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Bulgaria: Shadows of the holocaust
1152
to the patient and his or her family. There is therefore still much to do in the field of leprosy control in countries with epidemic leprosy. The two major developments of the past fourteen years have been the impetus provided by the introduction of primary health care as the cornerstone of health care provision in virtually all developing countries and the standard use of multidrug chemotherapy for leprosy, with either a two-drug or a
devastating
three-drug regimen. In some places, however, the integration of existing vertical leprosy control activities into the basic health services has led to a deterioration in patient care. Integration of health programmes often requires more specialist supervision, not less, to ensure the maintenance of highquality care. Multidrug therapy requires retraining of staff and reassessment of patients, as well as the regular and guaranteed supply of fairly expensive drugs. Hence skilled manpower, logistic capability, and money are needed for countries with the least of all three. Nepal is one of the poorest leprosy endemic countries, is short of skilled and has some of the most beautiful mountain in the world-which, not surprisingly, makes scenery communications a nightmare. The population is only 19 million, and the number of registered leprosy patients is manageable, with about 20 000 at present on treatment. The drug and other financial needs for this number can easily be met by the various supporting donor agencies but the organisation of an effective control programme, in particular by the government authorities, requires much more than money. Several non-governmental leprosy organisations, all members of the International Federation of Antileprosy Associations (ILEP), are working in Nepal, and most of the antileprosy medicines for this country, as for several other countries where leprosy is endemic, comes from the foundation established by the Japanese millionaire industrialist, Ryoichi Sasakawa. Leprosy organisations are slowly and rather uncomfortably shifting their relationship with the government health authorities from one of implementer to that of supporter of the local medical administration. At the same time effective case finding, treatment, case holding, disability prevention, health education, monitoring, and evaluation have to continue and the slide towards mediocrity has to be countered. In parts of southern Nepal the open frontier enables Indian nationals to sample the services on both sides of the border and choose what suits them best. The overall flow will be determined largely by the quality of services offered, and where these are equal there will be little net movement. Where there is an established externally supported programme on one side and a neglected government programme on the other, the customers will go where a free and caring programme exists, and, when satisfied customers spread the word, the numbers will inevitably grow. In general Nepal gains much more from the Indian health services than the other way round since, at its best, Indian hospital care is as good as can be found anywhere in the world. There can therefore be no question of turning away Indians coming to health facilities in southern Nepal for the free leprosy service. Unfortunately these patients have often defaulted from treatment elsewhere, have sustained nerve damage, and are more disabled than the Nepali patients. Antileprosy drugs will kill their mycobacteria, but that is really the least of their problems. The care that these people can be realistically offered still remains woefully inadequate. A correspondent
manpower,
Bulgaria: Shadows of the holocaust Attempts to curb a poliomyelitis epidemic that has been raging in Bulgaria since January have sparked an outbreak of what the authorities primly refer to as "social tension". Two weeks ago the Ministry of Health ordered the immediate immunisation or reimmunisation of all children under 2 years of age, and of those aged under 7 who had not been immunised or who had not completed their immunisation schedules. This order was strongly resisted by Bulgaria’s ethnic minorities-Turks and gypsies-who believed rumours that the treatment was intended not to immunise but to sterilise the children. The gypsies were clearly harking back to memories of Hitler’s "final solution", the Turks to the more recent assimilation policies of the last years of the Zhikov regime. The rumours-and the mistrust they generate-are particularly strong among the gypsies of the Razgrad region. Yet it is precisely the gypsies whom the Ministry of Health most wants to reach. Most of the poliomyelitis cases come from gypsy families, whose poor living conditions facilitate the spread of the disease, and among whom few children have been immunised. The Ministry of Health has publicly attacked the anti-immunisation rumours as "monstrous and slanderous" and has instructed all health-care workers associated with the emergency programme to take every possible step to win the gypsies’ confidence.
