- Email: [email protected]
MATERNAL HEALTH
1063
he nearly gave up. It is interesting that his discoveries spring from his study of the work on lithium; the substance that has transformed the prognosis for so many manic-depressives. Both Edelman and Berridge regard science as a kind of battle with nature; an attempt to defeat an adversary who jealously guards secrets. Everyone agrees that making a discovery is a triumph; "something glorious" as Edelman calls it. What I shall take from these fascinating interviews is a renewal of my belief that creativity demands breadth of interest. These great scientists are not only curious about everything but they are also men of culture who are well-informed outside their own specialties. I am sure that their scientific discoveries owe a great deal to crossfertilisation from their other interests.
Anthony Storr
arises: were the obsessional GTS patients also depressed? If obsessional scores in GTS patients do not correlate with depressive symptoms, one might argue that obsessional compulsive symptoms in GTS occur independently of depression. The results, however, showed that there was a high correlation between depression and obsessionality scores in GTS. Taken together, these findings suggest that GTS patients have a propensity to develop primary obsessional compulsive disorder and to develop secondary obsessional compulsive symptoms when they become depressed. I agree with the conclusion of Robertson et al that obsessionality is an especially prominent feature of GTS, but must add that I regard these results as evidence that the occurrence of depression is likewise important in the understanding of obsessional compulsive behaviours in patients with the
syndrome. Danitza Jadresic
PSYCHIATRY
Obsessionality
in Tourette
syndrome
Gilles de la Tourette syndrome (GTS) is characterised by motor tics and vocalisations. The disorder is associated with a wide range of psychological symptoms
multiple
including obsessional compulsive behaviours, depression and anxiety, self-injurious behaviour, and aggression.1 Obsessional compulsive symptoms, in particular, have received close attention. Tiqueurs often report a subjective tension just before their tics or vocalisations, which they may be able to delay for a few seconds or minutes until subjective discomfort overwhelms them. This phenomenon resembles the mounting anxiety experienced before the generally purposeful compulsions of obsessional compulsive disorder.2 A sizeable proportion of GTS patients have obsessional compulsive behaviours, such as checking, washing, and counting rituals, and obsessional thoughts of an aggressive or sexual nature.12 Conversely, patients with obsessional compulsive disorder have an increased incidence of tic disorders, including GTS.2 For these reasons, some researchers have suggested that obsessional compulsive disorder is an intrinsic part of GTS; and segregation analyses have indicated that obsessional compulsive disorder is a variant expression of GTS in affected families.3 Moreover, there is increasing evidence that the basal ganglia are involved in the pathophysiology of obsessional compulsive disorder.4 Thus, positron emission tomography studies of patients with obsessional compulsive disorder have shown raised glucose metabolic rates in the prefrontal striatal system-ie, in the caudate nuclei and the orbital gyri of the frontal lobes. We know, for example, that obsessional compulsive symptoms commonly accompany depressive illness and vice versa. In examining the relation between obsessional compulsive disorder and GTS, one has to establish whether the obsessional compulsive symptoms are not a secondary manifestation of another neurotic disorder. Robertson and colleagues tried to answer the question by comparing obsessional compulsive, depressive, and anxiety symptoms in a group of GTS patients with those in depressed and normal control groups. Obsessional scores were high in both the GTS and depressed groups; depression scores in GTS were higher than in controls but lower than in non-GTS depressed patients. These observations suggest, as the researchers that is point out, obsessionality in GTS The then disproportionally high patients. question
1. Robertson MM, Trimble MR, Lees AJ. The psychopathology of Gilles de la Tourette syndrome: a phenomenological analysis. Br J Psychiatry 1988; 152: 383-90. 2. Pitman RK, Green RC, Jenike MA, et al. Clinical comparison of
Tourette’s disorder and obsessive-compulsive disorder. Am J 1166-71. 3. Pauls DL, Pakstis AJ, Kurlan R, et al. Segregation and linkage analysis of Tourette’s syndrome and related disorders. J Am Acad Child Adolesc Psychiatry 1990; 29: 195-203. 4. Baxter LR, Schwartz JM, Guze BH, et al. PET imaging in obsessive compulsive disorder with and without depression. J Clin Psychiatry
Psychiatry 1987; 144:
1990; 51: 61-69. 5. Robertson MM, Channon S, Baker J, et al. The psychopathology of Gilles de la Tourette syndrome: a controlled study. Br J Psychiatry 1993; 162: 114-47.
