1150
might be done about the veritable abbatoir of hysterectomies, the excessive number of radical mastectomies, the high rate of caesarean section. These commentators look forward to displacement of the male image of the physician and female dominance of the medical profession. They believe that medicine today is too instrumental, impersonal, career-directed. Women will change this, because they are person-oriented rather than technology-oriented, more empathic, and kinder and gentler altogether. With their greater interest in social matters related to illness and health, they are thought more likely to enter primary-care, family medicine practice. In a letter to the New York Times one woman writes, "I would like to believe that women, because of their genderdetermined upbringing, education and social roles (never mind the possibility of biological differences) might be more sensitive than men to the effects of violence and killing". Lila Wallis, president of the American Women’s Medical Association, writes, "Women are different biological entities, with different hormones, different patterns of health and disease, and different responses to stress". Some of the effects anticipated-hoped for or dreadedmay come into being as predicted. The social demands created by woman physicians will undoubtedly result in big changes. Apart from a crumbling of discriminatory practices, some of the first effects will be changes at the workplace. "Flex-time" service in residency training programmes and even in medical education generally may become the rule; institutional creches will certainly be provided in the very near future, where they do not already exist, and we are moving towards paid maternity and paternity leave. Women’s ills will be taken more seriously, too, without a doubt. A new specialty is proposed - "women’s medicine"-which will focus on women’s physiology and women’s psychology. The medical and pharmaceutical establishments will be pressed to explore women’s special needs-primary prevention of breast cancer and research into diseases that affect both sexes but now are studied only in men.2 Of course, this will not all happen at once and immediately. Perhaps it will not happen at all. Is there truly a feminine mystique, of special nurturing qualities, attributable to "left-brain" dominance, or is this another masked prejudicial concept, to justify not taking women seriously, not giving them access to power and authority because they are physically and emotionally weaker? Another consideration is an implacable sexism in humanity that might counter the impact of mere numbers. Remember that for a long time over 80% of all health workers have been female, but the ruling discipline has been that of the medical profession, and the ruling class the male doctors. Like the "white tribe" in South Africa, the male minority of doctors have held sway over the female majority. One disturbing prospect is that feminisation of medical practice, in a society remaining rigidly sexist, will mean that medicine will take on the attributes of other feminine occupations. When the Russian medical profession became predominantly female, the status and income of the medical profession declined--except in those high positions where men continued to predominate. Is that what will happen here? Institution for Social and Policy Studies, Yale University, New Haven, Connecticut, USA
George Silver
Eisenberg C. Medicine is no longer a man’s profession. N Engl 1989; 321: 1542-44. 2. Perrone J. For women only. AMA News Nov 17, 1989. 1.
J Med
Conference From "powerful
plants" to powerful medicines
In the 1960s many pharmaceutical companies looked to plants for compounds that could be used to treat a variety of diseases. Apart from a few isolated cases, this approach was unsuccessful and attention switched to synthetic organic chemistry. Recently, more systematic screening programmes have been adopted which focus on plant products used by tribal healers in primitive tribes throughout the world. A recent Ciba Foundation symposium on bioactive compounds from plants, held in Bangkok, considered this search for new drugs derived from plants. For this work to be effective, the information about the plants and their uses must be collected by trained observers-ethnobotanists. Michael Balick and Paul Cox, who work with indigenous peoples in Belize and Samoa, respectively, described the procedures for collecting this information. The investigator has to speak the local language
and understand the culture. The healers are important, both within their own societies and because of the knowledge they possess, and should be accorded due respect. The investigator should record full details of which parts of the plant are used, the method of preparation and application, and a precise description of the illness treated. Horror stories of casual recording abounded during the symposium-for example, plants cited as used for contraception without noting whether they were taken by the man or woman or before or after sexual intercourse. For this reason, the ethnobotanists were asked whether Western-trained doctors were taken on these expeditions. More horror stories! Many Westerners prove unable to adapt to different cultural practices and may offend the healers by insensitive attitudes. Others find the working conditions too primitive and catch the first plane