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Surgeons who prefer the open approach and those surgeons with the skill and necessary experience in the laparoscopic approach can take comfort in knowing that both techniques have been validated by Hall and colleagues ndings. However, as these authors recommend, for centres with suitable experience, laparoscopic pyloromyotomy is probably the preferred option. The incidence of infantile hypertrophic pyloric stenosis is higher in countries in the developed world than in developing countries,13 and laparoscopic pyloromyotomy is one of the most dicult operations to teach. So, if you are presented with fewer cases and are not experienced with this technique, an open pyloromyotomy will give similar complication rates. I do not recommend surgeons with limited experience to try to instruct laparoscopic pyloromyotomy to their residents or registrars until they reach an accumulated institutional experience. Aydin Yagmurlu
Department of Paediatric Surgery, Faculty of Medicine, Ankara University, 06100 Ankara, Turkey eayagmur@medicine.ankara.edu.tr
I declare that I have no conict of interest.

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Alain JL, Grousseau D, Terrier G. Extramucosal pyloromyotomy by laparoscopy. J Pediatr Surg 1991; 26: 119192. Adibe OO, Nichol PF, Flake AW, et al. Comparison of outcomes after laparoscopic and open pyloromyotomy at a high-volume pediatric teaching hospital. J Pediatr Surg 2006; 41: 167678. Hall NJ, de-Ajayi N, Al-Roubaie J, et al. Retrospective comparison of open versus laparoscopic pyloromyotomy. Br J Surg 2004; 91: 132529. Yagmurlu A, Barnhart DC, Vernon A, et al. Comparison of the incidence of complications in open and laparoscopic pyloromyotomy: a concurrent single institution series. J Pediatr Surg 2004; 39: 29296. St Peter SD, Holcomb GW III, Calkins CM, et al. Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg 2006; 244: 36370. Leclair MD, Plattner V, Mirallie E, et al. Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a prospective, randomized controlled trial. J Pediatr Surg 2007; 42: 69298. Hall NJ, Pacilli M, Eaton S, et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet 2009; published online Jan 17. DOI:10.1016/S0140-6736(09)60006-4. Haricharan RN, Aprahamian CJ, Morgan TL, Harmon CM, Georgeson KE, Barnhart DC. Smaller scarswhat is the big deal: a survey of the perceived value of laparoscopic pyloromyotomy. J Pediatr Surg 2008; 43: 9296. Ceccanti S, Mele E, Cozzi DA. The perceived cosmetic value of laparoscopic pyloromyotomy. J Pediatr Surg 2008; 43: 157980. Fischer JD. Smaller scarswhat is the big deal: a survey of the perceived value of laparoscopic pyloromyotomy. J Pediatr Surg 2008; 43: 1580. Haricharan RN, Aprahamian CJ, Celik A, et al. Laparoscopic pyloromyotomy: eect of resident training on complications. J Pediatr Surg 2008; 43: 97101. Mowatt G, Bower DJ, Brebner JA, et al. When and how to assess fast-changing technologies: a comparative study of medical applications of four generic technologies. Health Technol Assess 1997; 1: 1149. Bickler SW, Sanno-Duanda B. Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bull World Health Organ 2000; 78: 133036.

Societal transition and health

Published Online January 15, 2009 DOI:10.1016/S01406736(09)60043-X See Articles page 399

The fall of communism in the 1990s and the ensuing profound societal transition in central and eastern Europe and the former Soviet Union is a unique social experiment. Social, economic, and political changes aected all aspects of peoples lives, which resulted in changes in mortality, morbidity, and fertility rates.1 The experiment oers a rare opportunity to investigate societal factors that drive the health of a population. Although many studies have described these changes, the mechanisms of how societal change aects health remain grossly under-researched. Explanations pursued so far fall into two categories: biomedical (proximal) and social (upstream). Among proximal factors, alcohol has received most attention. Upstream factors, which arguably are the primary drivers of population health, have been investigated less vigorously, possibly because they are much harder to study than others. Two major issues aect the study of factors at the societal level: measurement and confounding.

We thus welcome the study, in The Lancet today, by David Stuckler and colleagues2 because they focus on upstream factors, particularly mass privatisation, and tackle the diculties of measurement and confounding. First, the report puts into practice the notion of social transition, which then allowed measurement of factors that can serve as proxies of societal change. And second, by taking advantage of the societal transition in eastern Europe and by pooling within-country time-series analyses, the investigators tried to control for dierences both between countries and over time (ie, controlled for confounding). Stuckler and colleagues argue convincingly that the speed of privatisation was an important determinant of mortality changes in the transition in central and eastern Europe and former Soviet Union. This nding is indirectly supported by evidence that the rise in mortality was highest in individuals with low education and in regions with high social stress.37 In other words, in populations vulnerable to loss of employment. They
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Unemployed Russians queue for food handouts outside a Moscow railway station (September, 1998)

