Talk:WikiJournal of Medicine/Estimating the lost benefits of not implementing a visual inspection with acetic acid screen and treat strategy for cervical cancer prevention in South Africa

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Article information

Author: Gwinyai Masukume1ORCID iD.svg 

Masukume, G. 


I've invited the corresponding authors of the following two studies to perform a peer review of this work: [1] [2]. Mikael Häggström (discusscontribs) 17:40, 3 June 2015 (UTC)

No response so far, though. Mikael Häggström (discusscontribs) 20:12, 20 June 2015 (UTC)
After a total of 31 peer review invitations, we finally have one at File:Peer review of cervical screening article.pdf. I copy the text to the box below. Mikael Häggström (discusscontribs) 18:39, 16 August 2015 (UTC)

Peer review 1

Peer review of cervical screening article.pdf


Reviewer-annotated pdf file.

Review by Usha Rani Poli ,
This review was submitted on , and refers to this previous version of the article

A good attempt was made by the authors to estimate the number of lost lives from cervical cancer ,which can be prevented by implementing screen & treat approach of cervical screening.

The authors have calculated the outcome measures like cancer deaths prevented and lives saved based on the similar programs that are taking place in the neighboring African countries. This may not reflect the actual situation of their country. It is idealistic to project the process measures of their country - like number of women screened with screen positives , no. of screen positive women treated in the same visit, no.of women referred ,and the detection rates of precancerous lesions if the program is integrated into routine health care system , before arriving at the outcome measures . This will facilitate to arrive at an accurate way of estimating lost benefits in South Africa. Hence the methodology of the study needs revision.


I thank Dr Usha Rani Poli for the comments.

Before arriving at the final outcomes/estimates, the model did take into account that not all screened women would benefit because of factors Dr Poli alludes to. Using data from Botswana[1], only 85% of women were successfully treated – the model also assumed this proportion of women would benefit if visual inspection with acetic acid was rolled out in South Africa. This 85% proportion was one of the best available contemporary estimates in the literature.

In addition, the model was deliberately conservative like the model by Chigwedere and colleagues [2] so that a minimum irrefutable number of lost benefits could be estimated. Data on the rate of screen positivity was obtained from a randomized controlled trial in a South African setting[3]. The rate of positivity at baseline was 23.1%; however screen positive rates from another study in South Africa were as high as 45% (HIV positive women)[4].

The model also assumed that all women who received a Pap smear benefited (Figure 3) which is certainly not the case. Hence the conservative nature of the model so that the number of cervical cancers and deaths from it that could have been prevented are difficult to dismiss. As highlighted above, Chigwedere et al employed a conservative approach.

Once again, I thank Dr Poli for the insightful comments. Part (discusscontribs) 19:47, 16 August 2015

  1. Ramogola-Masire, Doreen; de Klerk, Ronny; Monare, Barati; Ratshaa, Bakgaki; Friedman, Harvey M.; Zetola, Nicola M. (2012). "Cervical Cancer Prevention in HIV-Infected Women Using the “See and Treat” Approach in Botswana". JAIDS Journal of Acquired Immune Deficiency Syndromes 59 (3): 308–313. doi:10.1097/QAI.0b013e3182426227. ISSN 1525-4135. 
  2. Chigwedere, Pride; Seage, George R; Gruskin, Sofia; Lee, Tun-Hou; Essex, M (2008). "Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa". JAIDS Journal of Acquired Immune Deficiency Syndromes 49 (4): 410–415. doi:10.1097/QAI.0b013e31818a6cd5. ISSN 1525-4135. 
  3. Denny, Lynette; Kuhn, Louise; De Souza, Michelle; Pollack, Amy E.; Dupree, William; Wright, Thomas C. (2005). "Screen-and-Treat Approaches for Cervical Cancer Prevention in Low-Resource Settings". JAMA 294 (17): 2173. doi:10.1001/jama.294.17.2173. ISSN 0098-7484. 
  4. Firnhaber, Cynthia; Mao, Lu; Levin, Simon; Faesen, Mark; Lewis, David A.; Goeieman, Bridgette J.; Swarts, Avril J.; Rakhombe, Ntombiyenkosi et al. (2015). "Evaluation of a Cervicography-Based Program to Ensure Quality of Visual Inspection of the Cervix in HIV-Infected Women in Johannesburg, South Africa". Journal of Lower Genital Tract Disease 19 (1): 7–11. doi:10.1097/LGT.0000000000000040. ISSN 1089-2591. 

Peer review 2

Review by Harsha Khullar ,
This review refers to this previous version of the article

1) Does the introduction provide a rationale why the research at hand is needed?
Comment - In a country with low resource- it is an added advantage to screen women at risk.

2) Is patient consent commented?
Comment - Consents are very important and while doing VIA. Sometime patients may complain of burning sensation with acetic acid application. so she has to be told about this before proceeding for VIA.

3) Was there approval by an ethics committee or institutional review board?
Comment - It is an OPD procedure for screening - it is not necessary to be approved by ethics committee but yes for research and thesis work ethics committee's approval is a must.

Rest part of the queries are unchanged.

Best wishes

Dr. Harsha Khullar
Senior Consultant
Sir Ganga Ram Hospital
New Delhi, INDIA

Editorial comments

Comments by Mikael Häggström
These comments were submitted on , and refer to this previous version of the article

In summary, as I understand, this article uses Zambian data on coverage rates of visual inspection with acetic acid (VIA), together with Indian data of mortality in a population screened by VIA, to estimate that one round of VIA screening would have prevented 50 cases of cervical cancer and 40 deaths from it, compared to South African data on cervical cancer mortality with prevailing cervical screening.

  • It says in the introduction that: "What would have been the impact on cervical cancer high grade pre-cursor lesions, new cases and deaths from cervical cancer had SA implemented a nurse driven VIA based screening strategy in 2008 (when information on the efficacy of VIA was more certain)?"

Thanks for the insightful comments. I have responded below each one. Part (talk) 23:21, 22 August 2015

Does it compare to the past, or does it actually mean "...if information on the efficacy of VIA was more certain back then"? It seems unreasonable that information would have been lost in the meantime.

