- Email: [email protected]
Jordan
320 Supported by Specialized Center of Research in Arteriosclerosis Grant HL-14164, and Preventive Cardiology Academic Award HL-01472 from the National Heart, Lung, and Blood Institute.
Round the World From
REFERENCES 1. Kannel WB, Castelli
WP, Gordon T Cholesterol in the prediction of atherosclerotic disease. Ann Intern Med 1979; 90: 85-91. 2. Lipid Research Clinics Program. The Lipid Research Clinics’ primary prevention trial results. JAMA 1984; 251: 351-64. 3. Consensus conference. Lowering blood cholesterol to prevent heart disease. JAMA 1985; 253: 2080-90. 4. Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study; primary prevention trial with gemfibrozil in middle aged men with dyslipidemia. N Engl J Med 1987; 317: 1237-45. 5. Starzl TE, Bilheimer DW, Bahnson HD, et al. Heart-liver transplantation in a patient with familial hypercholesterolaemia. Lancet 1984; i. 1382-83. 6. Slack J. Genetic influences on coronary heart disease in young women. In Oliver M, ed. Coronary heart disease in young women. Edinburgh: Churchill Livingstone, 1978: 24-25. 7. Brunner D, Weisbort J, Meshulam N, et al. Relation of serum total cholesterol and high-density lipoprotem cholesterol percentage to the incidence of definite coronary events: twenty year follow-up of the Donolo-Tel Aviv Prospective Coronary Artery Disease Study Am J Cardiol 1987; 591: 1271-76. 8. Bush TL, Barrett-Connor E, Cowan LD, et al. Cardiovascular mortality and noncontraceptive use of estrogen in women: results from the Lipid Research Clinics’ program follow-up study. Circulation 1987; 75: 1102-09. 9. Criqui MH, Cowan LD, Tyroler HA, et al. Lipoproteins as mediators for the effects of alcohol consumption and cigarette smoking on cardiovascular mortality: results from the Lipid Research Clinics’ follow-up study. Am J Epidemiol 1987; 126: 629-37. 10 Kannel WB, Castelli WP, Gordon T, McNamara PM. Serum cholesterol, lipoproteins, and the risk of coronary heart disease. Ann Intern Med 1971; 74: 1-12. 11. Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High density lipoprotein as a protective factor against coronary heart disease. Am J Med 1977; 62: 707-11. 12. Gordon T, Kannel WB, Castelli WP, Dawber TR. Lipoproteins, cardiovascular disease, and death. Arch Intern Med 1981; 141: 1128-31. 13. Kannel WB. High density lipoproteins: epidemiologic profile and nsks of coronary artery disease Am J Cardiol 1983; 52: 96-126. 14. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J 1986; 111: 383-90. 15. Castelli WP, Doyle JT, Gordon T, et al. HDL cholesterol and other lipids in coronary heart disease; the cooperative lipoprotein phenotyping study. Circulation 1977; 55: 767-72. 16. Kannel WB. Metabolic risk factors for coronary heart disease in women: perspective from the Framingham study. Am Heart J 1987; 114: 413-19. 17. Stamler J, Wentworth D, Neaton JD. Is the relationship between serum cholesterol and nsk of premature death from coronary heart disease continuous and gradual. JAMA 1986; 256: 2823-28. 18. Grundy SM, Bilheimer D, Blackburn H, et al. Rationale of the diet-heart statement of the American Heart Association. Circulation 1982; 65: 839A-54A. 19. Katan MB Diet and HDL. In. Miller NE, Miller GJ, eds. Clinical and metabolic aspects of high-density lipoproteins. Amsterdam. Elsevier, 1984: 103-31 20. Grundy SM, Nix D, Whelen MF, Franklin L. Comparison of three cholesterol lowering diets in normolipidemic men. JAMA 1986; 256: 2351-55. 21 Wolf RN, Grundy SM. Influence of exchanging carbohydrate for saturated fatty acids on plasma lipids and lipoproteins in man. J Nutr 1983; 113: 1521-28 22. Jones DY, Judd JT, Taylor PR, Campbell WS, Nair PP. Influence of caloric contribution and saturation of dietary fat of plasma lipids in premenopausal women. Am J Clin Nutr 1987; 45: 1451-56. 23 Brussaard JH, Dallinga-Thie G, Groot PHE, Katan MB. Effects of amount and type of dietary fat on serum lipids, lipoproteins and apolipoproteins in man. Atherosclerosis 1980; 36: 515-27. 24. Kashyap ML, Barnhart RL, Srivastava LS, et al Effects of dietary carbohydrate and fat on plasma lipoproteins and apolipoproteins C-II and C-III in healthy men. J Lipid Res 1982; 23: 877-86 25 Coulston AM, Liu GC, Reaven GM. Plasma glucose, insulin, and lipid responses to high-carbohydrate low-fat diets in normal humans Metabolism 1983; 32: 52-56. 26. Kohlmeier M, Strickler G, Schlierf G. Influences of "normal" and "prudent" diets on biliary and serum lipids in healthy women. Am J Clin Nutr 1985; 42: 1201-05. 