- Email: [email protected]
Measles trouble spots
"Even when I appear in church they think into Italy’s bottomless state treasury; fines it’s going to be a blitz", he says. Although were envisaged for non-payment. The tax (as a member of the now disappearing is now defunct and Costa favours reimLiberal Party) committed to some degree bursement to those who have already paid of privatisation, he sees it as his first duty in 1994, but how will he find the necesto make the public structures function sary L650 billion, not to mention the before introducing new legislation. Plenty 6-7% interest calculated over 6 months? of laws and regulations are already in Unless timely action is taken, non-payplace but have never been properly ment will figure as evasion in the 1994 tax declaration. : applied. Costa is also particularly concerned about the transplant service and Another vexed question is the system of while Health Minister had begun to attack health coupons, floated in 1991 and the interminable waiting lists. Recently a aimed at assisting low-income families scandal broke involving clandestine traffic and unemployed persons to purchase necin corneas. In an interview given to the essary, in some cases life-saving, drugs. Milanese daily Coniere della Sera of May Though financed to the tune of L80 bil16, Costa mentions offering incentives to lion, the system was bedevilled with typiprospective organ donors. Also on his cal Italian red tape and proved a failure. But Costa’s prime headache is hospitals. agenda is the family doctor tax, introduced in 1993 amid bitter controversy. In a country with a surprisingly healthy This entailed payment of L85 000 per sinbalance of payments and a national gle person earning a taxable income above income that places it fifth or sixth in the 30 million, or per couple with over L45 global table, Italy’s hospitals all too often million, and it brought HI 00 billion lire descend to very low standards. Recent
months have witnessed a distressing number of reports of patients in need of emergency treatment being refused admission for lack of room. "Ghost" hospitals abound. Costa mentions one in Rome, 20 years on from the laying of its foundation stone and still uncompleted. Another, in a wealthy area, was found to contain a department that existed only on paper and whose paper staff were drawing full salaries while gainfully employed elsewhere in private structures. Yet others, built in remote places with lavish public expenditure doled out in return for bribes and promises of votes, stand gleaming and ready, complete with sophisticated equipment but still awaiting activation-or a blitz by Raffaele Costa. As successor to Maria Pia Garavaglia, who acquired a reputation for clarity and forthrightness during her brief tenure, much will be expected of him.
little regulation of these healers and no standardised training for them. The plan includes a proposal for control by a recognised body to raise standards and eliminate harmful practices. : Another feature of the new plan that will be watched with keen interest is the extent to which the existing medical aid schemes can be integrated into a national health insurance scheme. These schemes have found themselves under increasing pressure as health-care costs in the private sector have soared to unprecedented heights, necessitating hikes in premiums that have
led to strong resistance from commerce and industry, which have had to foot half of the bill, and many of them have been feeling the financial pinch. Although there have been dissenting voices, particularly from the alcohol and tobacco industries, the ANC’s plan, which will almost undoubtedly be endorsed by the Cabinet, has generally been welcomed as an honest attempt to redress the inequities in health care aggravated by nearly half a century of apartheid.