In 2007 the randomized controlled trial (RCT) published in the Lancet showing that VIA saved lives was available[1]. In 2005 a South African RCT had demonstrated that VIA works well in a South African setting[2]. However from 2008 to present (2015), despite the available level 1 evidence[3] South Africa has not implemented VIA on a wide scale unlike its neighbors. Thus the estimation starts in 2008 - when it was certain that VIA is safe, affordable, saves lives, etc. - and tries to determine the lost benefits starting from that year. The sentence in the article has been reworded to avoid/minimize misinterpretation. Part (talk) 19:57, 22 August 2015

  • It says in the Methods section that "The central assumption made was that SA could have feasibly screened about 58 000 women with VIA in five years like Zambia did." but I'd like a more step-wise explanation for this number, with such a conclusion at the end. Is it derived from the absolute number of screened women in Zambia, multiplied by the quotient of the populations? It may seem contradictory with "Assuming SA had screened 58 000 women like Zambia did,..." when there is in fact a factor of 3.5 between them.

  • Similarly, it should be clarified that the 5 year pap smear coverage of 22.7% in 5 years is a result of 13.6% / 3y x 5y.

This has been clarified. Part (talk) 20:29, 22 August 2015

  • In the Results section, Table 1 shows up to 12 months of time, but the overall result represents a 5 year interval, necessitating an explanation for the conversion of the intervals to reach the sum of 3 300 high-grade cervical pre-cursor lesions.

Data on the rate of high-grade pre-cancerous cervical lesions in a VIA screened and unscreened population are available for one year[2]. It would be highly unethical to leave women unscreened for 5 years in a trial setting to see what happens, thus 5 year etimates could not be obtained from the literature. Thus the model assumed all the women screened in Zambia (58 000) over 5 years were screened and treated in South Africa over 1 year. Because in real life more pre-cancerous lesions develop over 5 years, it is evident that the model understimates the benefit of VIA. That the model underestimates the outcomes is mentioned in the discussion. An explanation has been placed below Table 1. Part (talk) 20:54, 22 August 2015

  • In Table 2 there are two boxes termed "Expected cases in 5 years", and the explanation should be rewritten to point out the differences between them.

Explanation has been done to distinguish the two boxes. Part (talk) 21:05, 22 August 2015

  • Does Table 2 show data for a population corresponding to Zambia, since its result is approximately 3.5 times lower than the overall result of 40 deaths from cervical cancer

Please see above. Part (talk) 21:07, 22 August 2015

  • In the Discussion section, it says "Screening and treatment for cervical pre-cursor lesions is even more pertinent because HIV infection is a known factor that increases the risk of developing cervical cancer", which is not clearly logical without any mention of HIV prevalence in the area at hand.

In the discussion it is clearly mentioned with a reference that, "South Africa with the world’s largest HIV/AIDS treatment program...". In my view I think this is sufficient to show that HIV is a very big problem in South Africa. Nevertheless I have now added that South Africa has the highest number of individuals living with HIV worldwide. Part (talk) 21:15, 22 August 2015


South Africa unlike its neighbors failed to implement a strategy know to save lives - VIA (see above), despite it being better resourced (financially and health care personnel wise) than its neighbors. Women lost their lives because of this. Lives were tragically lost in Marikana and a Commission of Inquiry was setup. I am not aware of a Commission of Inquiry to investigate why South Africa did not setup VIA and why avoidable deaths were not prevented. Thus in my opinion mentioning Marikana is not random or off topic as it offers lessons for health care. Part (talk) 21:45, 22 August 2015

I think the estimation would be much more reliable if the actual coverage rate that VIA would have in South Africa could be estimated, even if just studied on a sample of the population. Otherwise, I think this is a decent estimation of the results of implementing VIA screening. Nevertheless, other aspects, such as cost and impact of false positive results, need to be considered before being able to judge whether VIA screening is actually better.


VIA has not been implemented nationally in South Africa, thus I am unsure where estimates of coverage can be obtained. Tangible estimates based on what was actually achieved in neighboring countries were used. These countries as highlighted in the paper are less well resourced (South Africa could possibly achieve more). The aim of the study was to generate conservative estimates and it is readily admitted that the estimates presented are underestimates. VIA has repeatedly been shown to be cost effective in comparison to the Pap smear and references are provided. The data used from neighboring countries took into account false positives and despite them VIA is still beneficial. Part (talk) 21:59, 22 August 2015

Conflicts of interest: I am editor-in-chief of Wikiversity Journal of Medicine, and fellow editorial board member with the article author. --Mikael Häggström (discusscontribs) 13:02, 22 August 2015 (UTC)

Inclusion in the journal

This article has now been up for discussion for a week regarding inclusion in Wikiversity Journal of Medicine, at the project's page in Wikipedia. My statement remains that I support including this article in the journal, since both the article and ensuing comments clearly add to knowledge about the situation of cervical screening in South Africa as well as Zambia. The external peer review does point out considerable weaknesses, but denying publication would result in a risk of someone else doing the same work all over again instead of building upon experience from this one. The supplementary picture seems very useful for the Healthcare in South Africa article. I will therefore proceed to include this article in the journal now. I interpret some comments by Abd that the article should be further revised first, but he is not a medical professional and I think there should be a consensus of multiple people before deciding on a different fate of the article. Also, there can still be an ongoing post-publication discussion. Mikael Häggström (discusscontribs) 15:00, 30 August 2015 (UTC)


  1. Sankaranarayanan, Rengaswamy; Esmy, Pulikkottil Okkuru; Rajkumar, Rajamanickam; Muwonge, Richard; Swaminathan, Rajaraman; Shanthakumari, Sivanandam; Fayette, Jean-Marie; Cherian, Jacob (2007). "Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial". The Lancet 370 (9585): 398–406. doi:10.1016/S0140-6736(07)61195-7. ISSN 01406736. 
  2. 2.0 2.1 Denny, Lynette; Kuhn, Louise; De Souza, Michelle; Pollack, Amy E.; Dupree, William; Wright, Thomas C. (2005). "Screen-and-Treat Approaches for Cervical Cancer Prevention in Low-Resource Settings". JAMA 294 (17): 2173. doi:10.1001/jama.294.17.2173. ISSN 0098-7484. 
  3. Burns, Patricia B.; Rohrich, Rod J.; Chung, Kevin C. (2011). "The Levels of Evidence and Their Role in Evidence-Based Medicine". Plastic and Reconstructive Surgery 128 (1): 305–310. doi:10.1097/PRS.0b013e318219c171. ISSN 0032-1052. 