MATERNAL HEALTH
Illiteracy and
maternal health: educate
or
die
On Thursday Dec 3, 1992, the adverse relation between illiteracy and maternal health was revisited. The venue was the conference hall at Abuja, the nascent Federal Capital Territory of Nigeria; the occasion was the 1992 Nigerian National Merit Award Winner’s Lecture. Prof Kelsey Harrison (1990 award winner), the dauntless proponent of better reproductive performance through formal education, addressed the audience of top government policy makerfi, academics, business entrepreneurs, and professionals. With the down-to-earth topic of "Mass Illiteracy is Very Dangerous for Maternal Health" / and using maternal mortality as the health indicator, Harrison began by stating the brute facts. The estimated maternal mortality rate for Nigeria is 800 per 100 000, that for Africa in general is 640, Asia 420, Latin America 270, and western Europe and North America 30. Nigeria, Harrison opined, shares, along with other subsaharan African countries, these colossal mountains of maternal deaths mainly as a result of circumstances that are rooted in underdevelopment of social, political, cultural, economic, and health factors, the bedrock being mass illiteracy. For example, in one study in Nigeriano mother out of 539 with secondary education or 499 with post-secondary education died vs 6 deaths in 1499 with primary education and 232 in 20 089 who had never been to school. These figures give a maternal mortality rate of 1056 per 100 000 births overall, 1154 per 100 000 for illiterate women, 400 per 100 000 for those who received
1064
primary education, and none at all for women with post-primary education. Deaths in most cases were usually due to related
one
or
more
of
the
main
pregnancy-
complications-abortion, anaemia, eclampsia, haemorrhage, and obstructed labour-but it is lifestyles,33 the ones they adopt of their own free will and the ones society forces on them largely through ignorance, fear, and superstition, that compel illiterate women to carry a disproportionate load of maternal deaths. Using the Nigerian scene to illustrate his case, Harrison touched
and cultural by illiterate women, and the recent difficulties posed to maternal health by "churches" and prayer houses. He made the point that the extent to which traditional cultures govern our lives is much greater without formal education than with it. More often, therefore, the illiterate woman is unable to resist aspects of her culture and tradition that are clearly detrimental to her health. For example, early recourse to childbearing (under 16 years), with its well-known adverse consequences, is largely a problem of teenage girls who follow the dictates of their traditions and marry before menarche. Also, partly because of poverty, ignorance, and superstition, illiterate women do not accept antenatal care, with all its proven advantages, as readily as do their literate counterparts. With no prior intentions to come to hospital, the illiterate women report to health institutions only when difficulties develop during labour or when existing disease worsens. Because of the delay occasioned by their late presentation, and the severity of their disease, these women quickly die, even before treatment can be initiated. As for "churches" and prayer houses, Harrison drew attention to the harm these organisations are inflicting on gullible, largely illiterate women who resort to them for obstetric services. What is to be done? Harrison proffered a key role for formal education; once women go to school and receive formal education they no longer see childbearing as their only path to self-fulfilment and higher social status in life. With education, women’s health-seeking behaviours change in a direction which is to their advantage. They are prepared to take the initiative in a way seldom seen in those without education. Recognising that the cost of education might prove a deterrent in many subsaharan countries, Harrison made computations showing that, although education is expensive, it is cheaper than illiteracy when viewed in the context of maternal health. Finally, as if to put cynics to rest, Harrison concluded his lecture with a passage entitled "the final proof, the sheer weight of its authority cannot be denied. "In the colonial era, there were two different approaches towards the improvement of health and living standards in the third world. One approach, adopted in much of subsaharan Africa, concentrated on social welfare and community development but not so much on universal literacy. To this end, programmes in environmental hygiene and sanitation, road construction, agriculture, market gardening and other income generating projects were established and run with some measure of efficiency. The second approach made formal education the centrepiece of social welfare and community development. Sri Lanka, the State of Kerala in India, Costa Rica, Cuba and China adopted it. Today, Sri Lanka and Nigeria are equally poor, but adult female literacy rates are 83% for Sri Lanka compared with 31 % for Nigeria, and maternal deaths per 100 000 deliveries are 50 for Sri Lanka and 800 for Nigeria. Indeed virtually all low