27. Zanni EE, Zannis VI, Blum CB, Herbert PN, Breslow JL Effect of egg cholesterol and dietary fats on plasma lipids, lipoproteins, and apoproteins of normal women consuming natural diets. J Lipid Res 1987; 28: 518-27. 28. Lewis B, Hammett F, Katan M, et al. Towards an improved lipid-lowering diet: additive effects of changes in nutrient intake. Lancet 1981; ii: 1310-13. 29. Shepherd J, Packard CJ, Patsch JR, Gotto AM, Taunton OD Effects of dietary polyunsaturated and saturated fat on the properties of high density lipoproteins and the metabolism and apolipoprotein A-I. J Clin Invest 1978; 61: 1582-92 30. Grundy SM, Florentin L, Nix D, Whelan MF. Comparison of monounsaturated fatty acids and carbohydrates for reducing raised levels of plasma cholesterol in man Am J Clin Nutr 1988; 47: 965-69. 31. Becker N, Illingworth DR, Alaupovic P, Connor WE, Sundberd EE. Effects of saturated, monounsaturated, and &ohgr;-6 polyunsaturated fatty acids on plasma lipids, lipoproteins, and apoproteins in humans. Am J Clin Nutr 1983; 37: 355-60 32. Mattson FH, Grundy SM. Comparison of effects of dietary saturated, monosaturated, and polyunsaturated fatty acids on plasma lipids and lipoproteins in man. J Lipid Res 1985, 26: 194-202. 33 Grundy SM. Comparison of monounsaturated fatty acids and carbohydrates for lowering plasma cholesterol. N Engl J Med 1986; 314: 745-48.
our
correspondents
Jordan A NEW TRANSPLANT PROGRAMME
Jordanian cardiologists are aiming to turn their country into a major regional centre for the investigation and treatment of cardiovascular problems. They hope that the diagnostic and treatment facilities available at the Queen Alia Heart Institute in Amman will attract referrals from other Arab countries. At the moment, only 12 % of the 3851 patients admitted to the institute last year were from outside Jordan, but the aim is to raise this figure to
30%. The institute has been in existence since 1971, but its importance within the region has been enhanced lately by the heart transplant programme started in 1985. This made Jordan the first country in the Arab and Islamic world to perform a successful cardiac transplant operation. Since then, six more tranplants have been done, and four of the patients are still alive, including the first recipient, who is now in full-time employment. The difficulties faced by the Jordanian cardiac surgeons were unique. As well as the usual technical and ethical constraints, they had to cope with strong religious sentiment and powerful lobbies. In a country and a region dominated by Islamic traditions and a rising tide of religious fundamentalism, embarking on such a procedure was fraught with difficulties. Dr Daoud Hanania, head of the department of cardiac surgery at the institute and pioneer of the transplant programme, was aware of the complex religious issues. He and his colleagues invited some of the country’s religious leaders to participate in a discussion of brain death at a conference of anaesthetists held in Jordan. On that occasion they responded favourably to the concept of brain death, and as a result the country’s theological council, the majlis al-fikih, took up the issue and endorsed the concept of brain death. This cleared the ground for legislative machinery to be set in motion. Since then Saudi Arabia, the most conservative of Islamic states, has endorsed the same concept. Subsequently, three heart transplant operations have been performed in that country. However, the Jordanian heart transplant programme has not been universally welcomed by the medical profession. Some senior doctors argue that such a transplant programme is too much of a luxury in a country where dysentery and eye infections are still endemic. They suggest that the programme was embraced mainly because of its prestige rather than its therapeutic benefits. Although Dr Hanania concedes that there is an element of prestige associated with the programme, he maintains that it offers "a therapeutic modality for a certain group of patients who are seriously ill". He does not accept that it is a drain on the general health budget. The institute is run by the Jordanian armed forces and is financed by the defence budget. According to him, the programme costs about c6000 per annum, but this covers only the cost of drugs and the upgrading of laboratory facilities. It does not include manpower costs and hospital accommodation, but Dr Hanania argues