Post-publication peer review

Comments by Abd, of which the only essential addition to above comments is that the title is very long. Mikael Häggström (discusscontribs) 18:58, 25 September 2015 (UTC)
Author response to comments interspersed in blue font

Thanks for the insightful comments. I have responded below each one. --Part [[User talk:Part|(talk)]} 14:40, 23 August 2015 I have not examined this paper in detail, but a few comments:

discussion of title
  • The title is awful. It's a double negative, making it crazy long. It is
Estimating the lost benefits of not implementing a visual inspection with acetic acid screen and treat strategy for cervical cancer prevention in South Africa
How about:
Estimating the benefit of a vinegar-test cervical cancer prevention strategy
Or add "In South Africa." However, that's merely the site of the estimate source data, would would be mentioned in the abstract.
The title has been changed to: Estimating the lost benefits of visual inspection with acetic acid for cervical cancer prevention in South Africa --Part (talk) 22:14, 22 August 2015
Dump "lost." Or call them "potential benefits." Simpler is better. Consider using VIA in the title, if that is an established acronym. It would be immediately explained in the text. --Abd (discusscontribs) 02:41, 23 August 2015 (UTC)
The Chigwedere paper which uses "lost benefits" in the title has been [cited over 200 times since 2008]. I am of the view there are many ways to title a paper and using "lost benefits" is one of them. Use of abbreviations is discouraged because it can cause confusion and that is standard practice e.g. TOF can mean Tetralogy of Fallot or Tracheo-oesophageal fistula. It is better to use the full term especially in the title. --Part (talk) 13:15, 23 August 2015
  • This is merely an estimate. The objection from the reviewer was overstated, estimates need not be accurate; rather, the study should attempt to estimate possible error.
  • The outside reviewer considered the paper not ready. I tentatively agree. The paper should not be published until the objections are addressed, in the paper (not merely in answers to the reviewer) or the reviewer or another reviewer confirms readiness, supported by editorial review.
"Marikana killings" (resolved)
  • The mention of the Marikana killings is indeed inappropriate, and demonstrates a non-objective attitude on the part of the authors, who clearly consider "not doing something" as equivalent to an act of murder. This, then, could be correlated with lack of objectivity in the data analysis. That's a serious problem. Societies make choices that impact life, and death. To make these choices sanely, we need objective data, not emotional response. Researchers are human beings and will have emotional responses, but part of any scientific training is practice in identifying these and taking particular care to avoid bias; the standard scientific method is to attempt to prove one's hypothesis wrong. Not to prove that it's right. It is clear that there is a motive of proof here, with the mention of "... so that a minimum irrefutable number of lost benefits could be estimated."
  • So, then, this is how the emotional argument would go. If there is any death that is "irrefutable," then someone has been murdered, which is horrible and unthinkable, and so we should immediately spend what it will take to stop this atrocity.
Is the unnecessary death of a woman not horrific and unthinkable? Is the modelling data used not objective? Is medical research not driven by the emotion to reduce or eliminate the morbidity and mortality caused by disease? --Part (talk) 23:11, 22 August 2015
Three questions asked. Is this rhetoric in a debate? If so, that's unfortunate. In scientific research, detachment is essential. When the research is mixed up with emotional response, this can include the response that "this is terribly important and any critique is going to cost lives!" I highly recommend that the author back up and recognize personal attachment and drop it. If the author does this, they will gain power, not lose it. Suppose that, later, they are speaking in public, toward implementation (i.e., political activity, informed by their research). If they are challenged, and if if their response displays hysteria, they may lose support, readily. They will look obsessed. If they can maintain detachment, they will be able to far more powerfully present fact, and, they might be able to do this even if they are wrong. This is about politics and how to convince real people. If the one attacking them appears obsessed, they are likely to "win." If neither party is obsessed, something useful might come out of the debate! So, the responding to the three questions:
  • Death is intrinsic to life. The only way to prevent death is to prevent birth. There are two issues here: research developing scientific knowledge and public policy, decision-making. To do research, we must drop "horror" and "unthinkable," and observe reality. The emotion remains and may play a role in public policy.
  • I am not assessing whether or not the data used is objective, that would take far more work than I've invested, and I'm not necessarily competent. In any study like this, there are many choices to make. There are many "objective" measures. They vary. If we are biased, we may select one set of measures, and consider them more reliable than others. Epidemiological research is famous for bias introduced in subtle ways. Indeed, consider the Ancel Keyes w:Seven Countries Study which became the basis for public health policy for years. I have a strong suspicion that I developed prostate cancer from reliance on health advice, given to me in about 1985, that was relying on the theory of fat being harmful. The advice may have cost many millions of premature deaths, already, and counting. No, we have to think about the unthinkable, and we need real science. I'm shocked to see an argument against this. It does not increase my confidence in the study, which could be a shame.
  • Science is done for many reasons. Some is done from an emotional reaction. Humans are complex. However, if the researcher cannot set aside that reaction in doing the research, the research can be, very easily, flawed, even deeply flawed. Much research is done out of curiosity and simple love of knowledge and discovery. Then, sometimes, the researcher finds something with an emotional impact on him or her. This can lead to ineffectiveness in communication, on the one hand, or the passion may motivate and empower. I brought up Semmelweiss, below, for a reason. Semmelweiss was ineffective, and the reason given is not a decent explanation for why, it is merely the obvious situation Semmelweiss faced.
Research may be funded with a goal of reducing morbidity and mortality. Researchers may have that goal in mind. However, "reducing morbidity and mortality" is not the same as crying "murder," and bringing in the Marikana killings. People are dying all the time because this or that does not exist. With the Marikana killings, people were shot to death. Societies, for very good reason, react more strongly to this than to, say, children dying because of inadequate medical care. That is, sins of commission are given greater weight, in political response and public policy, than sins of omission. With sins of commission, someone specific is responsible. With sins of omission, we are all responsible, though we may decide to focus on policy-makers. From the point of view of numbers of deaths (and, indeed, pain and suffering), that makes no sense. From the point of view of human political process, it's clockwork. --Abd (discusscontribs) 02:41, 23 August 2015 (UTC)
The role of science and scientists in political advocacy and the impact of emotional response on science and scientific advocacy
  • However the program will cost X. There are many, many preventable deaths in a population. Suppose that spending X as considered by this paper would prevent ten deaths per year, but spending X in another way ... say by providing a nutritional supplement to a vulnerable group ... might prevent a hundred deaths per year. If funds are limited, where should policy makers spend X?
  • To make optimal decisions, they need objective data and analysis. That is the job of scientists. Not political advocacy, as tempting as it might be.
It is untrue that scientists should not be involved in advocacy.[1] --Part (talk) 23:11, 22 August 2015
Look, my strongest training is in ontology. Statements like "should" are neither true nor false. They are judgments or opinions.
The author has responded with a straw man, a supposed claim that scientists should not be involved in advocacy. Scientists can be involved, and it can be a natural role. But it is distinct from the role of scientist. Scientists qua scientists are properly expert witnesses in the court of public and political opinion. We want expert witnesses to be unbiased, and to present what they actually know, ideally with the evidence by which they know it. If an expert witness in a murder trial starts talking about how horrible the murders were and how evil the murderer was, the testimony would be impeached. The expert witness is there for fact. The jury is there for assessing and weighing fact, and for emotion as well, which comes in, not in determining guilt (that is a question of fact as to specific claims), but in determining sanctions or penalties.
In publishing a scientific paper, not labelled as an editorial, a researcher is, my opinion, expected to follow the scientific method, which includes what I wrote, a serious attempt to prove oneself wrong. Once one has become convinced that a situation is tantamount to murder, horrific, and is unable to set this aside, that effort can be emotionally impossible. Rather, the emotional responses I'm talking about set human survival responses in motion, that are far, far from objective. The situation becomes an emergency. Setting the emotional response aside does not mean becoming inured to human suffering and tragedy. It does mean accepting it as happening (it is anciently considered inevitable, unavoidable) and then acting compassionately and with clear eyes.
If the author's motive in doing this work is to reduce suffering, great! But I was a "lay midwife." Obstetricians were opposed to what we were doing because they believed that they were doing everything possible in hospitals to make birth safe, and, within the context in which they lived, they were right. That is what they were trying to do. But trying is not the same thing as performance. Hospital birth had a higher incidence of serious infections that were not matched by births at home. Actual study of overall outcomes in matched cases showed slightly lower morbidity and mortality in home birth, not enough to be statistically significant. However, the costs of midwife-supported home birth were much lower than normal hospital births, obstetrician-attended. As midwives, we referred problem cases for hospital birth. (The studies took that into account, using matched conditions.)
The obstetricians were motivated by reducing suffering, I will assume. However, they were biased! It never occurred to them that by bringing women into the hospital, the baby might die as a result. Shades of Semmelweiss! What they thought of were all the births where if the mother was not in the hospital, the baby and/or the mother might die. --Abd (discusscontribs) 02:41, 23 August 2015 (UTC)

