- Email: [email protected]
Non-communicable disease in sub-Saharan Africa
CORRESPONDENCE
vaccine in the 1950s and Edward Hooper, author of The River, the book in which Hooper explains why he, and others, think that the vaccine might have been the source of entry of SIV, the ancestor of HIV-1, into human beings. Richard Horton seems to be content to condemn the theory on the basis of the negative results of testing a few selected samples of the 1950s Wistar vaccine for HIV-1 and for chimpanzee tissue. (Chimpanzee, which the makers say they did not use for manufacturing the vaccine, is thought to have been the source of the virus.) No doubt, like the manufacturers, Horton was encouraged by the fact that the 60 or more urine and faecal samples collected last year by my brother, William Hamilton, and his companions, from wild chimpanzees in the forests near Kisangani where the vaccine was developed, did not contain SIV. Bill did not, however, necessarily expect them to. As an evolutionary biologist who had made a unique study of the interaction of hosts and parasites, he was more concerned with testing a worrying hypothesis about the use of animal tissues for treating human beings, which, until that time, everyone seemed to dismiss. Since Bill was unable to interest anyone else in instigating the necessary studies in the Congo, he thought he should do so himself. He hoped to provide, if only on a small scale, facts rather than conjectures, and to show how strongly he felt that the theory should be tested. As is well known, he paid for this effort with his life. It is odd that Horton, a medical editor, says nothing about viral transfer between species causing epidemics, which was discussed more fully on day 2 of the conference. If AIDS was not caused by the polio vaccine, it could have been, and, as was shown by one speaker, could also have been caused iatrogenically in other ways, such as by repeated use of nonsterilisable needles. Many participants agreed that transfer of SIV to human beings was probably connected with unprecedented medical activity in Africa in the 20th century. This danger was that which the organisers of the conference sought to explore, as Robin Weiss emphasised in his summing up when he warned about xenotransplantation, but which was overshadowed, once again, by politics. Mary Bliss London E9 7DP, UK 1
74
Horton R. New data challenge OPV theory of AIDS origin. Lancet 2000; 356: 1005.
Non-communicable disease in sub-Saharan Africa Sir—Your public health quintet series, which ended on Sept 2,1 has reiterated the immense difficulties faced by the world’s poor, no matter where they are. Although most of the world’s poor are in less-developed countries, they also live in resource-rich nations. Whatever the most common diseases are in the local environment, the health issues encountered by the poor are generally much worse than those for richer individuals. Correction of the poverty itself through concerted effort by all concerned could provide the foundation for improved health. Policy makers and politicians must be courageous in acknowledging all specific causes of a population’s ill health, even those that are projected as likely to occur in a few decades, since one or two decades, in medical terms, is a short time.2 Zambia, for example, in sub-Saharan Africa, has a population of nearly 10 million but has no obvious policy, as far as I am aware, on non-communicable disease, which is an emerging public health issue in the sub-Saharan Africa region. Zambia has a striking paucity of information on cardiovascular health and disease, especially hypertension, that contributes to individuals’ global cardiovascular risk status. The quest for accurate information is essential if the country is to provide good cardiovascular health to survivors of the current scourge of more common disorder such as HIV and AIDS, malaria, tuberculosis, and medical complications of general economic malaise such as kwashiokor and marasmus. The minimum that should be expected from policy makers and public-health specialists is acknowledgment that hypertension and cardiovascular disease exist in the wider realm of non-communicable diseases. No health policy can, however, be formulated without a concerted effort by all health professionals, especially doctors and nurses. I acknowledge Zambia’s poor doctor-to-patient ratio of one per 11 000.3 Despite this poor ratio, all patients expect to have a basic clinical assessment, the taking of a history, and a physical examination, including measurement of blood pressure. I believe that blood pressure is a fundamental trait that can be measured in everyone. A well thought out basic minimum in clinical assessment commonly begets relevant and appropriate simple investigations that can lead to diagnosis of most features of cardiovascular disease. If
