- Email: [email protected]
ANTENATAL CARE FOR GURKHA WIVES
813 encore?" All sorts of interesting and worthwhile work was waiting to be done. One rule I made was that from then on I would not accept invitations that involved endless hours of boring committee meetings. The interesting consequence is that I have never been busier, and everything I do now is wholly enjoyable. Moreover this has proved to be a most productive period. In the three years since I left the chairman’s office, I have edited a large textbook and a small monograph. Now, besides editing a journal, I am working on three more books and am leading a more normal family life. I hope others who read Catchpole’s article will find his and my
for
an
thoughts reassuring. School of Medicine, University of Ottawa, Ottawa, Canada K 1 N 9A9
JOHN M. LAST
PHARMACEUTICALS IN BANGLADESH
SIR,-In
response
to
your
Round
the World
item
on
Gonoshasthaya Kendra Pharmaceuticals (July 4, p. 35) some pharmaceutical concerns have expressed their opinions (Sept. 5, p. 524, and Sept. 12, p. 586). Doctors, especially those who have worked in Bangladesh, need to make their views known. Inappropriate and extravagant prescribing has been recorded in many third world countriesand drug consumption patterns do not 2 always parallel the pattern of the most prevalent diseases.2 Promotional activities have created a demand greater than the need not been a proportionate improvement in health.3Expenditure on expensive and inessential drugs means that a large segment of population will be deprived of essential drugs. 60-80% of the populations of many countries do not have constant access to essential drugs. An essential drug list4 has been adopted by many developing
and, despite the great increase in drug usage, there has
developing
countries.1,5 The drug market in Bangladesh is, if anything, worse than the description given by your reporter. The drug control department, with its limited manpower, has to supervise about 17 000 registered pharmacies and countless other unregistered ones. Most drugs can be bought over the counter. The sales of vitamins and alkali preparations, tonics, and anabolic drugs far outweigh the sales of other drugs. Drugs which doctors in the developed countries have stopped using because of dangerous side-effects are still sold. An example is the widespread use of iodochlorhydroxyquin, usually on self-prescription. The Gonoshasthaya Kendra, which has already established a 6 pioneer role in community health care in rural areas of Bangladesh, has now come forward with a venture to supply essential drugs at minimum possible cost to the population. This project, if successful, would not only improve drug availability and use in Bangladesh countryside, but would also serve as a model from which other developing countries can learn. The drug companies are understandably concerned, but Gonoshasthaya Kendra Pharmaceuticals cannot replace them as the major supplier of drugs: all it can do is to set an example in the production of essential drugs at a low price and their proper distribution in deprived areas. The drug market in developing countries is almost certain to grow2 and the manufacturing concerns will surely remain profitable, but following the lead of the Gonoshasthaya Kendra Pharmaceuticals will mean much greater service to the country in which they operate. Gastrointestinal Unit, Western General Hospital,
Edinburgh
M. HASAN
Department of Orthopaedic Surgery, Princess Margaret Rose Orthopaedic Hospital, Edinburgh
M.R.H.KHAN
1. Anon. Drug use in the third world. Lancet 1980; ii: 1231-32. 2. Antezana FS. Essential drugs-whose responsibility? J Roy Soc Med 1981; 74: 175-77 3 Editorial. Desert-island drugs. Lancet 1978; i: 423-24. 4. Anon. W.H.O. on essential drugs. Lancet 1978; ii: 977-78. 5. Hanlon J. Are 300 drugs enough? New Sci Sept 7, 1978: 708-10. 6. Anon. Gonoshasthaya Kendra. Lancet 1976; i: 26-27.
