795
R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990; 335: 827-38. 9. Antiplatelet Trialists Collaboration. Secondary prevention of vascular disease by prolonged antiplatelet treatment. Br Med J 1988; 296: 320-31. 10. European Carotid Surgery Trialists’ Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991; 337: 1235-43. 11. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med 1991; 325: 445-53. 12. Garraway W, Akhter A, Hockey L, Prescott R. Management of acute stroke in the elderly: follow up of a controlled trial. Br Med J 1980; 281: 827-29. 13. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim L, Holme I. Benefit of a stroke unit: a randomised controlled trial. Stroke 1991;; 22: 1026-31. 8. Collins
REFERENCES 1. King’s Fund Consensus Conference. Treatment of stroke. Br Med J 1988; 297: 126-28. 2. Morris AD, Grossett GD, Squire IB, Lees KR, Bone I, Reid JL. Observations in an acute stroke unit: implications for a trial of thrombolytic therapy. Proceedings of Association of British Neurologists, April, 1991. J Neurol Neurosurg Psychiatry (in press). 3. Stevens R, Ambler N, Warren M. A randomised controlled trial of a stroke rehabilitation ward. Age Ageing 1984; 13: 65-75. 4. Stone SP. The Mount Vernon Stroke Service: a feasibility study to determine whether it is possible to apply the principles of stroke unit management to patients and their families on general medical wards. Age Ageing 1987; 16: 81-88. 5. Wood-Dauphine S, Shapiro S, Bass E, et al. A randomised trial of team care following stroke. Stroke 1984; 15: 864-72. 6. Bamford J, Sandercock P, Warlow C, Gray M. Why are patients with acute stroke admitted to hospital? Br Med J 1986; 292: 1369-72. 7. Ricci S, Celani M, La Risa F, et al. SEPIVAL: a community based study of stroke incidence in Umbria, Italy. J Neurol Neurosurg Psychiatry
1991; 54: 695-98.
VIEWPOINT The poor need
no more
charlatans
ELLEN M. EINTERZ
The world is full of charlatans, and Africa has some of the best. I have seen a healer pull a handful of worms from an aching tooth, like rabbits from a hat, and another excise-without ever cutting-a human femur from the belly of a man with appendicitis. I have seen "snake teeth" removed from infected hands and "tonsils" from inflamed throats by roadside barbers. I have seen traditional midwives whisk away progeny from postmenopausal women said to be five, ten, or fifteen years pregnant. Like most cures-and like no cure at all-charlatanism often works; most illnesses regress. Charlatans know this. So do healers. The difference between the two is that healers believe their actions have in themselves the power to cure, whereas charlatans know they rely on trickery. Traditional healers play an invaluable part in the health care of many societies, but few claim credence in the scientific method, and dramatic, wilful deception has its place in their stock of cures. It is perhaps for these reasons that charlatanism has crept easily and with such impunity into the practice of so-called scientific medicine in traditional societies. Examples are abundant. In one west African country, injectable vitamin B complex-known by all as B-Co-is one of the most frequently used drugs, prescribed by all grades of health professionals to treat ailments ranging from headache to abortion. Women with innocuous menstrual disorders are subjected to regular uterine curettage, or "washing of the belly". Throughout tropical countries, the prescription of antimotility drugs, adsorbents, and inappropriate antimicrobials for the treatment of childhood diarrhoea is common, despite almost two decades’ proof of the inefficacy and danger of these compounds. Fatigue is treated with parenteral doses of testosterone and megavitamins. Simple saline or glucose perfusions are touted as restorers of strength and revitalisers of blood, and patients who are never told otherwise check into hospitals for regular top-ups. Doctors and nurses oblige
complacently. Little is done by health professionals to dispel the common misconception that injections are inherently better than ingested drugs; indeed, much is done to foster it. Pharmacies in developing countries are full of brightly wrapped packages of salves and ointments, and of multicoloured capsules, syrups, and tablets. Many contain at least half a dozen "active" ingredients whose efficacy has never been scientifically tested or even questioned. Yet they are prescribed by doctors trained to do otherwise, and purchased by patients who have no way of knowing better.
