Round the World

1412 WORKLOAD AND DISTRIBUTION OF

The present

of

rate

physicians covering Clearly, side-effects

QUERIES

is about 600 per year from with about 1 million inhabitants. of great concern, since questions

queries

an area

are

about side-effects (32-5%) and possible teratogenicity (15-5%) and feasibility of nursing by drug-treated mothers (9’ 3%), add up to roughly 50%. Questions about possible teratogenicity are followed up with respect to outcome of the pregnancies. Even a small number of uneventful pregnancies is of great help the next time the same potentially teratogenic drug is in question. 14-7% of questions concern kinetics, 7’0% interactions, 2’0% pharmacy, 10’0% therapy and choice of drugs, and 9’ 0% documentation. We often advise that a report on the case under consideration should be delivered to the National Adverse Drug Reaction Committee. Pharmaceutical questions are usually referred to the hospital

pharmacy. COMPUTERISATION

To date we have received about 4000 questions. To simplify the handling of our data and to allow access from outside, the material is now being computerised into a data base called "Drugline".4With the assistance of the Karolinska Institute it has been possible to create a computer routine analogous to that of MEDLINE. Thus, our answers are provided with keywords according to the MESH vocabularyof the US National Library of Medicine and are retrieved in the same way. The utilisation of the data base is now being evaluated at a few university hospitals. All the items of the question protocol except identification of enquirer and patient are fed into the data base. Access is possible by the same methods as in MEDLINE, either by combining key words or by searching for words in the text. Drugline is run at the same computer centre as MEDLINE, serving all Scandinavia. It differs from the bibliographical data base MEDLINE in being a "knowledge" data base6 containing evaluated published information. EXPERIENCE AND PROSPECTS

The diversity of the questions received is convincing evidence that this specialised drug information is needed. Running the service has greatly increased the practical application and professional awareness of clinical pharmacology in health care, particularly in primary care. The interplay between clinical pharmacology and general practice has been discussed previously’ and was found to have great potential for the continuous improvement of pharmacotherapy. Sometimes the answers can be used for planning diagnostic investigations and pharmacotherapy. Quite often expensive treatment measures or investigations can be avoided by a critical look into the literature. Some of the questions may be further elaborated by our pharmacokinetics service laboratory. Sometimes special analyses are done-eg, drug concentrations in human milk and phenotyping patients with respect to drug metabolic capacity. Some of the answers that we think are of common interest have been published.8 The work in the drug information service offers an excellent opportunity for education of junior clinical staff; it provides some of the training facilities recognised as important in a World Health Organisation report on clinical pharmacology.9 Evaluation of medical literature and making integrated judgements are valuable for junior doctors, and the continuous provision of news is equally valuable for senior staff, not the least for maintaining relevant teaching programmes in clinical pharmacology and therapeutics. The

management of a drug information service is a stimulating interface between practising clinicians and their colleagues with special experience in clinical pharmacology and should be of mutual benefit. We thank Prof Sune Bergstrom, former head of the Karolinska Institute, for interest and support, and Mrs Jeannette Grunstein, for expert handling of secretarial and computer services at the Drug Information Centre. This work was supported by the Axelsson-Johnson Foundation and Stockholm County Council.

Correspondence should be

addressed

to

G. A.

REFERENCES 1. Davies DM, Ashton CH, Rao JG, et al. Comprehensive clinical drug information service: first year’s experience. Br Med J 1977; i: 89-90. 2. Getting the information we need-how drug information centres can help Drug Ther Bull 1978; 16: 41-43. 3. Alván G, Elwin C-E, Holmberg E, Öhman B, Sjöqvist F Läkemedelsinformationscentralen—ny form av medicinsk service inom Stockholms läns landsting. Läkartidningen 1980; 77: 1899-1901. 4. Alván G, Öhman B, Sjöqvist F. Drugline: a new database for evaluated drug information. Br J Clin Pharmacol 1982; 14: 597P. 5. Welch J. Are you making the most of"Index Medicus"? Br Med J 1982; 285: 1105-06. 6. Doszkocs TE, Rapp BA, Schoolman HM. Automated information retrieval in science and technology. Science 1980; 208: 25-30. 7. Smith A, Walker JG, Rawlins MD, Clinical pharmacology clinics in general practice. Br Med J 1977; ii: 169-70. 8. Eeg-Olofsson O, Malmros I, Elwin C-E, Stéen B. Convulsions m a breast-fed infant after maternal indomethacin. Lancet 1978; ii: 215. 9. Clinical Pharmacology scope, organization, training. Report of a WHO Study Group. WHO Techn Rep Ser 1976; 446.