practices,
on
harmful traditional
customs
poor acceptance of antenatal
care
income countries with low maternal mortality rates have adult female literacy rates exceeding 80%." Befittingly, it was Harrison who blew the whistle, at a deafening pitch, on maternal mortality in Nigeria and subsaharan Africa with his magnum opus2 in 1985. Subsequently, concern about the subject from a better informed international community has shifted from the mere chronicling of rates and causes of maternal deaths to more concerted efforts to effect substantial reductions in the carnage of maternal deaths. This thinking gave birth to the global safe motherhood movement, formalised at the WHO Safe Motherhood Movement Conference in Nairobi, Kenya, in 1987. But approaches have continued to differs Government policy-makers and well-meaning international
organisations have pursued a dogged family planning policy that, among other things, aims to reduce drastically the total number of children produced by each woman, since many countries with high maternal mortality rates also have high fertility rates (eg, 7 children per woman in Nigeria). Such a policy holds great promise for saving women’s lives by preventing unwanted pregnancies, but its effects in an illiterate community with low-contraceptive prevalence (eg, 5% in Nigeria) arising from ignorance and superstition are unclear. Moreover, family planning is unlikely to take root in a community that embraces high fertility as a means of correcting for a correspondingly high perinatal and infant mortality. To reduce deaths and improve maternal health, the subsaharan woman must be helped to enhance her own self-esteem and the worth she places on her life. At the same time we need to create an enabling environment where access to functional and basic but professional medical care is readily available. There is now overwhelming evidence," that, in the long term, no approach will be as successful as universal formal education. The Abuja lecture is another brilliant feather in the cap of this concept. Nimi
Briggs
1. Harrison KA. Mass illiteracy is very dangerous for maternal health. Nigerian National Merit Award, award winner’s lecture, 1992. 2. Harrison KA. Childbearing, health and social priorities: a survey of 22 774 consecutive hospital births in Zaria, Northern Nigeria. Br J Obstet Gynaecol 1985; 92 (suppl 5). 3. Armstrong S. Labour of death. New Scientist 1990; March 31: 50-55. 4. Editorial. Why retrain traditional birth attendants. Lancet 1983; i: 223-24. 5. White SM, Thorpe RG, Maine D. Emergency obstetric surgery performed by nurses in Zaria. Lancet 1987; ii: 612-13. 6. Briggs ND, Oruamabo RS. Technology-free obstetrics. Lancet 1991; 337: 553. 7. Harrison KA, Briggs ND, Oruamabo RS. Technology-free obstetrics. Lancet 1991; 338: 382. 8. Briggs ND. Safe motherhood initiative Nigeria, 1990. Contemp Rev Obstet Gynaecol 1992; 4: 127-31.
Prof Frederick P. Li and Dr Judy E. Garber, Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, Boston, MA, USA Dr Michael Crawford, Dr Mogens Bredgaard Sørensen, and Dr Jørgen B. Dahl, Department of Anaesthesiology, Hvidovre Hospital and MICU, University of Copenhagen, Denmark Prof Silvio Garattini, Istituto di Recherche Farmacologiche "Mario Negri", Milan, Italy Dr Anthony Storr, Oxford, UK Dr Danitza Jadresic, University Department of Psychiatry, Manchester Royal Infirmary, Manchester, UK Prof Nimi Briggs, Department of Obstetrics and Gynaecology, University of Port Harcourt, Nigeria
he nearly gave up. It is interesting that his discoveries spring from his study of the work on lithium; the substance that has transformed the prognosis for so many manic-depressives. Both Edelman and Berridge regard science as a kind of battle with nature; an attempt to defeat an adversary who jealously guards secrets. Everyone agrees that making a discovery is a triumph; "something glorious" as Edelman calls it. What I shall take from these fascinating interviews is a renewal of my belief that creativity demands breadth of interest. These great scientists are not only curious about everything but they are also men of culture who are well-informed outside their own specialties. I am sure that their scientific discoveries owe a great deal to crossfertilisation from their other interests.
