- Email: [email protected]
It could only happen to a vet
CORRESPONDENCE
Countries’ health performance Sir—In your May 26 editorial, you seem to believe that health for all by the year 2000 originated out of the blue as a statement of intent based on the experience of a remote region in the former Union of Soviet Socialist Republics (USSR). Not so. The International Conference on Primary Health Care was held in AlmaAta in Kazakhstan at the invitation of the USSR Government. The conference was attended by senior delegations from WHO’s then 134 member states and by representatives of 67 United Nations organisations, specialised agencies, and international non-governmental organisations. It was planned by WHO in response to a resolution adopted enthusiastically by the World Health Assembly in 1977 deciding that “the main social goal of governments and WHO in the coming decades should be the attainment by all the people of the world of a level of health that would permit them to lead a socially and economically productive life.” We never suggested that all people would be healthy by the year 2000. Moreover, a socially and economically productive life would obviously differ vastly between so-called less-developed and more-developed countries. However, the following principles remain the same for all. The existing gross inequality in the health status of people, especially between more-developed and lessdeveloped countries, as well as within countries, is politically, socially, and economically unacceptable. Attainment of the highest possible level of health is an important worldwide social goal that requires the action of many social and economic sectors. Health must be promoted and protected. Governments have a responsibility for the health of their people, especially through the provision of adequate health and social measures. People have the right to participate individually and collectively in the planning of their health care. Essential health care should be based on practical, scientifically sound, and socially acceptable methods, and technology made acceptable at an affordable cost to the community and country. Why the year 2000? The initiative, launched by WHO in 1975, purported to illustrate that objectives and targets for health can be defined as for other social and economic endeavours, such as universal child immunisation against the major infectious diseases of children
THE LANCET • Vol 358 • September 15, 2001
by 1990, which reached an average of 80% in that year. The target of the year 2000 gave a time span of a generation for fulfilment. At Alma-Ata,1 primary health care was defined as the key to the attainment of health for all and its parameters as: primary health care evolves from the socioeconomic, cultural, and political characteristics of the country and its communities; is based on the application of relevant results of social, biomedical, and health-services research, and public health experience; addresses the main health issues in the community, and provides promotive, preventive, curative, and rehabilitative services; provides at least education about prevailing health issues and the methods of preventing and controlling them, promotion of food supply and proper nutrition, adequate safe water and basic sanitation, maternal and child health care, including family planning, immunisation against the major infectious diseases of children, prevention and control of locally endemic diseases, appropriate treatment of common diseases and injuries, and provision of essential medicines; involves other sectors when relevant, such as education, agriculture, animal husbandry, food, industry, housing, public works, and communications, and demands their coordinated efforts; should be supported by appropriate referral systems; and relies at local and referral levels on health workers suitably trained socially and technically to work as a health team. It was realised that health systems needed to be established based on these outlines, and we issued guidelines,2 as well as a model for adaptation to local circumstances. We also issued guidelines on managerial systems,3 assessment of progress, efficiency, and effectiveness,4 and development and use of health policy, social, economic, and health status indicators.5 In 1981, the World Health Assembly decided on the following indicators: Health for All has received endorsement as policy at the highest official level; .mechanisms for involving people in the implementation of strategies have been formed or strengthened, and are functioning; At least 5% of the gross national product is spent on health; a reasonable proportion of the national health expenditure is devoted to local health care; resources are equitably distributed; less-developed countries with well-defined strategies and explicit resource allocations are receiving sustained support from more affluent countries if needed; primary health care
is available to the whole population; the nutritional status of children is adequate; infant mortality is lower than 50 per 1000 livebirths; life expectancy at birth is longer than 60 years; the adult literacy rate for men and women is more than 70%; and the gross national product per head exceeds US$500. We had in mind mainly lessdeveloped countries, but the USA and UK were among the first countries to prepare strategies. The above developments took place under Halfdan Mahler, WHO’s director general at the time. Since his and my simultaneous retirement in late 1988, advocacy and enthusiasm for Health for All have dwindled and been replaced by a one-disease-at-a-time programme, which has been proved ineffective. Joshua Cohen Former Adviser on Health Policy, DirectorGeneral’s Office, WHO, Geneva (e-mail: [email protected]) 1
2 3
4 5
Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. Geneva: WHO, 1978. Formulating strategies for health for all by the year 2000. Geneva: WHO, 1979. Managerial Process for National Health Development: Guiding Principles. Geneva: WHO, 1981. Health Programme Evaluation: Guiding Principles. Geneva: WHO, 1981. Development of Indicators for Monitoring Progress Towards Health for All by the Year 2000. Geneva: WHO, 1981.