Round the World From

our

Correspondents

Malaysia CALL FOR REFORM OF DRUG POLICIES

NON-GOVERNMENTAL organisations from South and South-East

Asia, meeting last month in Penang, issued a 10-point declaration

calling for "Health Now" rather than by the year 2000. The Penang declaration on rational health policies focused on the need for change in the manufacture, marketing, distribution, and use of pharmaceutical products. It called for the introduction of limited lists of essential drugs in both government and private health-care systems; the introduction of tighter drug registration procedures, including legislation to prevent the dumping of hazardous, useless, or substandard drugs; stricter controls on pricing; strengthened research efforts in the use and production of traditional medicines; and an emphasis on generic, rather than brand, names on all product literature and labels. The need for strong measures was emphasised by several speakers at the meeting, which was organised by the International Organisation of Consumers Unions (IOCU) and the Quaker International Affairs Programme (QIAP). Dr Claudio Sepulveda, coordinator of the programme on health and development of the United Nations Economic and Social Commission for Asia and the Pacific (ESCAP), examined in detail the structure and activities of the pharmaceutical industry in the region-an industry dominated by transnational corporations. "The health problems of our countries are not solvable by pharmaceuticals," he concluded: "the claim of the pharmaceutical industry to be working for the health of people is just not true. They have substituted the search for health with the search for wealth." Prof Musa Mohamad, Vice-Chancellor of the Universal Sains Malaysia (Science University of Malaysia), who is a pharmacist, expressed concern over the proliferation of drugs. Many of them were said to be marketed not because of their benefit to the health of the population, but merely because they could be sold. Dr T. Devaraj, president of the Malaysian Medical Association, called for a change in the present ways in which drugs were imported, manufactured, priced, distributed, sold, and used-as part of an overall change in health policies. Individual organisations represented at the meeting made plans to press for changes. One such plan for the Philippines was designed to

1413 the new import controls on many goods, introduced in response the economic crisis, as a starting point to ensure that non-essential medicines were not allowed into the country. The detailed plan of the Philippine groups received unanimous support from the meeting, as did a motion of support for the "pioneering and innovative" national drugs policy introduced in Bangladesh last year. The IOCU’s president, Mr Anwar Fazal, believed the meeting had clearly shown that people in these Asian countries were no longer prepared to tolerate the unethical marketing and pricing policies of the pharmaceutical and health industry. People were tired of waiting for the year 2000 for better health. They wanted health now, as a right, not as a privilege. And they were prepared to take action to achieve that right. Part of the action was the establishment of a south-east Asian network of Health Action International (HAI)-a worldwide coalition of organisations which are active on issues of rational health. The first priority of the ASEAN network of HAI will be the establishment of an independent information centre on pharmaceuticals. Groups will also be using the code on pharmaceuticals prepared by HAI1 as a guide for further action in the region. use

to

Pakistan ATTEMPTS TO CONTROL DAMAGE BY TOBACCO SMOKING

ABOUT 300 years ago the British Ambassador to the Court of Akbar the Great introduced smoking to the King. His court physician, concerned for his master’s health, bubbled the smoke through water. Into this he inserted some small fish which barely survived the experiment. Despite this warning, the King developed a liking for tobacco and the habit soon spread to his subjects. Today tobacco is widely used in Pakistan, either smoked through the hookah (hubble bubble), chewed as Pan containing tobacco and betel nut, used as a plug in the mouth (Niswar), or smoked in the form of Bidi; but cigarettes are the main source of tobacco

consumption. Since our forebears were responsible for introducing tobacco into appropriate that two Britons (David