I'll repeat, I have not studied the paper in detail. However, a benefit analysis should properly also consider cost, so this is half of what decision-makers would need. That's okay, a study need not be complete, but more complete is more better. :-).

Glancing again at the paper, what I'm seeing is that it's possible that the cost of the acetic acid screening could be substantially lower than that of the Pap smear. As well, paraprofessionals could be trained to do this screening, or, alternatively, it could be cheap to image the treated cervix, for later, remote, professional evaluation. You can do wonders with attachments to mobile phones. A speculum designed to illuminate the cervix (a phone light could be the light source) and present an image to a mobile phone could be very cheap. I'd consider all this obvious. So why has this shift not occurred? I make this comment from medical history: if you tell professionals they are murdering patients, they will not listen to you! At least, that is a predictable outcome. See w:Semmelweiss.

Telehealth e.g. telecervicography is already happening with VIA, more sophisticated than the suggestion you make.[2]. The case of Semmelweiss you mention was complicated by the fact that at that time germ theory was not well established, "Only after Pasteur, Koch, and Lister had produced more evidence of the germ theory and antiseptic techniques was the value of hand washing appreciated."[3]. --Part (talk) 23:11, 22 August 2015
Great. So my thinking is reasonable, and it's actually being done. This should be less expensive than Pap smears, or at least not more expensive, so the issues would be what was raised above, effectiveness, false positives and the costs of those, etc. If those questions have been answered, as claimed, what I wonder is why this is not being implemented, if it is not. And that would then get into issues of political effectiveness. And I do not recommend mixing that issue (political history) in the same paper with the establishment of benefit from VIA. Establish the effectiveness, and then attempt to gain support from decision-makers. Going after decision-makers with blame can sometimes prevail, but the saying is, "if you are going to shoot the King, don't miss." If you are going after decision-makers, you had better be prepared to remove them, and they will have allies, and then you are fighting a war, of a kind, at least, and meanwhile more women will die. No, the fast track is to engage the decision-makers, not blame them. But if you think they are murderers, that will be unthinkable to you, it will be compromising with evil. Bad Idea. This is not an effective way to transform society, it tends to do more harm than good. --Abd (discusscontribs) 02:41, 23 August 2015 (UTC)
The Semmelweiss case demonstrated the ineffectiveness of emotional response. Yes, there was no accepted theory. Once germ theory was accepted, the case for hand-washing became overwhelming. But Semmelweiss's evidence was very good. The actual study, as I recall, was quite clear. The problem developed later, when Semmelweiss was attempting to promote his discovery. He became obsessed. Please consider what I wrote: if you tell people they are murdering women by bad policy, they will reject you. It does not matter if you are "right" or not. I.e., if they listened to you and did what you are demanding, that lives would be saved. This is political wisdom. If you want to convince people, do not blame them. Let them figure that out for themselves. Avoiding that blame requires detachment. It's a skill, but it happens to be the same skill you need to do quality research. It happens to be the same skill you need for powerful response to critique. As well, I'll affirm, it happens to be the same skill you need to be free and happy in life.
And if you don't develop this skill, women will die, unnecessarily, because you will be ineffective. Be honest! Does this last point make you more or less convinced? --Abd (discusscontribs) 03:23, 23 August 2015 (UTC)
the issue of peer review vs editorial review
Although I am very grateful for your comments and suggestions I am of the view you are not a peer in this field. Any peer would be aware of the key VIA trials, would know that telehealth is already happening and would not be looking up the Chigwedere paper to establish what its basic conclusions are and checking what secondary prevention is. The article was written for a specialized audience and it is beyond its scope to define and explain material that is considered basic knowledge in the field. Furthermore, you say you did not study the paper in detail. --Part (talk) 13:15, 23 August 2015
I reworded these headers since I think neither of Abd's or mine would probably count as true peer reviews in the academic world. I think it's important to hold that all included articles in the journal have gotten an independent peer review as the one at top (I've specified this in the About page [[3]]), but there is additional advantage in being open to additional comments by anyone who is interested in the subject. It may bring additional ideas to mind when it's time to bring the article to attention to the editorial board to decide about inclusion, which by they way is about now. A TLDR of Abd's comments, as I understand, is that the wording of the article is indicating a favor of VIA, which would strictly require more multifactorial analysis than number of deaths. Mikael Häggström (discusscontribs) 14:58, 23 August 2015 (UTC)
(edit conflict with changes to above comment, blanking part of mine in response). Yes, this is editorial comment and process rather than peer review. This is a Wiki Journal of Medicine, and, on wikis, editorial process is a community function. This Journal is an experiment. As to my qualifications, and "peer review," no, I would not be a peer reviewer on a paper in this field. It occurs that peer reviewers are actually unqualified, and I've personally encountered that. My current strongest field is Cold fusion, and my recently published paper was reviewed by a physicist. The physicist had no idea of the state of research in the field (which would be common for physicists). Cold fusion looks like a physics topic, but it is actually a topic in experimental chemistry, with unknown physics involved. When the reviewer made ignorant comments, instead of attacking his qualifications, I recognized that I had failed to communicate, so I rewrote the paper. I'd say that everyone won.
The journal was mainstream, multidisciplinary, not targeted to specialists. The Wiki Journal of Medicine is not targeted to specialists, it is multidisciplinary, within "Medicine." Therefore the paper should be edited with a general medical audience (or even general audience) in mind, not a specialist audience. (Even if it only addresses a particular specialty. It is then educating the general audience as to the specialty.) Or it should be submitted to a specialist journal.
This paper has not been approved as ready for publication by a peer reviewer. Nor does it have, as yet, editorial approval. I've observed editorial involvement with papers for major journals, correspondence has been published. The editors do not pretend to fully comprehend the topic. Rather, they mediate and make overall editorial judgments. At a mainstream peer-reviewed journal, the attitude and behavior of the author, here, what I've seen so far, would run straight into a brick wall. There is a formal politeness, but actual high intransigence.
There is absolutely no problem with the material being hosted on Wikiversity, as-is, though subject to general editing. The issue is whether or not this is to be officially published, as-is, in this experimental Wiki peer-reviewed journal. It's a test of the system.
The papers in the Journal have identified authors. The whole issue of general editing of such papers is not clearly resolved, but this is clear to me: if there is attributed authorship, in open text (not merely in page history), the page should not be modified without author consent or at least the expectation of consent. It could be deleted, or placed in context, but a named author is to be protected, not misrepresented. Therefore I am not going in and personally removing the Marikana section, even though it is outrageously inappropriate. The paper will not be hacked without the permission of the author. If the author wants to make political comments (as I have on this page), I do that all the time, on Talk pages. It's generally allowed or even encouraged on Wikiversity. But it is not "neutral." The author justifies it by pointing to the cited paper on the AIDS treatment situation in South Africa. Even though there is a vast difference in impact, from that political error, that paper does not accuse or "indict." This paper does, explicitly, using the word, which is a sign of loss of academic objectivity, and the comments here have confirmed that impression.
