1415
easily obtained by foreign visitors. Emergency permits- are also given. The government promotes industrial development and 11 % of the total alcohol production in the country takes place in Gujarat. Jamnagar is one of the 19 districts of Gujarat State (the total number of districts in India is greater than 425). This district is not well developed industrially. The population is 1 393 076, which is 4-1% of the state’s population. We have examined public response to and official vigilence of prohibition. The excise duty collected on liquor licences is more than 90 000 rupees per year, not including that
supplied
to
the armed forces. There
are
about 700 licence
holders, each of whom is eligible for 650 ml (5 bottles) of liquor per month from an authorised dealer (there are no liquor shops); defence personnel are entitled to a monthly quota of about 10 500 litres of rum, 6000 litres of whisky, and 12 000 litres of beer. Much of this allowance finds its way to the civil population, as easy
earnings for military personnel. About 250 practising doctors and hospitals are entitled to 5-200 litres of spirit per month. The government spends much on safeguarding the Prohibition Act; and the police department remains alert. In this district in 1991 there were over 3070 instances of liquor-related crime: production, more than 500; possession, 600; sales, 400; consumption, 1550; and unspecified 20. The state of Gujarat remained "dry" throughout independence. These facts and figures presented here clearly indicate that many are not willing to abide by this law. Department of Physiology, M. P. Shah Medical College, Jamnagar 361 008, India 1. Jindal ML. Bombay
Prohibition Act and rules.
K. P. SKANDHAN Jodhpur: India Publishing House,
important safeguard of European public interest in lies securing openness in the new system. The Treaty of probably Maastricht specifically refers to the need for this: "... transparency of the decision-making process strengthens the democratic nature of the institutions and the public’s confidence in the administration". This issue seems important not only for health, but also as a point of principle concerning the relation between Europeans and their emerging system of government. To work effectively, the agency will need to command professional and public confidence, compensating for its physical remoteness at the same time. However, the proposal for the new EC agency, indeed the very framework of a future drug control policy, has been developed by the EC Directorate for Competition Policy-which has confined its consultations to "competent national authorities ... European and national industrial federations, and major pharmaceutical companies". The consultation extended to several non-EC companies, but effectively excluded professional and consumer bodies .2 The setting up of the new agency will be discussed at the EC summit in Edinburgh: it would be good to see some evidence of a commitment to openness. There can be no effective scrutiny or participation without it-openness is where trust begins. The
most
Social Audit, PO Box 111, London NW1 8XG, UK
CHARLES
MEDAWAR,
Director
1. Department of Health Press Release [H92/390], 13 November 1992. 2. Besselaar; Deloitte & Touche Europe Services: interim study concerning the establishment of a European agency for the evaluation of medicinal products: interim report 1992. Brussels: European Commission, 1992.
1990.
SIR,-Abhay and Rani Bang refer to the ban on the sale of alcohol from liquor shops in two places (Gadchiroli and Cuttack) in India. However, they report no data on the sale of illicit liquor in these places before and after prohibition. Experience from the USA from the 1930s, as well as from other Indian states that had prohibition at some time during the past 40 years, shows that a ban on the sale of good-quality alcoholic beverages merely leads to an increase in consumption of illicit liquor. This practice not only gives a lift to organised crime but also increases the risk of persons unknowingly drinking methylated alcohol provided by bootleggers, with disastrous consequences. Your correspondents who have taken pains to report the ban on the sale of alcohol in Cuttack, did not, surprisingly, record that at that town hundreds of people died recently after drinking illicit methylated alcohol. Treatment for alcoholism is through counselling of alcoholics and education of potential victims and not by merely banning the sale of alcohol. The complementary use of formal (such as banning of advertising) and informal (through early education) controls have been recommended as the best strategy.’1 Schwedenstrasse 30, D-6237 Liederbach, Germany 1. Heath DB. Prohibition
SANDEEP BHATTACHARYA
or liberalisation of alcohol and drugs: perspective. Rec Dev Alcohol 1992; 10: 129-45.
a
sociocultural
EC medicines agency SIR,—The proposal for the new EC medicines agency (Nov 14, p 1219) has stalled, partly because the Danish parliament has to approve the plans and because Belgium, Luxembourg, and Spain have reservations about its location. The country chosen to host the agency will be landing quite a prize. The UK Department of Health
has already announced its "very real interest" in having the
European Agency for the Evaluation of Medicines (EMEA) based in the UK.’ But will
preoccupation with the question of which country will
"win" distract attention from the more important issue? Surely the main issue is how to protect the health interests of the overwhelming number of EC consumers who will end up having important decisions made for them by another country. Since only one country can host the EMEA, should not the others be taking steps to ensure that the new agency serves them as well as it can?
