- Email: [email protected]
Public health in less-developed countries
CORRESPONDENCE
azathioprine-treated patients. The use of the 5 mg dose might be appropriate for patients deemed at high risk of acute rejection episodes when the unique therapeutic benefits of sirolimus outweigh possible toxic effects of the treatment. We show that sirolimus safely and effectively provides prophylaxis against acute rejection episodes, the dominant risk factor for long-term grafts. Barry D Kahan Division of Immunology and Organ Transplantation, Department of Surgery, University of Texas Medical School at Houston, Houston 77030, TX, USA (e-mail: [email protected]) 1
2
3
4
5
Hariharan S, Johnson CP, Bresnahan BA, Taranto SE, McIntosh MJ, Stablein D. Improved graft survival after renal transplantation in the United States: 1988 to 1996. N Engl J Med 2000; 342: 605–12. Geddes CC, Cole E, Wade J, et al. Factors influencing long-term primary cadaveric kidney transplantation—importance of renal functional mass versus avoidance of acute rejections: the Toronto Hospital experience 1985–1997. In: Cecka JM, Teraski PI, eds. Clinical transplants. Los Angeles: UCLA Tissue Typing Laboratory, 1998: 195–203. Podder H, Kahan BD. Pharmacokinetic interactions augment toxicities of sirolimuscyclosporine combinations. J Am Soc Nephrol (in press). Kreis H, Cisterne JM, Land W, et al. Sirolimus in association with mycophenolate mofetil induction for the prevention of acute graft rejection in renal allograft recipients. Transplantation 2000; 69: 1252–60. Kahan BD, Napoli KL, Kelly PA, et al. Therapeutic drug monitoring of sirolimus: correlations with efficacy and toxicity. Clin Transplant 2000; 14: 97–109.
Public health in less-developed countries Sir—Sarah Macfarlane and colleagues (Sept 2, p 841)1 recommend new forms of communication and cooperation at multiple levels in society, government, and international organisations to improve people’s health and wellbeing. Involvement of philanthropic establishments engaged in therapeutic interventions, professionals in veterinary public health, and agencies concerned with agricultural productivity would be vital to redress the existing inequalities of public health. Philanthopic societies with sizeable funds for health care operate at international and national level. Apart from the remarkable international role of the Rotary International or the James S McDonnell foundation in this connection, the Sri Sathya Sai Institute of Higher Medical Sciences has been operational in India through the 1990s. In 1991–96, free procedures offered to the community included 3052 open-
THE LANCET • Vol 356 • 18 November, 2000
heart surgeries, 4572 cardiac catheterisations, 4286 renal dialysis, and 71 kidney transplants. 2525 operations were done for eye trauma, corneal transplants, and vitreous and retinal diseases.2 Such organisations could start therapeutic intervention with antiretrovirals to halt mother-tochild transmission of HIV.3 They would also be ideal to start free or greatly subsidised multidrug therapy against HIV, chronic viral hepatitis, or neoplastic disorders. Many people have close contact with cattle or domestic animals in lessdeveloped countries. Such close contact encourages spread of zoonotic diseases in the community. The professionals with veterinary skills address health hazards, including trade in animal products, at an international level, and there are sources at this level to obtain practical and technical guidance in controlling the threat to human health posed by animals.4 Nevertheless, facilities and infrastructure for veterinary public-health services at remote locations are not adequate. Since the mid-1990s, measures against malnutrition, immunisation, and maternal health, as well as an integrated approach for treatment of all sick children have been in operation at primary-care level.5 A well-coordinated approach to handle human and animal illnesses at primary human and veterinary care centres in rural areas in resource-poor nations is desirable. Organisations such as the Food and Agricultural Organization (FAO) with a mandate to improve agricultural productivity and conditions of rural populations would be integral components at the primary-care level. Funds should be allocated to plan and execute integrated activities by staff in human and animal health centres as well as in agricultural productivity at grass-roots level. Well coordinated activity involving different disciplines should provide a novel opportunity to translate international mandates1 to reality in otherwise marginalised people in remote locations. Subhash C Arya Centre for Logistical Research and Innovation, M-122 (of part 2), Greater Kailash-II, New Delhi- 110048, India (e-mail: [email protected]) 1
2
3
Macfarlane S, Racelis M, Muli-Musiime F. Public health in developing countries. Lancet 2000; 356: 841–46. Safaya AN. Free high-tech health care in India. World Health Forum 1998; 19: 196–200. Baggaley R, van Praag E, Antiretroviral interventions to reduce mother-to-child transmission of human immunodeficiency
4
5
virus: challenges for health systems, communities and society. Bull World Health Organ 2000; 78: 1036–44. Stohr K, Meslin FX. The role of veterinary public health in prevention of zoonoses. Arch Virol Suppl 1997; 13: 207–18. Nicoll A. Integrated management of childhood illness in resource-poor countries: an initiative from the World Health Organization. Trans R Soc Trop Med Hyg 2000; 94: 9–11.
