Nicaragua: The ending of war and AIDS

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Palestinians were afraid to leave their areas (Hawalli and al-Negra), and some Palestinian doctors who had worked throughout the occupation likewise dared not leave their hospitals. It was not possible to verify claims that upwards of 100 Palestinians had "disappeared" since the Iraqi withdrawal. However, we met non-Kuwaitis who were having difficulty in obtaining food from the distribution centres. And Bedouins, Iraqis, Indians, and Palestinians who had fled from Kuwait or had been abducted were being held and denied re-admission by Kuwaiti soldiers at the border. Ian Pollock

Iraq: Bomb

now, die later

"Baghdad 22nd March, 1891."This is how a recent letter Iraq was dated. The sender had seen his country dragged back into conditions reminiscent of the last century in the short period since the outbreak of the Gulf War. It has been difficult to verify the extent of human suffering in Baghdad and the centre and south of Iraq

from

because the transport and telecommunication network has been virtually destroyed. As a result, the scale of the health problems resulting from the war itself and from the economic embargo have remained largely hidden from the outside world. However, last week, H. Jack Geiger, professor of community medicine at the City University of New York and president of Physicians for Human Rights (PHR), returned from a five-day fact-fmding visit to Iraq and was able to report on the scale of the problem. During the visit the PHR team toured Baghdad and the southern towns of Karbala, Najaf, and Hilla. In the capital they visited the main hospitals, including Medical City, which is Baghdad’s main teaching hospital, Saddam Paediatric Hospital, the Maternity Hospital, and AlYarmouk Hospital. On his return Geiger spoke of the rapidly worsening health and sanitation conditions in Baghdad. The prevalence of diarrhoea and that of dehydration in children are increasing alarmingly, and in one hospital 7% of children admitted for these reasons do not survive. According to Geiger, with the shortage of food in general and baby milk in particular, malnutrition is also causing concern, and hospitals in Baghdad have started to open malnutrition wards. A few children had kwashiorkor. Geiger reported that baby milk is currently selling on the black market at 40 dinars a tin in a country where the average monthly wage is around 180 dinars. The poor were being forced to sell their personal possessions in order to buy food. Geiger acknowledged that it was very difficult to provide an accurate picture of the scale of the difficulties. He reported that UNICEF has set up eleven health centres in Baghdad, and these are important sources of information on medical needs, morbidity, and mortality. However, the findings of the various centres are difficult to collate because telephone lines are down, and communications have been made even more difficult by the scarcity of fuel for

transportation. The allied bombardment destroyed much of the country’s infrastructure and essential services. Geiger reports that electricity supply in Baghdad is still running at only 4% of its pre-war level. Mobile generators are keeping 40% of the capital’s 260 sewage pumping stations functioning, but only part time, so the attendant health risks will be considerable. The PHR team reported that the

stench of sewage was very evident when they visited Medical City. The lack of power supply is also hampering water purification. The three (out of seven) water purification stations that are operational are able to provide only 10% of their previous output. Most people in Baghdad are now boiling water collected from the Tigris, but this has created a further risk. The only available fuel is that used for small kerosene stoves, which have proved very dangerous. According to Geiger several young children have been admitted to hospitals with second or third degree bums resulting from accidents related to the use of these stoves. In one Medical City ward there were eight such cases on the day the team visited. In Baghdad, where power supply to hospitals is intermittent and unreliable, work is restricted to dealing with emergencies only. Even then doctors are not able to carry out routine diagnostic procedures because X-ray units and laboratories are barely functioning. It is thus difficult to monitor how far the rising death toll can definitely be attributed to causes such as cholera and how much to impaired delivery of health care. Acute shortages of anaesthetic gases has meant that patients needing surgery are being given smaller than usual doses of anaesthetics in order to conserve stocks. There are also shortages of other medical supplies, including antibiotics, insulin, and simple dressings. According to Geiger the level of shortages varies from one hospital to another, but moving supplies is proving difficult because of the lack of fuel. Petrol is selling at 8 dinars per litre on the black market, and in this once oil-rich country bicycles and carts have virtually replaced all other vehicles. Although there are no visible signs of malnutrition in the streets of Baghdad, in Geiger’s view this is bound to come. There are other eye-witness reports of people, including the soldiers who man the checkpoints, begging for food, especially bread. The consumption of animal protein in Iraq used to be one of the highest in the world, but dietary habits are changing rapidly. People are now moving towards vegetarianism, driven by high cost and fear of disease from contaminated meat in the absence of refrigeration. If a major catastrophe is to be averted, Geiger is convinced that there needs to be immediate help in the form of fuel, power generators, water purification and sanitation equipment, food, and medical supplies. He likened Iraq to a skeleton covered with skin and muscle but with an impaired circulatory system and no nervous system. The situation is very grave. London

Peter Kandela

Nicaragua: The ending of war and AIDS There are striking variations in AID S case detection rates between the countries of the Central American isthmus, and the politics of this troubled region seem to have been playing a part. By the end of August, 1990, Honduras had reported 626 cases to the World Health Organisation (WHO), El Salvador had reported 192, Panama 180, Costa Rica 169, Guatemala 80, and Nicaragua only 8. Analysis of World Bank and other data suggests a correlation between the number of known cases in each country and the extent of military and economic aid delivered by the USA during the 1980s, measured in terms of dollars and by the numbers of

