- Email: [email protected]
Estonia FORUM MEDICORUM ESTONIAE
1385 lower. Under the President’s
laboratory accident? There is no medical or scientific reason why it
plan, "negligible" would be a 1 in 100 000 or even higher risk. Just about any risk would be acceptable if the EPA decided that the economic benefits to farmers and manufacturers of a pesticide justified continued use. As Janet Hathaway, an attorney for the activist National Resources Defense Council, points out, the new ban would not mean much if the EPA, as it invariably does, chose
should not be a notifiable disease and dealt with as such. Now that AIDS is appearing in teenagers the sooner a requirement for notification is introduced the better. Growing numbers of children are also infected, and soon one in every ten paediatric beds will be occupied by children with AIDS. Facilities for treating and caring for children with AIDS are virtually non-existent.
that risk
was
not to use
1 in 1000 000
or even
it.
in the President’s plan is an old law that of a pesticide carcinogen in processed foods. prohibits Paradoxically, the EPA routinely sets allowable pesticide carcinogen residues on raw food. Under the law, it is safe to eat tainted fresh tomatoes but not tainted tomato paste. The President wants to replace the law regulating processed food (called the Delaney clause after its Congressional sponsor) with his new "negligible" risk approach. Here he has the backing of the National Academy of Sciences, which says the Delaney clause is scientifically A
principal target
even a trace
unjustified. The truth is that pesticides are already getting into processed foods. This became apparent last May in a lawsuit against the EPA filed by John K. Van de Kamp, Attorney General of California, along with environmentalists and organised labour. Mr Van de Kamp accused the EPA of improperly permitting the use of at least twenty cancer-causing pesticides. Seven of them, said the suit, were found in minute amounts in such processed foods as cereal, orange juice, baby foods, crackers, flour, and sugar. EPA officials traditionally respond to this form of publicity by telling the media that all foods are safe. Actually, there is a small risk from eating some raw foods. EPA executives regularly use human and animal studies to calculate the cancer mortalities. They just do not want to start another panic like the one that forced the maker of ’Alar’, a pesticide used by apple growers, to remove the produce from the market. Studies of higher exposures in man confirm the danger. A review of published work by Kenneth P. Cantor and Aaron Blair of the National Cancer Institute shows pesticide applicators suffered excess deaths from lung cancers. Farmers had raised levels of cancer of the lip, stomach, prostate, and brain, non-melanoma skin cancer, leukaemia, non-Hodgkin’s lymphoma, and multiple myeloma. This evidence is unlikely to worry Congress or the White House. Whatever happens to President Bush’s plan to clarify pesticide laws, the EPA and Congress, historically, have been more solicitous to the farmers and pesticide manufacturers than to consumers. 115 Blue Hills Road, Amherst, Massachusetts 01002, USA
J. B. SIBBISON
AIDS IN TEENAGERS
THE patient has mental symptoms and is on zidovudine for his AIDS. He is soon going to be discharged, and he threatens to go out and spread AIDS. The epidemic rolls on, and figures suggest that 1 % of teenagers may be affected. Talk among those looking after AIDS patients, especially those with early mental symptoms, suggests that this angry patient’s response is not untypical-a minority of AIDS victims are actively and intentionally spreading the disease. How different would it be if the patient had syphilis rather than AIDS. His infection would be notified to the local health authority, the contacts traced and tested, and the patient treated and observed. So it would be if it were tuberculosis or even poliomyelitis, so why not AIDS? What hope have we for controlling the AIDS epidemic if the infection is not treated as a dangerous contagious disease? AIDS meets all the criteria. Spread by sexual contact or by contaminated blood? Yes. Danger to anyone having sexual contact with an AIDS virus carrier? Yes. Fatal if untreated? Yes. Carriers are present and an immediate danger to the public? Yes. So what is the difference? Social stigma? Well that applied to those afflicted with syphilis. In a country where AIDS is every day a matter for newspaper comment and is widely discussed why is the reality of the AIDS epidemic not faced up to and treated as an infectious venereal disease, occasionally and tragically sometimes spread through accident, blood transfusion, maternal-infant transmission,
Estonia FORUM MEDICORUM ESTONIAE
peaceful struggle of the Estonians to regain their independence extends to the medical profession. Estonian physicians have become vocal in their rejection of the politicisation of medicine during Soviet rule. The Union of Estonian Physicians (Eesti Arstide Liit) and local medical groups have vigorously spoken out on such issues as the environment, physician training, scientific research, salaries, and health insurance. Strategies for achieving excellence in medicine in Estonia are being debated. Estonians feel that the Soviet rule during the past fifty years has reduced the republic to a developing country. Physicians are particularly anxious to improve the republic’s status and support Estonia’s efforts to rejoin the European family of nations. The political changes and the promise of increased autonomy have led to demands for a greater voice in the republic’s health planning. At present, under Moscow’s guidelines, about 3% of Estonia’s budget is earmarked for health care. This figure includes building and other capital expenditure. To reach the level of the developed nations in health care the budget allocation needs to be THE