that the staff are carrying out their normal duties irrespective of the procedure. Some doctors outside the institute insist that manpower and accommodation must be taken into account in any budgetary assessment. One senior doctor claimed that during the first transplant operation, a number of senior specialists were summoned from outside the institute to be with the patient for several days when postoperative complications developed. This should surely be taken into account, he argued. Such controversies do not extend to the kidney transplant programme which is being run by the same institute. Last year 28 transplants were performed. The success rate is high, and there is an abundance of live donors. These come mainly from the families of the patients, who, because of the culture of the Jordanian society, regard it as their duty to donate organs to their relatives. In recognition of the need for a coordinated Arab effort in the field of organ transplants, the Middle East Society of Organ Transplants was recently formed and is based in Kuwait. As one of
321 its
founders, Dr Hanania is convinced
that such
an
effort will
eventually ensure the availability of organs when the need arises in any of the member states. At the moment, finding suitable donors remains a problem. He explained that, despite close liaison with the neurosurgical unit, he has been waiting six months for a suitable heart donor, so far without success. He is hopeful that the formation of the regional society will help cut down the waiting time, now that the religious and ethical difficulties have been overcome. 107 Feltham Hill Road, Ashford, Middlesex,
PETER KANDELA
TW15 1HH
Niger
Once the necessary means are available to reduce the number of maternal deaths, an attack can also be made on the alarming level of maternal morbidity related to mechanical difficulties in delivery and to such conditions as vesicovaginal fistulae. The survival of a mother will of course also benefit her newly born baby, as well as her other children. 200 years after the Universal Declaration of the Rights of Man, it may well be time to recognise the right of the woman everywhere not to die in childbirth. Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, 92 Clamart,
EMILE PAPIERNIK
France
SAFE MOTHERHOOD
IT has taken a long time for maternal death in childbirth to be recognised as a serious health problem. The conference in Niamey organised by the World Bank, in cooperation with the United Nation’s Children’s Fund (UNICEF), World Health Organisation, United Nations Fund for Population Activities, United Nations Development Programme, and the African Development Bank, marked an important milestone in the raising of social and political awareness of the issue. But initially it required the efforts of militants, shocked by the indifference of authorities, to generate a minimal consensus that the occurrence of 500 000 deaths a year as a result of pregnancy and childbearing was unacceptable. The problem is vast, yet low-cost solutions are at hand. The risk of a mother dying as a result of pregnancy or childbirth is 300 to 1500 per 100 000 live births in the developing world, compared with 5 to 15 for women in industrial countries. A more striking indicator of underdevelopment is hard to come by. The disparity between the developed and developing world in infant mortality, which is already obviously too high, is of the order of 10 (10 deaths per 1000 live births in the industrial countries compared with 100 per 1000 in developing countries). Seen in this light, the need to address the problem of maternal mortality, where the disparity is something of the order of 100, becomes even more urgent. The causes of maternal mortality in the developing world are known and are constituted by the same obstetric complications that are found in most countries-haemorrhage, mechanical difficulties in delivery, and hypertension. These complications occur more commonly in very young women and in grand multiparae. The technical solutions are available and have already contributed to the reduction of maternal mortality rates in the industrial countries (from 300 per 100 000 live births in 1910 to 10 per 100 000 in 198OZ). The means are indeed simple: they require the accessibility of basic obstetric techniques to all women who give birth. The principal cause of maternal mortality in the developing world is the ahnost total absence of medical care at the place of delivery. When complications