NUMBER 108, AUGUST 1999
HAI News reports on the developments in the international campaign for more rational and fairer health and drug policies worldwide. The communication tool of Health Action international, an informal network of non-governmental organisations and individuals committed to striving for "health for all now", this newsletter also carries material supportive of the participants' work.
Cover story: HRT and Older Women in India
HRT and Older Women in India
by Lyla Bavadam
Introduction
Hormone replacement therapy or HRT is one of the treatments offered by medicine for the physical and psychological ailments of menopausal women. HRT is a clinical alternative offered by doctors to women whose oestrogen levels are either very low or non-existent; a process that happens either because of natural or surgical menopause. HRT replaces the body's decreasing oestrogen and can often provide relief for many symptoms. Used over a long period of time, HRT is also believed to act as a preventive against some diseases.
There are two categories of usage recommended for HRT. One is short-term use for relief of symptoms caused by lowered oestrogen. The effectiveness and validity of short-term HRT therapy is not generally disputed. It is the long-term use of HRT treatment that gives rise to debate. The long-term therapy can extend for a period of five to ten years or even be lifelong. Physicians recommend long-term use of HRT as part of preventive care for older women against diseases like osteoporosis, heart disease and Alzheimer's disease. The therapy does have its side effects as well as strong contraindications for use.
HRT and the Indian scene
HRT is not commonly prescribed in India for two reasons. One is the expense and the other is a mindset that argues against interfering with a natural stage. Before discussing HRT, it must be noted that this therapy in India is almost exclusively in the domain of private medical practice. Even within this, it is estimated that only about one percent of post-menopausal urban women is on HRT. Nevertheless, there is a growing tendency in India to medicalise menopause. This tendency is attributed to three reasons:
A growing area of concern among health activists is the promotion of HRT by corporate medical giants who are trying to medicalise menopause. Examples of corporate influenced research on HRT are well documented in the west. In an article discussing the controversies of HRT, Drs Motashaw and Dave quote a US study which states that by the year 2005 there will be 25.3 million women between the ages of 50-64 in the USA who would be potentially eligible for HRT. The estimated cost of treating these women, considering only drug cost and monitoring, would be US$5 billion.
There are indications that HRT manufacturers are interested in the Indian market. In a paper entitled `The Menopause and HRT: Growing Public Health Challenges' Dr Rashmi Shah stated, "76 percent of the world's post menopausal women will be in developing countries." Indian activists express the fear that western corporations are showing an interest in the growing youth consciousness of Indian women. So far, HRT advertising (a fairly accurate indicator of an industry's interest in a market) in India has been restricted to medical journals.
Short-term HRT has a higher acceptance and compliance from Indian women. Short-term use has been found to be effective in cases of burning sensation while urinating, hot flashes, vaginal dryness, incontinence, insomnia, dizziness; collectively known as vasomotor symptoms that appear and disappear in the early stages of menopause. The cheapest tablet available in India is Estriol. The cost of a 2mg tablet is Rs 3. The usual dosage is two tablets per day and the course is for three months. Thus per course the user spends Rs 540. Success is usually assured but often the course needs to be repeated frequently over a period of two years. The latest HRT prescription, a pill called Infar, is more convenient to use since it has to be taken only once a day. Its drawback so far is that one month's treatment costs Rs 1000; that works out to more than Rs 30 per pill - well beyond the reach of the average Indian woman.
Views on HRT
A study of 500 women undertaken by the Institute for Research in Reproduction (IRR), India showed that only 40.1 percent agreed to take short-term therapy for up to one year. With regard to long-term therapy for more than five years, 67.8 percent refused the HRT. Among the common reasons for refusal were nuisance of vaginal bleeding and a feeling that menopause was a natural occurrence and needed no treatment. Lack of awareness was also a reason for low usage. Of the 156 women who agreed to use it on a long-term basis, 55.1 percent were willing to take it provided the per month cost was between Rs 50-100 (current costs are in the range of Rs 200 per month).