increased three to four fold. Examination of the present state of the profession and of the republic’s health needs shows that the health of the people is not good. According to the chairman of the Medical Society of Saaremaa, the life expectancy of a male in his district is only 59 years. The doctor/patient ratio is high (46 physicians per 10 000 population-twice the rate in the United States), but the physicians’ effectiveness is reduced by assignment of duties not related to their training, and waiting times for health care are long. The dedication of Estonian doctors and other health professionals to service to the people is even more remarkable in view of their poor remuneration. The current salary of medical workers is only 68% of the mean income of all workers. Serious questions concerning training of physicians are now being raised. During the recent Forum Medicorum Estoniae, several speakers expressed concern over the early and narrow specialisation, which begins in the third or fourth year of the six-year course. Those training medical students say that too much time is allocated to courses designed to "develop the student’s outlook on the world". These include courses such as History of Soviet Communist Party, ScientificCommunism, and the Scientific Basis for Atheism. Plans are being made to reduce the numbers of doctors qualifying, not by changing admission policies for medical students but by raising academic standards so that fewer will graduate. The state of medical research in Estonia was described by the Health Ministry’s chief surgeon, Dr Juri Manniste, as a "combination of world class and primitive". The Estonian Heart Centre of Tallin, directed by Dr Toomas-Andres Sulling, lays claim to being one of the best in the USSR. However, research developments in many other areas appear to be rudimentary. Dr Manniste proposed improvement of exchange programmes with Western scientists and raising of the level of training in sciences to permit mutual acceptance and accreditation. The Minister of Health proposed new systems for the training and retraining of physicians, combining social and public health care systems, matching salaries to qualifications, developing principles and guidelines for a new health insurance system, and manufacture of medical supplies in Estonia. The last point is a telling one. Although disposable syringes are being manufactured in Estonia, they are not generally available, and smaller rural hospitals are reusing broken syringes mended with tape.
1386 The forum concluded with a declaration. Besides addressing environmental concerns and criticising the past political conditions which had "marred the psyche and thought process of our people", the document includes the following statement: "Our profession has been debased and we have been deprived of means to serve our people in a manner we are capable of. In order to fulfill the mission which has been assigned to us by fate, we must steadfastly stand in the defence of our people’s health and rights; Medical science constitutes an integral and inseparable part of mankind’s culture. We cannot permit its destruction in a manner which has already befallen our spiritual heritage during the past
half-century." The document concluded with a plea to the world’s physicians to raise their voices in the defence of the Estonian, Latvian, and
Lithuanian people.
New Zealand ORGAN DONOR REGISTRY IN
JEOPARDY
programme to increase the pool of donor organs for transplantation has foundered after irreconcilable disagreements between central Government and area health boards. The scheme originated with the National Kidney Foundation. Currently 500 New Zealanders are sustained by renal dialysis; two-thirds of these people want transplantation. The Kidney Foundation argued that if the wishes of potential donors were known it would be easier to approach relatives and more organs would become available. The National Heart Foundation, with an undisclosed number of people waiting for heart transplantation, also supported the proposal. Similar schemes operate in other parts of the world. In Britain people carry a card indicating their willingness to donate, although relatives of card-carriers are still approached. In Belgium and Austria everyone is presumed to be a donor unless they opt out. Medical staff in America are required by law to seek permission from the relatives of possible donors. In New Zealand the Department of Health supported the Kidney Foundation’s proposal. The scheme entailed linkage with the National Master Patient Index, a compulsory register of all people who enter public hospitals. The idea was that when people renewed their drivers’ licences, they would fill out a form indicating their willingness to give kidneys, eyes, or heart. Each area health board would use staff in the records departments of hospitals to check if they were already on the NMPI, and enrol them if they were not. In 1987 the register was launched at the Ministry of Transport headquarters in Wellington amid much publicity. Whether to become a donor or not quickly became a common topic of discussion among members of the public. Within two years 770 000 New Zealanders had indicated their willingness to donate organsnearly half of all people taking out drivers’ licences. But if the scheme was enjoying