916 been curable. Now health authorities of the developing world, where so many are ill, face a choice between the improvement of sanitation and the provision of immunisation or the use of a wide spectrum of efficient drugs, since they can afford very little of either. In most ten

it is practicable to distinguish health service, and the following

developing countries

cardinal purposes of

a

list would satisfy most people: (1.) Prevention of communicable disease of high

preva-

Improvement of adverse sanitary conditions. Improvement of housing. Improvement of nutrition. Protection of the mother.

(2.) (3.) (4.) (5.) (6.) Family planning. (7.) Protection of the child under five. (8.) School health. (9.) Extension of primary care. (10.) Maintenance of secondary medical care. Of this list, eight are concerned with prevention of ill-health in various ways and two with curative medicine. Commercial organisations have a curious rule, the 80/20 rule, which says, for example, that 80% of sales are made by 20% of salesmen. It is true in so many countries that 20% of health activities, those concerned with curative medicine, are absorbing 80% of the money available. Worse still, the urban focus of health services means that 80% of people, those in rural areas, have to be satisfied with 20% of the health services available. New patterns should be devised to balance curative and preventive services more efficiently. The major problem is that most ministries of health do not have executive power for all the factors that will lead to the promotion of health, especially those concerned with the sanitary environment, housing and food. One reason why curative activities swallow up the major share of resources is that while it is the health minister’s job to obtain funds for the whole ministry from Government in budget debate, it is usually the job of his chief officers to allocate funds within the ministry itself. Since the hospital and curative side dominates and the maintenance of the system is the major concern rather than its change, the disproportion between the recognised functions of prevention and cure remains. Even if it proves possible to balance this account more fairly in favour of prevention this would still omit the allocation of funds for the actual physical improvement of the environment or for the basic relief of poor nutritional standards. The Government agencies responsible (usually works and agriculture) confer relatively low priority on these activities.

I have in mind

in organisation which might overcome these difficulties. If the balance between prevention and cure is to be changed it has to be done following a calculated decision by the Minister of Health, with the full political support of the Government, to distribute funds equitably between four major health functions: food, environment, preventive health, and curative services. The heads of the four departments should be equal in status, and each would have technical staff to carry out specific departmental functions. Thus a minister of health would become responsible for four decentralised departments. If the allocation of funds was the function of an advisory board of health in which the four departmental heads had equal voices then there would be a greater chance of a more equitable distribution of money between them. Funds previously given to other ministries for food and environmental improvement could be added to the budget of the ministry of health. Such a reshuffle of responsibilities is very difficult, but not impossible. After all no other ministry has anything approaching the same vested interest in the improvement of the environment and nutrition. a

possible change

to

the Editor

VERTICAL TRANSMISSION OF HEPATITIS B AND

BREAST-FEEDING SIR,-Beasley al.l presented data indicating that breastfeeding did not affect the attack-rate of hepatitis-B infection m et

lence.



Letters

infants born of Taiwanese mothers who were asymptomatic carriers of hepatitis-B surface antigen (HBsAg). Of 92 breastfed infants followed for one year, 49% developed detectable HBsAg and 4% developed antibody (anti-HBs), an infectionrate of 53%. Of 55 infants who were not breast-fed, 53% developed HBsAg and 7% anti-HBs, an infection-rate of 60‘c. Beasley et al. stated that these data provide "evidence against breast-feeding as a mechanism for vertical transmission". Breast milk of hepatitis-B carrier mothers has been tmphcated as a possible cause of newborn infection for two reasons: (1) the possible ingestion of infectious serum that exudes from cracked nipples, a common occurrence; and (2) the possibility that, virus may be present in breast milk. Thus, breast-feeding must be considered as one of many possible modes of transmission of hepatitis-B virus. The infant of an HBsAg-positive carrier mother may be exposed to infection in utero, at the time of birth, during the postpartum period in hospital, and at home after discharge. During delivery an infant is born in a "bath of blood". Therefore, infection may occur as a result of ingestion of hepatitis-B virus. In addition the virus may be inadvertently inoculated by various routine procedures carried out in the delivery room. For example, vigorous suction procedures may cause minor submucosal tears in the infant’s mouth and pharynx. During the course of labour certain monitoring procedures involve the use of needles that penetrate the infant’s scalp, thereby inoculating the agent. The injection of vitamin K may penetrate skin that is contaminated with virus. The Taiwanese infant who leaves the hospital lives in a community where the HBsAg carrier-rate ranges between 15 and 20%. Consequently, in this environment an infant may be exposed to siblings and other household members who may be carriers. Under these circumstances, the Taiwanese infant may be exposed by horizontal as well as vertical transmission of the virus. On the other hand, in the United States and in many European countries the risk of horizontal transmission is negligible because the carrier-rate is less than 1%. The occurrence of hepatitis-B infection in 60% of the infants who were not breast-fed may be a reflection of the multiple factors involved in vertical and horizontal transmission of hepatitis B in a highly endemic area like Taiwan. Under these circumstances, the addition of breast-feeding could conceivably have a negligible effect because maximum exposure could have occurred via other routes. On the other hand, in the United States and in Europe where the HBsAg carrier-rate is low, it is possible that breast-feeding may be an important mechanism of vertical transmission. The potential benefits of breast-feeding for infants in developing areas of the world far outweigh the potential risks of hepatitis-B infection from breast milk. Artificial milk formulas are too costly and adequate refrigeration facilities are usually not available. Beasley et al. have provided reassuring data to justify the continuation of breast-feeding for infants who live in these areas. On the other hand, in countries where hepatitis-B infection is not endemic and artificial milk formulas are safe and available, I believe that infants of carrier mothers should be fed sterile cow’s milk rather than human breast milk that may contain hepatitis-B virus particles. Department of Pediatrics, New York University School of New York, N.Y. 10016, U.S.A. 1. Beasley, R.

Medicine,

SAUL KRUGMAN

P., Stevens, C. E., Shieao, I-S., Meng, H-C. Lancet, Oct 18,

1975, p. 740.

Letter: Vertical transmission of hepatitis B and breast-feeding.

916 been curable. Now health authorities of the developing world, where so many are ill, face a choice between the improvement of sanitation and the p...
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