scotia B3H 1R2, Canada

1 Koplan J, Bond T, Merson M, et al. Towards a common defi nition of global health. Lancet 2009; 373: 1993–95.

2 Horton R. Offl ine: is global health neocolonialist? Lancet 2013; 382: 1690.

3 Foreign Aff airs, Trade and Development Canada, News Releases. Harper government launches new international trade plan. http://www.international.gc.ca/media/comm/news-communiques/2013/11/27a.aspx?lang=eng (accessed Jan 9, 2014).

4 The Economist. Canada’s foreign policy: snubbed. Oct 14, 2010. http://www.economist.com/node/17254504 (accessed Dec 6, 2013).

5 Jones N. Canada to investigate muzzling of scientists. Nature, April 2, 2013. http://blogs.nature.com/news/2013/04/canada-to-investigate-muzzling-of-scientists.html (accessed Dec 6, 2013).

Premature mortality in patients with epilepsy We read with interest Seena Fazel and colleagues’ Article (Nov 16, p 1646)1 on premature mortality in epilepsy. Sleep disturbance has been reported to be more prevalent (two-times more) in patients with partial epilepsy compared with controls, and most domains of sleep were substantially affected.2 In addition, sleep disturbance in individuals with epilepsy is associated with substantial impairment of quality of life.2 Interestingly, a meta-analysis showed that non-depressed patients with insomnia have a two-fold risk of developing depression compared with people with no sleep diffi culties.3 In a cohort study of 75 000 Norwegians, sleeping problems were shown to be a marker of suicide risk, preponderantly due to the presence of sleeping problems and mixed anxiety and depression.4 Consequently, neuropsychiatric disorders and sleep disruptions could have a common

We commend Seena Fazel and colleagues1 on their study highlighting the risk of premature death in people with epilepsy and the role of psychiatric comorbidity in increasing this mortality. Although the observed odds ratio for premature mortality was similar to that in a previous study using similar methods,2 we wonder to what extent the mortality estimates were infl ated by inclusion of status epilepticus in the epilepsy cohort. In most cases, status epilepticus is a symptom of an acute brain insult (ie, stroke, anoxia) and does not fulfi l criteria for epilepsy.3 Such cases of status epilepticus have a high