Health
care
in
developing countries
SIR,-I have recently visited western Nigeria to examine attendance records and vital statistics data for nearly 30 years (1963-92), with respect to a health-care scheme covering a district with a population of about 100 000. During this period cemented wells and piped water (albeit running sporadically) were introduced, as well as immunisation programmes for the under 5s. Repeated health education efforts were also mounted. Although attendance at clinics tended to increase over the years, illness patterns remained remarkably similar, apart from a striking reduction in the frequency of parasitic disease from 15% of diagnoses in 1965 to 3% in 1990. The most debilitating and common complaint continues to be malaria with no changes in incidence, though it is most prominent in the young before they acquire some degree of resistance. There was little change in life expectancy or in reproductive behaviour.’ Overall, the findings seemed to confirm that public and community health measures continue to be of great benefit. The full article will be published in the Nigerian Medical Journal. The investigation was made possible by a grant from the Wellcome Trust and support from Oxford Polytechnic. School of Social Sciences, Oxford Polytechnic, Headington, Oxford OX3 0BP, UK
Varicella and
C. RENATE BARBER
acyclovir
SIR,-As a medical practitioner in a third-world country, I am familiar with those instances when treatment cannot be recommended to patients because of non-medical reasons, mainly poverty. The use of oral acyclovir 800 mg five times daily for 7 days has been described for varicella in immunocompetent adults. In India, this treatment would cost nearly 3000 rupees. At most, what one can hope to achieve is to go back to work, which is often non-existent, 1-2 days earlier. This is unlikely to save more than 200 rupees, even in well-paid employees. Obviously, here the physical availability of the drug does not mean it is a therapeutic option. I hope that a state will not be reached when advances in clinical practice become unattainable for people in certain parts of the world. There have been suggestions that only a previous unmodified natural infection gives total immunity to varicella.1 So inhibition of
easily obtained by foreign visitors. Emergency permits- are also given. The government promotes industrial development and 11 % of the total alcohol production in the country takes place in Gujarat. Jamnagar is one of the 19 districts of Gujarat State (the total number of districts in India is greater than 425). This district is not well developed industrially. The population is 1 393 076, which is 4-1% of the state’s population. We have examined public response to and official vigilence of prohibition. The excise duty collected on liquor licences is more than 90 000 rupees per year, not including that
supplied
to
the armed forces. There
are
about 700 licence
holders, each of whom is eligible for 650 ml (5 bottles) of liquor per month from an authorised dealer (there are no liquor shops); defence personnel are entitled to a monthly quota of about 10 500 litres of rum, 6000 litres of whisky, and 12 000 litres of beer. Much of this allowance finds its way to the civil population, as easy
earnings for military personnel. About 250 practising doctors and hospitals are entitled to 5-200 litres of spirit per month. The government spends much on safeguarding the Prohibition Act; and the police department remains alert. In this district in 1991 there were over 3070 instances of liquor-related crime: production, more than 500; possession, 600; sales, 400; consumption, 1550; and unspecified 20. The state of Gujarat remained "dry" throughout independence. These facts and figures presented here clearly indicate that many are not willing to abide by this law. Department of Physiology, M. P. Shah Medical College, Jamnagar 361 008, India 1. Jindal ML. Bombay
Prohibition Act and rules.
K. P. SKANDHAN Jodhpur: India Publishing House,
important safeguard of European public interest in lies securing openness in the new system. The Treaty of probably Maastricht specifically refers to the need for this: "... transparency of the decision-making process strengthens the democratic nature of the institutions and the public’s confidence in the administration". This issue seems important not only for health, but also as a point of principle concerning the relation between Europeans and their emerging system of government. To work effectively, the agency will need to command professional and public confidence, compensating for its physical remoteness at the same time. However, the proposal for the new EC agency, indeed the very framework of a future drug control policy, has been developed by the EC Directorate for Competition Policy-which has confined its consultations to "competent national authorities ... European and national industrial federations, and major pharmaceutical companies". The consultation extended to several non-EC companies, but effectively excluded professional and consumer bodies .2 The setting up of the new agency will be discussed at the EC summit in Edinburgh: it would be good to see some evidence of a commitment to openness. There can be no effective scrutiny or participation without it-openness is where trust begins. The
most
Social Audit, PO Box 111, London NW1 8XG, UK
CHARLES
MEDAWAR,
Director
1. Department of Health Press Release [H92/390], 13 November 1992. 2. Besselaar; Deloitte & Touche Europe Services: interim study concerning the establishment of a European agency for the evaluation of medicinal products: interim report 1992. Brussels: European Commission, 1992.