arise, the woman has to be transferred to a referral service. She may die on the way (for example, if she has a post-partum haemorrhage). In the time taken to reach the referral service, she may develop a ruptured uterus or a fatal infection. Referral services are few, distant, and overloaded. Despite the best efforts of teams working there, they are unable to cope. It is imperative that maternity services are equipped to carry out simple obstetric interventions such as manual placenta removal, to use forceps, to do a caesarean section, and to administer an anaesthetic or a blood transfusion. These services, and a supply of modest equipment, must be made available more widely, near to where the women are .3 This is the concept around which a consensus is now emerging. The conference at Niamey has mobilised ministers and health and development administrators from francophone African countries in the same way that anglophone countries were mobilised during a conference in Nairobi in 1987. 1. Rosenfeld A, Maine D Maternal mortality—a neglected tragedy where is the M in MCH. Lancet 1985; ii: 83-85 2. Hogberg U, Wall S Secular trends in maternal mortality in Sweden from 1750 to 1980. Bull WHO 1986; 64: 79-84. 3. WHO Technical Group report Essential obstetric functions at first referral level. Geneva World Health Organisation, 1986.
In England Now IT was my first week as consultant cardiologist. The first patient I asked to see on the urology ward was an 85-year-old man with a permanent pacemaker. Could I advise about his fitness for a general anaesthetic? "Well, sir, I hear you’ve got a pacemaker", I started. "No doctor", said the man, "I’ve got two"-and clutched both pectorals, one in each hand. He had two, too. I didn’t understand. Certainly there felt as if there were two generator boxes buried under the skin. One of the surgeons wondered if one pacemaker was for the left ventricle, and the other for the right. Other explanations occurred to me: perhaps two were necessary for his balance-to stop him leaning to one side? Certainly in this hospital they didn’t do anything by halves! I was impressed-they weren’t leaving anything to chance. And I supposed, in these days of technological advance, that back-up systems might be necessary. But I did wonder what the hospital accountant would think. As it turned out, the first pacemaker was implanted in 1974 and was a Lucas induction coil powered by external batteries. In 1978 this pacemaker failed, and a standard ventricular pacemaker was inserted in the opposite side, the induction coil being left in situ. These Yorkshiremen never part with anything! was
*
*
*
WHEN I worked for the regional hospital board we had one chairman who was outstanding. He was a highly conscious aristocrat and a blissfully unconscious aphorist. His general advice-if aristocratically slanted-was nearly always good, but he had in addition the uncommon capacity to throw off memorable one-liners. I remember, and still relish, four of the best of these: Never post a letter that you have enjoyed writing. Do not add your bad reasons to your good ones. Bad-tempered usually means bad at his job. Get him to put it down on paper, that will help him to find out what it is that he really wants. The chairman had the best understanding that I have ever met in a layman of what medicine is about, and he therefore had a healthy respect for doctors. But he realised that the profession must contain all sorts. He always said (I class this as an opinion rather than an aphorism) that he found it easier to deal with mild rogues than with slight fools. When I first heard this I was young and could not help being surprised that he had come across such people in his own social class. As the years have gone by, however, I have observed the
aristocracy more closely. *
*
*
WITH the increased emphasis these days on what is called "safer sex", I suppose it was inevitable that there would be a proliferation of slot-machines dispensing articles that, in the more modest days of my youth, were euphemistically termed "rubber goods". I dare say it is very right and proper to encourage such protection, but I feel it ought to be made clear that these items do have a failure rate, especially if used with more enthusiasm than caution. However, one firm seems to have accepted responsibility for this, for I have just seen a slot-machine bearing a large label which reads: "EMERGENCY SERVICE. In the event of breakage, ’phone..."