Yes, Mikael, Wiki studies/TLDR is a common wiki response to open and free discussion. Wikiversity is academic, and I hope, in-depth discussion is welcome and even necessary here. This is not an encyclopedia, where discussion is restricted to article edits, and people have actually been banned for allegedly writing too much. Thanks for attempting to summarize. The summary is incomplete, I've raised a number of issues, and I don't see a problem of restricting analysis to one kind of benefit or loss (change in mortality). The cited AIDS paper presented this, more precisely, as loss of person-years, because ... everyone dies, mortality is 100% of the population, only the assumed cause changes. The issue, then, is term of life (and quality of life is an issue as well). But I would not withhold approval based on incompleteness, itself. A paper need not address every aspect of an issue. It could note its own incompleteness, that is common. "We did not examine ...."
Turning to the author, I do not see experience at consensus development in the presence of dispute, in spite of registration on in 2006. I see other things that the author would do well to note, but, here, or in most places, "I'm right" doesn't fly. Rather, we seek agreement, wherever possible. I wish the author success in personal development and in the world. And, as well and specifically, success in saving women's lives. --Abd (discusscontribs) 16:40, 23 August 2015 (UTC)
[An article for a more general audience] has already been written. As I mentioned, I am of the view you are not a peer. It seems you do not know the difference between screening and diagnosis which are among the basic concepts of medicine. I appreciate and value your comments and mention of Marikina will be removed. Part (discusscontribs) 18:34, 23 August 2015 (UTC)
Thanks. For the paper, I suggest you state the facts or careful analysis, not the moral implications, if this is a scientific paper. Let the reader draw those conclusions. You are repeating yourself about "peer," it's called beating a dead horse. I'm an editor. As is anyone who cares to be, on a wiki. As to screening and diagnosis, I could write an essay distinguishing them, and consider it obvious. They are related. VIA is a screening process, not a diagnostic one. However, VIA evidence could be an element in diagnosis, as can be any other related observation.
Thanks, as well, for pointing to your excellent popular article. That article did not raise, for me, the kinds of issues that were raised here. It points out the situation. It mentions the lost opportunity of HIV/AIDS treatment and connects it with cervical cancer screening in a straightforward way. It "indicts" nobody. Calling to action provides space for political decision-makers to join you. And if they don't, the first priority, if your goal is functional transformation, would be to find out why, and address those concerns if possible, not to blame decision-makers.
You are a physician, you care about women, and you care about each life, that is expected of physicians. However, public policy decisions cannot be made in quite the same way, because one is dealing with populations, and sometimes limited choices, and what is done always creates something not done. It's triage. Triage saves lives, but can involve painful choices, and, of course, if one errs, lives can be lost.
As a scientist, your job is different than that of a physician. Your job is to develop fact and objective, unbiased analysis. I don't know what you need to do. Maybe wear different hats in different jobs.
I did fail to understand something, because it is not emphasized in the paper. It is more visible in the article. VIA is often combined with immediate treatment. What is treated may be precancerous lesions, so, indeed, this is prevention of a kind. It does not address the root cause, it is not prevention in that sense. It can prevent the development of malignancies. However, then, the issue of false positives comes up. I've faced this, I was diagnosed with prostate cancer. The original symptom was rising PSA. A TRUSP biopsy was recommended. Eventually, I had it done. Positive. 10% malignant cells in one needle sample out of 12. Surgery was recommended, or radiation therapy. I did the research and elected watchful waiting (and I also became stricter in carbohydrate restriction, on a high-fat diet). PSA levels actually went down. 3 years later, levels started rising again and I had another biopsy. Negative. Do I have prostate cancer? Probably. But I also am unlikely to die from it. (I'm 71). The treatment options are highly invasive, with high complication rates and impact on quality of life. I dodged that bullet by becoming informed, medical advice was warped, largely by malpractice legal reality in the U.S. One will never be sued for recommending an unnecessary procedure, but if one does not recommend it, liability can be found. So medical practices set up rules for their physicians. I've been able to find physicians who will talk about it. They tell me the official recommendation, and will discuss my ideas with me. When I had a urologist who would just tell me I was ignorant and he knew better, I fired him and got a better urologist. He would have had me missing parts of my body. (And what he was telling me was wrong, I found out. He was actually ignorant, even though he knew a lot, he didn't know everything. PSA levels, for example, vary substantially, on a monthly cycle, probably. It's not been well studied.)
So my question about false positives is the risk or harm of unnecessary treatment. It may be low, and if that treatment is cheap and not a serious harm, it may well be good public policy to treat, and follow up. Key in a VIA program would also be additional diagnostic support. Pap smears for those who show VIA abnormalities? Much more efficient use of resources.
By the way, this: [[4]], a published letter from someone with his head screwed on straight. "Medical authors have been known to use spin – as the media do – in scientific writing to achieve personal agendas." Yes they do, don't they?
Let me suggest your most powerful response to this. Laugh. Best wishes. --Abd (discusscontribs) 22:05, 23 August 2015 (UTC)
I have been naive in the spirit of community participation because the screen and treat approach was stated upfront even in the former title and is repeated in the paper. I realize that you have been [banned from Wikipedia] and I can understand why. I am unable to engage further with you. Thank you for your interest in my work. Part (discusscontribs) 08:21, 24 August 2015 (UTC)
It's interesting work. I'd like to see it be successful, in measurable results. That ArbCom case is very old and has often been misrepresented, including here. The link shown is to a section on a one-year topic ban, which expired, I was not "banned from Wikipedia" by ArbCom. I have never told the full story of what happened there. Perhaps that would be useful, since misrepresentation of it is common. I am not and have never been banned here, or anywhere else in the WMF family of wikis, other than the "community ban" on Wikipedia, which I could appeal, but I found working on Wikipedia to be horribly inefficient, like slogging through a swamp when there is an easy path nearby called Wikiversity.
What I did here, in this discussion, would be a violation of Wikipedia guidelines. It is allowed or even encouraged on Wikiversity, just as discussion like this would be allowed in seminars in a brick-and-mortar university.
In any case, authors of papers here are not required to interact with the community. The community, however, has the right to question, criticize, comment, etc. This is not "peer review," it is editorial review, which is similar to the process in any peer-reviewed journal. In a wiki journal, I assert, the community has supervisory responsibility and power.
Wikiversity is for learning resources and activities. I've learned a great deal, and I hope others have, as well, and that this will continue into the future. --Abd (discusscontribs) 14:56, 24 August 2015 (UTC)
suggested focus on what works (in political action)