It could only happen to a vet Sir—On BBC Radio 4’s Today programme I heard two items that were juxtaposed. The first was the shortage of doctors and of lecturers and professors to train them and the second was the redundancy of a large number of veterinary surgeons after the foot and mouth outbreak, and the perceived reluctance of farmers to return to livestock farming. Some years ago I had an acquaintance who was a well respected consultant physician in the Midlands area of the UK. When he was faced with an apparently insoluble problem he would call upon his son, a well respected veterinary surgeon in the north of England. As they explained to me one Christmas, a veterinary surgeon is allowed to treat human beings, but a doctor is not allowed to treat animals! If this case is so, why not set up short courses to enable vets to switch to human practice and also change some
929
CORRESPONDENCE
of the veterinary colleges into schools of medicine? Having seen the care and attention given by vets to animals giving birth, I’ve no doubt that some would make excellent obstetricians. John H Taylor Veterinary Times, Olympus House, Werrington Centre, Peterborough PE4 6NA, UK
Another sniffer dog for the clinic? Sir—Williams and Pembroke1 reported a patient whose dog constantly sniffed at a mole on her leg. On one occasion, the dog even tried to bite the lesion off. Although the patient was not concerned about the lesion, the constant attention from the dog prompted her to seek medical advice. The lesion was excised and histology showed the lesion to be a malignant melanoma measuring 1·86 mm in thickness. Since that time the patient has remained well, with no sign of recurrence. We report a man aged 66 years, who developed a patch of eczema on the outer side of his left thigh. It grew slowly, over 18 years, to about 1–2 cm in diameter. When dry, the lesion would become scabby, and it caused occasional itching. It was treated with several topical agents, including steroids and antifungals, without effect. A pet labrador called Parker came to the home in 1994. About 2 years ago, the dog began to persistently push his nose against his owner’s trouser leg, sniffing the lesion beneath it. This prompted the patient to return to his family physician for review. In September, 2000, the lesion was excised. Histological assessment of the lesion showed it to be a basal cell carcinoma that had been fully excised. Since excision of the lesion, Parker has shown no further interest in the area. With these two patients, the dogs could smell the lesions through clothing, and showed no further interest once the lesions had been excised. The combination of pets contributing to preventing morbidity and possible mortality in their owners has predictably generated much media interest. Having seen Williams and Pembroke’s report, Cognetta, a dermatologist in Florida, USA, teamed up with a retired police-dog handler with 33 years’ experience in training dogs, including service in Vietnam, leading the K9 bomb unit. They used conventional sniffer-dog techniques to train George, a schnauzer, to recognise in-vitro malignant melanoma samples. Consequently George was introduced to a patient with several moles thought
930
to be cancer-free. However one mole caused George to go crazy, and excision of the lesion confirmed early malignant disease. Although all these data are anecdotal, we believe that the phenomenon of some dogs seeming able to detect unique odours of certain skin cancers worthy of investigation in rigorously controlled experiments. Whether they can detect odours associated with other specific diseases such as tuberculosis or Ebola virus should also be investigated to aid early detection. *John Church, Hywel Williams *Abney Court, Bourne End, Buckinghamshire SL8 5DL, UK; and Queens Medical Centre, Nottingham 1 2
Williams H, Pembroke A. Sniffer dogs in the melanoma clinic? Lancet 1989; 1: 734. Jeffreys D. Amazing dog that sniffs out cancer. Daily Mail 1997; April 22: 45.