Surgery provides temptation to invoke mystique and to dazzle for the sake ofbedazzlement.2 A young doctor newly installed in a district hospital in central Africa described his work to me. "And I have done four caesareans already", he declared, showing me the cobweb-strewn closet used as an operating room. "Of course", he added, knowing I would understand, "three of them were not really necessary". The poor need no more charlatans. The costs of quackery are enormous. Meagre incomes are squandered, proper treatment is delayed or withheld, debilitating side-effects of powerful drugs and injudicious interventions are suffered, resistant strains of bacteria and parasites develop, and confidence in the profession is lost. Yet the pressures on health workers to dabble in charlatanism are intense.3 Ideas reinforced over and over again, such as the superiority of injections over tablets, are difficult to alter. It is easier and less time-consuming to stick a needle into a muscle than to try to convince a patient that the oral preparation is better. Any treatment that differs from that desired by the patient is likely to be regarded as a sign that the practitioner lacks understanding of the problem. Pharmaceutical companies, ADDRESS: Hôpital d’Arrondissement de Kolofata, B.P. 111 Mora, Extrême-Nord, Cameroon. Correspondence to Dr Ellen M
Einterz,
MD.
796
with
their aggressive and often cajoling marketing techniques, increase the pressure on doctors to abandon knowledge gained during training and to flow with the current, however aimless it may be.4 In addition, in many countries, the incomes of hospitals and, to some extent, doctors, are related proportionately to the quantity and cost of the medicines and interventions prescribed. Only an individual of rare integrity is likely to be able to ignore completely this conflict of interest. Yet it is only the integrity of the individual and, by extension, of the profession than can bring an end to such exploitative practices. Recognition of the problem is an essential first step. Drug companies, health systems, and cultural barriers within unschooled societies should not be blamed for the decisions of health professionals to abandon the science of their art. Charlatanism has no place in the practice of
medicine. The poor do not need it, and the profession cannot afford it. Let us leave the rabbits in the hat. Even in the least developed countries, we have the knowledge and the tools to do better.
REFERENCES 1. World Health Organisation. The rational use of drugs in the management of acute diarrhea in children. Geneva: World Health Organisation, 1990.
2. Barros
FC, Vaughan JP, Victoria CG, Huttly SRA. Epidemic of
caesarean
sections in Brazil. Lancet 1991; 338: 167-69.
J-M. Why do people like medicines? A perspective from Africa. Lancet 1985; i: 210-11. Chetley A. A healthy business? World health and the pharmaceutical industry. London: Zed Books, 1990.
3. Michel 4.
BOOKSHELF Neonatal Nutrition and Metabolism Edited by William W. Hay Jr. St Louis: 1991. Pp 558. 69.95. ISBN 0-815142153.
Mosby YearBook.
The availability of surfactant in commercial quantities for the management of hyaline membrane disease means that face the we disconcerting prospect of mass of underemployment neonatologists. Fortunately, a novel area of interest and importance has been discovered, just in time to avert this distressing vision of the future-nutrition. In 1989, when I reviewed neonatal publications cited in Medline, papers on pulmonary and cerebral disease outnumbered those on nutrition by a factor of 18. But it is increasingly recognised that early nutritional management has a crucial effect on long-terrn outcomes, and that nutrition is also relevant to pathology in neonatologists’ favourite organs, the lungs and brain. Publication of a book devoted to nutritional matters in neonates is thus most welcome. Hay has collected a distinguished group of authors, mainly from North America, to contribute to what is likely to become regarded as a classic. His book is strong on relevant basic science, and is divided into four parts dealing with growth and development, the role of specific nutrients, feeding, and the place of nutritional management in specific neonatal disorders. It is difficult to fault the content, which is comprehensive and sufficiently detailed to provide specific advice about topics such as breastfeeding. It is a sign of the pace of development in neonatal nutrition, rather than a criticism of the book, that several recent and potentially far-reaching observations are either not included or only briefly alluded to. The role of feed type in determining the incidence of necrotising enterocolitis and neurodevelopmental outcome is one such example (one wonders how long it will be before non-breastfed children will be suing their mothers over lost IQ points); the relation between bronchopulmonary dysplasia, parenteral lipid administration, and vitamin A deficiency is another. The extent to which neonatologists are prepared to use the gut when feeding sick low-birthweight infants varies considerably, perhaps a reflection of the lack of solid clinical trial data, and readers should not be too disappointed to find an absence of didactic advice on this important point. Indeed this topic, like several others in neonatal nutrition,
greatly benefit from replacement of dogma by empiricism; with more stimulation from books such as this, would
the show should run and run. Institute of Child Health, University of Birmingham, Birmingham B16SET, UK
IAN BOOTH
Healthy Cities Edited by John Ashton. Buckingham: Open University Press. 1991. Pp 235. D4.99. ISBN 0-335094767.