Politically, I'd suggest focus on what works, how costs can be lowered and outcomes improved, without any finger-pointing or hysterics about murder. If needed, I would suggest additional clinical trials that compare acetic acid screening with Pap smears and other measures. (Or, perhaps better, given that the appearance is that this testing works, initial implementation of a vinegar test screening would include careful monitoring, so that it is an additional clinical trial.) I would suggest developing cost/prevented death statistics. The double negative title actually betrays the problematic thinking.

In their landmark paper which I cited, Chigwedere et al write, "Access to appropriate public health practice is often determined by a small number of political leaders. In the case of South Africa, many lives were lost because of a failure to accept the use of available ARVs to prevent and treat HIV/AIDS in a timely manner." Is this not pointing fingers? [There have been hundreds of trials on VIA]. Please see level 1 evidence comment above, I do cite papers comparing Pap smear head to head with VIA. --Part (talk) 23:11, 22 August 2015
On the issue of VIA vs Paper smears, that was a basic foundation for the paper, I knew that. I was pointing out the usefulness of additional monitoring that would make actual implementation a clinical trial. Basically, the "estimate" of effectiveness could become a measure of effectiveness.
I will look at the Chigwedere paper, if it is accessible. The statement is not clearly "pointing fingers" at any individual, and the problem is far more well-established. I want to see how this is presented, and where and why that statement was made.
[The Chigwedere paper]. First of all, the paper appears to be in a section of the journal devoted to "Perspectives: Epidemiology and Social Science" That would indicate an editorial, an opinion piece. This paper then recounts a well-known history. I was aware of it, i.e., the governmental denial of HIV as the cause of AIDS, in South Africa. The title of the paper appears to be a model for the title of this paper. "Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa." So, there was a government policy, easily identified, open, widely known, and they ask and attempt to answer the question of what the human cost was of this action. In an editorial in a journal devoted to AIDS. The policy was not merely a failure to act, it was an active rejection of assistance and a positive interference in possible treatment. Yet, in spite of increased possible culpability, I see nothing in the paper condemning Mbeki or the government, comparing what they did to murder. They just report fact and analysis, with no hysteria. The facts and analysis are quite enough:
... more than 330,000 lives or approximately 2.2 million person-years were lost because a feasible ARV treatment program was not implemented in South Africa. Thirty-five thousand babies were born with HIV, resulting in 1.6 million person-years lost by not implementing a mother-to-child transmission prophylaxis program using nevirapine. The total lost benefits of ARVs are at least 3.8 million person-years for the period 2000–2005.
The situation in South Africa, as of the writing of the Chigwedere paper, continued to be problematic. Calling attention to the political situation was not a scientific move, it was a political one, where normal engagement had not worked, where strong opposition to treatment continued. This may have been part of the world scientific community putting pressure on South Africa. Reviewing the situation, I'm not seeing, so far, that it was effective. However, the estimate of cost in life stands. --Abd (discusscontribs) 04:54, 23 August 2015 (UTC)
discussion of prevention vs diagnostic/treatment, based on a misunderstanding; however, the lotus of knowledge grows in the swamp of error

One more semantic issue: this is not a prevention strategy. It is a diagnostic/treatment strategy. It does not prevent cervical cancer; rather it is designed to detect such cancer early and prevent avoidable premature death. --Abd (discusscontribs) 14:54, 22 August 2015 (UTC)