home. However, some stay, and are invariably impressed by the work of the tribal healers. One difficulty is the lack of any direct correspondence between the disease classifications of indigenous peoples and Western medicine. In Central America there is an illness called susto, which is caused by "shock". The trouble is that different peoples are shocked by different things: primitive tribes may find a camera frightening and believe that taking a photograph captures their soul. This is easy to mock, but, as Balick pointed out, a Westerner confronted by a tiger might show symptoms of susto. What seems to be common to all cultures is the role of primary health care. In developed countries, many patients visit their doctor for reassurance as much as for specific treatments. Tribal healers also believe that it is as important to treat the soul of the patient as to treat the body-a different way of saying the same thing. The plant products that are collected are sent to Europe or the US for screening-almost exclusively for compounds that show anticancer or anti-HIV activity. This revelation led to a lively debate at the symposium. Why should a plant extract used to cure a parasite infection show antitumour activity? Balick explained that he concentrates on the plants that appear in many different local pharmacopoeias-he calls them "powerful plants". These plants have proven bioactivity in man, and their use over many generations shows that they have no adverse side-effects. No claims are made that they will be effective against cancers, but they are more promising starting materials than plants collected at random. Preliminary results show a higher "hit rate" in the anticancer and anti-HIV screens of compounds isolated in this way.
1151
Since the plant extracts are used by tribal healers to treat parasitic or bacterial infections-and people throughout the world are dying of such infections-it was asked why the screens are not directed at the componds that have these activities. The sad answer was that people with such diseases tend not to have enough money to make the development of the drugs commercially viable.
Joan Marsh The conference
proceedings will be published in October,
1990.
Medicine and the Law Duty to warn about likely adverse effects A 48-year-old West Indian woman with hypertension sued the district health authority and doctors at the district hospital for negligence in not warning her about adverse effects of minoxidil. The drug had led to excessive hair growth and darkening of the face, causing great distress and limiting her social life. She had been attending an outpatient clinic since 1980 with essential hypertension, which had not responded to treatment. In December, 1982, when she had been on nadolol 200 mg, hydralazine 25 mg thrice daily, xipamide 40 mg, and spironolactone 25 mg, her blood pressure (BP) was still 170/120 mm Hg. The hydralazine was stopped and replaced with minoxidil 2-5 mg twice daily. Over the next 16 months control continued to be poor, and the dose of minoxidil was gradually increased to 40 mg per day. In April, 1984, her BP was 190/115 mm Hg and she severe
complained that she was taking too many tablets; all were stopped, including minoxidil, which was replaced with labetalol. She was depressed, and mianserin was also prescribed. In June, however, she re-started minoxidil 40 mg daily, nadolol, and xipamide. At this time she complained of unsightly darkening of the skin below the left eye. In August her BP was 190/120 mm Hg, and the dose of minoxidil was increased to 50 mg (the maximum recommended) and nadolol to 240 mg daily. This treatment continued for 11 months. At the end of July, 1985, she attended hospital very upset, complaining of profuse hair growth, especially on the face but also on the arms, breasts, and legs, which had started 5-6 weeks earlier and had got worse. It was accompanied by itching and a change in the skin. She was admitted for investigation and slow tailing-off of minoxidil, which was recognised as the cause. Minoxidil was stopped on Aug 1, 1985, and captopril substituted. Over the next year the
excess
hair
gradually disappeared,
and her skin
pigmentation returned to normal. The patient should have been warned about the hypertrichosis. The data sheet states: "Hypertrichosis occurs in most patients treated with Loniten [the brand name] and all patients should be warned of this possibility before starting therapy. Spontaneous reversal to the pretreatment state can be expected one to three months after cessation of therapy." Since hypertrichosis is so predictable, it must be assumed to be dose-dependent-ie, the higher the dose and the longer it is used, the greater the hair growth. Prescribing information for doctors rarely states whether particular unwanted effects are dose-dependent or not, but prescribers need to be aware that the greater the dose, the greater the intensity of the effect, and the greater the variety of effects (and intensity). It follows that if abnormal hair growth has not occurred in a patient taking minoxidil, the likelihood that it will start becomes greater with every increase in dosage. When, as in this case, a patient is seen by different physicians, the doctor cannot be sure what the patient has been told previously (unless it is recorded), and it is the doctor’s responsibility to warn the patient, especially if he increases the dose.
