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ivermectin have access to it? Are there not any bottle-necks inbetween? Until 1989 I was working in SouthernDarfur, in Sudan, where a well known focus exists in the Radom area (Buram district). No ivermectin was available in the province. I wrote to the manufacturer but the medical and laboratory standards required at that time by them to obtain the drug could not be fulfilled in a rural dispensary. From 1989 to 1992,worked in the Forest region of Guinea (capital Conakry), where infection is very common, although it rarely causes blindness. In 1991 ivermectin became available through the national onchocerciasis-control programme, but only in small quantities. Because onchocerciasis causes troublesome itching, people were highly motivated to search for relief; and the reputation of ivermectin spread fast. And, as happens with rare commodities for which there is a great demand, some people had to pay a lot to get the drug, whereas many could not get it at all. Many essential drugs are now supplied to developing countries by major non-profit drug suppliers such as UNIPAC (Copenhagen), IDA (Amsterdam), ECHO (UK), Medeor (Germany), and others, to government agencies, but also to missions and non-governmental organisations. To my knowledge, they still could not provide ivermectin a few months ago, and referred requests to the manufacturer. I think ivermectin would become more available to the patients needing it if these existing channels were also used. Charging a small amount for supply might discourage unjustified requests. Separate forms for ivermectin orders, special and unrealistic requirements for its use, and separate channels for its supply considerably complicate matters for busy peripheral health-care workers and thus limit access of ivermectin to the needy.
patients needing
Korte Gasthuisstraat 26, 2000 Antwerpen, Belgium
world’s largest and greyest bureaucracy have gripped the minds of most, apart from the very young, for too long for change to be far from fear. Association for the Promotion of Healthcare in the Former Soviet Union, 9d Stanhope Road, Highgate, London N6 5NE, UK
STEWART BRITTEN
Randomised comparison of amniocentesis and transabdominal and cervical chorionic villus sampling: duplicate publication SiR,—Iwas surprised and disappointed to see Dr Smidt-Jensen and colleagues’ report (Nov 21, p 1237). These workers did not reference an almost identical paper of theirs published in Ultrasound in Obstetrics and Gynecology.l All papers from this journal are indexed in Current Contents and EMBASE. The essence of the study was to compare transabdominal chorionic villus sampling (CVS), transcervical CVS, and amniocentesis in a group of women at low genetic risk. Both studies contained data for over 3000 women and the results and conclusions in the two papers are obviously the same, although in the report in Ultrasound in Obstetrics and Gynecology there was a higher number of patients undergoing CVS than in the paper in The Lancet published 20 months later. Department of Obstetrics and Gynaecology, King’s College School of Medicine and Dentistry, London SE5 8RX, UK 1.
STUART
CAMPBELL,
Editor in Chief Ultrasound in Obstetrics and Gynecology
Smidt-Jensen S, Permin M, Philip J. Sampling success and risk by transabdominal chorionic villus sampling, transcervical chorionic villus sampling, and amniocentesis: a randomized study. Ultrasound Obstet Gynecol 1991; 1: 86-90.
WIM VAN DAMME
Health sector reform in the former Soviet Union SiR.—Your Jan 23 editorial and Dr Vaile’s report (Jan 30, p 310) have drawn attention to the pitfalls of western ad hoc activities in the former Soviet Union (FSU). HealthProm’s experience of developing partnership projects in Russia, as yet in their infancy, confirms some of the difficulties. A brief visit is highly unlikely to bring much benefit unless it is followed up by planned and co-ordinated activity, but planning and co-ordination are very difficult to achieve in the FSU. The reasons for the frequent mismatch between western professional consultant or advisor and host lie on both sides. In the FSU there is a lack of experience of planning, budgeting, and, most importantly, critical analysis. Decisions were until recently only made at a high level, and even heads of hospitals were expected only to administrate and would not have been rewarded for any critical assessment of policy implications. The proposals we have received since administrators and doctors in the FSU have been able to develop their own contacts with the west have mostly been Utopian and almost always grandiose in their scope. On our side there is a common failure to understand the dire state of economies and extreme social insecurity in the FSU. Western visitors sometimes make recommendations before ascertaining the ability of managers to implement even the smallest of them. Closer inspection often reveals a hundred reasons why an essential change cannot be brought about. At ward or polyclinic level those who at first sight have nothing to lose can often see no incentive to change the operation of a machine which has groaned on in the same monotonous way for decades. Western professionals can help, but only if to start with they open their eyes to the difficulties that our colleagues in Russia and the republics face. The collapse of communism has not of itself brought an ability to change, though it has released a painful and urgent awareness of the need for change. Many of us trained in the west at a time when change was much slower and encountered much deeper resistence than is now the case, but change took place nonetheless. In the Soviet Union not so very long ago to institute change was to risk death-and the years of Stalin’s terror and the dead hand of the
Authors’reply SIR,-After the First World Congress of Ultrasound in Obstetrics and Gynaecology, held in London, January, 1991, the chief organiser, Prof Stuart Campbell invited speakers to provide his new journal Ultrasound in Obstetrics and Gynecology with proceedings of the congress. At the time of the congress, enrolment to our CVS study was not yet completed. Total pregnancy complications, stillbirths, and neonatal deaths could not therefore be registered. Campbell’s statement about patient numbers is not correct. The number of subjects randomised at the time of the congress was 3347 and the number published in The Lancet was 4199. In The Lancet report, all pregnancies, including those sampled with an introductory metal catheter, were completed and enlisted. The material was described in a different way and the multivariate statistical evaluation was done and the basis of all the results reported. Both genetic low-risk and high-risk women were included with a detailed description of study withdrawals and exclusions. We regard the Ultrasound in Obstetrics and Gynecology paper as a progress report and wanted a final publication, including all the pregnancies enrolled and completed and final statistics. The Lancet report is such a publication, and we do not consider that report a
duplicate publication. Department of Obstetrics and Gynaecology, Rigshospitalet, University of Copenhagen, 2100
Copenhagen,
Denmark
STEEN SMIDT-JENSEN JOHN PHILIP
The Swedish undernurse—an
endangered
species? SiR,—The Swedish health-care system has been considerably shaken up by the recession. The budget is shrinking, and jobs have had to go. In many acute disciplines, it is the undemurses who have born the brunt of these cuts. In my specialty, anaesthesia and intensive care, undemurses had filled the gaps caused by a shortage of anaesthetists and anaesthetic nurses 20 or more years ago. They looked after equipment and assisted at induction of general anaesthesia and during regional anaesthesia. Although they could monitor the patient during