widespread public support, at another level it was in deep trouble. The Ministry of Transport decided to bring in lifetime drivers’ licences, and within twelve months every driver got a new one. This created a huge bulge in the numbers and area health boards were flooded with tens of thousands of forms. They protested to the Health Department that they did not have the resources to enter the donor information. Some of the smaller boards have coped, but the larger boards have not. By July, 1989, only 18% of the names of potential donors had been computerised. Dr Bruce Morrison, medical advisor to the National Kidney Foundation, estimates that nearly 1 million names need to be entered for the scheme to be fully operational. The Department of Health has been unmoved by the Boards’ pleas for additional funding. A senior departmental executive claims the register is being used by boards as "a political chestnut" to extract more funding from the Government. The operation of the register, maintains the Department, "is entirely a matter of local board management ... If they think it is important, they have to make it a priority". The Department argues that, since transplantation is cost effective, boards should see the economic sense in developing the register. Wellington lawyer Trevor Roberts, a member of the Wellington Area Health Board for the past ten years, describes the failure of the donor register as "a casualty of bigger underlying problems". A
Funding allocations to boards have been severely cut by the Government in the past two years. Only 7% of gross domestic product goes on health. New Zealand is seventeenth of OECD countries in health spending. Roberts calls it a rationing system and says that elective surgery is always first to go when health budgets shrink. He maintains that cost effectiveness is not the only criterion for boards trying to operate on impossible budgets: "If it costs $100 000 now to save$200 000 in 18 months time, we can’t do it because we haven’t got the money now. You can’t allocate resources when they are capped at the top". The donor scheme seems to have come to a standstill, the institutions locked into opposing positions with no one willing to move. The Department of Health is conducting research to see "whether the current scheme should be pursued or if there’s a better way of doing it". Doctors in the transplant area fear this may presage the scrapping of the scheme. 21 Albany Road, Heme Bay, Auckland, New Zealand
SANDRA CONEY
PIONEERING
Nepal A FACULTATIVE TRANSVESTITE?
I WAS returning with the health workers from our day’s work in rural Nepal. Our trail was miles from the tourist routes and separated from the nearest roads or airstrips by major rivers and mountains. I pondered that few if any other Europeans had plodded that path as we passed an old woman with wispy hair in a thin plait tied by a red ribbon carrying fodder on her back. I nodded to her with the customary, "Greetings older sister". Back came her "Greetings", and she was gone towards her simple home, children, and goats. That evening one of the staff asked with a giggle, "Remember the woman carrying the fodder?" He did not wait for my response before continuing with a smirk, "She was a man. I too thought he was a woman when I first saw him wearing women’s clothes." Before I could say anything a woman member of staff said simply, "It’s his habit", in exactly the tone she would use for saying it was his habit to wear a Nepali hat or shorts. I admit I was curious but accepted her wisdom, and the conversation lapsed. A few days later we held a public meeting to discuss the selection of volunteers who would receive simple health training. As always, people came from miles around, delighted at the opportunity to participate in their health programme. Women congregated to one side of our courtyard and men to the other and there was a lot of social chit chat while we sang health songs. Just before the meeting began the old "woman" we had met carrying fodder arrived and took her place among the women. Dressed in a simple blouse and lungi with glass bangles, he would not have been unusual except that he was addressed as "Maila" (literally "second son") by everyone. He took part in the discussions but not in the voting, where women voted for women volunteers and men for male volunteers. Not long after there was a local festival which involved chains of young people travelling from homestead to homestead singing and dancing to throbbing drums. The girls were shy, but inhibitions loosened as they were rewarded at each house with local alcohol. It made a lovely rest day after our week-long training. Then in the evening the performance was repeated by the men of the community, who were in high spirits. I was surprised to see Maila among the revellers, wearing traditional men’s attire with his long hair blowing loose. I joined the celebrations and had to endure the usual barrage of personal questions, "How old are you?", "How many children have you got?", and "How much do you earn?" Maila asked about my watch, and I took the opportunity to ask him why he was wearing shirt and trousers that night when I had previously met him wearing blouse and lUngI. That was readily answered. He liked wearing women’s clothes. He had first started wearing his sisters’ clothes when he was about 10 or 12 and continued wearing women’s clothes as he grew older, except when doing men’s work like ploughing. That evening he had to wear men’s clothes or his wife would have expected to join the celebrations too. Then Maila was off to make his frenzied contribution to the drumming.