Can a city be a healthy place to live? Residents of eight Basque cities said yes, and their requirements in order of priority were freedom from pollution, especially water, air, and noise; public areas for leisure; improved public transport; and consideration given to their wishes. Are these aims achievable, indeed compatible? The healthy cities movement believes they are, and its guru John Ashton sets out the agenda with the help of 33 international colleagues (half of them women, which makes a change) in what is likely to become the handbook (Bible?) of the movement. Does their agenda convince? To the sceptic, no change is yet visible in cities such as Liverpool and Sheffield, where cars dominate the scene, unemployment spirals up, and urban decay is clearly in evidence-which may indicate that the powers of a city to change itself are limited in the absence of political motivation and a sympathetic government. But there are some hopeful signs in this book which is, after all, written only 5 years after the WHO took up the concept of healthy cities. The first third of the book is about the philosophy (intersectoral working, a community diagnosis, and effective links with local communities are the core) and is inevitably repetitious. Len Duhl’s thoughtful chapter Healthy Cities: Myth or Reality is full of insights into the strengths and weaknesses of the ideal. He points to the lack of political skills of health workers, the dearth of "social entrepreneurs" who will work in the large policy arena of local government (those who do may not share our values), and of the bum-out which results from multiple inconclusive meetings. Duhl
describes the need for information systems and the success of small-scale local programmes but does not mention the powerful vested interests (fast food, cigarette companies,
R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990; 335: 827-38. 9. Antiplatelet Trialists Collaboration. Secondary prevention of vascular disease by prolonged antiplatelet treatment. Br Med J 1988; 296: 320-31. 10. European Carotid Surgery Trialists’ Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991; 337: 1235-43. 11. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med 1991; 325: 445-53. 12. Garraway W, Akhter A, Hockey L, Prescott R. Management of acute stroke in the elderly: follow up of a controlled trial. Br Med J 1980; 281: 827-29. 13. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim L, Holme I. Benefit of a stroke unit: a randomised controlled trial. Stroke 1991;; 22: 1026-31. 8. Collins
REFERENCES 1. King’s Fund Consensus Conference. Treatment of stroke. Br Med J 1988; 297: 126-28. 2. Morris AD, Grossett GD, Squire IB, Lees KR, Bone I, Reid JL. Observations in an acute stroke unit: implications for a trial of thrombolytic therapy. Proceedings of Association of British Neurologists, April, 1991. J Neurol Neurosurg Psychiatry (in press). 3. Stevens R, Ambler N, Warren M. A randomised controlled trial of a stroke rehabilitation ward. Age Ageing 1984; 13: 65-75. 4. Stone SP. The Mount Vernon Stroke Service: a feasibility study to determine whether it is possible to apply the principles of stroke unit management to patients and their families on general medical wards. Age Ageing 1987; 16: 81-88. 5. Wood-Dauphine S, Shapiro S, Bass E, et al. A randomised trial of team care following stroke. Stroke 1984; 15: 864-72. 6. Bamford J, Sandercock P, Warlow C, Gray M. Why are patients with acute stroke admitted to hospital? Br Med J 1986; 292: 1369-72. 7. Ricci S, Celani M, La Risa F, et al. SEPIVAL: a community based study of stroke incidence in Umbria, Italy. J Neurol Neurosurg Psychiatry
1991; 54: 695-98.