MALARIA PROPHYLAXIS WITH CHLOROQUINE SIR,-The W.H.O. recommendation that chloroquine be used as the drug of choice for malaria prophylaxis has done much to increase the incidence of chloroquine resistant strains of Plasmodium falciparum, and I read with dismay the report from Dr Bengtsson and colleagues in Sweden (Aug. 1, p. 249) of three cases of malaria in expatriates who had taken the recommended four tablets of chloroquine a week as a prophylactic. Now Bengtsson et al. recommend that this be followed by a course of sulphonamides. Having worked for several years in East and Central Africa and the Sudan in" areas of undoubted chloroquine resistance I am impressed just how effective the long-tried prophylactics proguanil and pyrimethamine still are. I have occasionally seen proven falciparum malaria in people who had, allegedly, taken these drugs regularly, but invariably they responded to conventional doses of chloroquine used curatively. Chloroquine is not an efficient prophylactic drug and four tablets a week could cause side-effects, notably to the eye, in expatriates on short-term contracts. Chloroquine surely must be kept as the drug of choice for treatment of malaria for as long as possible. To use it as a prophylactic means that the only effective treatment is quinine, in the event of genuine chloroquine resistance developing. Quinine has caused several deaths and complications in the past and I would dread to see it return as the number one treatment drug. Furthermore physicians treating the indigenous populations in malaria countries are abusing chloroquine and tend to prescribe it in unnecessarily large doses, usually by injection, thereby increasing the risk of resistant strains, reducing the acquired immunity of the population, and, ultimately, exposing them to the risk of chloroquine resistant falciparum cerebral malaria which carries a high mortality. Abuse of antimalarial drugs is just as serious as that of antibiotics and insecticides. 11 The
-
Avenue,
Roundhay, Leeds 8
C. H. MCCLEERY
ANTENATAL CARE FOR GURKHA WIVES
SIR,-Your Sept. 19 editorial misses the point made by Captain Rasor in the Journal of the Royal Army Medical Corps in his article on the obstetric problems in the wives of Gurkha soldiers serving in the New Territories, Hong Kong. He was at pains to point out that the attitude of peasant Nepalese women to their obstetric care is different from that of the wives of British soldiers. Unless cajoled to attend for antenatal care they report to the unit’s Family Hospital for the first time in established labour, too late to be safely transferred to the British Military Hospital should complications be found. The result is that the perinatal mortality rate, at 21-55 per 1000, is nearly double the rate for British wives (12-4per 1000). If threats for failing to report pregnancies sound harsh, they are only made with the interest of the Gurkha families in mind and in the hopes of providing proper antenatal care and of making arrangements for complicated cases to be delivered in hospital. T. L. T. LEWIS, 109
Harley Street,
London W1N 1DG
Hon. Consultant in Obstetrics and Gynaecology to the Army
MALNUTRITION’S ROLE IN BLINDNESS
SIR,-The study by Dr Sommer and his associates (June 27, p. 1407) on blinding malnutrition in West Java is a fundamental contribution to the epidemiology of nutritional blindness. These workers report cases of classic corneal xerophthalmia, but malnutrition in less florid forms can also contribute to blindness in children. Chronic malnutrition interferes with host defence mechanisms, and milder degrees of conjunctival and corneal xerosis may well enhance the susceptibility of the eye to infections. In many 1. Chandra RK. Nutritional deficiency and susceptibility to infection Bull Wld Hlth Org 1979; 57: 167-77.
for
an
thoughts reassuring. School of Medicine, University of Ottawa, Ottawa, Canada K 1 N 9A9
JOHN M. LAST
PHARMACEUTICALS IN BANGLADESH
SIR,-In
response
to
your
Round
the World
item
on
Gonoshasthaya Kendra Pharmaceuticals (July 4, p. 35) some pharmaceutical concerns have expressed their opinions (Sept. 5, p. 524, and Sept. 12, p. 586). Doctors, especially those who have worked in Bangladesh, need to make their views known. Inappropriate and extravagant prescribing has been recorded in many third world countriesand drug consumption patterns do not 2 always parallel the pattern of the most prevalent diseases.2 Promotional activities have created a demand greater than the need not been a proportionate improvement in health.3Expenditure on expensive and inessential drugs means that a large segment of population will be deprived of essential drugs. 60-80% of the populations of many countries do not have constant access to essential drugs. An essential drug list4 has been adopted by many developing
and, despite the great increase in drug usage, there has
developing
countries.1,5 The drug market in Bangladesh is, if anything, worse than the description given by your reporter. The drug control department, with its limited manpower, has to supervise about 17 000 registered pharmacies and countless other unregistered ones. Most drugs can be bought over the counter. The sales of vitamins and alkali preparations, tonics, and anabolic drugs far outweigh the sales of other drugs. Drugs which doctors in the developed countries have stopped using because of dangerous side-effects are still sold. An example is the widespread use of iodochlorhydroxyquin, usually on self-prescription. The Gonoshasthaya Kendra, which has already established a 6 pioneer role in community health care in rural areas of Bangladesh, has now come forward with a venture to supply essential drugs at minimum possible cost to the population. This project, if successful, would not only improve drug availability and use in Bangladesh countryside, but would also serve as a model from which other developing countries can learn. The drug companies are understandably concerned, but Gonoshasthaya Kendra Pharmaceuticals cannot replace them as the major supplier of drugs: all it can do is to set an example in the production of essential drugs at a low price and their proper distribution in deprived areas. The drug market in developing countries is almost certain to grow2 and the manufacturing concerns will surely remain profitable, but following the lead of the Gonoshasthaya Kendra Pharmaceuticals will mean much greater service to the country in which they operate. Gastrointestinal Unit, Western General Hospital,
Edinburgh
M. HASAN
Department of Orthopaedic Surgery, Princess Margaret Rose Orthopaedic Hospital, Edinburgh
M.R.H.KHAN
1. Anon. Drug use in the third world. Lancet 1980; ii: 1231-32. 2. Antezana FS. Essential drugs-whose responsibility? J Roy Soc Med 1981; 74: 175-77 3 Editorial. Desert-island drugs. Lancet 1978; i: 423-24. 4. Anon. W.H.O. on essential drugs. Lancet 1978; ii: 977-78. 5. Hanlon J. Are 300 drugs enough? New Sci Sept 7, 1978: 708-10. 6. Anon. Gonoshasthaya Kendra. Lancet 1976; i: 26-27.