laboratory accident? There is no medical or scientific reason why it
plan, "negligible" would be a 1 in 100 000 or even higher risk. Just about any risk would be acceptable if the EPA decided that the economic benefits to farmers and manufacturers of a pesticide justified continued use. As Janet Hathaway, an attorney for the activist National Resources Defense Council, points out, the new ban would not mean much if the EPA, as it invariably does, chose
should not be a notifiable disease and dealt with as such. Now that AIDS is appearing in teenagers the sooner a requirement for notification is introduced the better. Growing numbers of children are also infected, and soon one in every ten paediatric beds will be occupied by children with AIDS. Facilities for treating and caring for children with AIDS are virtually non-existent.
that risk
was
not to use
1 in 1000 000
or even
it.
in the President’s plan is an old law that of a pesticide carcinogen in processed foods. prohibits Paradoxically, the EPA routinely sets allowable pesticide carcinogen residues on raw food. Under the law, it is safe to eat tainted fresh tomatoes but not tainted tomato paste. The President wants to replace the law regulating processed food (called the Delaney clause after its Congressional sponsor) with his new "negligible" risk approach. Here he has the backing of the National Academy of Sciences, which says the Delaney clause is scientifically A
principal target
even a trace
unjustified. The truth is that pesticides are already getting into processed foods. This became apparent last May in a lawsuit against the EPA filed by John K. Van de Kamp, Attorney General of California, along with environmentalists and organised labour. Mr Van de Kamp accused the EPA of improperly permitting the use of at least twenty cancer-causing pesticides. Seven of them, said the suit, were found in minute amounts in such processed foods as cereal, orange juice, baby foods, crackers, flour, and sugar. EPA officials traditionally respond to this form of publicity by telling the media that all foods are safe. Actually, there is a small risk from eating some raw foods. EPA executives regularly use human and animal studies to calculate the cancer mortalities. They just do not want to start another panic like the one that forced the maker of ’Alar’, a pesticide used by apple growers, to remove the produce from the market. Studies of higher exposures in man confirm the danger. A review of published work by Kenneth P. Cantor and Aaron Blair of the National Cancer Institute shows pesticide applicators suffered excess deaths from lung cancers. Farmers had raised levels of cancer of the lip, stomach, prostate, and brain, non-melanoma skin cancer, leukaemia, non-Hodgkin’s lymphoma, and multiple myeloma. This evidence is unlikely to worry Congress or the White House. Whatever happens to President Bush’s plan to clarify pesticide laws, the EPA and Congress, historically, have been more solicitous to the farmers and pesticide manufacturers than to consumers. 115 Blue Hills Road, Amherst, Massachusetts 01002, USA
J. B. SIBBISON
AIDS IN TEENAGERS
THE patient has mental symptoms and is on zidovudine for his AIDS. He is soon going to be discharged, and he threatens to go out and spread AIDS. The epidemic rolls on, and figures suggest that 1 % of teenagers may be affected. Talk among those looking after AIDS patients, especially those with early mental symptoms, suggests that this angry patient’s response is not untypical-a minority of AIDS victims are actively and intentionally spreading the disease. How different would it be if the patient had syphilis rather than AIDS. His infection would be notified to the local health authority, the contacts traced and tested, and the patient treated and observed. So it would be if it were tuberculosis or even poliomyelitis, so why not AIDS? What hope have we for controlling the AIDS epidemic if the infection is not treated as a dangerous contagious disease? AIDS meets all the criteria. Spread by sexual contact or by contaminated blood? Yes. Danger to anyone having sexual contact with an AIDS virus carrier? Yes. Fatal if untreated? Yes. Carriers are present and an immediate danger to the public? Yes. So what is the difference? Social stigma? Well that applied to those afflicted with syphilis. In a country where AIDS is every day a matter for newspaper comment and is widely discussed why is the reality of the AIDS epidemic not faced up to and treated as an infectious venereal disease, occasionally and tragically sometimes spread through accident, blood transfusion, maternal-infant transmission,
Estonia FORUM MEDICORUM ESTONIAE
peaceful struggle of the Estonians to regain their independence extends to the medical profession. Estonian physicians have become vocal in their rejection of the politicisation of medicine during Soviet rule. The Union of Estonian Physicians (Eesti Arstide Liit) and local medical groups have vigorously spoken out on such issues as the environment, physician training, scientific research, salaries, and health insurance. Strategies for achieving excellence in medicine in Estonia are being debated. Estonians feel that the Soviet rule during the past fifty years has reduced the republic to a developing country. Physicians are particularly anxious to improve the republic’s status and support Estonia’s efforts to rejoin the European family of nations. The political changes and the promise of increased autonomy have led to demands for a greater voice in the republic’s health planning. At present, under Moscow’s guidelines, about 3% of Estonia’s budget is earmarked for health care. This figure includes building and other capital expenditure. To reach the level of the developed nations in health care the budget allocation needs to be THE