the country it was perhaps Simpson, Director of Action

on Smoking and Health, and myself), with Simon Chapman of Australia, should be invited by the Pakistan Department of Health and the International Union against Cancer (UICC) to take part in a three-day workshop on the control of smoking, held in Rawalpindi, the northern city on the edge of the Himalayan foothills. The conference was opened by the Minister of Health, Dr Nasir Uddin Jogezai, who was well supported by his State Minister for Health, Bagum Afifa Mamdot, together with the Director General of Health, the Director of the National Institute of Health, and the Health Directors of Peshawar and the Punjab. Senior cardiologists, oncologists, and several high-ranking medical officers of the Pakistan Armed Forces were also present, together with representatives of voluntary agencies and religious leaders. Pakistan uses 50 000 hectares of fertile land for tobacco production mainly in the North-West Frontier Province. Tobacco growth has increased greatly in recent years, but almost all is used inside the country, very few cigarettes being exported. In response to the workshop the Pakistan Tobacco company, a subsidiary of BAT and the largest cigarette manufacturer in the country, produced a 16-page coloured supplement in the popular weekly journal, Mag. It included an interview with Mr Nizam Shah, the company’s chairman, who was trained by BAT in London. He indicated that two-thirds of the firm’s capital investment came from foreign sources. He was concerned at the adverse effect the growing antismoking campaign had had on the cigarette market. The rapid growth of cigarette smoking in the past ten years is reflected in the 8-fold increase in tobacco tax paid to the Government in this time. Two of the most popular brands, Capstan and Morven, each have a yield of 29 mg of tar, higher than any brand sold in the UK. The highest selling brand, K2 Filter, sold at 4 - 50 rupees (about 25p) for twenty. A TV advertisement for this brand showed a youth strong enough to kill a tiger and climb K2, Pakistan’s highest peak!

1 Health Action International. A draft international code 1982. PO Box 1045, Penang, Malaysia.

on

pharmaceuticals. Penang,

Pakistan’s leaders certainly have reason for concern at the growing consumption of cigarettes and the rapidly increasing incidence of lung cancer and coronary heart disease. Although national statistics are not available, Colonel Zulfiqar, a senior cardiologist in Rawalpindi, told me that when working in a Lahore hospital thirty years ago he had seen only an occasional patient with myocardial infarction. Now through his large coronary care unit 600-800 patients pass each year. Dr Samad, cardiologist in charge of a major unit in Karachi which undertakes angiography, told me that 20% of his patients with myocardial infarction were below the age of 40 and many came from underprivileged homes. This is in line with our own findings in Brent, London, where there appears to be an

increased incidence of severe coronary disease in younger Asian patients. Mean cholesterol levels of their infarct patients were in the region of 240-260 mg/dl (6 - 2-6 - 7 mmol/l) and most of the patients were heavy smokers. Professor Zaidi from Karachi reported that he has seen 652 patients with cancer of the lung between 1980 and 1982. It is now the commonest form of cancer in males, having risen from 6th place in recent years. Cancers of the lip, tongue, gum, and mouth due to tobacco use were also very frequent. As a consequence, about 5007o of all cancers in men were believed to be due to tobacco use. Chronic bronchitis was also a major problem. Against this fearful background the workshop considered what effective action could be taken. UICC, which organised the conference in association with the Pakistan Department of Health, has already been responsible for smoking control workshops in some 20 countries. David Simpson pointed out that with the fall in tobacco consumption in Britain, America, and other industrialised countries the major tobacco companies were doing their best to increase consumption in the Third World. Like the British Ambassador to Akbar the Great, BAT are attempting to do just this to Pakistan as well as to many other countries. 60% of BAT’s profits are derived from developing countries. Since this is a wholly British industry, we felt a special sense of concern at the devastating effects that tobacco promotion was having on this commonwealth country. Fortunately the Health Department is already taking some steps to control tobacco use. By Presidential decree smoking is not allowed in hospital wards and dispensaries, educational institutions, cinemas, theatres, and public libraries. It is forbidden in public transport and to some extent on Pakistan Airways domestic flights. But how far this decree is followed we could not confirm. After three days of discussion the following recommendations were referred to the Minister of Health for presentation to the Cabinet: (1) All forms of tobacco advertising, including sports promotion, should be banned. (2) Until this happens, all advertisements should carry a prominent Government health warning. (3) Tobacco advertisers should provide funding for one antismoking message for every three cigarette advertisements. (4) Sale of tobacco products should be prohibited by law to persons under the age of 18 and all retail outlets should prominently display a sign to that effect. National (5) surveys of the prevalence of smoking and tobacco should be undertaken. (6) A testing centre for determining the tar and nicotine content of cigarettes should be established. (7) The Government should approach the Food and Agriculture Organisation and the World Bank for advice and assistance about tobacco crop substitution. On the last day we hired a car and climbed up to Murree, the hill station at 7000 feet, which still showed signs of the old British Raj. We lunched in the Hotel Cecil and surveyed the bare hills, mainly deforested within human memory. The tobacco companies have accelerated Pakistan’s deforestation as a result of their insatiable need for fuel to cure tobacco leaf. We stood on a grassy hilltop, surrounded by flowering gentians, and looked towards the distant snow-covered peaks and tried not to think of K2’s other meaning. Department of Community Medicine, Horace Joules Hall, Central Middlesex Hospital,

London NW10 7NS

KEITH BALL