Round the World From
REFERENCES 1. Kannel WB, Castelli
WP, Gordon T Cholesterol in the prediction of atherosclerotic disease. Ann Intern Med 1979; 90: 85-91. 2. Lipid Research Clinics Program. The Lipid Research Clinics’ primary prevention trial results. JAMA 1984; 251: 351-64. 3. Consensus conference. Lowering blood cholesterol to prevent heart disease. JAMA 1985; 253: 2080-90. 4. Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study; primary prevention trial with gemfibrozil in middle aged men with dyslipidemia. N Engl J Med 1987; 317: 1237-45. 5. Starzl TE, Bilheimer DW, Bahnson HD, et al. Heart-liver transplantation in a patient with familial hypercholesterolaemia. Lancet 1984; i. 1382-83. 6. Slack J. Genetic influences on coronary heart disease in young women. In Oliver M, ed. Coronary heart disease in young women. Edinburgh: Churchill Livingstone, 1978: 24-25. 7. Brunner D, Weisbort J, Meshulam N, et al. Relation of serum total cholesterol and high-density lipoprotem cholesterol percentage to the incidence of definite coronary events: twenty year follow-up of the Donolo-Tel Aviv Prospective Coronary Artery Disease Study Am J Cardiol 1987; 591: 1271-76. 8. Bush TL, Barrett-Connor E, Cowan LD, et al. Cardiovascular mortality and noncontraceptive use of estrogen in women: results from the Lipid Research Clinics’ program follow-up study. Circulation 1987; 75: 1102-09. 9. Criqui MH, Cowan LD, Tyroler HA, et al. Lipoproteins as mediators for the effects of alcohol consumption and cigarette smoking on cardiovascular mortality: results from the Lipid Research Clinics’ follow-up study. Am J Epidemiol 1987; 126: 629-37. 10 Kannel WB, Castelli WP, Gordon T, McNamara PM. Serum cholesterol, lipoproteins, and the risk of coronary heart disease. Ann Intern Med 1971; 74: 1-12. 11. Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High density lipoprotein as a protective factor against coronary heart disease. Am J Med 1977; 62: 707-11. 12. Gordon T, Kannel WB, Castelli WP, Dawber TR. Lipoproteins, cardiovascular disease, and death. Arch Intern Med 1981; 141: 1128-31. 13. Kannel WB. High density lipoproteins: epidemiologic profile and nsks of coronary artery disease Am J Cardiol 1983; 52: 96-126. 14. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J 1986; 111: 383-90. 15. Castelli WP, Doyle JT, Gordon T, et al. HDL cholesterol and other lipids in coronary heart disease; the cooperative lipoprotein phenotyping study. Circulation 1977; 55: 767-72. 16. Kannel WB. Metabolic risk factors for coronary heart disease in women: perspective from the Framingham study. Am Heart J 1987; 114: 413-19. 17. Stamler J, Wentworth D, Neaton JD. Is the relationship between serum cholesterol and nsk of premature death from coronary heart disease continuous and gradual. JAMA 1986; 256: 2823-28. 18. Grundy SM, Bilheimer D, Blackburn H, et al. Rationale of the diet-heart statement of the American Heart Association. Circulation 1982; 65: 839A-54A. 19. Katan MB Diet and HDL. In. Miller NE, Miller GJ, eds. Clinical and metabolic aspects of high-density lipoproteins. Amsterdam. Elsevier, 1984: 103-31 20. Grundy SM, Nix D, Whelen MF, Franklin L. Comparison of three cholesterol lowering diets in normolipidemic men. JAMA 1986; 256: 2351-55. 21 Wolf RN, Grundy SM. Influence of exchanging carbohydrate for saturated fatty acids on plasma lipids and lipoproteins in man. J Nutr 1983; 113: 1521-28 22. Jones DY, Judd JT, Taylor PR, Campbell WS, Nair PP. Influence of caloric contribution and saturation of dietary fat of plasma lipids in premenopausal women. Am J Clin Nutr 1987; 45: 1451-56. 23 Brussaard JH, Dallinga-Thie G, Groot PHE, Katan MB. Effects of amount and type of dietary fat on serum lipids, lipoproteins and apolipoproteins in man. Atherosclerosis 1980; 36: 515-27. 24. Kashyap ML, Barnhart RL, Srivastava LS, et al Effects of dietary carbohydrate and fat on plasma lipoproteins and apolipoproteins C-II and C-III in healthy men. J Lipid Res 1982; 23: 877-86 25 Coulston AM, Liu GC, Reaven GM. Plasma glucose, insulin, and lipid responses to high-carbohydrate low-fat diets in normal humans Metabolism 1983; 32: 52-56. 26. Kohlmeier M, Strickler G, Schlierf G. Influences of "normal" and "prudent" diets on biliary and serum lipids in healthy women. Am J Clin Nutr 1985; 42: 1201-05. 27. Zanni EE, Zannis VI, Blum CB, Herbert PN, Breslow JL Effect of egg cholesterol and dietary fats on plasma lipids, lipoproteins, and apoproteins of normal women consuming natural diets. J Lipid Res 1987; 28: 518-27. 