Audit and research

308

Epidemiology in central

and eastern

Europe

SiR,—John Newton’s conclusion (July 18, p 170), that the quality epidemiology in the countries of central and eastern Europe (CCEE) is generally poor, is justified. However, he is not wholly correct in his analysis of the reasons for this situation. Epidemiology has existed and, at least in some countries, was not politically suppressed. The difficulty was that since the late 1940s epidemiology was based on the Soviet model, concentrating on control of communicable diseases. In this narrow field, epidemiology achieved some respectable results,l but since communicable disease control needs only limited aetiological research, epidemiological methodology was limited to descriptive methods. Furthermore, as with other scientific disciplines, public health was isolated from developments in the west, and the shift towards non-communicable disease epidemiology in the 1960s did not take place in the CCEE. More recently, those who attempted to develop it were faced with a shortage of funds. Nevertheless, there is now a growing body of high quality epidemiological research into non-communicable disease taking place in the CCEE. For example, staff of Charles University and the Institute of Hygiene and Epidemiology in Prague are working with colleagues from the London School of Hygiene and Tropical Medicine on studies of the determinants of the epidemic of cardiovascular disease, on effects of environmental pollution on infant health, and on the mortality patterns associated with the Czech mining industry. Newton is unduly pessimistic about the probability of new schools of public health emerging in the near future. Programmes funded by the World Bank to develop new schools of public health and health service management in Hungary and Romania will start early in 1993. The European Community TEMPUS programme has funded a major project to restructure public health training in medical universities in Hungary. This involves universities in Canada, Denmark, France, Norway, Spain, and the UK. With a budget of almost C500 000, the programme is providing library facilities, computers, teacher training, and study visits to western Europe. Its first year has been very successful, with a complete review of the undergraduate curriculum. The second and third years will concentrate on postgraduate training, linking with developments in the school of public health. Proposals for similar projects have been submitted in respect of the Czech Republic and Romania. Finally, a new school of public health is being developed in Krakow, Poland, with assistance from the American organisation Project HOPE. All these projects will need time to take effect but we hope that we can persuade Newton to share our optimism.

of

Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK

MARTIN MCKEE

Third Medical Faculty, Charles University, Prague, Czechoslavakia

MARTIN BOBAK

School of Public Health, Krakow, Poland

ADAM NAZIM

CHARLES NORMAND

1. Feachem RGA, Preker A. The Czech and Slovak Federal Republic: the health sector, issues and priorities. Washington: World Bank, 1991.

Costs of Medline and CD-ROM

searching

information is an important part of medical research and clinical practice. Much time and money is devoted to it by physicians and hospitals. In these times of diminishing resources, those facilities should function efficiently. Judicious and justifiable use of modem technology can help. The Rouen University Hospitals have two medical libraries: one is at the School of Medicine for students and junior doctors, the other is in one of the hospitals, for the 280 staff members. In the hospital, all expenses are paid by the hospital and literature searches are done by a medical librarian, more efficiently than by even experienced end-users.1 From April, 1987, to December, 1990, Medline was accessed (on the Questel Server) through a Minitel videotext terminal, and after this date, through a PS/2 microcomputer. The cost of online Medline is C20 per hour, with an additional jO.08 per reference. In April, 1991, Medline on CD-

SIR,-Access

to

(Compact Disc-Read Only Memory) was obtained (Compact Cambridge edition). At first only one CD player was available. In January, 1992, a second player was bought, and two ROM

in March, 1992. Medline remains accessible online. Since Medline has been available both online and on CD-ROMs, the cost per search has declined strikingly: No of No of CD Cost/search Monthly

more

Dates (mo/yr)

1-3/1991 3-6/1991 1-2/1992 3-6/1992

drives 0 1 2 4

*Including the subscription to

searches (f) (E) 10 1364 135 5.8 730* 127 51 178 909* 42 609* 145 the Medhne CD-ROM (f1400/year), and the cost

reduction to zero of the cost of the CD players (E560 per player) over 4 years. If one assumes a mean of 145 searches per month, the subscription to CD-ROM Medline, and the cost of the first CD player is reimbursed in a little more than three months, the second player in 5 months, and the last two in 8 months. This is much less than earlier estimates.2 However, the complete Medline collection comes on 18 CD discs. Access to all this information implies either exchanging discs (which is time-consuming and painful on the wrists), or having multiple CD players, or online access. Four players enables access to the last four years of information directly. Online access to Medline is restricted essentially to exhaustive searches over long periods, especially when very few references are found on the most recent discs, or to searches limited to records added to Medline since the last disc update. In both cases, in fact, the online search is prepared and tested first on the CD-ROMs, to keep to a minimum the time spent and the number of references accessed online. This cost-analysis should also be done in other countries, since it involves country-specific costs (essentially communication costs), and should be repeated over time, since the reducing cost of the materials (computers, CD players) will make them increasingly costeffective. Medical

Library, Regional Centre for Hospital Information, and Service of Pharmacology, CHU de Rouen, 76031 Rouen, France

B. THIRION

S. J. DARMONI N. MOORE

1. McKibbon KA, Haynes RB, Dilks CJ, et al. How good are clinical Medline searches?

A comparative study of clinical end-user and librarian searches.