From December, 1982, until April, 1984, minoxidil caused no apparent extra hair growth, but for most of this period the patient took less than 20 mg a day. She stopped taking the drug for 7 weeks between April and June, when she began again at a dose of 40 mg daily. Then for almost a year she took 50 mg a day. It was only in the last 6 weeks of that period that she noticed excess hair growth. Increased pigmentation is not mentioned in the standard prescribing information on minoxidil. It is, however, reported in several publications. The most detailed says that abnormal hair growth "may be accompanied by darkening of the skin and coarsening of the facial features".1 A review notes "an increase in skin pigmentation, mainly in blacks and in mixed population’? Upjohn international voluntary reporting database included eight cases of pigmentation. In March, 1990, the defendants offered a payment of k 1500 plus costs to settle the claim, which the plaintiff accepted. Prescribers have a clear duty to inform patients about likely adverse effects that might worry them, but how far this duty extends to a prescriber who continues treatment started by a colleague does not seem to have been considered by the courts. We suggest that a subsequent prescriber who increases the dose must inform or remind the patient of a risk that is dose-related. Even if the dose is not increased the patient should be told about risks related to the duration of exposure to the drug.
Andrew Herxheimer Nick
Young
1. Kosman ME. Evaluation of a new antihypertensive agent: minoxidil. JAMA 1980; 244: 73-75. 2. Velasco M, Silva H. Role of vasodilators in the treatment of arterial hypertension. In: Velasco M, ed. Clinical pharmacology and therapeutics (Int Cogr Ser no 604). Amsterdam: Excerpta Medica, 1982: 9-19. 3. Dukes MNG, Swartz B. Responsibility for drug-induced injury. Amsterdam: Elsevier, 1988: 115-20.
Noticeboard Marketing of breast milk substitutes Infant food multinationals are continuing to undermine breastfeeding through their aggressive marketing of formula milk throughout the third world, according to a report from Action for Corporate Accountability (ACA).1 At least eight formula companies, says ACA, are violating the WHO/UNICEF International Code of Marketing of Breastmilk Substitutes. The was introduced in 1981 to protect infants and their parents from misleading and dangerous formula promotion. As a result of its findings, ACA is now organising an international boycott of Nestle and American Home Products (AHP), two of the largest formula producers. The provision of free formula milk to third-world maternity wards and nursing homes is a particularly serious breach of the WHO code. Mothers coerced into bottle feeding in this way leave hospital with a tin of formula and a dwindling supply of breast milk. If they persist in bottle feeding, their babies are 25 times more likely to die of a gastrointestinal, respiratory, or other infection. The cost of purchasing further formula poses an enormous financial strain and puts the nutritional status of whole families at risk. Typically, artificial milk consumes around 50% of the household income. In Sierra Leone 40 kg of Nestle’s ’Lactogen’ costs 108% of the minimum urban wage. The International Baby Food Action Network (IBFAN) estimates the same money will buy 220 kg of fish, 16.5 kg of cassava leaves, and 92 kg of rice. Monitoring of formula producers’ marketing strategies carried out last year by IBFAN and ACA uncovered regular "donations" of formula to hospitals in the Philippines, Malaysia, and throughout the Caribbean and South America. Nestle alone provides free supplies to hospitals in at least 20 counties. In the Dominican
code
might be done about the veritable abbatoir of hysterectomies, the excessive number of radical mastectomies, the high rate of caesarean section. These commentators look forward to displacement of the male image of the physician and female dominance of the medical profession. They believe that medicine today is too instrumental, impersonal, career-directed. Women will change this, because they are person-oriented rather than technology-oriented, more empathic, and kinder and gentler altogether. With their greater interest in social matters related to illness and health, they are thought more likely to enter primary-care, family medicine practice. In a letter to the New York Times one woman writes, "I would like to believe that women, because of their genderdetermined upbringing, education and social roles (never mind the possibility of biological differences) might be more sensitive than men to the effects of violence and killing". Lila Wallis, president of the American Women’s Medical Association, writes, "Women are different biological entities, with different hormones, different patterns of health and