Sir—Sarah Macfarlane and colleagues1 and Robert Beaglehole and Ruth Bonita, in their Sept 2 commentary,2 omit any mention of the genetic disease burden that will loom ever bigger when AIDS disappears and malaria is rolled back. As Bela Ringelhann and I have previously noted,3 with a population increase of 1 million every 4 months in west Africa alone, which has an incidence of one person in three with abnormal haemoglobin traits, 140 000 pregnancies would occur for parents with S and C globin genes. One in four of these pregnancies (35 000 according to the Hardy-Weinberg equation) will produce children with abnormal haemoglobin disease.3 We are already witnessing the enormous hereditary disease burden in west Africans in native countries and the UK, Europe, Canada, and the USA. In anticipation of this enormous public-health issue, which confronts Ghanaians in the 21st Century, the University of Cape Coast has created a Chair of Human Genetics (named after Aggrey of Africa, 1875–1927) specifically to address this difficulty. The aim is to: promote the study of genetic epidemiology through teaching, research, and extension programmes; start collaborative research with international and local institutions on genetic disorders in African and African-American populations; assist the departments of botany and zoology at the University of Cape Coast to include programmes in features of human biology and bioinformatics; do workshops on human genetics and give public lectures in seminars on features of genetic epidemiology at university centres in Ghana. The curtailing of genetic disease burden in a community (especially in African community) is far more difficult than dealing with acquired disease. Political leadership in local and central government is, in my opinion, the most important requirement in rolling back an acquired menace such as malaria, as is proven in Singapore. The control of genetic disease is, however, more subtle. Because of the ethical and ethnic issues in genetic counselling and family
1769
For personal use only. Not to be reproduced without permission of The Lancet.
azathioprine-treated patients. The use of the 5 mg dose might be appropriate for patients deemed at high risk of acute rejection episodes when the unique therapeutic benefits of sirolimus outweigh possible toxic effects of the treatment. We show that sirolimus safely and effectively provides prophylaxis against acute rejection episodes, the dominant risk factor for long-term grafts. Barry D Kahan Division of Immunology and Organ Transplantation, Department of Surgery, University of Texas Medical School at Houston, Houston 77030, TX, USA (e-mail: [email protected]) 1
2
3
4
5
Hariharan S, Johnson CP, Bresnahan BA, Taranto SE, McIntosh MJ, Stablein D. Improved graft survival after renal transplantation in the United States: 1988 to 1996. N Engl J Med 2000; 342: 605–12. Geddes CC, Cole E, Wade J, et al. Factors influencing long-term primary cadaveric kidney transplantation—importance of renal functional mass versus avoidance of acute rejections: the Toronto Hospital experience 1985–1997. In: Cecka JM, Teraski PI, eds. Clinical transplants. Los Angeles: UCLA Tissue Typing Laboratory, 1998: 195–203. Podder H, Kahan BD. Pharmacokinetic interactions augment toxicities of sirolimuscyclosporine combinations. J Am Soc Nephrol (in press). Kreis H, Cisterne JM, Land W, et al. Sirolimus in association with mycophenolate mofetil induction for the prevention of acute graft rejection in renal allograft recipients. Transplantation 2000; 69: 1252–60. Kahan BD, Napoli KL, Kelly PA, et al. Therapeutic drug monitoring of sirolimus: correlations with efficacy and toxicity. Clin Transplant 2000; 14: 97–109.