VIEWPOINT The poor need
no more
charlatans
ELLEN M. EINTERZ
The world is full of charlatans, and Africa has some of the best. I have seen a healer pull a handful of worms from an aching tooth, like rabbits from a hat, and another excise-without ever cutting-a human femur from the belly of a man with appendicitis. I have seen "snake teeth" removed from infected hands and "tonsils" from inflamed throats by roadside barbers. I have seen traditional midwives whisk away progeny from postmenopausal women said to be five, ten, or fifteen years pregnant. Like most cures-and like no cure at all-charlatanism often works; most illnesses regress. Charlatans know this. So do healers. The difference between the two is that healers believe their actions have in themselves the power to cure, whereas charlatans know they rely on trickery. Traditional healers play an invaluable part in the health care of many societies, but few claim credence in the scientific method, and dramatic, wilful deception has its place in their stock of cures. It is perhaps for these reasons that charlatanism has crept easily and with such impunity into the practice of so-called scientific medicine in traditional societies. Examples are abundant. In one west African country, injectable vitamin B complex-known by all as B-Co-is one of the most frequently used drugs, prescribed by all grades of health professionals to treat ailments ranging from headache to abortion. Women with innocuous menstrual disorders are subjected to regular uterine curettage, or "washing of the belly". Throughout tropical countries, the prescription of antimotility drugs, adsorbents, and inappropriate antimicrobials for the treatment of childhood diarrhoea is common, despite almost two decades’ proof of the inefficacy and danger of these compounds. Fatigue is treated with parenteral doses of testosterone and megavitamins. Simple saline or glucose perfusions are touted as restorers of strength and revitalisers of blood, and patients who are never told otherwise check into hospitals for regular top-ups. Doctors and nurses oblige
complacently. Little is done by health professionals to dispel the common misconception that injections are inherently better than ingested drugs; indeed, much is done to foster it. Pharmacies in developing countries are full of brightly wrapped packages of salves and ointments, and of multicoloured capsules, syrups, and tablets. Many contain at least half a dozen "active" ingredients whose efficacy has never been scientifically tested or even questioned. Yet they are prescribed by doctors trained to do otherwise, and purchased by patients who have no way of knowing better.
Surgery provides temptation to invoke mystique and to dazzle for the sake ofbedazzlement.2 A young doctor newly installed in a district hospital in central Africa described his work to me. "And I have done four caesareans already", he declared, showing me the cobweb-strewn closet used as an operating room. "Of course", he added, knowing I would understand, "three of them were not really necessary". The poor need no more charlatans. The costs of quackery are enormous. Meagre incomes are squandered, proper treatment is delayed or withheld, debilitating side-effects of powerful drugs and injudicious interventions are suffered, resistant strains of bacteria and parasites develop, and confidence in the profession is lost. Yet the pressures on health workers to dabble in charlatanism are intense.3 Ideas reinforced over and over again, such as the superiority of injections over tablets, are difficult to alter. It is easier and less time-consuming to stick a needle into a muscle than to try to convince a patient that the oral preparation is better. Any treatment that differs from that desired by the patient is likely to be regarded as a sign that the practitioner lacks understanding of the problem. Pharmaceutical companies, ADDRESS: Hôpital d’Arrondissement de Kolofata, B.P. 111 Mora, Extrême-Nord, Cameroon. Correspondence to Dr Ellen M
Einterz,
MD.
796
with
their aggressive and often cajoling marketing techniques, increase the pressure on doctors to abandon knowledge gained during training and to flow with the current, however aimless it may be.4 In addition, in many countries, the incomes of hospitals and, to some extent, doctors, are related proportionately to the quantity and cost of the medicines and interventions prescribed. Only an individual of rare integrity is likely to be able to ignore completely this conflict of interest. Yet it is only the integrity of the individual and, by extension, of the profession than can bring an end to such exploitative practices. Recognition of the problem is an essential first step. Drug companies, health systems, and cultural barriers within unschooled societies should not be blamed for the decisions of health professionals to abandon the science of their art. Charlatanism has no place in the practice of
medicine. The poor do not need it, and the profession cannot afford it. Let us leave the rabbits in the hat. Even in the least developed countries, we have the knowledge and the tools to do better.
REFERENCES 1. World Health Organisation. The rational use of drugs in the management of acute diarrhea in children. Geneva: World Health Organisation, 1990.