Comput Biomed

Res

1990; 23: 583-93. 2. Fox GN. Computer literature searching: will docs byte? Fam Pract Res J 1991; 11: 9-14.

Audit and research SIR,-Professor Sherwood (July 4, p 37) implies that we must choose between audit and research. The use of audit funds to address questions more appropriately answered by research lends some support to his contention but highlights a fundamental difference between the two activities-the nature of the question being asked. In audit one is asking whether an activity, known to be capable of achieving a specific outcome, is actually achieving that outcome in the hands of those undertaking the audit. This presupposes knowledge of efficacy, measurability of outcome, and agreement on an acceptable standard against which performance can be measured. Audit is about doing the right thing and doing it better-is an efficacious intervention effective? In this context research is asking what the right thing is. Free thinking and audit are not incompatible, although the scope for the former may be restricted in the setting of the latter. The lack of knowledge about the efficacy of many medical interventions (and, I suspect, the difficulties of obtaining support for small research projects) underlies the move to conduct research in the context of audit. The constraints of the audit cycle, the questions about who it is for, and the fears expressed by Sherwood about "dullness" and "intellectual coercion" are likely to lead to poor research as well as ineffective audit despite the apparent increase in a questioning attitude that is engendered by the profession embracing audit. One solution to this paradox is to restrict formal audit activity to those topics for which it is appropriate-namely, interventions with

309

evidence of efficacy-and to direct research to those areas (the majority) where such evidence is lacking. None of this should detract from the need for critical examination by medical practitioners of the quality of medical activity; much of this can

provide valuable insights into areas where improvements can be made and may facilitate the conduct of formal audit-eg, by improving the quality of clinical case records. However, encouraging inappropriate audit activity, just to get people involved, could be counterproductive since it might reduce the pressure for the basic studies of efficacy that must underpin audit and should underpin medical practice. Academic Unit of Public Health Medicine, School of Public Health, University of Leeds, Leeds LS2 9LN, UK

Banking umbilical

ANTONY J. FRANKS

cord blood

SIR,-Dr Hows and colleagues (July 11, p 73) indicate that banked human umbilical cord (HUC) blood is likely to prove preferable to bone marrow from volunteer donors, as a source of haemopoietic stem cells for the transplantation of children with leukaemia or Fanconi’s anaemia. However, there is a difficulty that needs careful consideration. The HUC blood belongs to the baby, at least until adaptation to extrauterine life has taken place and umbilical pulsation has ceased. It is unethical to rely on permission obtained in advance from the mother to take the blood unless the critical importance of the transitional feto/placental circulation is not only fully explained to her but also is defended in practice by the birth attendants. Unfortunately, in many parts of the world the importance of perinatal feto/placental haemodynamics is poorly understood, as shown by the arbitrary way in which the cord is often tripleclamped at birth to obtain arterial and venous samples for blood gas and acid-base studies. This practice not only abruptly interrupts the umbilical circulation but may also deprive the newly born infant of an amount of blood equivalent to at least a third of its normal circulating volume. This may have serious consequences for the baby, especially if sick or premature.1 Of course, such a practice would be advantageous to those wishing to bank HUC blood, since the placenta may then yield perhaps three time as much blood as would be the case were normal fetal circulatory adaptation allowed to proceed. While appreciating that the Southmead team are aware of this difficulty, they do not fully discuss it in their paper. University of Bristol, Department of Child Health, Southmead Hospital,