Public health in less-developed countries Sir—Sarah Macfarlane and colleagues (Sept 2, p 841)1 recommend new forms of communication and cooperation at multiple levels in society, government, and international organisations to improve people’s health and wellbeing. Involvement of philanthropic establishments engaged in therapeutic interventions, professionals in veterinary public health, and agencies concerned with agricultural productivity would be vital to redress the existing inequalities of public health. Philanthopic societies with sizeable funds for health care operate at international and national level. Apart from the remarkable international role of the Rotary International or the James S McDonnell foundation in this connection, the Sri Sathya Sai Institute of Higher Medical Sciences has been operational in India through the 1990s. In 1991–96, free procedures offered to the community included 3052 open-
THE LANCET • Vol 356 • 18 November, 2000
heart surgeries, 4572 cardiac catheterisations, 4286 renal dialysis, and 71 kidney transplants. 2525 operations were done for eye trauma, corneal transplants, and vitreous and retinal diseases.2 Such organisations could start therapeutic intervention with antiretrovirals to halt mother-tochild transmission of HIV.3 They would also be ideal to start free or greatly subsidised multidrug therapy against HIV, chronic viral hepatitis, or neoplastic disorders. Many people have close contact with cattle or domestic animals in lessdeveloped countries. Such close contact encourages spread of zoonotic diseases in the community. The professionals with veterinary skills address health hazards, including trade in animal products, at an international level, and there are sources at this level to obtain practical and technical guidance in controlling the threat to human health posed by animals.4 Nevertheless, facilities and infrastructure for veterinary public-health services at remote locations are not adequate. Since the mid-1990s, measures against malnutrition, immunisation, and maternal health, as well as an integrated approach for treatment of all sick children have been in operation at primary-care level.5 A well-coordinated approach to handle human and animal illnesses at primary human and veterinary care centres in rural areas in resource-poor nations is desirable. Organisations such as the Food and Agricultural Organization (FAO) with a mandate to improve agricultural productivity and conditions of rural populations would be integral components at the primary-care level. Funds should be allocated to plan and execute integrated activities by staff in human and animal health centres as well as in agricultural productivity at grass-roots level. Well coordinated activity involving different disciplines should provide a novel opportunity to translate international mandates1 to reality in otherwise marginalised people in remote locations. Subhash C Arya Centre for Logistical Research and Innovation, M-122 (of part 2), Greater Kailash-II, New Delhi- 110048, India (e-mail: [email protected]) 1
2
3
Macfarlane S, Racelis M, Muli-Musiime F. Public health in developing countries. Lancet 2000; 356: 841–46. Safaya AN. Free high-tech health care in India. World Health Forum 1998; 19: 196–200. Baggaley R, van Praag E, Antiretroviral interventions to reduce mother-to-child transmission of human immunodeficiency
4
5
virus: challenges for health systems, communities and society. Bull World Health Organ 2000; 78: 1036–44. Stohr K, Meslin FX. The role of veterinary public health in prevention of zoonoses. Arch Virol Suppl 1997; 13: 207–18. Nicoll A. Integrated management of childhood illness in resource-poor countries: an initiative from the World Health Organization. Trans R Soc Trop Med Hyg 2000; 94: 9–11.
Sir—Sarah Macfarlane and colleagues1 and Robert Beaglehole and Ruth Bonita, in their Sept 2 commentary,2 omit any mention of the genetic disease burden that will loom ever bigger when AIDS disappears and malaria is rolled back. As Bela Ringelhann and I have previously noted,3 with a population increase of 1 million every 4 months in west Africa alone, which has an incidence of one person in three with abnormal haemoglobin traits, 140 000 pregnancies would occur for parents with S and C globin genes. One in four of these pregnancies (35 000 according to the Hardy-Weinberg equation) will produce children with abnormal haemoglobin disease.3 We are already witnessing the enormous hereditary disease burden in west Africans in native countries and the UK, Europe, Canada, and the USA. In anticipation of this enormous public-health issue, which confronts Ghanaians in the 21st Century, the University of Cape Coast has created a Chair of Human Genetics (named after Aggrey of Africa, 1875–1927) specifically to address this difficulty. The aim is to: promote the study of genetic epidemiology through teaching, research, and extension programmes; start collaborative research with international and local institutions on genetic disorders in African and African-American populations; assist the departments of botany and zoology at the University of Cape Coast to include programmes in features of human biology and bioinformatics; do workshops on human genetics and give public lectures in seminars on features of genetic epidemiology at university centres in Ghana. The curtailing of genetic disease burden in a community (especially in African community) is far more difficult than dealing with acquired disease. Political leadership in local and central government is, in my opinion, the most important requirement in rolling back an acquired menace such as malaria, as is proven in Singapore. The control of genetic disease is, however, more subtle. Because of the ethical and ethnic issues in genetic counselling and family
1769
For personal use only. Not to be reproduced without permission of The Lancet.