Standard methods to measure HIV drug concentrations Sir—The management of HIV infection is complex and dependent on several factors for a successful clinical outcome. An increasing number of studies have identified relations between plasma concentrations and antiviral response or toxic effects for the HIV-1 protease inhibitors and the non-nucleoside reverse transcriptase inhibitors.1,2 Consequently, there has been much interest in the use of assessment of drug concentrations of these agents in clinical practice. In the hope of capitalising on this increased interest, many laboratories have expanded their services to include measurement of drug concentrations, calling it therapeutic drug monitoring testing (TDM). However, the use of TDM is limited by a lack of standard assay methods, with resultant wide between-laboratory variability. A survey of 17 laboratories in the USA and Europe revealed that only two labs accurately reported drug concentrations of six different protease inhibitors and non-nucleoside reverse transcriptase inhibitors within 20% of the true value, and one laboratory correctly reported only 38% of the samples assayed.3 In addition, data suggest different drug concentrations when serum or plasma is sampled, and degradation of stored frozen plasma samples over time.4,5 Additional variability may also occur from differences in sample shipment, processing, and drug standards used in the assay.
If clinicians elect to use TDM for the clinical care of their HIV-1infected patients, the concentrations they receive, and the subsequent interpretation of the data, will only be as good as the quality of the laboratory processing the samples. Standardisation of laboratory methods for TDM between laboratories, as well as for sampling and storage, are urgently needed. Until these policies are developed, clinicians should carefully assess a laboratory for the following factors: what type of quality-assurance or quality-control programmes does that laboratory use; and does the laboratory validate their assays externally before making them commercially available (eg, do they participate in between-laboratory variability studies? If possible, do they ask pharmaceutical manufacturers to assist in validating their assays?). Any laboratory that does not do these functions should be viewed with caution. We are not in opposition to the widespread availability of TDM for HIV drugs, but we are concerned that limited data are available to guide clinicians about the appropriate processing, storage, analysis, and interpretation of these data, which could ultimately lead to inappropriate clinical decision making. *Andrew D Luber, Concepta Merry *Tower I D Medical Associates, Los Angeles, CA, 90048, USA; Northwestern University School of Medicine, Chicago, IL 1
2
3
4
5
Fletcher CV, Kakuda TN, Anderson PL, Henry K, Schacker T, Brundage RC. Viral dynamics of concentration-targeted vs standard dose therapy with zidovudine (ZDV), lamivudine (3TC), and indinavir (IDV). Program and abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 1999; San Francisco, CA (abstr 322). Burger DM, Hugen PWH, Droste J, Huitema ADR. Therapeutic drug monitoring (TDM) of nelfinavir (NFV) 1250 mg BID in treatment-naive patients improves therapeutic outcome after 1 year: results from ATHENA. Presented at: 2nd International Workshop on Clinical Pharmacology of HIV Therapy. 2-4 April 2001. Noordwijk, Netherlands (abstr 6.2a). Aarnoutse R, Burger D, Verweij-Van Wissen C, Van Ewijk-Beneken Kolmer E, Wuis E, Kehster Y. An international interlaboratory quality control (QC) program for therapeutic drug monitoring (TDM) in HIV infection. Presented at: 8th Conference on Retroviruses and Opportunistic Infections. February 5-8, 2001. Chicago, IL (abstr 734). Luber AD, Gunawan S, Lee S, Aquino G, Chaturvedi P, Scarsella A. Serum and plasma drug levels of amprenavir display limited inter- and intrapatient variability. AIDS 2000; 14 (suppl 4): 28 (abstr P267). Turner ML, Acosta EP. Long-term stability of nelfinavir mesylate in human plasma. Clin Chem 2000; 46: 2019–20.