Anthony Storr
arises: were the obsessional GTS patients also depressed? If obsessional scores in GTS patients do not correlate with depressive symptoms, one might argue that obsessional compulsive symptoms in GTS occur independently of depression. The results, however, showed that there was a high correlation between depression and obsessionality scores in GTS. Taken together, these findings suggest that GTS patients have a propensity to develop primary obsessional compulsive disorder and to develop secondary obsessional compulsive symptoms when they become depressed. I agree with the conclusion of Robertson et al that obsessionality is an especially prominent feature of GTS, but must add that I regard these results as evidence that the occurrence of depression is likewise important in the understanding of obsessional compulsive behaviours in patients with the
syndrome. Danitza Jadresic
PSYCHIATRY
Obsessionality
in Tourette
syndrome
Gilles de la Tourette syndrome (GTS) is characterised by motor tics and vocalisations. The disorder is associated with a wide range of psychological symptoms
multiple
including obsessional compulsive behaviours, depression and anxiety, self-injurious behaviour, and aggression.1 Obsessional compulsive symptoms, in particular, have received close attention. Tiqueurs often report a subjective tension just before their tics or vocalisations, which they may be able to delay for a few seconds or minutes until subjective discomfort overwhelms them. This phenomenon resembles the mounting anxiety experienced before the generally purposeful compulsions of obsessional compulsive disorder.2 A sizeable proportion of GTS patients have obsessional compulsive behaviours, such as checking, washing, and counting rituals, and obsessional thoughts of an aggressive or sexual nature.12 Conversely, patients with obsessional compulsive disorder have an increased incidence of tic disorders, including GTS.2 For these reasons, some researchers have suggested that obsessional compulsive disorder is an intrinsic part of GTS; and segregation analyses have indicated that obsessional compulsive disorder is a variant expression of GTS in affected families.3 Moreover, there is increasing evidence that the basal ganglia are involved in the pathophysiology of obsessional compulsive disorder.4 Thus, positron emission tomography studies of patients with obsessional compulsive disorder have shown raised glucose metabolic rates in the prefrontal striatal system-ie, in the caudate nuclei and the orbital gyri of the frontal lobes. We know, for example, that obsessional compulsive symptoms commonly accompany depressive illness and vice versa. In examining the relation between obsessional compulsive disorder and GTS, one has to establish whether the obsessional compulsive symptoms are not a secondary manifestation of another neurotic disorder. Robertson and colleagues tried to answer the question by comparing obsessional compulsive, depressive, and anxiety symptoms in a group of GTS patients with those in depressed and normal control groups. Obsessional scores were high in both the GTS and depressed groups; depression scores in GTS were higher than in controls but lower than in non-GTS depressed patients. These observations suggest, as the researchers that is point out, obsessionality in GTS The then disproportionally high patients. question
1. Robertson MM, Trimble MR, Lees AJ. The psychopathology of Gilles de la Tourette syndrome: a phenomenological analysis. Br J Psychiatry 1988; 152: 383-90. 2. Pitman RK, Green RC, Jenike MA, et al. Clinical comparison of
Tourette’s disorder and obsessive-compulsive disorder. Am J 1166-71. 3. Pauls DL, Pakstis AJ, Kurlan R, et al. Segregation and linkage analysis of Tourette’s syndrome and related disorders. J Am Acad Child Adolesc Psychiatry 1990; 29: 195-203. 4. Baxter LR, Schwartz JM, Guze BH, et al. PET imaging in obsessive compulsive disorder with and without depression. J Clin Psychiatry
Psychiatry 1987; 144:
1990; 51: 61-69. 5. Robertson MM, Channon S, Baker J, et al. The psychopathology of Gilles de la Tourette syndrome: a controlled study. Br J Psychiatry 1993; 162: 114-47.