1990.
SIR,-Abhay and Rani Bang refer to the ban on the sale of alcohol from liquor shops in two places (Gadchiroli and Cuttack) in India. However, they report no data on the sale of illicit liquor in these places before and after prohibition. Experience from the USA from the 1930s, as well as from other Indian states that had prohibition at some time during the past 40 years, shows that a ban on the sale of good-quality alcoholic beverages merely leads to an increase in consumption of illicit liquor. This practice not only gives a lift to organised crime but also increases the risk of persons unknowingly drinking methylated alcohol provided by bootleggers, with disastrous consequences. Your correspondents who have taken pains to report the ban on the sale of alcohol in Cuttack, did not, surprisingly, record that at that town hundreds of people died recently after drinking illicit methylated alcohol. Treatment for alcoholism is through counselling of alcoholics and education of potential victims and not by merely banning the sale of alcohol. The complementary use of formal (such as banning of advertising) and informal (through early education) controls have been recommended as the best strategy.’1 Schwedenstrasse 30, D-6237 Liederbach, Germany 1. Heath DB. Prohibition
SANDEEP BHATTACHARYA
or liberalisation of alcohol and drugs: perspective. Rec Dev Alcohol 1992; 10: 129-45.
a
sociocultural
EC medicines agency SIR,—The proposal for the new EC medicines agency (Nov 14, p 1219) has stalled, partly because the Danish parliament has to approve the plans and because Belgium, Luxembourg, and Spain have reservations about its location. The country chosen to host the agency will be landing quite a prize. The UK Department of Health
has already announced its "very real interest" in having the
European Agency for the Evaluation of Medicines (EMEA) based in the UK.’ But will
preoccupation with the question of which country will
"win" distract attention from the more important issue? Surely the main issue is how to protect the health interests of the overwhelming number of EC consumers who will end up having important decisions made for them by another country. Since only one country can host the EMEA, should not the others be taking steps to ensure that the new agency serves them as well as it can?
Health
care
in
developing countries
SIR,-I have recently visited western Nigeria to examine attendance records and vital statistics data for nearly 30 years (1963-92), with respect to a health-care scheme covering a district with a population of about 100 000. During this period cemented wells and piped water (albeit running sporadically) were introduced, as well as immunisation programmes for the under 5s. Repeated health education efforts were also mounted. Although attendance at clinics tended to increase over the years, illness patterns remained remarkably similar, apart from a striking reduction in the frequency of parasitic disease from 15% of diagnoses in 1965 to 3% in 1990. The most debilitating and common complaint continues to be malaria with no changes in incidence, though it is most prominent in the young before they acquire some degree of resistance. There was little change in life expectancy or in reproductive behaviour.’ Overall, the findings seemed to confirm that public and community health measures continue to be of great benefit. The full article will be published in the Nigerian Medical Journal. The investigation was made possible by a grant from the Wellcome Trust and support from Oxford Polytechnic. School of Social Sciences, Oxford Polytechnic, Headington, Oxford OX3 0BP, UK
Varicella and
C. RENATE BARBER
acyclovir
SIR,-As a medical practitioner in a third-world country, I am familiar with those instances when treatment cannot be recommended to patients because of non-medical reasons, mainly poverty. The use of oral acyclovir 800 mg five times daily for 7 days has been described for varicella in immunocompetent adults. In India, this treatment would cost nearly 3000 rupees. At most, what one can hope to achieve is to go back to work, which is often non-existent, 1-2 days earlier. This is unlikely to save more than 200 rupees, even in well-paid employees. Obviously, here the physical availability of the drug does not mean it is a therapeutic option. I hope that a state will not be reached when advances in clinical practice become unattainable for people in certain parts of the world. There have been suggestions that only a previous unmodified natural infection gives total immunity to varicella.1 So inhibition of
