synonymous with tubewell usage and sugthis basis that tubewell use reduced Classical, gested but not El Tor choleraYIn the present study observed tubewell use did not relate to distance from tubewell or protection from cholera. These findings accord with those in West Bengal in which usage was influenced by religious, political, and social factors9 and suggest that saturating a village with tubewells may not increase tubewell use. was



Cases of non-cholera diarrhoea were not concentrated about the canal and these diseases may differ from cholera in the extent to which they are caused by waterborne organisms.2Tubewell use did not protect against these diseases.

Surface water is preferred for some purposes because of temperature, convenience, superstition, and ideas of disease transmission as well as on account of the high iron content of local tubewell water. Iron causes the tubewell water to be coloured brown and taste unpleasant, and such water discolours food, clothes, and

teeth. 12 The unexpected finding that tubewell users do not have lower cholera infection-rates suggests that their regular use of contaminated surface-water sources main-

tains infection-rates equal to those of tubewell nonusers. Even tubewell-water drinkers preferred surface water for bathing, washing, and preparing food. Tubewell breakdowns resulted in use of alternative water sources, yet there were no clusters of cases at these times. Cross contamination by individuals or floods may account for similar disease-rates in families predominantly using canals or tanks. To reduce the incidence of cholera in the face of heavy environmental vibrio contamination, tubewells must be used to the exclusion of all other more contaminated water sources. The effect of improved water supply on health will be restricted by traditional patterns of water use and is likely to be negligible unless coordinated with public-health education or other programmes leading to reduced use of contaminated sources. Tubewells may be made effective more easily in areas with few competing water sources.

We thank the staff of the Cholera Research Laboratory for expert technical assistance and P. Brachman, R. Cash, A. Choudhury, W. Greenough, A. Langmuir, K. Monsur, and K. Rothman for valuable suggestions; and Dr Eugene Gangarosa for advice and encouragement in the preparation of the manuscript. This study was funded by N. I. H. research agreement R07AI10048-15 with the Johns Hopkins Center for Medical Research the Cholera Research Laboratory, an autonomous organisation supported by the Governments of the People’s Republic of Bangladesh, the U.S.A., the U.K., and Australia.

and by

Requests for reprints should be addressed to


J. L.


As you swallow your daily antidepressant and tonic in the garden, spare a thought this summer for the poor hayfever sufferers. At this time of year we blearily view the sun with dark suspicion and watery eyes, for we know that, inevitably, sneezing, pruritus, and rhinorrhoea are upon us. Small comfort to know that our susceptibility to hayfever is positively correlated 1

with intelligence. The washing machines, human or mechanical, are now working tirelessly to maintain our handkerchief supplies. The pollen count is printed daily and publicly discussed, but every sufferer knows that this is only for the amusement of those without hayfever; we accurately know it by counting our sneezes. We pray for rain and to hell with the Tests, Wimbledon, and Ascot. Our cars are like hothouses. We sit snuffling in stuffy, darkened rooms, with windows shut to keep out the myriads of poisonous pollen particles. We sleep fitfully, if we can breathe at all. Even Gulliver was not laid low by such tiny enemies. The doctor can bring some relief, but, as ever, at a cost. Hayfever is alleviated by antihistamines, but at the price of sapping energy, initiative, and forward, let alone lateral, thinking. We may even sleep inappropriately (sic) during lectures or committees. It seems unfair that, with all those new antibiotics, chemists cannot synthesise an antihistamine that does not possess such hypnotic effects. (Please keep trying.) But spontaneous relief eventually comes as the pollen count falls. The windows are opened, and the July and August sun soon softens the memory of dread June for another year. So spare a thought for us drugged sufferers. If we fall asleep while you are talking, make allowances. If we fall asleep lecturing, sympathise. If we fall asleep driving, give us sick leave. How many road accidents, I wonder, are caused by pollen? How many June drivers coming towards you at a collision speed of 90 m.p.h. (27 metres/sec) are either sneezing uncontrollably or are hypnotised by antihistamines? I must go and

The Marks family have run the garage near the hospital gate for the past fifty years, and provided us with an excellent personal service. Last night my car developed a leak in the exhaust system. This morning one of the hospital car watchers inquired: "Where’s your car?" and I was able to reply: "It’s gone to St. Marks with a fistula-in-ano." "

1. Unpublishable results

Families with H.S. graduates had greater tubewell use, but tubewell use per se did not affect cholera or noncholera diarrhoea incidence. Thus, the protection associated with education or wealth is not related to water use, but may be related to personal hygiene, nutrititional status, and crowding. The role of these factors needs evaluation in order to provide a basis for rational and effective developments to improve health.


of the author

1. United Nations Children’s Fund


WS/187/75, Guidelines


May 16, 1975. 2. Levine, R. J., Khan, M. R., D’Souza, S., Nahn, D. R. Lancet, 1976, ii, 84. 3. Woodward, W. E., Mosley, W. H., McCormack, W. M. J. infect. Dis. 1970, 121, suppl., 10. 4. Lindenbaum, J., Greenough, W. B., III, Benenson, A. S., Oseasohn, R., Rizvi, S., Saad, A. Lancet, 1965, i, 1081. 5. McCormack, W. M., Mosley, W. H., Fahimuddin, M., Benenson, A. S. Am. J. Epidem. 1969, 89, 393. 6. Mosley, W. H, Chowdhury, A. K. M. A., Aziz, K. M. A. Demographic Characteristics of a Population Laboratory in Rural East Pakistan. Center for Population Research, National Institute of Child Health and Human Development, Bethesda, Maryland 20014, 1970. 7 Islam, S., Curlin. G. Cholera Research Laboratory Technical Committee Report, Dacca, 1975. 8. Miettinen, O. S. J. Am. statist. Ass. 1974, 69, 380. 9. Bang, F. B, Bang, M. B., Bang, B G. Am. J. trop. Med. Hyg. 1975, 24, 326. 10. World Health Organisation, (EH/SEARO/74.1) Report on Rural Water Supply Bangladesh, Geneva, 1974. 11. Sommer, A., Woodward, W. E. Lancet, 1972, ii, 985. 12. Khan, M. The Role of Water Sources in the Incidence of Cholera in Rural Bangladesh, Cholera Research Laboratory, Institute of Public Health,

Dacca, 1975.

Letter: How do doctors learn about drugs?

89 tubewell synonymous with tubewell usage and sugthis basis that tubewell use reduced Classical, gested but not El Tor choleraYIn the present study...
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