increased three to four fold. Examination of the present state of the profession and of the republic’s health needs shows that the health of the people is not good. According to the chairman of the Medical Society of Saaremaa, the life expectancy of a male in his district is only 59 years. The doctor/patient ratio is high (46 physicians per 10 000 population-twice the rate in the United States), but the physicians’ effectiveness is reduced by assignment of duties not related to their training, and waiting times for health care are long. The dedication of Estonian doctors and other health professionals to service to the people is even more remarkable in view of their poor remuneration. The current salary of medical workers is only 68% of the mean income of all workers. Serious questions concerning training of physicians are now being raised. During the recent Forum Medicorum Estoniae, several speakers expressed concern over the early and narrow specialisation, which begins in the third or fourth year of the six-year course. Those training medical students say that too much time is allocated to courses designed to "develop the student’s outlook on the world". These include courses such as History of Soviet Communist Party, ScientificCommunism, and the Scientific Basis for Atheism. Plans are being made to reduce the numbers of doctors qualifying, not by changing admission policies for medical students but by raising academic standards so that fewer will graduate. The state of medical research in Estonia was described by the Health Ministry’s chief surgeon, Dr Juri Manniste, as a "combination of world class and primitive". The Estonian Heart Centre of Tallin, directed by Dr Toomas-Andres Sulling, lays claim to being one of the best in the USSR. However, research developments in many other areas appear to be rudimentary. Dr Manniste proposed improvement of exchange programmes with Western scientists and raising of the level of training in sciences to permit mutual acceptance and accreditation. The Minister of Health proposed new systems for the training and retraining of physicians, combining social and public health care systems, matching salaries to qualifications, developing principles and guidelines for a new health insurance system, and manufacture of medical supplies in Estonia. The last point is a telling one. Although disposable syringes are being manufactured in Estonia, they are not generally available, and smaller rural hospitals are reusing broken syringes mended with tape.
1386 The forum concluded with a declaration. Besides addressing environmental concerns and criticising the past political conditions which had "marred the psyche and thought process of our people", the document includes the following statement: "Our profession has been debased and we have been deprived of means to serve our people in a manner we are capable of. In order to fulfill the mission which has been assigned to us by fate, we must steadfastly stand in the defence of our people’s health and rights; Medical science constitutes an integral and inseparable part of mankind’s culture. We cannot permit its destruction in a manner which has already befallen our spiritual heritage during the past
half-century." The document concluded with a plea to the world’s physicians to raise their voices in the defence of the Estonian, Latvian, and
Lithuanian people.
New Zealand ORGAN DONOR REGISTRY IN
JEOPARDY
programme to increase the pool of donor organs for transplantation has foundered after irreconcilable disagreements between central Government and area health boards. The scheme originated with the National Kidney Foundation. Currently 500 New Zealanders are sustained by renal dialysis; two-thirds of these people want transplantation. The Kidney Foundation argued that if the wishes of potential donors were known it would be easier to approach relatives and more organs would become available. The National Heart Foundation, with an undisclosed number of people waiting for heart transplantation, also supported the proposal. Similar schemes operate in other parts of the world. In Britain people carry a card indicating their willingness to donate, although relatives of card-carriers are still approached. In Belgium and Austria everyone is presumed to be a donor unless they opt out. Medical staff in America are required by law to seek permission from the relatives of possible donors. In New Zealand the Department of Health supported the Kidney Foundation’s proposal. The scheme entailed linkage with the National Master Patient Index, a compulsory register of all people who enter public hospitals. The idea was that when people renewed their drivers’ licences, they would fill out a form indicating their willingness to give kidneys, eyes, or heart. Each area health board would use staff in the records departments of hospitals to check if they were already on the NMPI, and enrol them if they were not. In 1987 the register was launched at the Ministry of Transport headquarters in Wellington amid much publicity. Whether to become a donor or not quickly became a common topic of discussion among members of the public. Within two years 770 000 New Zealanders had indicated their willingness to donate organsnearly half of all people taking out drivers’ licences. But if the scheme was enjoying widespread public support, at another