MALARIA PROPHYLAXIS WITH CHLOROQUINE SIR,-The W.H.O. recommendation that chloroquine be used as the drug of choice for malaria prophylaxis has done much to increase the incidence of chloroquine resistant strains of Plasmodium falciparum, and I read with dismay the report from Dr Bengtsson and colleagues in Sweden (Aug. 1, p. 249) of three cases of malaria in expatriates who had taken the recommended four tablets of chloroquine a week as a prophylactic. Now Bengtsson et al. recommend that this be followed by a course of sulphonamides. Having worked for several years in East and Central Africa and the Sudan in" areas of undoubted chloroquine resistance I am impressed just how effective the long-tried prophylactics proguanil and pyrimethamine still are. I have occasionally seen proven falciparum malaria in people who had, allegedly, taken these drugs regularly, but invariably they responded to conventional doses of chloroquine used curatively. Chloroquine is not an efficient prophylactic drug and four tablets a week could cause side-effects, notably to the eye, in expatriates on short-term contracts. Chloroquine surely must be kept as the drug of choice for treatment of malaria for as long as possible. To use it as a prophylactic means that the only effective treatment is quinine, in the event of genuine chloroquine resistance developing. Quinine has caused several deaths and complications in the past and I would dread to see it return as the number one treatment drug. Furthermore physicians treating the indigenous populations in malaria countries are abusing chloroquine and tend to prescribe it in unnecessarily large doses, usually by injection, thereby increasing the risk of resistant strains, reducing the acquired immunity of the population, and, ultimately, exposing them to the risk of chloroquine resistant falciparum cerebral malaria which carries a high mortality. Abuse of antimalarial drugs is just as serious as that of antibiotics and insecticides. 11 The
-
Avenue,
Roundhay, Leeds 8
C. H. MCCLEERY
ANTENATAL CARE FOR GURKHA WIVES
SIR,-Your Sept. 19 editorial misses the point made by Captain Rasor in the Journal of the Royal Army Medical Corps in his article on the obstetric problems in the wives of Gurkha soldiers serving in the New Territories, Hong Kong. He was at pains to point out that the attitude of peasant Nepalese women to their obstetric care is different from that of the wives of British soldiers. Unless cajoled to attend for antenatal care they report to the unit’s Family Hospital for the first time in established labour, too late to be safely transferred to the British Military Hospital should complications be found. The result is that the perinatal mortality rate, at 21-55 per 1000, is nearly double the rate for British wives (12-4per 1000). If threats for failing to report pregnancies sound harsh, they are only made with the interest of the Gurkha families in mind and in the hopes of providing proper antenatal care and of making arrangements for complicated cases to be delivered in hospital. T. L. T. LEWIS, 109
Harley Street,
London W1N 1DG
Hon. Consultant in Obstetrics and Gynaecology to the Army
MALNUTRITION’S ROLE IN BLINDNESS
SIR,-The study by Dr Sommer and his associates (June 27, p. 1407) on blinding malnutrition in West Java is a fundamental contribution to the epidemiology of nutritional blindness. These workers report cases of classic corneal xerophthalmia, but malnutrition in less florid forms can also contribute to blindness in children. Chronic malnutrition interferes with host defence mechanisms, and milder degrees of conjunctival and corneal xerosis may well enhance the susceptibility of the eye to infections. In many 1. Chandra RK. Nutritional deficiency and susceptibility to infection Bull Wld Hlth Org 1979; 57: 167-77.