2. Barros
FC, Vaughan JP, Victoria CG, Huttly SRA. Epidemic of
caesarean
sections in Brazil. Lancet 1991; 338: 167-69.
J-M. Why do people like medicines? A perspective from Africa. Lancet 1985; i: 210-11. Chetley A. A healthy business? World health and the pharmaceutical industry. London: Zed Books, 1990.
3. Michel 4.
BOOKSHELF Neonatal Nutrition and Metabolism Edited by William W. Hay Jr. St Louis: 1991. Pp 558. 69.95. ISBN 0-815142153.
Mosby YearBook.
The availability of surfactant in commercial quantities for the management of hyaline membrane disease means that face the we disconcerting prospect of mass of underemployment neonatologists. Fortunately, a novel area of interest and importance has been discovered, just in time to avert this distressing vision of the future-nutrition. In 1989, when I reviewed neonatal publications cited in Medline, papers on pulmonary and cerebral disease outnumbered those on nutrition by a factor of 18. But it is increasingly recognised that early nutritional management has a crucial effect on long-terrn outcomes, and that nutrition is also relevant to pathology in neonatologists’ favourite organs, the lungs and brain. Publication of a book devoted to nutritional matters in neonates is thus most welcome. Hay has collected a distinguished group of authors, mainly from North America, to contribute to what is likely to become regarded as a classic. His book is strong on relevant basic science, and is divided into four parts dealing with growth and development, the role of specific nutrients, feeding, and the place of nutritional management in specific neonatal disorders. It is difficult to fault the content, which is comprehensive and sufficiently detailed to provide specific advice about topics such as breastfeeding. It is a sign of the pace of development in neonatal nutrition, rather than a criticism of the book, that several recent and potentially far-reaching observations are either not included or only briefly alluded to. The role of feed type in determining the incidence of necrotising enterocolitis and neurodevelopmental outcome is one such example (one wonders how long it will be before non-breastfed children will be suing their mothers over lost IQ points); the relation between bronchopulmonary dysplasia, parenteral lipid administration, and vitamin A deficiency is another. The extent to which neonatologists are prepared to use the gut when feeding sick low-birthweight infants varies considerably, perhaps a reflection of the lack of solid clinical trial data, and readers should not be too disappointed to find an absence of didactic advice on this important point. Indeed this topic, like several others in neonatal nutrition,
greatly benefit from replacement of dogma by empiricism; with more stimulation from books such as this, would
the show should run and run. Institute of Child Health, University of Birmingham, Birmingham B16SET, UK
IAN BOOTH
Healthy Cities Edited by John Ashton. Buckingham: Open University Press. 1991. Pp 235. D4.99. ISBN 0-335094767.
Can a city be a healthy place to live? Residents of eight Basque cities said yes, and their requirements in order of priority were freedom from pollution, especially water, air, and noise; public areas for leisure; improved public transport; and consideration given to their wishes. Are these aims achievable, indeed compatible? The healthy cities movement believes they are, and its guru John Ashton sets out the agenda with the help of 33 international colleagues (half of them women, which makes a change) in what is likely to become the handbook (Bible?) of the movement. Does their agenda convince? To the sceptic, no change is yet visible in cities such as Liverpool and Sheffield, where cars dominate the scene, unemployment spirals up, and urban decay is clearly in evidence-which may indicate that the powers of a city to change itself are limited in the absence of political motivation and a sympathetic government. But there are some hopeful signs in this book which is, after all, written only 5 years after the WHO took up the concept of healthy cities. The first third of the book is about the philosophy (intersectoral working, a community diagnosis, and effective links with local communities are the core) and is inevitably repetitious. Len Duhl’s thoughtful chapter Healthy Cities: Myth or Reality is full of insights into the strengths and weaknesses of the ideal. He points to the lack of political skills of health workers, the dearth of "social entrepreneurs" who will work in the large policy arena of local government (those who do may not share our values), and of the bum-out which results from multiple inconclusive meetings. Duhl
describes the need for information systems and the success of small-scale local programmes but does not mention the powerful vested interests (fast food, cigarette companies,