28. Lewis B, Hammett F, Katan M, et al. Towards an improved lipid-lowering diet: additive effects of changes in nutrient intake. Lancet 1981; ii: 1310-13. 29. Shepherd J, Packard CJ, Patsch JR, Gotto AM, Taunton OD Effects of dietary polyunsaturated and saturated fat on the properties of high density lipoproteins and the metabolism and apolipoprotein A-I. J Clin Invest 1978; 61: 1582-92 30. Grundy SM, Florentin L, Nix D, Whelan MF. Comparison of monounsaturated fatty acids and carbohydrates for reducing raised levels of plasma cholesterol in man Am J Clin Nutr 1988; 47: 965-69. 31. Becker N, Illingworth DR, Alaupovic P, Connor WE, Sundberd EE. Effects of saturated, monounsaturated, and &ohgr;-6 polyunsaturated fatty acids on plasma lipids, lipoproteins, and apoproteins in humans. Am J Clin Nutr 1983; 37: 355-60 32. Mattson FH, Grundy SM. Comparison of effects of dietary saturated, monosaturated, and polyunsaturated fatty acids on plasma lipids and lipoproteins in man. J Lipid Res 1985, 26: 194-202. 33 Grundy SM. Comparison of monounsaturated fatty acids and carbohydrates for lowering plasma cholesterol. N Engl J Med 1986; 314: 745-48.
our
correspondents
Jordan A NEW TRANSPLANT PROGRAMME
Jordanian cardiologists are aiming to turn their country into a major regional centre for the investigation and treatment of cardiovascular problems. They hope that the diagnostic and treatment facilities available at the Queen Alia Heart Institute in Amman will attract referrals from other Arab countries. At the moment, only 12 % of the 3851 patients admitted to the institute last year were from outside Jordan, but the aim is to raise this figure to
30%. The institute has been in existence since 1971, but its importance within the region has been enhanced lately by the heart transplant programme started in 1985. This made Jordan the first country in the Arab and Islamic world to perform a successful cardiac transplant operation. Since then, six more tranplants have been done, and four of the patients are still alive, including the first recipient, who is now in full-time employment. The difficulties faced by the Jordanian cardiac surgeons were unique. As well as the usual technical and ethical constraints, they had to cope with strong religious sentiment and powerful lobbies. In a country and a region dominated by Islamic traditions and a rising tide of religious fundamentalism, embarking on such a procedure was fraught with difficulties. Dr Daoud Hanania, head of the department of cardiac surgery at the institute and pioneer of the transplant programme, was aware of the complex religious issues. He and his colleagues invited some of the country’s religious leaders to participate in a discussion of brain death at a conference of anaesthetists held in Jordan. On that occasion they responded favourably to the concept of brain death, and as a result the country’s theological council, the majlis al-fikih, took up the issue and endorsed the concept of brain death. This cleared the ground for legislative machinery to be set in motion. Since then Saudi Arabia, the most conservative of Islamic states, has endorsed the same concept. Subsequently, three heart transplant operations have been performed in that country. However, the Jordanian heart transplant programme has not been universally welcomed by the medical profession. Some senior doctors argue that such a transplant programme is too much of a luxury in a country where dysentery and eye infections are still endemic. They suggest that the programme was embraced mainly because of its prestige rather than its therapeutic benefits. Although Dr Hanania concedes that there is an element of prestige associated with the programme, he maintains that it offers "a therapeutic modality for a certain group of patients who are seriously ill". He does not accept that it is a drain on the general health budget. The institute is run by the Jordanian armed forces and is financed by the defence budget. According to him, the programme costs about c6000 per annum, but this covers only the cost of drugs and the upgrading of laboratory facilities. It does not include manpower costs and hospital accommodation, but Dr Hanania argues that the staff are carrying out their normal duties irrespective of the procedure. Some doctors outside the institute insist that