Measles trouble spots
duced in the territories in 1978, but not until 10 years later in Israel (Am J Publ Health 1989; 79: 1648-52). During the current measles outbreak in Israel, the age for routine measles-mumpsrubella vaccination was lowered from 15 months to 12 months and staff at healthy mother and child clinics are telephoning parents whose children are due for vaccination. Usually, every year about 10 000 children miss their vaccinations so, as Slater puts it, a "big respectable outbreak" could occur every 3-4 years because of the build-up of susceptibles. In Gaza, however, since 1988, children have been offered vaccination against measles at age 9 months, followed by measles-mumps-rubella at 15 months. In 1990, both Israel and Gaza offered a second routine dose to children aged 6 to confront the measles outbreaks that have recurred over the years, albeit with steep decline in incidence rates. Because a measles outbreak was expected during 1990-91, the health authorities in Gaza launched an intensive programme. All children aged 2-12 received a second dose in the autumn of 1990 to create sufficient herd immunity. A less intensive programme was adopted by
1
1
1
South Africa’s health
plan
The African National Congress has not let any grass grow under its feet. It has published its wide-ranging health plan almost before members of the new Cabinet, to which it is being presented this week, have had time to warm the seats of their chairs. In doing so, it has shown rare wisdom, because although, at its best, medical care in South Africa was and is probably as good as can be found anywhere in the world, it was simply not available to large sectors of the community. In essence, the plan aims to discourage further expansion of the private sector, and to concentrate on channelling resources into the public sector to
provide
a
comprehensive primary
health-care service for all sections of the population. As a first stop, the initial fiveyear plan aims to establish a single, integrated national health system which will be funded through existing taxation. However, the creation of a national health insurance scheme will also be high on the new government’s agenda, and further revenue to pay for the scheme will be raised by practically doubling taxes on alcohol and tobacco. Commenting on the health plan, Minister of Health Dr Nkosazana Zuma stated that the health and well-being of South Africa’s children are a top priority, and she hopes that by the end of the year, under-sixes will be able to get free medical care if the proposed legislation can be enacted in time. Others who will be entitled to free medical care will be the elderly, the disabled, and pregnant and nursing mothers. One aspect of the plan, which has caused raised eyebrows in some medical circles, is the proposal to make traditional healers part of the health-care system, particularly as there has in the past been
1350
:
going through another measles epidemic-nearly 1000 cases have been reported in 1994. Gaza has had only 6 suspected cases this year. Although there must be political, social, and other reasons for the difference, the bottom line is that Israel is
:
the immunisation control programme in the territories has been far more intensive than that inside Israel. Dr Paul Slater, head of epidemiology in Israel’s Health Ministry, believes that with measles it is almost impossible to achieve the necessary herd immunity to prevent transmission" (Isrl Med Sci 1991; 27: 19-21). But Dr Theodore Tulchinsky, the Israeli Health Ministry’s coordinator for health in the territories, does not ’, agree. Historically, improvements in prechildhood vaccination ventive proin the territories have preceded grammes changes in Israel proper. In Israel, measles-mumps-rubella vaccine replaced the measles vaccine in 1988, a year later than in the territories (Rev Infect Dis 1990; 12: 951-58). Likewise, combined trivalent oral poliovaccine and inactivated poliovaccine (the "Gaza system") were intro-
Timothy Keates
Nick Lee
Slater (Isr J Med Sci 1991; 27: 19-21). When an outbreak of measles occurred in 1990-91 during the Gulf War in the nearby Israeli town of Beersheva, and despite a substantial number of measles cases
Unnecessary
sections in USA
of Israel, Gaza and unconfirmed clinical reports of "low fever and measleslike rashes", despite instructions to staff to direct all suspected cases of measles to hospital for laboratory confirmation. There is no such directive in Israel. The rationale for the directive, says Tulchinsky, is that "in the crowded conditions of . Gaza the maximum control of measles is important and requires the clarification of every suspect case". In reality the situation is more complicated, according to Dr Yetia Abed, director of the Gaza Health Services Research Center and now chief epidemiologist of the Palestinian Council of Health. In 1993, 48 cases of mild fever and rash were admitted to hospital as suspected cases of measles, mostly from UNRWA. 12 underwent laboratory tests but none was found to be measles. "We reported all 48 as measles because that was how they were registered, even though we believed them to be other syndromes-eg, rickettsia, roseola, rubella", he said. : When Gaza was under Egyptian administration the legal requirement for immunisation was not enforced. Now, agreement of all parties, compliance in Gaza today is near 96% and, according to Abed, if inoculations are not offered, mothers petition healthcare providers for them. "We made sure that it [the vaccina-
throughout the rest received only sporadic
by
tion schedule]
was never
interrupted dur-
intifada", says Dr Riyad El-Zaanoun, director of the Palestinian
ing
the
Council of Health and the Palestinian interim
authority.
