282 REMEDIES FOR THIRD WORLD DISEASES SIR,-Dr Garattini (June 11, p 1338) highlights the obstacle that the profit motive sets in the way of Health fo...

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SIR,-Dr Garattini (June 11, p 1338) highlights the obstacle that the profit motive sets in the way of Health for All by the Year 2000. Diseases once well known in today’s industrialised countries are still endemic in the third world, and the term "tropical diseases" is inappropriate for illnesses determined only partly by geography and mainly by socioeconomic conditions, such as the diarrhoeal and respiratory diseases that rank first among the killing diseases worldwide. The answer is not only a matter of drugs: the approach needs to be global, and not limited to health intervention alone. In that sense industrialised countries have a major responsibility, for it is they who have the financial and technological resources. Development, however, will not take place without using local resources, and that relies almost entirely on national and international political will. Indeed, as Garattini points out, lack of money is not the main reason behind the ability of developing countries to implement appropriate health policies, including drug development, production, purchase, and distribution. The WHO’s Special Programme for Research and Training in Tropical Diseases, in which Italy participates with growing interest and financial contributions, is not intended to provide the answer but rather to trigger other initiatives. Even so, at the programme’s joint coordinating board, some delegations have repeatedly pointed out the need to redirect funds to developing countries:1 since 1975 almost half the funds have gone to finance projects in industrialised countries (and one-fifth of the total budget in just one country2). The development of safe and effective new drugs, vaccines, and other technologically appropriate tools for preventing and treating endemic diseases must be multifaceted. Development cooperation, both multilateral and bilateral, should promote, in the medium and long term, the development of local research and production capabilities; in the short term it should assure proper access of people in developing countries to essential drugs, including new

malaria, if only to avoid being invalided home. There are fourteen native languages in Sierra Leone. Learning all of them would be a formidable task. 233

Boroughbridge Road,


York Y02 6AY


SIR,-Your Parliamentary correspondent (June 4, p 1290) reports the submissions of Professor Maynard and Professor Culyer to a House of Commons committee, suggesting an innovative system of capitation payment with the "gatekeeper" general practitioner having incentives to manage patient care budgets. The submission stated that other countries have few lessons to offer Britain. One overseas arrangement that is worth noting is the Health Service Organisation (HSO) that exists in the Province of Ontario. HSOs, which receive capitation funding from the government plan, exist side by side with government insured fee-for-service practice; patients have complete freedom to move from one arrangement to the other. The incentives of capitation for the physician to keep patients satisfied and healthy exist, and there is no limit to the number of members that an HSO can enrol. In addition there is an ambulatory care incentive payment which is a monetary payment to the HSO if there is a demonstrated saving of hospital costs. Since 1986 there has been no extra billing of patients in Ontario. There is no private medical insurance in Canada; the situation is essentially one of competing arrangements within a universal state-funded system. The fact that observers of competitive market models of health care are not aware of this Canadian model is excusable. Most citizens of the province are also not informed of its existence. East End Health Centre, Toronto, Ontario M4E 2V8




Industrialised countries, through development cooperation policies, may favour the establishment of joint ventures between national industries and enterprises in developing countries, as foreseen, for example, by the 1987 Italian law on development cooperation. Similarly the stimulus for consistent investment in the development of drugs or vaccines may come from special agreements between governments and the pharmaceutical industry. An example of this is the agreement signed last year between the Italian Ministry of Foreign Affairs and a leading national industrial group for the development of the antimalarial vaccine. New drugs for use in third world countries are needed and the potential for their development exists-but only via political commitment worldwide to readjust the imbalance in financial resources can this potential be realised. EDUARDO MISSONI MARTA DI GENNARO FRANCESCA VICHI SARA SWARTZ GUIDO BERTOLASO

Health Sector, Directorate General

for Development Cooperation, Ministry of Foreign Affairs, 00194 Rome, Italy

1 UNDP World Bank WHO. Tenth


Headquarters, Geneva, June 24 and 25,

of the joint 1987). TDR

coordinating board (WHO JCB(10) 87 3

2. UNDP World Bank WHO TDR management summary report

(Dec 31, 1987).