we, as health professionals, became patients we would not accept any less. Zambia does not need an immediate multimillion pound study. Initially, an appropriate prevalence study is urgently needed to profile cardiovascular health. Such a study will have to be a collaborative effort between a team experienced in bloodpressure research (possibly from a resource-rich nation) and a keen local health practitioner with full support from policy makers. With some knowledge of the extent of cardiovascular disease, Zambia could safely begin to extrapolate research information from other countries to assist in country-specific policy making. Cardiovascular ill health clearly exists even in rural Zambia, where stroke admissions use immense health-care resources. Rural patients with minor stroke remain in the community, whereas those with major strokes frequently die before receiving medical attention.4 A case series of stroke assessed by cerebral angiography showed that atherosclerosis is rare in Zambia but hypertension remains the most common underlying cause of stroke.5 The survivors of communicable diseases will judge us better if we acknowledge that non-communicable diseases exist, and be grateful if we formulate policy on prevention and management of cardiovascular disease. Joseph Yikona University Department of Medicine and Pharmacology, Royal Hallamshire Hospital, sheffield S10 2JF, UK (e-mail: [email protected]) 1
2
3
4
5
MacFarlane S, Racelis M, Muli-Musiime F. Public health in developing countries. Lancet 2000; 356: 841–46. Murray CJL, Lopez AD, eds. The global burden of disease. Cambridge, Mass: Harvard University Press, 1996. Bissio R, ed. The world guide 1997/98: a view from the South. Instituto del Tercer Mundo, 1997: 597–98. Birbeck GL. Barriers to care for patients with neurologic disease in rural Zambia. Arch Neurol 2000; 57: 414–47. Umerah BC. Angiography of stroke in central Africa. AJR Am J Roentgenol 1980; 134: 963–65.
DEPARTMENT OF ERROR Subclinical microtraumatisation of the scrotal contents in extreme mountain biking—In this Research letter by Ferdinand Frauscher and colleagues (Oct 21, p 1414), the third sentence of the last paragraph on page 1414 should be, “The mechanical component responsible for these changes can be reduced by improving the padding of the seat or shorts, adjusting the saddle angle to either horizontal or downward in front, adjusting the saddle height, using an ergonomically designed saddle, and by taking frequent rests during each ride.”
THE LANCET • Vol 357 • January 6, 2001
For personal use only. Not to be reproduced without permission of The Lancet.
vaccine in the 1950s and Edward Hooper, author of The River, the book in which Hooper explains why he, and others, think that the vaccine might have been the source of entry of SIV, the ancestor of HIV-1, into human beings. Richard Horton seems to be content to condemn the theory on the basis of the negative results of testing a few selected samples of the 1950s Wistar vaccine for HIV-1 and for chimpanzee tissue. (Chimpanzee, which the makers say they did not use for manufacturing the vaccine, is thought to have been the source of the virus.) No doubt, like the manufacturers, Horton was encouraged by the fact that the 60 or more urine and faecal samples collected last year by my brother, William Hamilton, and his companions, from wild chimpanzees in the forests near Kisangani where the vaccine was developed, did not contain SIV. Bill did not, however, necessarily expect them to. As an evolutionary biologist who had made a unique study of the interaction of hosts and parasites, he was more concerned with testing a worrying hypothesis about the use of animal tissues for treating human beings, which, until that time, everyone seemed to dismiss. Since Bill was unable to interest anyone else in instigating the necessary studies in the Congo, he thought he should do so himself. He hoped to provide, if only on a small scale, facts rather than conjectures, and to show how strongly he felt that the theory should be tested. As is well known, he paid for this effort with his life. It is odd that Horton, a medical editor, says nothing about viral transfer between species causing epidemics, which was discussed more fully on day 2 of the conference. If AIDS was not caused by the polio vaccine, it could have been, and, as was shown by one speaker, could also have been caused iatrogenically in other ways, such as by repeated use of nonsterilisable needles. Many participants agreed that transfer of SIV to human beings was probably connected with unprecedented medical activity in Africa in the 20th century. This danger was that which the organisers of the conference sought to explore, as Robin Weiss emphasised in his summing up when he warned about xenotransplantation, but which was overshadowed, once again, by politics. Mary Bliss London E9 7DP, UK 1
74
Horton R. New data challenge OPV theory of AIDS origin. Lancet 2000; 356: 1005.