a
member of
self-governing :
Overall coverage in Israel is about 90%, reaching the target level proposed for each country by 1995 by the World Summit for Children and the World Health Assembly. According to Dr Alex Leventhal, the Ministry’s head of public health, "We are proud that we are more democratic" by not forcing children to be immunised, and despite this, coverage is about 10% higher than that in the United States, where age 6 school entry and armed forces induction vaccinations are mandatory" (and where measles vaccination began in 1963). A measles outbreak in the Israel Defense Forces during the 1982 nationwide epidemic resulted in 3000 reported cases amongst soldiers aged 18 to 25 years, indicating high risk within this population characteristic of the shifting age distribution towards more cases amongst older children and adults (Isr J Med Sci 1985; 21: 93-96). Another outbreak occurred in 1993.
:
According second dose
least
one
to
Slater, Israel applied the
to ensure
that children get
caesarean
at
dose, and only secondarily to
22-6% of all US births in 1992 were by caesarean section, almost twice the expected rate, according to a report by Mary Gabay and Sidney Wolfe of Public Citizen’s Health Research Group.’ Gabay and Wolfe studied the method of delivery for 3-97 million births and calculated that the optimum national rate of caesarean section should be nearer 12%. In 1970, the rate was 5-5% and peaked in 1988 at 24-7%. Figures for individual states range from 28-4% in Arkansas to 16-3% in Colorado. One hospital in Michigan had a section rate of 63-7%. The five states with the highest section rates were Arkansas, * Gaza Health Services Research : Center, Gaza. Louisiana (28-2%), Mississippi (27-7%), in about 60-65% of population teligible refugees only, : : Texas Gaza. (27-0%), and West Virginia t Epidemiology Dept, Ministry of Health. : (26-3%). Caesarean section remains the : 1) Vaccination against measles instituted in Israel in 1967; § in Gaza in 1976. : commonest operative procedure in the US. protect people whose immunity had fallen Gabay and Wolfe argue that the below protective levels. "Good reasonable increased use of vaginal birth after caeprogrammes should aspire to control but sarean section (VBAC) accounts for most not to eradicate measles and no one is tryof the fall off. Rates of VBAC have risen from 6-6% in 1985 to 25-4% in 1992. ing to do it", asserts Slater. "It’s hard to believe that Gaza is the first country in the The correct range for VBAC rates, the world to eliminate measles". Tulchinsky authors suggest, is 50-55%. Only 90 hosagrees that "there’s a controversy. But pitals were identified that had section he’s had two epidemics since 1990 and rates at or below 15% and VBAC rates at we’ve had none". He stands by the costor above 45%. The five states with the effectiveness of his "more modem" and highest section rates also had the lowest "energetic" approach (Bull WHO 1993; rates of VBAC. 71: 93-103), pointing out that the immuThe main indications for caesarean secnisation programme has virtually flattened tion were past section (35% of all cases), the curve and predicting that if measles dystocia (abnormal progress of labour, outbreaks do occur they will be further 30-4%), breech presentation (11-7%), and fetal distress (9-2%). The report recomapart and considerably less severe. mends that a trial of labour should be Rachelle H B Fishman offered to most women who have had a previous section. The same advice was given in 1988 by the American College of Another HIV Obstetricians and Gynecologists. Dystocia can be largely overcome by active manA fourth inhibitor of HIV reverse tranis its the agement of labour-eg, by artificial rupscriptase working way through accelerated approval process of the Food ture of membranes and by augmentation and Drug Administration. Stavudine, or of labour with oxytocin. External cephalic version to turn a breech presentation can d4T, is a nucleoside analogue,. An adbe successful in over 60% of cases, and visory committee on May 20 was "supportive of a recommendation for fetal distress, as measured by electronic approval" of the new drug, with the caveat fetal monitoring, is often spurious. Randomised trials of electronic fetal monitorthat very little is known about its specific with interactions other indications, drugs, ing vs intermittent ausculation reveal that electronic monitoring not only fails to or effects in populations other than young white men. D4T has been used on 10 000 improve outcome but also leads to unnecessarily high section rates. If the target people, all of them intolerant of or resissection rate of around 12% were achieved, tant to the other three anti-HIV drugs. 