THE LANCET • Vol 358 • September 15, 2001
Countries’ health performance Sir—In your May 26 editorial, you seem to believe that health for all by the year 2000 originated out of the blue as a statement of intent based on the experience of a remote region in the former Union of Soviet Socialist Republics (USSR). Not so. The International Conference on Primary Health Care was held in AlmaAta in Kazakhstan at the invitation of the USSR Government. The conference was attended by senior delegations from WHO’s then 134 member states and by representatives of 67 United Nations organisations, specialised agencies, and international non-governmental organisations. It was planned by WHO in response to a resolution adopted enthusiastically by the World Health Assembly in 1977 deciding that “the main social goal of governments and WHO in the coming decades should be the attainment by all the people of the world of a level of health that would permit them to lead a socially and economically productive life.” We never suggested that all people would be healthy by the year 2000. Moreover, a socially and economically productive life would obviously differ vastly between so-called less-developed and more-developed countries. However, the following principles remain the same for all. The existing gross inequality in the health status of people, especially between more-developed and lessdeveloped countries, as well as within countries, is politically, socially, and economically unacceptable. Attainment of the highest possible level of health is an important worldwide social goal that requires the action of many social and economic sectors. Health must be promoted and protected. Governments have a responsibility for the health of their people, especially through the provision of adequate health and social measures. People have the right to participate individually and collectively in the planning of their health care. Essential health care should be based on practical, scientifically sound, and socially acceptable methods, and technology made acceptable at an affordable cost to the community and country. Why the year 2000? The initiative, launched by WHO in 1975, purported to illustrate that objectives and targets for health can be defined as for other social and economic endeavours, such as universal child immunisation against the major infectious diseases of children
THE LANCET • Vol 358 • September 15, 2001
by 1990, which reached an average of 80% in that year. The target of the year 2000 gave a time span of a generation for fulfilment. At Alma-Ata,1 primary health care was defined as the key to the attainment of health for all and its parameters as: primary health care evolves from the socioeconomic, cultural, and political characteristics of the country and its communities; is based on the application of relevant results of social, biomedical, and health-services research, and public health experience; addresses the main health issues in the community, and provides promotive, preventive, curative, and rehabilitative services; provides at least education about prevailing health issues and the methods of preventing and controlling them, promotion of food supply and proper nutrition, adequate safe water and basic sanitation, maternal and child health care, including family planning, immunisation against the major infectious diseases of children, prevention and control of locally endemic diseases, appropriate treatment of common diseases and injuries, and provision of essential medicines; involves other sectors when relevant, such as education, agriculture, animal husbandry, food, industry, housing, public works, and communications, and demands their coordinated efforts; should be supported by appropriate referral systems; and relies at local and referral levels on health workers suitably trained socially and technically to work as a health team. It was realised that health systems needed to be established based on these outlines, and we issued guidelines,2 as well as a model for adaptation to local circumstances. We also issued guidelines on managerial systems,3 assessment of progress, efficiency, and effectiveness,4 and development and use of health policy, social, economic, and health status indicators.5 In 1981, the World Health Assembly decided on the following indicators: Health for All has received endorsement as policy at the highest official level; .mechanisms for involving people in the implementation of strategies have been formed or strengthened, and are functioning; At least 5% of the gross national product is spent on health; a reasonable proportion of the national health expenditure is devoted to local health care; resources are equitably distributed; less-developed countries with well-defined strategies and explicit resource allocations are receiving sustained support from more affluent countries if needed; primary health care
is available to the whole population; the nutritional status of children is adequate; infant mortality is lower than 50 per 1000 livebirths; life expectancy at birth is longer than 60 years; the adult literacy rate for men and women is more than 70%; and the gross national product per head exceeds US$500. We had in mind mainly lessdeveloped countries, but the USA and UK were among the first countries to prepare strategies. The above developments took place under Halfdan Mahler, WHO’s director general at the time. Since his and my simultaneous retirement in late 1988, advocacy and enthusiasm for Health for All have dwindled and been replaced by a one-disease-at-a-time programme, which has been proved ineffective. Joshua Cohen Former Adviser on Health Policy, DirectorGeneral’s Office, WHO, Geneva (e-mail: [email protected]) 1
2 3
4 5
Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. Geneva: WHO, 1978. Formulating strategies for health for all by the year 2000. Geneva: WHO, 1979. Managerial Process for National Health Development: Guiding Principles. Geneva: WHO, 1981. Health Programme Evaluation: Guiding Principles. Geneva: WHO, 1981. Development of Indicators for Monitoring Progress Towards Health for All by the Year 2000. Geneva: WHO, 1981.