level it was in deep trouble. The Ministry of Transport decided to bring in lifetime drivers’ licences, and within twelve months every driver got a new one. This created a huge bulge in the numbers and area health boards were flooded with tens of thousands of forms. They protested to the Health Department that they did not have the resources to enter the donor information. Some of the smaller boards have coped, but the larger boards have not. By July, 1989, only 18% of the names of potential donors had been computerised. Dr Bruce Morrison, medical advisor to the National Kidney Foundation, estimates that nearly 1 million names need to be entered for the scheme to be fully operational. The Department of Health has been unmoved by the Boards’ pleas for additional funding. A senior departmental executive claims the register is being used by boards as "a political chestnut" to extract more funding from the Government. The operation of the register, maintains the Department, "is entirely a matter of local board management ... If they think it is important, they have to make it a priority". The Department argues that, since transplantation is cost effective, boards should see the economic sense in developing the register. Wellington lawyer Trevor Roberts, a member of the Wellington Area Health Board for the past ten years, describes the failure of the donor register as "a casualty of bigger underlying problems". A
Funding allocations to boards have been severely cut by the Government in the past two years. Only 7% of gross domestic product goes on health. New Zealand is seventeenth of OECD countries in health spending. Roberts calls it a rationing system and says that elective surgery is always first to go when health budgets shrink. He maintains that cost effectiveness is not the only criterion for boards trying to operate on impossible budgets: "If it costs $100 000 now to save$200 000 in 18 months time, we can’t do it because we haven’t got the money now. You can’t allocate resources when they are capped at the top". The donor scheme seems to have come to a standstill, the institutions locked into opposing positions with no one willing to move. The Department of Health is conducting research to see "whether the current scheme should be pursued or if there’s a better way of doing it". Doctors in the transplant area fear this may presage the scrapping of the scheme. 21 Albany Road, Heme Bay, Auckland, New Zealand
SANDRA CONEY
PIONEERING
Nepal A FACULTATIVE TRANSVESTITE?
I WAS returning with the health workers from our day’s work in rural Nepal. Our trail was miles from the tourist routes and separated from the nearest roads or airstrips by major rivers and mountains. I pondered that few if any other Europeans had plodded that path as we passed an old woman with wispy hair in a thin plait tied by a red ribbon carrying fodder on her back. I nodded to her with the customary, "Greetings older sister". Back came her "Greetings", and she was gone towards her simple home, children, and goats. That evening one of the staff asked with a giggle, "Remember the woman carrying the fodder?" He did not wait for my response before continuing with a smirk, "She was a man. I too thought he was a woman when I first saw him wearing women’s clothes." Before I could say anything a woman member of staff said simply, "It’s his habit", in exactly the tone she would use for saying it was his habit to wear a Nepali hat or shorts. I admit I was curious but accepted her wisdom, and the conversation lapsed. A few days later we held a public meeting to discuss the selection of volunteers who would receive simple health training. As always, people came from miles around, delighted at the opportunity to participate in their health programme. Women congregated to one side of our courtyard and men to the other and there was a lot of social chit chat while we sang health songs. Just before the meeting began the old "woman" we had met carrying fodder arrived and took her place among the women. Dressed in a simple blouse and lungi with glass bangles, he would not have been unusual except that he was addressed as "Maila" (literally "second son") by everyone. He took part in the discussions but not in the voting, where women voted for women volunteers and men for male volunteers. Not long after there was a local festival which involved chains of young people travelling from homestead to homestead singing and dancing to throbbing drums. The girls were shy, but inhibitions loosened as they were rewarded at each house with local alcohol. It made a lovely rest day after our week-long training. Then in the evening the performance was repeated by the men of the community, who were in high spirits. I was surprised to see Maila among the revellers, wearing traditional men’s attire with his long hair blowing loose. I joined the celebrations and had to endure the usual barrage of personal questions, "How old are you?", "How many children have you got?", and "How much do you earn?" Maila asked about my watch, and I took the opportunity to ask him why he was wearing shirt and trousers that night when I had previously met him wearing blouse and lUngI. That was readily answered. He liked wearing women’s clothes. He had first started wearing his sisters’ clothes when he was about 10 or 12 and continued wearing women’s clothes as he grew older, except when doing men’s work like ploughing. That evening he had to wear men’s clothes or his wife would have expected to join the celebrations too. Then Maila was off to make his frenzied contribution to the drumming.