SIR,-Dr Skrabanek (May 21, p 1155) infers that in complying with the requirements of the Misuse of Drugs (Notification of, and Supply to Addicts) Regulations 1983, doctors are acting as police informers. Information derived from the addicts index is maintained in the strictest medical confidence and is not made available to any other agencies, including law enforcement agencies. Notifications are directed to the chief medical officer at the Home Office, on the basis of a doctor-to-doctor communication. The purpose of the index is twofold-as an epidemiological tool, it provides an indicator of incidence, prevalence, and geographical distribution of drug misuse which is used in planning drug misuse and AIDS services more effectively; and to reduce duplication of prescribing to the same patient. Inquiring doctors may be given information (on a call-back system) as to whether a named patient is currently notified, and the name of the previously notifying doctor. Any further information can only then be exchanged on a doctor-to-doctor basis with regard to clinical management of the patient. Compliance with notification is even more important in the light of AIDS, so that the size of this potential risk group can be assessed, and facilities put in place to provide targeted health education and harm reduction services in areas of high prevalence. ,

Mental Health and Illness Division, Department of Health and Social Security, London SE1 6BY



SiR,—Brother Meegan and Professor McCormick (July 16, p 152) are right in emphasising the importance of understanding local customs and local languages when working in the third world but I cannot agree that

"Aspiring health workers m the poor world should time learning the language rather than attending a potted course in tropical diseases". I have worked in Ecuador, where I learnt as much of the language as I could, but without my knowledge of surgery and tropical diseases I would have been of little use. More recently I worked briefly in Sierra Leone. There it is essential to know about lassa fever, schistosomiasis, and even spend


SIR,-Commentary from Westminster in your issue of June 25 does not provide a balanced view of House of Commons attitudes towards alcohol and some of the statistics provided were so selective as to be very one-sided. For example, your Westminster correspondent says that the UK spends more (7-3%) on alcohol than on clothes, cars, hospitals, and schools. That figure was for 1984/85; by 1987 the figure had fallen to 6 7%, the same as in 1966. In 1950 it was 7-7%. He correctly states that wine consumption has risen nearly 3000% since 1945 (an all-time low following the war

283 but is wrong to suggest that consumption of alcohol as a whole has doubled in the past 25 years. Consumption has risen from 4-5 litres per head in 1962 to 7-2 litres in 1987 (60%). Consumption of alcohol has fallen by 9% since 1979, and the consumption of beer and spirits by 13% and 12%, respectively, over the same period. Instead of comparing the UK consumption with that of Eastern Europe and the Soviet Union, it might be more relevant to show that the UK in 1986 consumed 7’ 1 litres per head and lay 24th in an international league table, well behind France (13-2 litres), Spain (11-5), and

Switzerland (11-0). Brewers’ Society, 42 Portman Square, London W1H 0BB



Chairman, Social Responsibility Committee


SiR,—Greenwood et aP conclude that prophylaxis with dapsonepyrimethamine (’Maloprim’) plus presumptive treatment significantly reduced malaria-related mortality in children aged 1-4 years in comparison with presumptive chloroquine treatment alone in The Gambia. While acknowledging that efficient chemoprophylaxis with an effective drug may indeed reduce the incidence of malaria and its more serious outcomes, we believe that the more important question for Africa-namely, can a community-based disease-control programme which effectively delivers presumptive treatment for febrile illness reduce malariarelated morbidity and mortality?-remains unresolved. In the Saradidi study,z treatment for malaria was provided by village health workers overall and malaria-related mortality was low and comparable in both treatment and control groups. The lack of any detectable effect was ascribed to there already being "a high level of chloroquine use for illness presumed to be due to malaria before the programme was initiated" in both areas. In a prospective study of 900 villagers in Indonesia, presumptive chloroquine treatment of febrile illness may have reduced malaria-related mortality, but the number of deaths was small (9 in children less than 5 years of age) and there were no controls.3 Presumptive chloroquine therapy of febrile episodes compared with weekly chloroquine prophylaxis in Burkina Fas04 revealed no difference in mortality among children aged 1-2. Treatment, chemoprophylaxis, and surveillance were clinic based and few deaths occurred in either group. Presumptive therapy was well accepted by the community, while compliance with chemoprophylaxis waned after a year. In Greenwood’s study the incidence of presumptive chloroquine therapy of clinical malaria by village health workers was less than might have been expected. Previous studies in The Gambia have suggested an attack rate of clinical malaria of 0-21 episodes per child per year when children were examined monthly; and of 0-77 when surveillance was weekly.5 Children in the presumptive treatment group received an average of only 0-34 courses of chloroquine treatment per year. This may represent underuse of village health workers by families6 or widespread availability of chloroquine from other sources. In sum, studies of the utilisation and impact of presumptive therapy suggest that the epidemiological heterogeneity in Africa must be borne in mind; it may prove difficult to generalise from one area to another. The study in The Gambia was well designed and executed but one methodological issue deserves comment. Disease-specific mortality data were obtained through administration of postmortem questionnaires to the child’s family. The validity of this method is based on one study in which diagnoses made from mothers’ histories of their childrens’ illness at the time of hospital admission were compared with diagnoses established after admissionEven in this setting of concurrent illness malaria was diagnosed correctly in only 12/16 cases, and accuracy would be expected to decrease as the time between the child’s death and parental interview increases. (Although the delay was not specified by Greenwood et al, it was up to 3 months in a previous study of theirs in The Gambia.8) Few malaria-related deaths were identified (7 in the presumptive treatment vs 1 in the chemoprophylaxis