79% of those patients are still alive after some 473000 of 966000 sections under18 months. Despite a 21% incidence of taken in 1991 would have been prevented, peripheral neuropathy, the overall safety at a saving of over$1-3 billion to the and side-effect profile looks encouraging. beleaguered US health-care system. In a comparative trial on 359 patients, : Many hospitals have already recognised d4T was compared with zidovudine, and the financial burden of these high operafound to be significantly better at boosting tive rates and have begun caesarean or maintaining CD4 cell levels and at reduction programmes by means of audit decreasing HIV antigen levels. : and peer review of obstetric decision making. Two key elements in these proPaul M Rowe grammes include enhancing the role of
drug
i
1351
months have witnessed a distressing number of reports of patients in need of emergency treatment being refused admission for lack of room. "Ghost" hospitals abound. Costa mentions one in Rome, 20 years on from the laying of its foundation stone and still uncompleted. Another, in a wealthy area, was found to contain a department that existed only on paper and whose paper staff were drawing full salaries while gainfully employed elsewhere in private structures. Yet others, built in remote places with lavish public expenditure doled out in return for bribes and promises of votes, stand gleaming and ready, complete with sophisticated equipment but still awaiting activation-or a blitz by Raffaele Costa. As successor to Maria Pia Garavaglia, who acquired a reputation for clarity and forthrightness during her brief tenure, much will be expected of him.
little regulation of these healers and no standardised training for them. The plan includes a proposal for control by a recognised body to raise standards and eliminate harmful practices. : Another feature of the new plan that will be watched with keen interest is the extent to which the existing medical aid schemes can be integrated into a national health insurance scheme. These schemes have found themselves under increasing pressure as health-care costs in the private sector have soared to unprecedented heights, necessitating hikes in premiums that have
led to strong resistance from commerce and industry, which have had to foot half of the bill, and many of them have been feeling the financial pinch. Although there have been dissenting voices, particularly from the alcohol and tobacco industries, the ANC’s plan, which will almost undoubtedly be endorsed by the Cabinet, has generally been welcomed as an honest attempt to redress the inequities in health care aggravated by nearly half a century of apartheid.
Measles trouble spots
duced in the territories in 1978, but not until 10 years later in Israel (Am J Publ Health 1989; 79: 1648-52). During the current measles outbreak in Israel, the age for routine measles-mumpsrubella vaccination was lowered from 15 months to 12 months and staff at healthy mother and child clinics are telephoning parents whose children are due for vaccination. Usually, every year about 10 000 children miss their vaccinations so, as Slater puts it, a "big respectable outbreak" could occur every 3-4 years because of the build-up of susceptibles. In Gaza, however, since 1988, children have been offered vaccination against measles at age 9 months, followed by measles-mumps-rubella at 15 months. In 1990, both Israel and Gaza offered a second routine dose to children aged 6 to confront the measles outbreaks that have recurred over the years, albeit with steep decline in incidence rates. Because a measles outbreak was expected during 1990-91, the health authorities in Gaza launched an intensive programme. All children aged 2-12 received a second dose in the autumn of 1990 to create sufficient herd immunity. A less intensive programme was adopted by
1
1
1
South Africa’s health
plan
The African National Congress has not let any grass grow under its feet. It has published its wide-ranging health plan almost before members of the new Cabinet, to which it is being presented this week, have had time to warm the seats of their chairs. In doing so, it has shown rare wisdom, because although, at its best, medical care in South Africa was and is probably as good as can be found anywhere in the world, it was simply not available to large sectors of the community. In essence, the plan aims to discourage further expansion of the private sector, and to concentrate on channelling resources into the public sector to
provide
a
comprehensive primary