MATERNAL HEALTH
Illiteracy and
maternal health: educate
or
die
On Thursday Dec 3, 1992, the adverse relation between illiteracy and maternal health was revisited. The venue was the conference hall at Abuja, the nascent Federal Capital Territory of Nigeria; the occasion was the 1992 Nigerian National Merit Award Winner’s Lecture. Prof Kelsey Harrison (1990 award winner), the dauntless proponent of better reproductive performance through formal education, addressed the audience of top government policy makerfi, academics, business entrepreneurs, and professionals. With the down-to-earth topic of "Mass Illiteracy is Very Dangerous for Maternal Health" / and using maternal mortality as the health indicator, Harrison began by stating the brute facts. The estimated maternal mortality rate for Nigeria is 800 per 100 000, that for Africa in general is 640, Asia 420, Latin America 270, and western Europe and North America 30. Nigeria, Harrison opined, shares, along with other subsaharan African countries, these colossal mountains of maternal deaths mainly as a result of circumstances that are rooted in underdevelopment of social, political, cultural, economic, and health factors, the bedrock being mass illiteracy. For example, in one study in Nigeriano mother out of 539 with secondary education or 499 with post-secondary education died vs 6 deaths in 1499 with primary education and 232 in 20 089 who had never been to school. These figures give a maternal mortality rate of 1056 per 100 000 births overall, 1154 per 100 000 for illiterate women, 400 per 100 000 for those who received
1064
primary education, and none at all for women with post-primary education. Deaths in most cases were usually due to related
one
or
more
of
the
main
pregnancy-
complications-abortion, anaemia, eclampsia, haemorrhage, and obstructed labour-but it is lifestyles,33 the ones they adopt of their own free will and the ones society forces on them largely through ignorance, fear, and superstition, that compel illiterate women to carry a disproportionate load of maternal deaths. Using the Nigerian scene to illustrate his case, Harrison touched
and cultural by illiterate women, and the recent difficulties posed to maternal health by "churches" and prayer houses. He made the point that the extent to which traditional cultures govern our lives is much greater without formal education than with it. More often, therefore, the illiterate woman is unable to resist aspects of her culture and tradition that are clearly detrimental to her health. For example, early recourse to childbearing (under 16 years), with its well-known adverse consequences, is largely a problem of teenage girls who follow the dictates of their traditions and marry before menarche. Also, partly because of poverty, ignorance, and superstition, illiterate women do not accept antenatal care, with all its proven advantages, as readily as do their literate counterparts. With no prior intentions to come to hospital, the illiterate women report to health institutions only when difficulties develop during labour or when existing disease worsens. Because of the delay occasioned by their late presentation, and the severity of their disease, these women quickly die, even before treatment can be initiated. As for "churches" and prayer houses, Harrison drew attention to the harm these organisations are inflicting on gullible, largely illiterate women who resort to them for obstetric services. What is to be done? Harrison proffered a key role for formal education; once women go to school and receive formal education they no longer see childbearing as their only path to self-fulfilment and higher social status in life. With education, women’s health-seeking behaviours change in a direction which is to their advantage. They are prepared to take the initiative in a way seldom seen in those without education. Recognising that the cost of education might prove a deterrent in many subsaharan countries, Harrison made computations showing that, although education is expensive, it is cheaper than illiteracy when viewed in the context of maternal health. Finally, as if to put cynics to rest, Harrison concluded his lecture with a passage entitled "the final proof, the sheer weight of its authority cannot be denied. "In the colonial era, there were two different approaches towards