Vera Rich
Italy: Policing pharmacies and pill piracy Recently the special inspection units of the Ministry of Health-the splendidly named I Carabinieri del Nucleo Antisofisticazione, Nas for short-have been inspecting pharmacies the length and breadth of the country. 225 out of 854 pharmacies were found guilty of some infringement of the law. The commonest offences were the stocking and sale of time-expired products, the sale of herbal preparations as medicines, sale of medicines without their attached coupon (necessary for reimbursement), and the sale of drugs not registered by the Ministry. In many respects Italy still functions as a loose collection of city states and provinces, and it came as no surprise to find wide geographical variations in these infringements. The most honest regions were Trentino in the north, adjacent to Austria, and Basilicata in the south, both with perfect records. At the bottom of the class were Lombardy, Lazio (the region that includes Rome), Sicily, and Emilia
Romagna (around Bologna). Nas does much more than simply monitor pharmacies, and an article in Newsweek at the end of last year suggested that Italy was the "world headquarters of pill piracy". This was reinforced by a piece in the doctors’ newspaper Medicus last month that began with the question "What do drugs, Rolex watches, Vuitton luggage and Cartier jewellery all have in common?". The answer, of course, was that all are prime targets for counterfeiting. According to Nas, much of the production of counterfeit drugs takes place in and around Milan with raw materials from as far away as Singapore and Turkey. Scrip (Nov 14, 1990) reports that a London-based firm of investigators has confirmed an Italian connection in recent counterfeiting of ’Selokeen’ (metoprolol) in the Netherlands and ’Zantac’ (ranitidine) in the UK. David B. Jack
to the patient and his or her family. There is therefore still much to do in the field of leprosy control in countries with epidemic leprosy. The two major developments of the past fourteen years have been the impetus provided by the introduction of primary health care as the cornerstone of health care provision in virtually all developing countries and the standard use of multidrug chemotherapy for leprosy, with either a two-drug or a
devastating
three-drug regimen. In some places, however, the integration of existing vertical leprosy control activities into the basic health services has led to a deterioration in patient care. Integration of health programmes often requires more specialist supervision, not less, to ensure the maintenance of highquality care. Multidrug therapy requires retraining of staff and reassessment of patients, as well as the regular and guaranteed supply of fairly expensive drugs. Hence skilled manpower, logistic capability, and money are needed for countries with the least of all three. Nepal is one of the poorest leprosy endemic countries, is short of skilled and has some of the most beautiful mountain in the world-which, not surprisingly, makes scenery communications a nightmare. The population is only 19 million, and the number of registered leprosy patients is manageable, with about 20 000 at present on treatment. The drug and other financial needs for this number can easily be met by the various supporting donor agencies but the organisation of an effective control programme, in particular by the government authorities, requires much more than money. Several non-governmental leprosy organisations, all members of the International Federation of Antileprosy Associations (ILEP), are working in Nepal, and most of the antileprosy medicines for this country, as for several other countries where leprosy is endemic, comes from the foundation established by the Japanese millionaire industrialist, Ryoichi Sasakawa. Leprosy organisations are slowly and rather uncomfortably shifting their relationship with the government health authorities from one of implementer to that of supporter of the local medical administration. At the same time effective case finding, treatment, case holding, disability prevention, health education, monitoring, and evaluation have to continue and the slide towards mediocrity has to be countered. In parts of southern Nepal the open frontier enables Indian nationals to sample the services on both sides of the border and choose what suits them best. The overall flow will be determined largely by the quality of services offered, and where these are equal there will be little net movement. Where there is an established externally supported programme on one side and a neglected government programme on the other, the customers will go where a free and caring programme exists, and, when satisfied customers spread the word, the numbers will inevitably grow. In general Nepal gains much more from the Indian health services than the other way round since, at its best, Indian hospital care is as good as can be found anywhere in the world. There can therefore be no question of turning away Indians coming to health facilities in southern Nepal for the free leprosy service. Unfortunately these patients have often defaulted from treatment elsewhere, have sustained nerve damage, and are more disabled than the Nepali patients. Antileprosy drugs will kill their mycobacteria, but that is really the least of their problems. The care that these people can be realistically offered still remains woefully inadequate. A correspondent
manpower,
Bulgaria: Shadows of the holocaust Attempts to curb a poliomyelitis epidemic that has been raging in Bulgaria since January have sparked an outbreak of what the authorities primly refer to as "social tension". Two weeks ago the Ministry of Health ordered the immediate immunisation or reimmunisation of all children under 2 years of age, and of those aged under 7 who had not been immunised or who had not completed their immunisation schedules. This order was strongly resisted by Bulgaria’s ethnic minorities-Turks and gypsies-who believed rumours that the treatment was intended not to immunise but to sterilise the children. The gypsies were clearly harking back to memories of Hitler’s "final solution", the Turks to the more recent assimilation policies of the last years of the Zhikov regime. The rumours-and the mistrust they generate-are particularly strong among the gypsies of the Razgrad region. Yet it is precisely the gypsies whom the Ministry of Health most wants to reach. Most of the poliomyelitis cases come from gypsy families, whose poor living conditions facilitate the spread of the disease, and among whom few children have been immunised. The Ministry of Health has publicly attacked the anti-immunisation rumours as "monstrous and slanderous" and has instructed all health-care workers associated with the emergency programme to take every possible step to win the gypsies’ confidence.
Vera Rich
Italy: Policing pharmacies and pill piracy Recently the special inspection units of the Ministry of Health-the splendidly named I Carabinieri del Nucleo Antisofisticazione, Nas for short-have been inspecting pharmacies the length and breadth of the country. 225 out of 854 pharmacies were found guilty of some infringement of the law. The commonest offences were the stocking and sale of time-expired products, the sale of herbal preparations as medicines, sale of medicines without their attached coupon (necessary for reimbursement), and the sale of drugs not registered by the Ministry. In many respects Italy still functions as a loose collection of city states and provinces, and it came as no surprise to find wide geographical variations in these infringements. The most honest regions were Trentino in the north, adjacent to Austria, and Basilicata in the south, both with perfect records. At the bottom of the class were Lombardy, Lazio (the region that includes Rome), Sicily, and Emilia
Romagna (around Bologna). Nas does much more than simply monitor pharmacies, and an article in Newsweek at the end of last year suggested that Italy was the "world headquarters of pill piracy". This was reinforced by a piece in the doctors’ newspaper Medicus last month that began with the question "What do drugs, Rolex watches, Vuitton luggage and Cartier jewellery all have in common?". The answer, of course, was that all are prime targets for counterfeiting. According to Nas, much of the production of counterfeit drugs takes place in and around Milan with raw materials from as far away as Singapore and Turkey. Scrip (Nov 14, 1990) reports that a London-based firm of investigators has confirmed an Italian connection in recent counterfeiting of ’Selokeen’ (metoprolol) in the Netherlands and ’Zantac’ (ranitidine) in the UK. David B. Jack