Non-communicable disease in sub-Saharan Africa Sir—Your public health quintet series, which ended on Sept 2,1 has reiterated the immense difficulties faced by the world’s poor, no matter where they are. Although most of the world’s poor are in less-developed countries, they also live in resource-rich nations. Whatever the most common diseases are in the local environment, the health issues encountered by the poor are generally much worse than those for richer individuals. Correction of the poverty itself through concerted effort by all concerned could provide the foundation for improved health. Policy makers and politicians must be courageous in acknowledging all specific causes of a population’s ill health, even those that are projected as likely to occur in a few decades, since one or two decades, in medical terms, is a short time.2 Zambia, for example, in sub-Saharan Africa, has a population of nearly 10 million but has no obvious policy, as far as I am aware, on non-communicable disease, which is an emerging public health issue in the sub-Saharan Africa region. Zambia has a striking paucity of information on cardiovascular health and disease, especially hypertension, that contributes to individuals’ global cardiovascular risk status. The quest for accurate information is essential if the country is to provide good cardiovascular health to survivors of the current scourge of more common disorder such as HIV and AIDS, malaria, tuberculosis, and medical complications of general economic malaise such as kwashiokor and marasmus. The minimum that should be expected from policy makers and public-health specialists is acknowledgment that hypertension and cardiovascular disease exist in the wider realm of non-communicable diseases. No health policy can, however, be formulated without a concerted effort by all health professionals, especially doctors and nurses. I acknowledge Zambia’s poor doctor-to-patient ratio of one per 11 000.3 Despite this poor ratio, all patients expect to have a basic clinical assessment, the taking of a history, and a physical examination, including measurement of blood pressure. I believe that blood pressure is a fundamental trait that can be measured in everyone. A well thought out basic minimum in clinical assessment commonly begets relevant and appropriate simple investigations that can lead to diagnosis of most features of cardiovascular disease. If
we, as health professionals, became patients we would not accept any less. Zambia does not need an immediate multimillion pound study. Initially, an appropriate prevalence study is urgently needed to profile cardiovascular health. Such a study will have to be a collaborative effort between a team experienced in bloodpressure research (possibly from a resource-rich nation) and a keen local health practitioner with full support from policy makers. With some knowledge of the extent of cardiovascular disease, Zambia could safely begin to extrapolate research information from other countries to assist in country-specific policy making. Cardiovascular ill health clearly exists even in rural Zambia, where stroke admissions use immense health-care resources. Rural patients with minor stroke remain in the community, whereas those with major strokes frequently die before receiving medical attention.4 A case series of stroke assessed by cerebral angiography showed that atherosclerosis is rare in Zambia but hypertension remains the most common underlying cause of stroke.5 The survivors of communicable diseases will judge us better if we acknowledge that non-communicable diseases exist, and be grateful if we formulate policy on prevention and management of cardiovascular disease. Joseph Yikona University Department of Medicine and Pharmacology, Royal Hallamshire Hospital, sheffield S10 2JF, UK (e-mail: [email protected]) 1
2
3
4
5
MacFarlane S, Racelis M, Muli-Musiime F. Public health in developing countries. Lancet 2000; 356: 841–46. Murray CJL, Lopez AD, eds. The global burden of disease. Cambridge, Mass: Harvard University Press, 1996. Bissio R, ed. The world guide 1997/98: a view from the South. Instituto del Tercer Mundo, 1997: 597–98. Birbeck GL. Barriers to care for patients with neurologic disease in rural Zambia. Arch Neurol 2000; 57: 414–47. Umerah BC. Angiography of stroke in central Africa. AJR Am J Roentgenol 1980; 134: 963–65.
DEPARTMENT OF ERROR Subclinical microtraumatisation of the scrotal contents in extreme mountain biking—In this Research letter by Ferdinand Frauscher and colleagues (Oct 21, p 1414), the third sentence of the last paragraph on page 1414 should be, “The mechanical component responsible for these changes can be reduced by improving the padding of the seat or shorts, adjusting the saddle angle to either horizontal or downward in front, adjusting the saddle height, using an ergonomically designed saddle, and by taking frequent rests during each ride.”
THE LANCET • Vol 357 • January 6, 2001
For personal use only. Not to be reproduced without permission of The Lancet.