group) (p=0-07), and imprecision in the


of death and the

small number of deaths argue against drawing definite conclusions. Greenwood et al note that dapsone has been reported to cause fatal agranulocytosis in military personnel taking this drug as chemoprophylaxis in Vietnam.9 Although no obvious adverse effects from maloprim prophylaxis were detected in their study, the number of children involved was probably too small for maloprimassociated agranulocytosis to be expected." Since this condition appears to develop suddenly and idiosyncratically, surveillance based on white blood cell counts alone may not be sensitive enough to pick up this adverse effect. Because of its small size, well-developed primary health care structure, and the seasonal nature of malaria transmission, The Gambia is not typical of African countries in which the feasibility of large-scale chemoprophylaxis or drug-based malaria control programmes needs to be assessed, and logistic, administrative, and financial concerns may provide greater constraints in other countries." Even if chemoprophylaxis is shown to be highly effective, we must be circumspect about the implications for Africa. The extension of chloroquine resistance requires that alternative drugs be used; dihydrofolate reductase inhibitor/sulpha combinations remain the most likely alternatives, but their use implies greater risk of adverse effects and increased cost. Presumptive therapy remains the most realistic and feasible strategy for much of the developing world; intensive efforts to determine how to deploy it most effectively are of critical importance. Malaria Branch, Division of Parasitic Diseases, Center for Infectious Diseases, Centres for Disease Control, Atlanta, Georgia 30333, USA


1. Greenwood BM,






Bradley AK, Byass P, et al. Companson of two strategies for control of malaria within a primary health care programme m The Gambia Lancet 1988; i: 1121-27 Spencer HC, Kaseje DCO, Mosely WH, Sempebwa EKN, Huong A, Roberts JM. Impact on mortality and fertility ofcommunity-based malaria control programme m Saradidi, Kenya. Ann Trop Med Parasitol 1987; 81 (suppl 1) 36-45. Hoffman SL, Masbar F, Hussein PR, et al. Absence of malaria mortality in villagers with chloroquine-resistant Plasmodium falciparum treated with chloroquine. Trans R Soc Trop Med Hyg 1984, 78: 175-78 Baudon D, Roux J, Camevale P, et al. Etude de deux strategies de controle des paludisme, la chimiotherapie systematique des acces febriles et la chimioprophylaxie hebdomadaire dans douze villages de Haute-Volta, en zone de savane et zone rizicole de 1980 a 1982. Doc Tech OCCGE 98450/84: 1-79 Greenwood BM, Bradley AK, Greenwood AM, et al. Mortality and morbidity from malaria among children in a rural area of The Gambia, West Africa. Trans R Soc Trop Med Hyg 1987; 81: 478-86. Kaseje DCO, Spencer HC, Sempebwa EKN Usage of community-based chloroquine treatment for malaria in Saradidi, Kenya Ann Trop Med Parasitol

1987; 81 (suppl 1). 111-15. PL, Bowman A, Marsh K, Greenwood BM. The accuracy of the clinical histories given by the mothers of severely ill African children. Ann Trop Paediatr 1987; 7: 187-89. 8 Greenwood BM, Greenwood AM, Bradley AK, Tulloch S, Hayes R, Oldfield FSJ. Deaths in infancy and early childhood m a well vaccinated, rural, West African population. Ann Trop Paediatr 1987; 7: 91-99 9. Ognibene AJ Agranulocytosis due to dapsone Ann Intern Med 1970; 72: 521-24. 10. Friman G, Nystrom-Rosander C, Jonsell G, Bjorkman A, Lekas G, Svendstrup B. 7. Alonso


Agranulocytosis associated with malaria prophylaxis with Maloprim. Br Med J 1983; 286: 1244-45 MacCormack CP, Lwilhula G. Failure to participate in a malaria chemosuppression programme: North Mara, Tanzania. J Trop Med Hyg 1983, 86: 99-107

RAPIDS, RAFTS, AND RATS SiR,—Many new ideas have been introduced to satisfy the holidaymaker’s appetite for adventure. A raft trip down rapids is one example. Two travellers set off independently to northern Thailand in search of excitement. They met on a wooden raft on the Tha Thon river, attempting to traverse the rapids during the monsoon season. They nearly drowned when the raft capsised. Having swallowed a considerable amount of river water they then trekked along the mud banks before reaching base camp where they parted company and continued on their separate adventure trails. One week later, both were admitted to a Bangkok hospital with the abrupt onset of severe headache, intense myalgia, and high fever. No diagnosis was made, but both recovered on oral penicillin and were discharged after a few days. This coincided with the end of their holidays and both