disease, and different responses to stress". Some of the effects anticipated-hoped for or dreadedmay come into being as predicted. The social demands created by woman physicians will undoubtedly result in big changes. Apart from a crumbling of discriminatory practices, some of the first effects will be changes at the workplace. "Flex-time" service in residency training programmes and even in medical education generally may become the rule; institutional creches will certainly be provided in the very near future, where they do not already exist, and we are moving towards paid maternity and paternity leave. Women’s ills will be taken more seriously, too, without a doubt. A new specialty is proposed - "women’s medicine"-which will focus on women’s physiology and women’s psychology. The medical and pharmaceutical establishments will be pressed to explore women’s special needs-primary prevention of breast cancer and research into diseases that affect both sexes but now are studied only in men.2 Of course, this will not all happen at once and immediately. Perhaps it will not happen at all. Is there truly a feminine mystique, of special nurturing qualities, attributable to "left-brain" dominance, or is this another masked prejudicial concept, to justify not taking women seriously, not giving them access to power and authority because they are physically and emotionally weaker? Another consideration is an implacable sexism in humanity that might counter the impact of mere numbers. Remember that for a long time over 80% of all health workers have been female, but the ruling discipline has been that of the medical profession, and the ruling class the male doctors. Like the "white tribe" in South Africa, the male minority of doctors have held sway over the female majority. One disturbing prospect is that feminisation of medical practice, in a society remaining rigidly sexist, will mean that medicine will take on the attributes of other feminine occupations. When the Russian medical profession became predominantly female, the status and income of the medical profession declined--except in those high positions where men continued to predominate. Is that what will happen here? Institution for Social and Policy Studies, Yale University, New Haven, Connecticut, USA
George Silver
Eisenberg C. Medicine is no longer a man’s profession. N Engl 1989; 321: 1542-44. 2. Perrone J. For women only. AMA News Nov 17, 1989. 1.
J Med
Conference From "powerful
plants" to powerful medicines
In the 1960s many pharmaceutical companies looked to plants for compounds that could be used to treat a variety of diseases. Apart from a few isolated cases, this approach was unsuccessful and attention switched to synthetic organic chemistry. Recently, more systematic screening programmes have been adopted which focus on plant products used by tribal healers in primitive tribes throughout the world. A recent Ciba Foundation symposium on bioactive compounds from plants, held in Bangkok, considered this search for new drugs derived from plants. For this work to be effective, the information about the plants and their uses must be collected by trained observers-ethnobotanists. Michael Balick and Paul Cox, who work with indigenous peoples in Belize and Samoa, respectively, described the procedures for collecting this information. The investigator has to speak the local language
and understand the culture. The healers are important, both within their own societies and because of the knowledge they possess, and should be accorded due respect. The investigator should record full details of which parts of the plant are used, the method of preparation and application, and a precise description of the illness treated. Horror stories of casual recording abounded during the symposium-for example, plants cited as used for contraception without noting whether they were taken by the man or woman or before or after sexual intercourse. For this reason, the ethnobotanists were asked whether Western-trained doctors were taken on these expeditions. More horror stories! Many Westerners prove unable to adapt to different cultural practices and may offend the healers by insensitive attitudes. Others find the working conditions too primitive and catch the first plane home. However, some stay, and are invariably impressed by the work of the tribal healers. One difficulty is the lack of any direct correspondence between the disease classifications of indigenous peoples and Western medicine. In Central America there is an illness called susto, which is caused by "shock". The trouble is that different peoples are shocked by different things: primitive tribes may find a camera frightening and believe that taking a photograph captures their soul. This is easy to mock, but, as Balick pointed out, a Westerner confronted by a tiger might