Screening for cervical cancer with VIA, the Pap smear or the HPV test is classified as secondary prevention. Please see the references I cite. --Part (talk) 23:11, 22 August 2015
Citing "the references" for a specific fact without specifying a specific reference is frustrating to the a reader. However, I simply looked up "secondary prevention." The tests are secondary prevention, yes but prevention of what? That was the issue. They are secondary prevention of death from cervical cancer, not of cervical cancer itself. "Secondary prevention" is the prevention (or reduction) of harm from a thing. Calling it, then, the "prevention of the thing" is losing context. [This article] on primary, secondary, and tertiary prevention actually, in an example, denies that secondary prevention of the mentioned affliction is prevention of the affliction. This is a distraction from the point. The point is a diagnostic measure that is used, then, to reduce morbidity and mortality from cervical cancer. The issue the paper studies is the estimated loss (deaths) from failure to diagnose in the most efficient way, but I suggested this be stated in a positive way: the benefit, in reduction of deaths, from implementing a superior diagnostic tool. Prevention of cervical cancer is not even on the radar. Secondary prevention of harm from cervical cancer is. The word "prevention" in English ordinarily refers to primary prevention. You could argue that the target audience will not be confused, but what is the target audience? Generally, the fewer words in a title and abstract, if they are chosen well, the greater the power.
Please see comments in bold above. --Part (talk) 13:37, 23 August 2015
In my own life, I have discovered that framing activity as creating benefit rather than reducing harm is more inspiring and effective. Practical psychology. --Abd (discusscontribs) 03:21, 23 August 2015 (UTC)
Regarding whether it's about prevention or not, I revised ([[5]]) the definition at the Wikipedia article Cervical screening since it appears to be mainly a form of secondary prevention because it detects abnormal changes in the cervix before they can develop into cervical cancer. Mikael Häggström (discusscontribs) 14:41, 23 August 2015 (UTC)
This led me to a far deeper understanding of what VIA screening/treatment is about. VIA is not about the detection of cervical cancer, though the process will detect it as a side effect. It is about the detection of w:neoplasia, which may -- or may not -- be, or develop, into cancer. VIA does not prevent neoplasia, it detects it; so this is called secondary prevention; that is, it reduces the possible harm from neoplasia. Because neoplasms are not, per se, cancer, but may develop into cancer if not treated, this, then, is, in fact, primary cancer prevention. It should actually reduce the incidence of malignancy, i.e., cancer.
I do not find VIA screening to be only relevant in developing countries. All countries include "low-resource settings." Money spent on Pap smears might better be spent in a more sophisticated system that would reserve Pap smears for further testing of neoplasia detected by VIA screening. The Wikipedia article on cervical screening gives disadvantages to VIA screening. The most serious problem could be "false positive," leading to unnecessary treatment, but this would be a problem with any visual inspection, and "false positive" has not been well-defined. The identification of skin neoplasia would be quite the same. So making this an argument against VIA would be quite analogous to saying "Don't look at the patient's skin because you might mistake a harmless mole for cancer." Rather, treatment is an option, and treatment that could harm fertility should not be done based on VIA alone, unless the results are so blatantly cancerous that treatment is urgent. That's a medical decision, to be made by the patient in consultation with an expert, not by a screening health worker. The claim that there is no permanent record is based on pure visual inspection without photography, which would be inferior. Of more concern is false negatives, and what this means is that some level of other screening should be maintained.
Another analogy would be PSA testing in men, about which I described my experience. PSA is related to prostate cancer, but PSA levels also rise with age, and vary naturally. It is a concern about PSA testing that it leads to unnecessary treatment, and, in fact, even the far more specific TRUSP biopsy frequently leads to unnecessary treatment, and I saw such actually advised. "If it were me, I'd get it out!" I.e., cancer is dangerous, eliminate it, ASAP! However, not all cancers are actually invasive, there are issues of growth rate, etc. I was encouraged to take a fear-based approach, which, in my view, was poor medicine. Had I not done the research myself, I'd be missing parts of my body, not to mention a serious impact on my life in the recovery period. The reality is, I understand, that most men my age have some level of prostate cell malignancy, (OMG! Cancer!!! We might die!!!) but treatment of small, not-rapidly growing malignancy may not improve life expectancy, and present treatment methods have high complication rates and impact on quality of life.
The harm is not PSA testing, per se. There are more useful PSA tests, not established in practice. However, overtreatment is not about the test, it is about the reaction to the test results. In another article published by the present author, he points out how medical information may be conveyed in a misleading way. Applying that to this, and in lay language, "You have a growth on your cervix, and this could become cancer. We can treat it today, it will take a few minutes. May we go ahead?"
Is there a risk of damage to fertility? How high a risk? That information should be conveyed to patients, by people who speak their language and know their culture. They are not stupid children. If they are ignorant, then education is in order, as part of the whole public health effort.
The author here is involved in medical practice with women, and is, I presume, an expert on this. I would think the risk of harm from cryotherapy, from unnecessary treatment of small-scale cervical intraepithelial neoplasia, would be small, particularly when compared with benefit in risk reduction. If the CIN is large-scale, I would think that ad-hoc treatment by a field worker would be inappropriate, but telemedicine would be used, with transmission of images and consultation. I'd think that if large-scale CIN is found, prompt Pap smear could be indicated. (Telemedicine has an increased cost, mostly in the time of the specialist. Hence a sane public health system would be designed with clear protocols that reserve immediate consultation for cases requiring more experienced assessment. Images would be transmitted for all exams, but for review and monitoring. As well, a health worker, until proven to have sound assessment skills, should be carefully supervised. These are all normal considerations with any public health screening effort.)
If evidence of carcinoma in situ is seen, the woman needs prompt major care and support. One of the purposes of screening is to detect such cases as soon as possible, as the good doctor knows. Field workers would be trained in counseling, according to social norms and necessities in the region, and ideally would come from the local community, they would not be outsiders. --Abd (discusscontribs) 16:57, 24 August 2015 (UTC)
  • I am now narrowing this to specific issues so that discussion may be more focused. --Abd (discusscontribs) 22:40, 24 August 2015 (UTC)


The title is overlong, creating problems with Wikiversity function. Some displays cannot now show the full title, and this has actually caused confusion for me. For example, see [diff display] or page history display. Page title and full article title can be different. The page title can be an abbreviated form of the full article title. The page title contains many words that do not add to the core meaning. For example, "implementing VIA" is not really different from "VIA." When we talk about the benefit of a thing, we are assuming it is implemented!

The title as is now (it was changed and then changed back at author request), contains a complex double negative: Estimating the lost benefits of not implementing a visual inspection with acetic acid screen and treat strategy for cervical cancer prevention in South Africa. I suggest a careful parsing. Often, when we have an idea in mind, we may see text that says the opposite, even, and read what we have in mind, into it. Proofreaders (and I've been a proofreader) must struggle against this.