manpower and accommodation must be taken into account in any budgetary assessment. One senior doctor claimed that during the first transplant operation, a number of senior specialists were summoned from outside the institute to be with the patient for several days when postoperative complications developed. This should surely be taken into account, he argued. Such controversies do not extend to the kidney transplant programme which is being run by the same institute. Last year 28 transplants were performed. The success rate is high, and there is an abundance of live donors. These come mainly from the families of the patients, who, because of the culture of the Jordanian society, regard it as their duty to donate organs to their relatives. In recognition of the need for a coordinated Arab effort in the field of organ transplants, the Middle East Society of Organ Transplants was recently formed and is based in Kuwait. As one of
321 its
founders, Dr Hanania is convinced
that such
an
effort will
eventually ensure the availability of organs when the need arises in any of the member states. At the moment, finding suitable donors remains a problem. He explained that, despite close liaison with the neurosurgical unit, he has been waiting six months for a suitable heart donor, so far without success. He is hopeful that the formation of the regional society will help cut down the waiting time, now that the religious and ethical difficulties have been overcome. 107 Feltham Hill Road, Ashford, Middlesex,
PETER KANDELA
TW15 1HH
Niger
Once the necessary means are available to reduce the number of maternal deaths, an attack can also be made on the alarming level of maternal morbidity related to mechanical difficulties in delivery and to such conditions as vesicovaginal fistulae. The survival of a mother will of course also benefit her newly born baby, as well as her other children. 200 years after the Universal Declaration of the Rights of Man, it may well be time to recognise the right of the woman everywhere not to die in childbirth. Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, 92 Clamart,
EMILE PAPIERNIK
France
SAFE MOTHERHOOD
IT has taken a long time for maternal death in childbirth to be recognised as a serious health problem. The conference in Niamey organised by the World Bank, in cooperation with the United Nation’s Children’s Fund (UNICEF), World Health Organisation, United Nations Fund for Population Activities, United Nations Development Programme, and the African Development Bank, marked an important milestone in the raising of social and political awareness of the issue. But initially it required the efforts of militants, shocked by the indifference of authorities, to generate a minimal consensus that the occurrence of 500 000 deaths a year as a result of pregnancy and childbearing was unacceptable. The problem is vast, yet low-cost solutions are at hand. The risk of a mother dying as a result of pregnancy or childbirth is 300 to 1500 per 100 000 live births in the developing world, compared with 5 to 15 for women in industrial countries. A more striking indicator of underdevelopment is hard to come by. The disparity between the developed and developing world in infant mortality, which is already obviously too high, is of the order of 10 (10 deaths per 1000 live births in the industrial countries compared with 100 per 1000 in developing countries). Seen in this light, the need to address the problem of maternal mortality, where the disparity is something of the order of 100, becomes even more urgent. The causes of maternal mortality in the developing world are known and are constituted by the same obstetric complications that are found in most countries-haemorrhage, mechanical difficulties in delivery, and hypertension. These complications occur more commonly in very young women and in grand multiparae. The technical solutions are available and have already contributed to the reduction of maternal mortality rates in the industrial countries (from 300 per 100 000 live births in 1910 to 10 per 100 000 in 198OZ). The means are indeed simple: they require the accessibility of basic obstetric techniques to all women who give birth. The principal cause of maternal mortality in the developing world is the ahnost total absence of medical care at the place of delivery. When complications arise, the woman has to be transferred to a referral service. She may die on the way (for example, if she has a post-partum haemorrhage). In the time taken to reach the referral service, she may develop a ruptured uterus or a fatal infection. Referral services are few, distant, and overloaded. Despite the best efforts of teams working there, they are unable to cope. It is imperative that maternity services are equipped to carry out simple obstetric interventions such as manual placenta removal, to use forceps, to do a caesarean section, and to administer an anaesthetic or a blood transfusion. These services, and a supply of modest equipment, must be made available more widely, near to where the women are .3 This is the concept around which a consensus is now emerging. The conference at Niamey has mobilised ministers and health and development administrators from francophone African countries in the same way that anglophone countries were mobilised during a conference in Nairobi in 1987. 1. Rosenfeld A, Maine D Maternal mortality—a neglected tragedy where is the M in MCH. Lancet 1985; ii: 83-85 2. Hogberg U, Wall S Secular trends in maternal mortality in Sweden from 1750 to 1980. Bull WHO 1986; 64: 79-84. 3. WHO Technical Group report Essential obstetric functions at first referral level. Geneva World Health Organisation, 1986.
In England Now IT was my first week as consultant cardiologist. The first patient I asked to see on the urology ward was an 85-year-old man with a permanent pacemaker. Could I advise about his fitness for a general anaesthetic? "Well, sir, I hear you’ve got a pacemaker", I started. "No doctor", said the man, "I’ve got two"-and clutched both pectorals, one in each hand. He had two, too. I didn’t understand. Certainly there felt as if there were two generator boxes buried under the skin. One of the surgeons wondered if one pacemaker was for the left ventricle, and the other for the right. Other explanations occurred to me: perhaps two were necessary for his balance-to stop him leaning to one side? Certainly in this hospital they didn’t do anything by halves! I was impressed-they weren’t leaving anything to chance. And I supposed, in these days of technological advance, that back-up systems might be necessary. But I did wonder what the hospital accountant would think. As it turned out, the first pacemaker was implanted in 1974 and was a Lucas induction coil powered by external batteries. In 1978 this pacemaker failed, and a standard ventricular pacemaker was inserted in the opposite side, the induction coil being left in situ. These Yorkshiremen never part with anything! was
*
*
*
WHEN I worked for the regional hospital board we had one chairman who was outstanding. He was a highly conscious aristocrat and a blissfully unconscious aphorist. His general advice-if aristocratically slanted-was nearly always good, but he had in addition the uncommon capacity to throw off memorable one-liners. I remember, and still relish, four of the best of these: Never post a letter that you have enjoyed writing. Do not add your bad reasons to your good ones. Bad-tempered usually means bad at his job. Get him to put it down on paper, that will help him to find out what it is that he really wants. The chairman had the best understanding that I have ever met in a layman of what medicine is about, and he therefore had a healthy respect for doctors. But he realised that the profession must contain all sorts. He always said (I class this as an opinion rather than an aphorism) that he found it easier to deal with mild rogues than with slight fools. When I first heard this I was young and could not help being surprised that he had come across such people in his own social class. As the years have gone by, however, I have observed the
aristocracy more closely. *
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WITH the increased emphasis these days on what is called "safer sex", I suppose it was inevitable that there would be a proliferation of slot-machines dispensing articles that, in the more modest days of my youth, were euphemistically termed "rubber goods". I dare say it is very right and proper to encourage such protection, but I feel it ought to be made clear that these items do have a failure rate, especially if used with more enthusiasm than caution. However, one firm seems to have accepted responsibility for this, for I have just seen a slot-machine bearing a large label which reads: "EMERGENCY SERVICE. In the event of breakage, ’phone..."