health-care service for all sections of the population. As a first stop, the initial fiveyear plan aims to establish a single, integrated national health system which will be funded through existing taxation. However, the creation of a national health insurance scheme will also be high on the new government’s agenda, and further revenue to pay for the scheme will be raised by practically doubling taxes on alcohol and tobacco. Commenting on the health plan, Minister of Health Dr Nkosazana Zuma stated that the health and well-being of South Africa’s children are a top priority, and she hopes that by the end of the year, under-sixes will be able to get free medical care if the proposed legislation can be enacted in time. Others who will be entitled to free medical care will be the elderly, the disabled, and pregnant and nursing mothers. One aspect of the plan, which has caused raised eyebrows in some medical circles, is the proposal to make traditional healers part of the health-care system, particularly as there has in the past been
1350
:
going through another measles epidemic-nearly 1000 cases have been reported in 1994. Gaza has had only 6 suspected cases this year. Although there must be political, social, and other reasons for the difference, the bottom line is that Israel is
:
the immunisation control programme in the territories has been far more intensive than that inside Israel. Dr Paul Slater, head of epidemiology in Israel’s Health Ministry, believes that with measles it is almost impossible to achieve the necessary herd immunity to prevent transmission" (Isrl Med Sci 1991; 27: 19-21). But Dr Theodore Tulchinsky, the Israeli Health Ministry’s coordinator for health in the territories, does not ’, agree. Historically, improvements in prechildhood vaccination ventive proin the territories have preceded grammes changes in Israel proper. In Israel, measles-mumps-rubella vaccine replaced the measles vaccine in 1988, a year later than in the territories (Rev Infect Dis 1990; 12: 951-58). Likewise, combined trivalent oral poliovaccine and inactivated poliovaccine (the "Gaza system") were intro-
Timothy Keates
Nick Lee
Slater (Isr J Med Sci 1991; 27: 19-21). When an outbreak of measles occurred in 1990-91 during the Gulf War in the nearby Israeli town of Beersheva, and despite a substantial number of measles cases
Unnecessary
sections in USA
of Israel, Gaza and unconfirmed clinical reports of "low fever and measleslike rashes", despite instructions to staff to direct all suspected cases of measles to hospital for laboratory confirmation. There is no such directive in Israel. The rationale for the directive, says Tulchinsky, is that "in the crowded conditions of . Gaza the maximum control of measles is important and requires the clarification of every suspect case". In reality the situation is more complicated, according to Dr Yetia Abed, director of the Gaza Health Services Research Center and now chief epidemiologist of the Palestinian Council of Health. In 1993, 48 cases of mild fever and rash were admitted to hospital as suspected cases of measles, mostly from UNRWA. 12 underwent laboratory tests but none was found to be measles. "We reported all 48 as measles because that was how they were registered, even though we believed them to be other syndromes-eg, rickettsia, roseola, rubella", he said. : When Gaza was under Egyptian administration the legal requirement for immunisation was not enforced. Now, agreement of all parties, compliance in Gaza today is near 96% and, according to Abed, if inoculations are not offered, mothers petition healthcare providers for them. "We made sure that it [the vaccina-
throughout the rest received only sporadic
by
tion schedule]
was never
interrupted dur-
intifada", says Dr Riyad El-Zaanoun, director of the Palestinian
ing
the
Council of Health and the Palestinian interim
authority.
a
member of
self-governing :
Overall coverage in Israel is about 90%, reaching the target level proposed for each country by 1995 by the World Summit for Children and the World Health Assembly. According to Dr Alex Leventhal, the Ministry’s head of public health, "We are proud that we are more democratic" by not forcing children to be immunised, and despite this, coverage is about 10% higher than that in the United States, where age 6 school entry and armed forces induction vaccinations are mandatory" (and where measles vaccination began in 1963). A measles outbreak in the Israel Defense Forces during the 1982 nationwide epidemic resulted in 3000 reported cases amongst soldiers aged 18 to 25 years, indicating high risk within this population characteristic of the shifting age distribution towards more cases amongst older children and adults (Isr J Med Sci 1985; 21: 93-96). Another outbreak occurred in 1993.