There are a series of negatives in the title. "Lost" means not happening," "not implementing" is an obvious negative, and "prevention" is also a negative, i.e., attempting to stop something from happening. The mind will overload reading a title like this. So, let's be careful and parse it. I see immediately, "the benefits of not implementing (VIA)." What are the benefits of not implementing VIA, and what does it mean for those benefits to be lost?

I could give an answer to that question, now, but it is not the question the paper asks. It actually addresses the estimated benefits of implementing VIA. (reduced morbidity and mortality.) And this would be clearly stated that way.

My view is that the author must approve of all changes to the page, other than possible neutral framing. Our purpose here is not to decide article content by consensus. It is to work with the author to create the best possible paper, we are editors, and that is the job of editors. Wikiversity respects attributed authorship, this is normal here. We do not normally engage in this kind of process, because pages here are not normally peer-reviewed and subject to such scrutiny. So I am recommending that the author consider the situation. The paper was rejected as not ready by a peer-reviewer. If that stands, I don't see how the paper can be published in WJM. The peer-reviewer might look at an improved article and approve it, which assumes that the objections of the reviewer have been adequately addressed, usually by clarifying and improving the paper. Another peer-reviewer might be found, but the article should have maximum quality or that process could be quite inefficient.

Wiki editorial process runs on consensus. When necessary, that can be "rough consensus," but there is often a loss of quality when process stops short of maximized consensus. Here, there were three participants as to local review. The author, who sits on the editorial board, the "editor-in-chief," who also sits on the board, and myself. Two of us agreed that the title was problematic, and the editor-in-chief changed the title. That was an error. Our goal is not the immediate best title. Our goal is long term, the best paper, including the best title. I thought the moved title was improved, but it was still problematic, and the author insisted it was right and asked that it be moved back.

We are, here, developing strong process that will result, if we do our work carefully, in a Wikiversity Journal of Medicine that earns respect and recognition. It's worth taking the time to do this right. To the author, I highly recommend truly careful consideration of suggested changes. You are more expert than the others here in the relevant field, but we bring a different perspective and might, in some cases, have more expertise in communication. Instead of looking for what is wrong with what we write, seek what is right, and address our concerns. The problem with creating WJM will be finding strong editorial support, the kind of critical review that I've seen in actually being published in a major journal. After two-layer peer review came editorial review, piles of nitpicking corrections, with deadlines, since this was a print journal. I refused a couple of corrections, but accepted most if they were, at worst, harmless.

Mikael, maybe it is time to start cranking up publicity on Wikipedia for this journal, inviting editors here. We will educate them in Wikiversity practices.

Two more points: the author defended his title by citing a major paper, "Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa." That is not a double negative. It is a single negative. I have argued that the title would be better without the "Not." A single negative could be used here, but I've argued that for political reasons, the positive is better accentuated. That paper was important, but looking at the history, it is not clear that it had the desired impact. That situation was much more difficult, so it is difficult to assess if better writing would have helped. As far as I can tell, the VIA situation is not as politically complicated as was the HIV/AIDS situation.

A title is designed to attract, to punch through noise, creating a context in which the paper will be quickly understood. Generally, the shorter the title the better, as long as the necessary information is conveyed. My suggestion is to create a very short title, too short, perhaps, then carefully restore necessary information to it. For example, "Estimating the benefit of a VIA screen and treat strategy." Many studies are done in a specific context, that is all covered in the abstract, it is not necessarily in the title. "a" implies an example, not a definite noun. VIA screen and treat does accomplish cervical cancer prevention, but that is part of the benefit. Etc. What title is going to inspire readers,? and, in a table of contents, impress readers with the cogency and wisdom of paper selection? What is going to make readers want to regularly read WJM?

The author objected to the use of an acronym like VIA. However, I look at [this document] which is similar in some ways to the author's paper, only it's about Vietnam. The title does not mention Vietnam. "Screening and treatment to reduce the risk and incidence of cervical cancer." The document does not give an estimated benefit, however. It does give data which could be used to estimate benefit.

The paper is already published here. It is accessible, and will stay that way. This is not Wikipedia, where what some might not like is mercilessly edited or deleted. We must maintain site neutrality, but we do so inclusively, not exclusively. If I really don't like a paper, I can write a critique. Papers in general in WJM will be subject to critique (on the attached talk page, or, more formally, as responses that are approved editorially for WJM (which is an editorial decision in established journals, not necessarily involving peer review.) --Abd (discusscontribs) 22:40, 24 August 2015 (UTC)

The title is rather long, but the double negative does reflect the fact that South Africa did not implement VIA screening, so I also understand this choice. Mikael Häggström (discusscontribs) 14:42, 30 August 2015 (UTC)

Publicly accessible documents If possible, cited papers should have links to free public-access versions. Many of the papers have these. It would have saved me substantial time searching if the links had been provided. Many journals allow authors to release prepublication or as-submitted papers. --Abd (discusscontribs) 22:40, 24 August 2015 (UTC)

For which links have you found public-access versions? Mikael Häggström (discusscontribs) 14:39, 30 August 2015 (UTC)

Review of issues

This section should reflect high consensus, either as to result or assessment of the paper, or as to identification of issues that do not have consensus. If any user believes that closure of an issue is improper, it may be reverted by removing the archive template. However, detailed evidence or argument should be in the discussion above. --Abd (discusscontribs) 18:27, 24 August 2015 (UTC)


Discussions are closed for review purposes.

Title There is objection to the title as overlong and containing a double negative. There was a change, with agreement that it was an improvement. I don't see consensus yet that this is complete. --Abd (discusscontribs) 18:27, 24 August 2015 (UTC) page moved back, "author request." --Abd (discusscontribs) 20:41, 24 August 2015 (UTC)

It is rather long, but does reflect the fact that South Africa didn't implement VIA screening. Mikael Häggström (discusscontribs) 14:42, 30 August 2015 (UTC)

Estimation of benefit The peer reviewer considered the methodology incomplete, and that the paper was not yet ready for publication on that basis. While the author responded, there has been no follow-up, no additional comment from the reviewer, or other peer-review. --Abd (discusscontribs) 18:27, 24 August 2015 (UTC) Other issues The above subsections are not a complete list. This subsection may be replaced with other more specific issues. --Abd (discusscontribs) 18:27, 24 August 2015 (UTC)

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