show symptoms of susto. What seems to be common to all cultures is the role of primary health care. In developed countries, many patients visit their doctor for reassurance as much as for specific treatments. Tribal healers also believe that it is as important to treat the soul of the patient as to treat the body-a different way of saying the same thing. The plant products that are collected are sent to Europe or the US for screening-almost exclusively for compounds that show anticancer or anti-HIV activity. This revelation led to a lively debate at the symposium. Why should a plant extract used to cure a parasite infection show antitumour activity? Balick explained that he concentrates on the plants that appear in many different local pharmacopoeias-he calls them "powerful plants". These plants have proven bioactivity in man, and their use over many generations shows that they have no adverse side-effects. No claims are made that they will be effective against cancers, but they are more promising starting materials than plants collected at random. Preliminary results show a higher "hit rate" in the anticancer and anti-HIV screens of compounds isolated in this way.
1151
Since the plant extracts are used by tribal healers to treat parasitic or bacterial infections-and people throughout the world are dying of such infections-it was asked why the screens are not directed at the componds that have these activities. The sad answer was that people with such diseases tend not to have enough money to make the development of the drugs commercially viable.
Joan Marsh The conference
proceedings will be published in October,
1990.
Medicine and the Law Duty to warn about likely adverse effects A 48-year-old West Indian woman with hypertension sued the district health authority and doctors at the district hospital for negligence in not warning her about adverse effects of minoxidil. The drug had led to excessive hair growth and darkening of the face, causing great distress and limiting her social life. She had been attending an outpatient clinic since 1980 with essential hypertension, which had not responded to treatment. In December, 1982, when she had been on nadolol 200 mg, hydralazine 25 mg thrice daily, xipamide 40 mg, and spironolactone 25 mg, her blood pressure (BP) was still 170/120 mm Hg. The hydralazine was stopped and replaced with minoxidil 2-5 mg twice daily. Over the next 16 months control continued to be poor, and the dose of minoxidil was gradually increased to 40 mg per day. In April, 1984, her BP was 190/115 mm Hg and she severe
complained that she was taking too many tablets; all were stopped, including minoxidil, which was replaced with labetalol. She was depressed, and mianserin was also prescribed. In June, however, she re-started minoxidil 40 mg daily, nadolol, and xipamide. At this time she complained of unsightly darkening of the skin below the left eye. In August her BP was 190/120 mm Hg, and the dose of minoxidil was increased to 50 mg (the maximum recommended) and nadolol to 240 mg daily. This treatment continued for 11 months. At the end of July, 1985, she attended hospital very upset, complaining of profuse hair growth, especially on the face but also on the arms, breasts, and legs, which had started 5-6 weeks earlier and had got worse. It was accompanied by itching and a change in the skin. She was admitted for investigation and slow tailing-off of minoxidil, which was recognised as the cause. Minoxidil was stopped on Aug 1, 1985, and captopril substituted. Over the next year the
excess
hair
gradually disappeared,
and her skin
pigmentation returned to normal. The patient should have been warned about the hypertrichosis. The data sheet states: "Hypertrichosis occurs in most patients treated with Loniten [the brand name] and all patients should be warned of this possibility before starting therapy. Spontaneous reversal to the pretreatment state can be expected one to three months after cessation of therapy." Since hypertrichosis is so predictable, it must be assumed to be dose-dependent-ie, the higher the dose and the longer it is used, the greater the hair growth. Prescribing information for doctors rarely states whether particular unwanted effects are dose-dependent or not, but prescribers need to be aware that the greater the dose, the greater the intensity of the effect, and the greater the variety of effects (and intensity). It follows that if abnormal hair growth has not occurred in a patient taking minoxidil, the likelihood that it will start becomes greater with every increase in dosage. When, as in this case, a patient is seen by different physicians, the doctor cannot be sure what the patient has been told previously (unless it is recorded), and it is the doctor’s responsibility to warn the patient, especially if he increases the dose.