It could only happen to a vet Sir—On BBC Radio 4’s Today programme I heard two items that were juxtaposed. The first was the shortage of doctors and of lecturers and professors to train them and the second was the redundancy of a large number of veterinary surgeons after the foot and mouth outbreak, and the perceived reluctance of farmers to return to livestock farming. Some years ago I had an acquaintance who was a well respected consultant physician in the Midlands area of the UK. When he was faced with an apparently insoluble problem he would call upon his son, a well respected veterinary surgeon in the north of England. As they explained to me one Christmas, a veterinary surgeon is allowed to treat human beings, but a doctor is not allowed to treat animals! If this case is so, why not set up short courses to enable vets to switch to human practice and also change some
929
CORRESPONDENCE
of the veterinary colleges into schools of medicine? Having seen the care and attention given by vets to animals giving birth, I’ve no doubt that some would make excellent obstetricians. John H Taylor Veterinary Times, Olympus House, Werrington Centre, Peterborough PE4 6NA, UK
Another sniffer dog for the clinic? Sir—Williams and Pembroke1 reported a patient whose dog constantly sniffed at a mole on her leg. On one occasion, the dog even tried to bite the lesion off. Although the patient was not concerned about the lesion, the constant attention from the dog prompted her to seek medical advice. The lesion was excised and histology showed the lesion to be a malignant melanoma measuring 1·86 mm in thickness. Since that time the patient has remained well, with no sign of recurrence. We report a man aged 66 years, who developed a patch of eczema on the outer side of his left thigh. It grew slowly, over 18 years, to about 1–2 cm in diameter. When dry, the lesion would become scabby, and it caused occasional itching. It was treated with several topical agents, including steroids and antifungals, without effect. A pet labrador called Parker came to the home in 1994. About 2 years ago, the dog began to persistently push his nose against his owner’s trouser leg, sniffing the lesion beneath it. This prompted the patient to return to his family physician for review. In September, 2000, the lesion was excised. Histological assessment of the lesion showed it to be a basal cell carcinoma that had been fully excised. Since excision of the lesion, Parker has shown no further interest in the area. With these two patients, the dogs could smell the lesions through clothing, and showed no further interest once the lesions had been excised. The combination of pets contributing to preventing morbidity and possible mortality in their owners has predictably generated much media interest. Having seen Williams and Pembroke’s report, Cognetta, a dermatologist in Florida, USA, teamed up with a retired police-dog handler with 33 years’ experience in training dogs, including service in Vietnam, leading the K9 bomb unit. They used conventional sniffer-dog techniques to train George, a schnauzer, to recognise in-vitro malignant melanoma samples. Consequently George was introduced to a patient with several moles thought
930
to be cancer-free. However one mole caused George to go crazy, and excision of the lesion confirmed early malignant disease. Although all these data are anecdotal, we believe that the phenomenon of some dogs seeming able to detect unique odours of certain skin cancers worthy of investigation in rigorously controlled experiments. Whether they can detect odours associated with other specific diseases such as tuberculosis or Ebola virus should also be investigated to aid early detection. *John Church, Hywel Williams *Abney Court, Bourne End, Buckinghamshire SL8 5DL, UK; and Queens Medical Centre, Nottingham 1 2
Williams H, Pembroke A. Sniffer dogs in the melanoma clinic? Lancet 1989; 1: 734. Jeffreys D. Amazing dog that sniffs out cancer. Daily Mail 1997; April 22: 45.