No blanket ban or approval can be given to HRT. Just as there are definite indications for its prescription there are also definite contraindications for its usage. Two points of view are as follows:
Supporting HRT is an 83-year-old gynaecologist who chose HRT for herself. In fact she is probably the oldest HRT user in the country having been on the treatment for more than 30 years. She reports absolutely no negative effects from her two pills per day dosage. Her son, also a gynaecologist, explains why she started HRT when most women of her generation would normally have ignored the idea of medication for menopause. "She'd had a hysterectomy, she had a crack in her femur, she is a Parsi [a community that is supposed to have the second highest rate in the world for osteoporosis after the Jews], she's fair [another predisposing factor for osteoporosis]... she's classical osteoporosis," he says. Requesting anonymity, the 83-year-old recalls the days when physicians ignored menopause: "The earlier response of doctors was to dismiss symptoms like hot flashes as psychological. There was no acceptance of the possibility of it being a physiological reaction. They used to say the woman was hysterical and gave her sedatives. It's a very sensible change now to give hormones instead of sedatives. I believe every woman should be on it. It is happiness for themselves."
Dr Rani Bang, gynaecologist and co-founder of the non-government organisation SEARCH (Society for Education, Action & Research in Community Health) in India objects to the tendency among doctors to promote HRT without there being substantial studies to prove its long-term effects. Bang says, "Doctors presently treat HRT as some sort of miracle medicine. It is frightening." She recalls an incident where she took an elderly relative to a gynaecologist who, without ascertaining the patient's history instantly advised HRT. Again, the prescription was based entirely on the patient's age and the fact that she was feeling a bit depressed. In Bang's case the prescription could have had disastrous implications since her relative was being treated for cervical cancer as well. Bang had to intervene and tell the prescribing doctor of the patient's pre-existing condition.
While researching this topic, the writer witnessed another appalling incident. It occurred in a small suburban clinic in Mumbai. The patient was a 49-year-old woman who complained of constant body ache, headaches, depression, loneliness and a general feeling of being useless. She said she had not menstruated for over a year. The doctor, who had no previous case history of the woman, merely asked her age and then prescribed Estriol, a low dose HRT. He told her she could take it for the rest of her life. He did this without inquiring into her medical antecedents. Nor did he advocate constant medical monitoring or tell her about possible side effects.
Older women and health programmes
Older women in India are a medically marginalised group, an outcome of earlier thinking that linked family planning with women's health. As a result of this thinking, health programmes for women in India are almost purely designed and targeted towards reproductive health. The mindset is so deeply ingrained that for policy makers, the two issues are inextricable. The medically deprived status of older women who have reached menopause is a continuance of this line of thought with policy makers believing that once a woman's reproductive years are over she no longer needs any specific programmes.
In India, the two main government bodies responsible for the public health care system, the Ministry of Health and the Directorate of Health, have no current health programme that caters to the specific reproductive health needs of ageing women. There is no intention of starting any such programme. It is also interesting to note that the Reproductive and Child Health (RCH) programme of the government which is meant to comprehensively cover health aspects of women and children only addresses women who are in their reproductively fertile age. It does not provide for the health issues of women who have passed the reproductive stage. An important document in this field, the Introductory Report to the National Family Health Survey, does not even mention menopause as an issue.
The predicament that faces older women is best summed up by a comment by Dr Ashok Kumar, deputy commissioner at the Department of Family Welfare in Delhi who says "after a woman has passed childbearing stage she becomes the responsibility of the primary health care programme. I agree that in reality she has very specific health care needs and the primary health care system is really very primary [basic] in what it offers."
One of the reasons that had contributed to this lacunae in policy was the low average life span of the Indian woman who did not live long enough after menopause for ailments related to her reproductive systems to manifest themselves. According to the Statistical Outline of India, the average Indian lifespan in 1957 was 34 years. The current life span is drastically higher with women living to an average of 61 years - this means that women will live approximately a quarter to one third of their lives in a post-menopause stage. Statisticians say that life spans are growing.