provide an important clue about what happened in these regions, but for any one study to exclude the eect of other aspects of the transition is dicult. In addition to confounding, there is also the issue of eect modication. As the investigators noted, rapid social changes took place in all countries in these regions but only some of the countries experienced a profound mortality crisis. The eect of rapid social changes, such as mass privatisation, was probably modied by other factors. Several candidates exist for such eectmodifying variables, of which we give four examples. First, the countries most aected by the transition (in terms of fall in both the gross domestic product and life expectancy) started, economically, from a lower baseline than countries that were less aected. Additionally, the fall in life expectancy was most striking in countries with the steepest increase in income inequality.8 At low baseline levels of gross domestic product, and at a time of rapid increase of material inequalities, it is easy to fall into poverty (and suer its consequences). Second, some populations seem to be more vulnerable to societal changes than others. For example, mortality
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rates in the former Soviet Union seemed prone to considerable uctuations even before the transition. This uctuation might partly indicate the historically poor health status of some populations. For instance, Russian life expectancy at birth in 1935 (not a year of famine) was 40 years (both sexes combined),9 compared with 62 years in the UK. Third, both the poor health status and the apparent vulnerability to mortality shocks in some populations might indicate the accumulation of disadvantage and risk over a lifetime. For example, poor health in Russian men and women reects not only current social status but is also inuenced by disadvantage in childhood and young adulthood.10 Fourth, governmental response might also have a role. When faced with rapid rises in mortality due to crises from transition, epidemics, and famines, governments respond dierently: some with determination, some with neglect. Arguably, in post-communist countries most aected by transition, both policy response (Popov V, New Economic School, Moscow, Russia, personal communication) and management of transition were poor.11 Even with the use of an ingenious design, such as that adopted by Stuckler and colleagues, pre-existing societal characteristics cannot be taken into account. This aw is not a criticism, but rather an illustration of the diculties faced by investigators who wish to disentangle the eects of dierent factors that act at the societal level. With all the caveats, Stuckler and colleagues study is relevant beyond eastern Europe. Countries in other regions are, and have been, undergoing economic and social transitions.12 That the extent and speed of such changes are important is increasingly apparent. Additionally, however, the social and health eect of transition depend on specic historical and political contexts. *Martin Bobak, Michael Marmot
Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK m.bobak@ucl.ac.uk
We declare that we have no conict of interest. 1 2 UNICEF. A decade of transition: regional monitoring report no 8. Florence: IRC, 2001. Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a cross-national analysis. Lancet 2009; published online Jan 15. DOI:10.1016/S0140-6736(09)60005-2.

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Shkolnikov V, Leon DA, Adamets S, Andreev E, Deev A. Educational level and adult mortality in Russia: an analysis of routine data 1979 to 1994. Soc Sci Med 1998; 47: 35769. Murphy M, Bobak M, Nicholson A, Rose R, Marmot M. The widening gap in mortality by educational level in the Russian Federation, 19802001. Am J Public Health 2006; 96: 129399. Leinsalu M, Vagero D, Kunst A. Estonia 19892000: enormous increase in mortality dierences by education. Int J Epidemiol 2003; 32: 108187. Jozan P, Forster DP. Social inequalities and health: ecological study of mortality in Budapest, 198083 and 199093. BMJ 1999; 318: 91415. Cornia GA. Labour market shocks, psychosocial stress and the transitions mortality crisis: research in progress 4 working paper. Helsinki: UNU/WIDER, 1997.

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Marmot M, Bobak M. International comparators and poverty and health in Europe. BMJ 2000; 321: 112428. Haynes M, Husain R. A century of state murder? Death and policy in twentieth-century Russia. London: Pluto Press, 2003. Nicholson A, Bobak M, Murphy M, Rose R, Marmot M. Socio-economic inuences on self-rated health in Russian men and women: a life course approach. Soc Sci Med 2005; 61: 234554. Klein LR, Pomer M, eds. The new Russia: transition gone awry. Stanford: Stanford University Press, 2001. Cornia GA, Paniccia R, eds. The mortality crisis in transitional economies. New York: Oxford University Press, 2000.

Mental-health stigma: expanding the focus, joining forces

Published Online January 21, 2009 DOI:10.1016/S01406736(08)61818-8 See Articles page 408

Despite ample international eorts, stigma against people with mental-health problems persists. This nding is underlined by Graham Thornicroft and colleagues INDIGO study, in The Lancet today.1 The results reveal high rates of discrimination on a global scale and show that many mentally ill people anticipate negative reactions even in the absence of discriminatory behaviours. This landmark study encourages us not only to continue ghting stigma in a global coalition,2 but also to step up our eorts. So far, we have tackled stigma mainly from a wide-angle viewattempting to create more favourable environments for mentally ill people. But we also need to look closer to home. First, clinical interventions must include strategies to enhance patients self-esteem, and to replace self-stigma with self-ecacy expectations.3

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PA Photos

Art against stigma Art exhibit by psychiatric patients, London, 2006.

These programmes must appreciate the complexities involved when a person decides whether or not to disclose their diagnosis, and value existing coping resources. Further, we should continue to strive to improve the quality of psychiatric treatments. Treatment success depends on therapeutic optimism. Recent research in neuroscience tells us that treatment expectations have a strong eect on outcome.4 To take advantage of these psychobiological mechanisms, we will have to start examining health-care professionals own attitudes and refute fatalistic notions about prognosis and treatment.5 Increasing attention on ghting self-stigma should not detract from eorts to tackle structural barriers to social integration. The INDIGO study shows that discrimination is predicted by treatment duration and experience of coercive measures. To counteract this kind of side-eect, mental-health policies need to be reviewed to nd ways of ensuring that people who need treatment receive it, with less reliance on compulsory treatment. This development could be aided by enhancing psychiatrists skills for cooperative clinical decision making.6 In challenging stigma and discrimination, we must bear in mind that stigma can only be deployed in contexts of unequal power. In addition to protecting the civil rights of mentally ill people by antidiscrimination legislation, we should empower them to actively pursue their rights and challenge discrimination through education and protest. For antistigma measures to take eect, we must continue to confront negative public attitudes. We should be encouraged to take a preventive view, and dispel stereotypes before they arise. School projects against stigma have been successful in improving
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