Standard methods to measure HIV drug concentrations Sir—The management of HIV infection is complex and dependent on several factors for a successful clinical outcome. An increasing number of studies have identified relations between plasma concentrations and antiviral response or toxic effects for the HIV-1 protease inhibitors and the non-nucleoside reverse transcriptase inhibitors.1,2 Consequently, there has been much interest in the use of assessment of drug concentrations of these agents in clinical practice. In the hope of capitalising on this increased interest, many laboratories have expanded their services to include measurement of drug concentrations, calling it therapeutic drug monitoring testing (TDM). However, the use of TDM is limited by a lack of standard assay methods, with resultant wide between-laboratory variability. A survey of 17 laboratories in the USA and Europe revealed that only two labs accurately reported drug concentrations of six different protease inhibitors and non-nucleoside reverse transcriptase inhibitors within 20% of the true value, and one laboratory correctly reported only 38% of the samples assayed.3 In addition, data suggest different drug concentrations when serum or plasma is sampled, and degradation of stored frozen plasma samples over time.4,5 Additional variability may also occur from differences in sample shipment, processing, and drug standards used in the assay.
If clinicians elect to use TDM for the clinical care of their HIV-1infected patients, the concentrations they receive, and the subsequent interpretation of the data, will only be as good as the quality of the laboratory processing the samples. Standardisation of laboratory methods for TDM between laboratories, as well as for sampling and storage, are urgently needed. Until these policies are developed, clinicians should carefully assess a laboratory for the following factors: what type of quality-assurance or quality-control programmes does that laboratory use; and does the laboratory validate their assays externally before making them commercially available (eg, do they participate in between-laboratory variability studies? If possible, do they ask pharmaceutical manufacturers to assist in validating their assays?). Any laboratory that does not do these functions should be viewed with caution. We are not in opposition to the widespread availability of TDM for HIV drugs, but we are concerned that limited data are available to guide clinicians about the appropriate processing, storage, analysis, and interpretation of these data, which could ultimately lead to inappropriate clinical decision making. *Andrew D Luber, Concepta Merry *Tower I D Medical Associates, Los Angeles, CA, 90048, USA; Northwestern University School of Medicine, Chicago, IL 1
2
3
4
5
Fletcher CV, Kakuda TN, Anderson PL, Henry K, Schacker T, Brundage RC. Viral dynamics of concentration-targeted vs standard dose therapy with zidovudine (ZDV), lamivudine (3TC), and indinavir (IDV). Program and abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 1999; San Francisco, CA (abstr 322). Burger DM, Hugen PWH, Droste J, Huitema ADR. Therapeutic drug monitoring (TDM) of nelfinavir (NFV) 1250 mg BID in treatment-naive patients improves therapeutic outcome after 1 year: results from ATHENA. Presented at: 2nd International Workshop on Clinical Pharmacology of HIV Therapy. 2-4 April 2001. Noordwijk, Netherlands (abstr 6.2a). Aarnoutse R, Burger D, Verweij-Van Wissen C, Van Ewijk-Beneken Kolmer E, Wuis E, Kehster Y. An international interlaboratory quality control (QC) program for therapeutic drug monitoring (TDM) in HIV infection. Presented at: 8th Conference on Retroviruses and Opportunistic Infections. February 5-8, 2001. Chicago, IL (abstr 734). Luber AD, Gunawan S, Lee S, Aquino G, Chaturvedi P, Scarsella A. Serum and plasma drug levels of amprenavir display limited inter- and intrapatient variability. AIDS 2000; 14 (suppl 4): 28 (abstr P267). Turner ML, Acosta EP. Long-term stability of nelfinavir mesylate in human plasma. Clin Chem 2000; 46: 2019–20.
THE LANCET • Vol 358 • September 15, 2001