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W.H.A. IN BOSTON
198
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ceptive regimens) and so it ought to have been particularly suitable for simple uneducated women; in fact experience has shown how easy it is for even wellmotivated women to forget their tablets. Chlormadinone seems to be well tolerated by the great majority of women using it, even those who had had unpleasant side-effects with other oral contraceptives; but unfortunately quite a number have irregular menstrual bleeding which in some is heavy and prolonged. Studies of blood coagulation factors have so far failed to show the changes which are thought to be adverse and possibly implicated in the thrombogenic properties of oestrogen-containing oral contraceptives. The new method, therefore, seems to have much to recommend it, provided its efficacy can be established. In the first clinical study3 to define the efficacy of continuous daily chlormadinone acetate, 320 women were observed for 1214 cycles and 2 pregnancies were reported, 1 as a failure of the method. In 1967, Martinez-Manautou and his colleagues4 reported 14 pregnancies, 13 allegedly due to patient failure, in 945 women observed for 8108 calendar months, a method failure of 0-2 pregnancies per 100 women-years and a use-effectiveness failure-rate of 2-1. These results, though apparently not quite as good as those often recorded for combined oral contraceptives, are nevertheless impressive, but they also indicate that the margin of error, if tablets are omitted, is greater than with combined regimens. Since then, a number of investigators, in various parts of the world, have greatly extended experience with chlormadinone acetate; and Christie5 states that the combined data on nearly 5000 women observed for nearly 55,000 cycles give a pregnancy-rate due
method failure of 0,85 per 100 therefore somewhat alarming, and certainly disappointing, when Butler and Hill6 reported 13 pregnancies among 208 women in Britain taking chlormadinone acetate, 0-5 mg. daily, who were observed for 1642 cycles, a use-effectiveness pregnancy-rate of 9’5 and method-failure rate of 6-5 per 100 woman-years. Some discussion 5has arisen about the reliability of the patients who conceived but did not admit to forgetting to take tablets, and the decreased likelihood of forgetfulness when calendar packs, as opposed to simple bottles, are used for dispensing the tablets; but the fact remains that these 13 pregnancies did occur for whatever reason. Furthermore, another British investigation by Howard et al.11 has produced results similar to those of Butler and Hill. 260 women completed 2080 cycles, 15 becoming pregnant, giving a use-effectiveness pregnancy-rate of 8,6 and a method-failure rate of 5.2 per 100 woman-years. What is more, the patients of Howard et al. received their tablets in calendar packs. In both these British series (though not in the large series mentioned by Christie) the pregnancy risk
woman-years.
2. Poller, L., 3. 4.
5. 6. 7. 8.
It
to
was
Thomson, J. M., Tabiowo, A., Priest, C. M. Br. med. J. 1969, i, 554. Martinez-Manautou, J., Cortez, V., Giner, J., Aznar, R., Rudel, H. W. Fert. Steril. 1966, 17, 49. Martinez-Manautou, J., Giner-Velasquez, J., Cortes-Gallegos, V., Aznar, R., Rojas, B., Guitterez-Najar, A., Rudel, H. W., Br. med. J. 1967, ii, 730. Christie, G. A. Lancet, 1969, i, 1262. Butler, C., Hill, H. ibid. p. 116. Christie, G. A. ibid. p. 1262. Howard, G., Elstein, M., Blair, M., Morris, N. F. ibid. July 5, 1969, p. 24.
seemed to increase with increasing duration of medication. At present there is no satisfactory explanation for the high pregnancy-rates in these carefully planned and well-supervised British trials, in contrast to the much lower rates reported from some other parts of the world. They naturally arouse misgivings as to the efficacy of continuous low-dosage chlormadinone acetate and they certainly preclude its use for women who require maximum protection against unwanted pregnancy.
W.H.A. IN BOSTON
IN the opening days of the World Health Assembly, held in Boston from July 8 to July 25, the sharp differences between the medical problems of the rich and the poor countries were emphasised. American delegates reported an encouraging drop in cigarette consumption (of 4%) but galloping inflation in health costs; this is now 21/2 times the general rate of inflation. The measures suggested to cope with it were not very startling-except perhaps that doctors could be trained in less time than has been traditionally taken, and that training and use of other health workers should be expanded. Many delegates agreed that there should be more fluidity between the various grades of health workers. Among concerns of the advanced countries were industrial pollution (West Germany), guidelines for heart transplants (Israel), and the need for quiet smog-free cars (United States), while many poorer countries cannot control infectious diseases simply for want of money for vaccines and drugs. There was much heart-searching in the discussions on malaria and dicophane (D.D.T.). The Netherlands delegate said that his country would follow Sweden in banning dicophane ; but Dr. M. G. Candau, director-general of the World Health Organisation, said that, though it was easy for some countries to stop using dicophane, it was impossible for others. Malaria, said the delegate from Guinea, kills 10% of all the children under 5 in his country. Research is planned to assess evidence of a carcinogenic effect of dicophane detected in the livers of mice: but the delegate from Indonesia said: " It is better to die of cancer in old age than from malaria in infancy." The malaria eradication programme has met with setbacks in many countries-sometimes from lack of funds and supplies, sometimes from administrative difficulties, and all too often from resistant mosquitoes. or plasmodia. New drugs and combinations, and the use of larvivorous fish, are being tried. Simpler methods of eradication are needed, said Dr. Candau; and in view not only of the imperfections of current methods but also of the appalling ecological effects of dicophane, one fervently hopes that some will be found. Dr. Rene Dubos, addressing the Assembly, emphasised the dangers of pollution as well as the emptiness of modern suburban life. There was acrimonious debate between Arab and Israeli delegates as to who was to blame for worsening health conditions in Gaza. But all delegates agreed on one thing: fluoridation is good for teeth.