:
According second dose
least
one
to
Slater, Israel applied the
to ensure
that children get
caesarean
at
dose, and only secondarily to
22-6% of all US births in 1992 were by caesarean section, almost twice the expected rate, according to a report by Mary Gabay and Sidney Wolfe of Public Citizen’s Health Research Group.’ Gabay and Wolfe studied the method of delivery for 3-97 million births and calculated that the optimum national rate of caesarean section should be nearer 12%. In 1970, the rate was 5-5% and peaked in 1988 at 24-7%. Figures for individual states range from 28-4% in Arkansas to 16-3% in Colorado. One hospital in Michigan had a section rate of 63-7%. The five states with the highest section rates were Arkansas, * Gaza Health Services Research : Center, Gaza. Louisiana (28-2%), Mississippi (27-7%), in about 60-65% of population teligible refugees only, : : Texas Gaza. (27-0%), and West Virginia t Epidemiology Dept, Ministry of Health. : (26-3%). Caesarean section remains the : 1) Vaccination against measles instituted in Israel in 1967; § in Gaza in 1976. : commonest operative procedure in the US. protect people whose immunity had fallen Gabay and Wolfe argue that the below protective levels. "Good reasonable increased use of vaginal birth after caeprogrammes should aspire to control but sarean section (VBAC) accounts for most not to eradicate measles and no one is tryof the fall off. Rates of VBAC have risen from 6-6% in 1985 to 25-4% in 1992. ing to do it", asserts Slater. "It’s hard to believe that Gaza is the first country in the The correct range for VBAC rates, the world to eliminate measles". Tulchinsky authors suggest, is 50-55%. Only 90 hosagrees that "there’s a controversy. But pitals were identified that had section he’s had two epidemics since 1990 and rates at or below 15% and VBAC rates at we’ve had none". He stands by the costor above 45%. The five states with the effectiveness of his "more modem" and highest section rates also had the lowest "energetic" approach (Bull WHO 1993; rates of VBAC. 71: 93-103), pointing out that the immuThe main indications for caesarean secnisation programme has virtually flattened tion were past section (35% of all cases), the curve and predicting that if measles dystocia (abnormal progress of labour, outbreaks do occur they will be further 30-4%), breech presentation (11-7%), and fetal distress (9-2%). The report recomapart and considerably less severe. mends that a trial of labour should be Rachelle H B Fishman offered to most women who have had a previous section. The same advice was given in 1988 by the American College of Another HIV Obstetricians and Gynecologists. Dystocia can be largely overcome by active manA fourth inhibitor of HIV reverse tranis its the agement of labour-eg, by artificial rupscriptase working way through accelerated approval process of the Food ture of membranes and by augmentation and Drug Administration. Stavudine, or of labour with oxytocin. External cephalic version to turn a breech presentation can d4T, is a nucleoside analogue,. An adbe successful in over 60% of cases, and visory committee on May 20 was "supportive of a recommendation for fetal distress, as measured by electronic approval" of the new drug, with the caveat fetal monitoring, is often spurious. Randomised trials of electronic fetal monitorthat very little is known about its specific with interactions other indications, drugs, ing vs intermittent ausculation reveal that electronic monitoring not only fails to or effects in populations other than young white men. D4T has been used on 10 000 improve outcome but also leads to unnecessarily high section rates. If the target people, all of them intolerant of or resissection rate of around 12% were achieved, tant to the other three anti-HIV drugs. 79% of those patients are still alive after some 473000 of 966000 sections under18 months. Despite a 21% incidence of taken in 1991 would have been prevented, peripheral neuropathy, the overall safety at a saving of over$1-3 billion to the and side-effect profile looks encouraging. beleaguered US health-care system. In a comparative trial on 359 patients, : Many hospitals have already recognised d4T was compared with zidovudine, and the financial burden of these high operafound to be significantly better at boosting tive rates and have begun caesarean or maintaining CD4 cell levels and at reduction programmes by means of audit decreasing HIV antigen levels. : and peer review of obstetric decision making. Two key elements in these proPaul M Rowe grammes include enhancing the role of
drug
i
1351