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US military and other personnel stationed there. Perhaps the one positive feature of the war and the economic blockade of Nicaragua was an unwitting hindering of the penetration of the virus from outside. Indeed 5 of the 8 Nicaraguan AIDS patients were living abroad when the diagnosis was made. In 1986 the Nicaraguan Ministry of Health convened an AIDS commission, which began educational work and testing along WHO recommended lines and was careful to discourage stigmatisation of at-risk groups. However, the present Government’s first year in office has been marked by some discouraging trends. Some officials have vilified homosexuals and denounced the distribution of condoms on religious grounds. The Minister of Health himself recently claimed that AIDS was not an issue for Nicaraguans, only for foreigners.1 These attitudes are particularly worrying because, with the ending of the war, ex-guerillas and refugees have been returning from camps in Honduras, where prevalence is known to be high, and from the USA. Some of these are already among those most recently found to be seropositive, of whom there are 47 to date. Most have been living in the capital, Managua, and well over half are

heterosexual. Work is continuing under the auspices of the Nimehuatzin Foundation, funded by the PanAmerican Health Organisation and the European Community. Their 1991 programme includes plans for 10 000 blood tests in the market areas of Managua, where prostitution is centred and where there is also some drug abuse. Derek Summerfield 1. Envio (published 113: 16-17.

by the Historical Institute of Central America). 1990;

Germany: Drug registration fraud Members of the German drug administration, the Bundesgesundheitsamt (BGA), have won their spurs as sleuths by proving that documents vital to the registration of 50 drugs have been forged. The drugs were different products from several firms, but they had two things in common-all were generic products, and their bioequivalence tests had been done by the same private laboratory in north Bavaria. The test results, the BGA suspected, were just too good to be true; such uniform data from any one drug seemed very unlikely. The head of the laboratory finally admitted the fraud. The laboratory probably hoped that by producing favourable results it would acquire more commissions from

pharmaceutical firms. Now it has closed and faces prosecution for fraud. None of the firms whose products seems to be involved. The BGA is now whether there have been similar manipulations investigating of data from drugs already been admitted for public use. The generic drugs market has expanded and become very competitive, mainly because with the recent health reforms health insurance firms are charged a fixed price for many pharmaceutical products so generics stand a good chance of commercial success-but they have to be shown to be as effective and safe as their branded product. However, to prove this requires such data on the original product, which may not be easy to obtain-as another criminal case, this time within BGA-indicates. Last year one of its members was dismissed and prosecuted because he tried to sell the were

tested

documents of a

cyclosporin to firms that intended to produce generic product. Annette Tuffs

Medicine and the Law ’Sudafed’ capsules poisoned with cyanide In 1982, seven people in Chicago died after ingesting ’Tylenol’ (paracetamol) capsules that had been laced with cyanide. Also in the USA, Stella Nickell was convicted of trying to disguise the murder of her husband by randomly poisoning medication which killed another woman. Recently, in Britain, ground glass was found to have been inserted at random into babyfood and thousands of jars had to be recalled from retailers. A further episode of such senseless and vindictive poisoning was uncovered a few weeks ago in Washington State. Cyanide granules had been inserted into some ’Sudafed’ capsules for cold relief. 28-year-old woman became dangerously ill after swallowing cyanide-contaminated capsules on Feb 2, 1991. Later, investigations into the deaths of a 44-year-old man and a 40-year-old woman revealed that they too had died from cyanide poisoning after ingesting capsules from the same lot number. Some 48 000 capsules of sudafed have been withdrawn from store shelves and analysed by the Food and Drug Administration, and, so far, six packets have been found to have been tampered with. Two were returned by purchasers after the publicity given to the investigation and one contaminated packet was noticed by FDA officials. In one case, there was a razor-like slit in the blister pack, and poisoned capsules had had their white timed-release pellets replaced with yellow cyanide granules. The 44-year-old man’s widow has filed a suit in the US District Court in Tacoma, accusing the manufacturer (Burroughs Wellcome) of negligence. She claims that the company should have told retailers to withdraw sudafed in the Olympia, Washington, area after it had learned of the first woman’s illness; that physicians in the A

should also have been informed about the first illness; and that the capsule packaging was not safe. Since the 1982 tylenol deaths, manufacturers of over-the-counter medicines have been required to provide two tamper-resistant features. Sudafed had three-a blue band around the middle of the capsule, a foil seal on the blister pack, and a plastic tape on the outside of the box. The police have ordered a nationwide recall of an estimated 1 million boxes of capsules, but so far have no idea about who is responsible. Washington Health Secretary Kristine Gebbie has ordered a review by the State Board of Pharmacy of regulations on all over-the-counter capsule medicines-a review, which, she indicated, could lead to a ban on all sales of such capsules without a area

prescription. Whether or not an action would lie against a manufacturer in similar circumstances in English law would depend in part on the Consumer Protection Act 1987, which covers injury by a product that is not as safe as it was reasonably expected to be. Usually, the safety issue will relate to the product itself, but packaging and warnings may also be covered if, for instance, tamper-resistant features were not provided when they should have been. The Act also requires manufacturers to take action once they know that a product has become unsafe in some way. Accordingly, failure by a manufacturer, supplier, or producer to take appropriate steps to protect potential consumers after learning that a product had been randomly contaminated with cyanide could be actionable. So far, no such action has been brought under the Act, which came into force on March 1, 1988, in Britain following a European Community directive. Diana Brahams