From December, 1982, until April, 1984, minoxidil caused no apparent extra hair growth, but for most of this period the patient took less than 20 mg a day. She stopped taking the drug for 7 weeks between April and June, when she began again at a dose of 40 mg daily. Then for almost a year she took 50 mg a day. It was only in the last 6 weeks of that period that she noticed excess hair growth. Increased pigmentation is not mentioned in the standard prescribing information on minoxidil. It is, however, reported in several publications. The most detailed says that abnormal hair growth "may be accompanied by darkening of the skin and coarsening of the facial features".1 A review notes "an increase in skin pigmentation, mainly in blacks and in mixed population’? Upjohn international voluntary reporting database included eight cases of pigmentation. In March, 1990, the defendants offered a payment of k 1500 plus costs to settle the claim, which the plaintiff accepted. Prescribers have a clear duty to inform patients about likely adverse effects that might worry them, but how far this duty extends to a prescriber who continues treatment started by a colleague does not seem to have been considered by the courts. We suggest that a subsequent prescriber who increases the dose must inform or remind the patient of a risk that is dose-related. Even if the dose is not increased the patient should be told about risks related to the duration of exposure to the drug.
Andrew Herxheimer Nick
Young
1. Kosman ME. Evaluation of a new antihypertensive agent: minoxidil. JAMA 1980; 244: 73-75. 2. Velasco M, Silva H. Role of vasodilators in the treatment of arterial hypertension. In: Velasco M, ed. Clinical pharmacology and therapeutics (Int Cogr Ser no 604). Amsterdam: Excerpta Medica, 1982: 9-19. 3. Dukes MNG, Swartz B. Responsibility for drug-induced injury. Amsterdam: Elsevier, 1988: 115-20.
Noticeboard Marketing of breast milk substitutes Infant food multinationals are continuing to undermine breastfeeding through their aggressive marketing of formula milk throughout the third world, according to a report from Action for Corporate Accountability (ACA).1 At least eight formula companies, says ACA, are violating the WHO/UNICEF International Code of Marketing of Breastmilk Substitutes. The was introduced in 1981 to protect infants and their parents from misleading and dangerous formula promotion. As a result of its findings, ACA is now organising an international boycott of Nestle and American Home Products (AHP), two of the largest formula producers. The provision of free formula milk to third-world maternity wards and nursing homes is a particularly serious breach of the WHO code. Mothers coerced into bottle feeding in this way leave hospital with a tin of formula and a dwindling supply of breast milk. If they persist in bottle feeding, their babies are 25 times more likely to die of a gastrointestinal, respiratory, or other infection. The cost of purchasing further formula poses an enormous financial strain and puts the nutritional status of whole families at risk. Typically, artificial milk consumes around 50% of the household income. In Sierra Leone 40 kg of Nestle’s ’Lactogen’ costs 108% of the minimum urban wage. The International Baby Food Action Network (IBFAN) estimates the same money will buy 220 kg of fish, 16.5 kg of cassava leaves, and 92 kg of rice. Monitoring of formula producers’ marketing strategies carried out last year by IBFAN and ACA uncovered regular "donations" of formula to hospitals in the Philippines, Malaysia, and throughout the Caribbean and South America. Nestle alone provides free supplies to hospitals in at least 20 counties. In the Dominican
code