the improvement of health and living standards in the third world. One approach, adopted in much of subsaharan Africa, concentrated on social welfare and community development but not so much on universal literacy. To this end, programmes in environmental hygiene and sanitation, road construction, agriculture, market gardening and other income generating projects were established and run with some measure of efficiency. The second approach made formal education the centrepiece of social welfare and community development. Sri Lanka, the State of Kerala in India, Costa Rica, Cuba and China adopted it. Today, Sri Lanka and Nigeria are equally poor, but adult female literacy rates are 83% for Sri Lanka compared with 31 % for Nigeria, and maternal deaths per 100 000 deliveries are 50 for Sri Lanka and 800 for Nigeria. Indeed virtually all low
practices,
on
harmful traditional
customs
poor acceptance of antenatal
care
income countries with low maternal mortality rates have adult female literacy rates exceeding 80%." Befittingly, it was Harrison who blew the whistle, at a deafening pitch, on maternal mortality in Nigeria and subsaharan Africa with his magnum opus2 in 1985. Subsequently, concern about the subject from a better informed international community has shifted from the mere chronicling of rates and causes of maternal deaths to more concerted efforts to effect substantial reductions in the carnage of maternal deaths. This thinking gave birth to the global safe motherhood movement, formalised at the WHO Safe Motherhood Movement Conference in Nairobi, Kenya, in 1987. But approaches have continued to differs Government policy-makers and well-meaning international
organisations have pursued a dogged family planning policy that, among other things, aims to reduce drastically the total number of children produced by each woman, since many countries with high maternal mortality rates also have high fertility rates (eg, 7 children per woman in Nigeria). Such a policy holds great promise for saving women’s lives by preventing unwanted pregnancies, but its effects in an illiterate community with low-contraceptive prevalence (eg, 5% in Nigeria) arising from ignorance and superstition are unclear. Moreover, family planning is unlikely to take root in a community that embraces high fertility as a means of correcting for a correspondingly high perinatal and infant mortality. To reduce deaths and improve maternal health, the subsaharan woman must be helped to enhance her own self-esteem and the worth she places on her life. At the same time we need to create an enabling environment where access to functional and basic but professional medical care is readily available. There is now overwhelming evidence," that, in the long term, no approach will be as successful as universal formal education. The Abuja lecture is another brilliant feather in the cap of this concept. Nimi
Briggs
1. Harrison KA. Mass illiteracy is very dangerous for maternal health. Nigerian National Merit Award, award winner’s lecture, 1992. 2. Harrison KA. Childbearing, health and social priorities: a survey of 22 774 consecutive hospital births in Zaria, Northern Nigeria. Br J Obstet Gynaecol 1985; 92 (suppl 5). 3. Armstrong S. Labour of death. New Scientist 1990; March 31: 50-55. 4. Editorial. Why retrain traditional birth attendants. Lancet 1983; i: 223-24. 5. White SM, Thorpe RG, Maine D. Emergency obstetric surgery performed by nurses in Zaria. Lancet 1987; ii: 612-13. 6. Briggs ND, Oruamabo RS. Technology-free obstetrics. Lancet 1991; 337: 553. 7. Harrison KA, Briggs ND, Oruamabo RS. Technology-free obstetrics. Lancet 1991; 338: 382. 8. Briggs ND. Safe motherhood initiative Nigeria, 1990. Contemp Rev Obstet Gynaecol 1992; 4: 127-31.
Prof Frederick P. Li and Dr Judy E. Garber, Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, Boston, MA, USA Dr Michael Crawford, Dr Mogens Bredgaard Sørensen, and Dr Jørgen B. Dahl, Department of Anaesthesiology, Hvidovre Hospital and MICU, University of Copenhagen, Denmark Prof Silvio Garattini, Istituto di Recherche Farmacologiche "Mario Negri", Milan, Italy Dr Anthony Storr, Oxford, UK Dr Danitza Jadresic, University Department of Psychiatry, Manchester Royal Infirmary, Manchester, UK Prof Nimi Briggs, Department of Obstetrics and Gynaecology, University of Port Harcourt, Nigeria