_
ceptive regimens) and so it ought to have been particularly suitable for simple uneducated women; in fact experience has shown how easy it is for even wellmotivated women to forget their tablets. Chlormadinone seems to be well tolerated by the great majority of women using it, even those who had had unpleasant side-effects with other oral contraceptives; but unfortunately quite a number have irregular menstrual bleeding which in some is heavy and prolonged. Studies of blood coagulation factors have so far failed to show the changes which are thought to be adverse and possibly implicated in the thrombogenic properties of oestrogen-containing oral contraceptives. The new method, therefore, seems to have much to recommend it, provided its efficacy can be established. In the first clinical study3 to define the efficacy of continuous daily chlormadinone acetate, 320 women were observed for 1214 cycles and 2 pregnancies were reported, 1 as a failure of the method. In 1967, Martinez-Manautou and his colleagues4 reported 14 pregnancies, 13 allegedly due to patient failure, in 945 women observed for 8108 calendar months, a method failure of 0-2 pregnancies per 100 women-years and a use-effectiveness failure-rate of 2-1. These results, though apparently not quite as good as those often recorded for combined oral contraceptives, are nevertheless impressive, but they also indicate that the margin of error, if tablets are omitted, is greater than with combined regimens. Since then, a number of investigators, in various parts of the world, have greatly extended experience with chlormadinone acetate; and Christie5 states that the combined data on nearly 5000 women observed for nearly 55,000 cycles give a pregnancy-rate due
method failure of 0,85 per 100 therefore somewhat alarming, and certainly disappointing, when Butler and Hill6 reported 13 pregnancies among 208 women in Britain taking chlormadinone acetate, 0-5 mg. daily, who were observed for 1642 cycles, a use-effectiveness pregnancy-rate of 9’5 and method-failure rate of 6-5 per 100 woman-years. Some discussion 5has arisen about the reliability of the patients who conceived but did not admit to forgetting to take tablets, and the decreased likelihood of forgetfulness when calendar packs, as opposed to simple bottles, are used for dispensing the tablets; but the fact remains that these 13 pregnancies did occur for whatever reason. Furthermore, another British investigation by Howard et al.11 has produced results similar to those of Butler and Hill. 260 women completed 2080 cycles, 15 becoming pregnant, giving a use-effectiveness pregnancy-rate of 8,6 and a method-failure rate of 5.2 per 100 woman-years. What is more, the patients of Howard et al. received their tablets in calendar packs. In both these British series (though not in the large series mentioned by Christie) the pregnancy risk
woman-years.
2. Poller, L., 3. 4.
5. 6. 7. 8.
It
to
was
Thomson, J. M., Tabiowo, A., Priest, C. M. Br. med. J. 1969, i, 554. Martinez-Manautou, J., Cortez, V., Giner, J., Aznar, R., Rudel, H. W. Fert. Steril. 1966, 17, 49. Martinez-Manautou, J., Giner-Velasquez, J., Cortes-Gallegos, V., Aznar, R., Rojas, B., Guitterez-Najar, A., Rudel, H. W., Br. med. J. 1967, ii, 730. Christie, G. A. Lancet, 1969, i, 1262. Butler, C., Hill, H. ibid. p. 116. Christie, G. A. ibid. p. 1262. Howard, G., Elstein, M., Blair, M., Morris, N. F. ibid. July 5, 1969, p. 24.
seemed to increase with increasing duration of medication. At present there is no satisfactory explanation for the high pregnancy-rates in these carefully planned and well-supervised British trials, in contrast to the much lower rates reported from some other parts of the world. They naturally arouse misgivings as to the efficacy of continuous low-dosage chlormadinone acetate and they certainly preclude its use for women who require maximum protection against unwanted pregnancy.
W.H.A. IN BOSTON
IN the opening days of the World Health Assembly, held in Boston from July 8 to July 25, the sharp differences between the medical problems of the rich and the poor countries were emphasised. American delegates reported an encouraging drop in cigarette consumption (of 4%) but galloping inflation in health costs; this is now 21/2 times the general rate of inflation. The measures suggested to cope with it were not very startling-except perhaps that doctors could be trained in less time than has been traditionally taken, and that training and use of other health workers should be expanded. Many delegates agreed that there should be more fluidity between the various grades of health workers. Among concerns of the advanced countries were industrial pollution (West Germany), guidelines for heart transplants (Israel), and the need for quiet smog-free cars (United States), while many poorer countries cannot control infectious diseases simply for want of money for vaccines and drugs. There was much heart-searching in the discussions on malaria and dicophane (D.D.T.). The Netherlands delegate said that his country would follow Sweden in banning dicophane ; but Dr. M. G. Candau, director-general of the World Health Organisation, said that, though it was easy for some countries to stop using dicophane, it was impossible for others. Malaria, said the delegate from Guinea, kills 10% of all the children under 5 in his country. Research is planned to assess evidence of a carcinogenic effect of dicophane detected in the livers of mice: but the delegate from Indonesia said: " It is better to die of cancer in old age than from malaria in infancy." The malaria eradication programme has met with setbacks in many countries-sometimes from lack of funds and supplies, sometimes from administrative difficulties, and all too often from resistant mosquitoes. or plasmodia. New drugs and combinations, and the use of larvivorous fish, are being tried. Simpler methods of eradication are needed, said Dr. Candau; and in view not only of the imperfections of current methods but also of the appalling ecological effects of dicophane, one fervently hopes that some will be found. Dr. Rene Dubos, addressing the Assembly, emphasised the dangers of pollution as well as the emptiness of modern suburban life. There was acrimonious debate between Arab and Israeli delegates as to who was to blame for worsening health conditions in Gaza. But all delegates agreed on one thing: fluoridation is good for teeth.