Critique of GINA global strategy

Pedersen et al.’s article in the January issue adds little to the scholarly review byBrand et al. on the same subject for the EuropeanRespiratory Society in 2008. The authors fail to disclose that their paper is a lightly edited version of a document previously published on the GINA web site a year before submission, accompanied by a professionally designed slide-set to propagate itsmessage. Either of those facts would have justified rejection and have spared a reviewer the trouble for additional comment. The paper suffers from multiple defects. A strategy with ‘‘global’’ aspirations must be comprehensible to ordinary family doctors and primary health care workers. The confused complexity of this paper is not. Alternative approaches to the problem are overlooked. The authors fail to engage in constructive discourse into several importantmatters raised byBrand et al. such as the very applicability of the term asthma in <5-year olds. Because of ‘‘insufficient evidence showing that the pathophysiology of preschool wheezing illness is similar to that of asthma in older children and adults. ’’ Brand et al. decided to avoid the word asthma in discussion of wheezing illness in pre-school children. Pedersen et al. sidestep the issue by ignoring it, acknowledge that asthma is difficult to diagnose in under-5 year olds, but assert that ‘‘Nevertheless, a diagnosis of asthma in young children can often be made based largely on symptom patterns and on a careful clinical assessment of family history and physical findings. ’’ They describe the symptoms, signs, and test results that are associatedwith asthma but are then unable to say how to translate any of that information into a positive diagnosis of asthma. Pedersen et al. proceed next to the management of asthma, a condition which they are unable to diagnose with any degree of confidence. The first step after diagnosis they advocate is an impractical three-way categorization of the child’s asthma: Controlled, Partly Controlled, or Uncontrolled asthma (Table 2). Since all patients whose asthma is not controlled require individualized modification of their management it seems necessary to distinguish between only two groups of individuals in clinical practice: patients whose asthma is controlled and patients whose asthma is not. Turning to medicinal measures Pedersen et al. virtually ignore what is recognized to be the greatest obstacle to effective asthma management. The word compliance occurs just twice in the ‘‘global strategy. ’’ Once in this sentence: ‘‘the child’s inhalation technique and compliance with the medication regimen should be carefully assessed andmonitored, as these are common problems in this age group;’’ and for the second time when this sentence is repeated verbatim in the summary in second last place as the 14th of 15 ‘‘Key messages. ’’ It should be remarked that the term compliance is no longer considered polite.Noncompliance implies a lack of respect for patient autonomy. Of the currently favored alternative words acceptance is mentioned only once and adherence is not mentioned at all. And what happens when a problem of ‘‘compliance’’ is discovered? No strategy is offered to deal with this overwhelmingly important problem in asthma management. With other aspects of management Pedersen et al. do no better. They admit that good evidence on the management of asthma in the<5-year agegroup is generally lacking yet have the temerity to prescribe a ‘‘global strategy’’ based largely on ‘‘expert’’ opinion (Evidence D). This is not evidential science but dogma. As the late Richard Feynman, Nobel Prize winner and iconic physicist, advised the National Science Teachers Association in 1966: ‘‘maybe doubt the experts. As a matter of fact, I can also define science anotherway: Science is the belief in the ignorance of experts. ’’ There also are serious ethical concerns with this publication. Firstly, there is no disclosure of conflicts of interest. In addition, Brand et al. is all but ignored, as mentioned before. But what is totally ignored is arguably the most authoritative statement we have on the management of asthma, including children under 5-year of age: The NHLBI:NAEP Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. These