PETER M. DUNN

Bristol BS10 5NB, UK

1 Dunn PM. Tight nuchal cord and neonatal hypovolaemic shock. Arch Dis Child 1988; 63: 570-71.

Natural

family planning

in

developing

countries SiR,—Dr Poole (July 11, p 120) says that natural methods of family planning (NFP) are of very limited use in developing countries. Four recent publications on this subject seem to contradict her views. In Liberia a use and cost-effectiveness study from 1983 to 1988 showed a total pregnancy rate of 4-3% (Pearl Index) and a cost of US$40 per user.’ In Zambia, the pregnancy rate was 8-9% and the user cost US$30.1 In India an investigation of 3003 illiterate and semiliterate women taught to use NFP showed a pregnancy rate of 2-04%,2 and a study sponsored by the Ministry for the Family of the former Federal Republic of Germany, showed a pregnancy rate of 2-3%. A pilot study to assess the effectiveness and acceptability of NFP, done by the Family Planning Research Institute of Tianjin, China, showed lifetable continuation and pregnancy rates of 9-7% (Dr M. Wang et al, Tianjin Family Planning Research Unit), which compare favourably with the termination rate of 11 -75% obtained for the intrauterine device in the same institute.’ There is no doubt, therefore, that NFP has proved as efficient as modem contraceptive methods, in some instances more efficient, and can be used effectively by both uneducated and educated couples.

Poole referred specifically to the failure of NFP in the Philippines. However, her opinions are not substantiated by publications of NFP effectiveness studies done in that country. Laing; compared the pregnancy rates for the calendar method (the least efficient natural method) and the contraceptive pill. Cumulative pregnancy rates showed that although in the short term oral contraception produced a lower pregnancy rate at one year of use than the calendar method (28 vs 36), at the end of the third year the calendar method was more effective than oral contraception (23 vs 18).5 Nor must we forget the primary health component of NFP. Breastfeeding, the natural method par excellence, affords more contraceptive protection worldwide than any other family planning method, whether artificial or natural. Consequently, NFP is closely integrated into maternal child health programmes in several developing countries. Furthermore, in developing populations, the knowledge acquired by an awareness of fertility and the power it confers in controlling that fertility, is very effective in promoting the personal development of women in society. Finally, the costeffectiveness of NFP when compared with artificial contraception is a further important consideration and attraction for health ministries in developing countries short of monies and medical manpower for curative medicine. Department of Obstetrics and Gynaecology, Family Planning Research Centre, Birmingham Maternity Hospital, Birmingham B15 2TG, UK Natural

ANNA M. FLYNN

1. Kambic RT, Gray RH, Lanctct AL, et al. Evaluation of natural family planning programmes in Liberia and Zambia. Am J Obstet Gynecol 1991; 165: 2078. 2. Dorairaj K. The modified mucus method in India. Am JObstet Gynecol 1991; 165: 2066-67. 3. Frank-Hermann P, Freundl G, Baur S, et al. Effectiveness and acceptability of the symptothermal method of natural family planning in Germany. Am J Obstet Gynecol 1991; 165: 2052-54. 4. Qian LJ, Li LZ, Wang M, et al. A randomised comparative study of the performance of seven different sizes of the Mahua ring inserted following measurement of the uterine cavity and one size of the same ring. Contraception 1990; 42: 391-401. 5. Laing JE. Natural family planning m the Philippines. Studies Fam Plann. 1984; 15: 49-61.

The commercial

pyramid

Dr Francesci’s report (July 18, p 181), SIR,-With respect "sweets or candies" translated from the US Department of Agriculture version of the food pyramid to the Italian mistakenly to

came out as

"sugar".

Since few Italians or others with comparable cuisines of excellence would ever sit down to a meal consisting exclusively of "sugar", I believe that the Italian food pyramid suffers not so much from "commercial manipulation" as from poor translation. World Sugar Research Organisation, University of Reading Innovation Centre, Reading RG6 2BX, UK

A.

J. VLITOS

Mefloquine prophylaxis against malaria for female travellers of childbearing age the regional drug information centre (CRIF),1 we increase in the number of inquiries from pregnant women about fetal risks after exposure to antimalarials, especially mefloquine. Over the past 2 years, 24 women (mean age 31-4 years) in their first trimester of pregnancy (mean 7-6 weeks, all primigravidae) asked about the risk of teratogenesis associated with the use of mefloquine during the conceptional and periconceptional period. All the women had been in regions of endemic malaria for a few weeks 1-2 months earlier, when they were either not pregnant or did not know they were. In accordance with local public hygiene service recommendations, a week before departure and weekly until return they took mefloquine 250 mg. Mefloquine is teratogenic in the rat and rabbit 32although it seemed to be safe in prophylaxis in pregnant Nigerian women.3 However, both the CDC4 and WHO/ contraindicate the drug for prophylaxis in pregnancy. All our women were reassured and advised to refer both inquiry and answer to their gynaecologist to plan any monitoring of the pregnancy. At CRIF follow-up, none of

SIR,-At

noticed

an