Currently, men and women in India in the 60 plus age group number about 60 million; that's about six percent of the population. Projections for the year 2025 show that this is expected to increase to approximately 165 million. Thus, in the space of 30 years the ageing population is expected to increase to the extent where more than 12 percent of the population will be age 60 or older. Judging by current gender proportions about half of this population will be women. The question then is how will this increasing age group be looked after. With the breakdown of traditional social structures, it is even more vital that the government recognises and implements its role as care givers for menopausal women.
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Lyla Bavadam is the recipient of the Panos Reproductive Health Media Fellowship for her research topic on 'Menopause in the Indian context'.
International
Holistic Approach to Herbal Medicines
In an era of molecular biology, genetic engineering and an annual global pharmaceutical market of over US$300 billion, herbal medicines serve the health care needs of eighty percent of the world's population. Dr K. Balasubramaniam, ARDA coordinator, presented a paper on Herbal Medicines: A Holistic Approach at the 2nd International Workshop on Herbal Medicines in the Caribbean. This workshop was held from the 14th - 16th June at St. Croix, US Virgin Islands. The paper advocated consumers' concerns on herbal medicines, which are:
- Ensuring the availability, accessibility and affordability of safe and effective herbal medicines of good quality to all those who need them now and in the long-term future.
- Regulating the manufacture, promotion, sales and use of herbal medicines to ensure the safety of consumers.
- Defining the place of herbal medicines in primary health care.
- Searching for new medicines among the many medicinal plants that are yet untapped.
- Looking for, protecting and preserving endangered plant species.
- Conserving biological diversity; and
- Searching, protecting and preserving indigenous cultures which are the repositories of the knowledge of medicinal plants.
With there being a growing demand on herbal medicines from consumers in developed countries, the multinational drug industry in the North is showing renewed and heightened interest in the South's medicinal plants. This lethal combination of increased consumer demand and renewed industry interest combined with a lack of national legislation has resulted in 'slaughter harvesting' of medicinal plants and massive depletion of bio-diversity.
Since 1970, the world's forests have declined from 4.4 sq. miles per 1,000 people to 2.8. The conflagration of tropical rain forest threaten not only countless species of valuable medicinal plants, but also the indigenous cultures and individuals who know their properties and use them in their daily lives.
Alarm bells have been sounded by inter-governmental and international agencies over the last two decades to raise global awareness on the loss of biological diversity. Health professionals have raised serious concerns on the lack of regulatory control of herbal medicines, nutraceuticals and dietary supplements.
Copies of the paper are available from the ARDA / Health and Pharmaceuticals Programme, CI ROAP, 250A Jalan Air Itam, 10830 Penang, Malaysia. Email: ardaroap@tm.net.my (41/99)
Africa
HAI Africa's work in West Africa
The Pharmaceutical Programme of World Council of Churches/Community Initiatives Support Services (WCC/CISS), in co-operation with MAP International West Africa, Essential Drugs and other Medicines (EDM) - WHO and other programme partners, held its first workshop to raise awareness on the essential drugs concept (EDC) and rational use of drugs (RDU) in Francophone Africa. The meeting was held from 22-29 May in Abidjan, Côte d'Ivoire. Participants included health professionals, mainly doctors and pharmacists working in church health institutions, from 12 countries in the region.
This initial meeting, deemed highly successful and motivating by all who attended, helped the Pharmaceutical Programme intensify its activities in Francophone Africa, facilitated the identification of partners in West Africa and created a resource pool of French-speaking facilitators conversant in EDC/RDU work and issues. It also provided an opportunity for the Pharmaceutical Programme, a key participant in the HAI Africa network, to include HAI Africa colleagues in one of its activities. This promoted the sharing of information and building contacts between church-based partners in the Pharmaceutical Programme and the HAI Africa network.
Participants discussed the importance of setting up of regional/national joint drug procurement units (JPUs), as well as training on drug management and prescribing. They realised the benefits of JPUs, especially in negotiating for lower drug prices, ensuring steady drug supplies and in coordinating training activities.
In discussing drug donations, participants identified the same problems that have been identified elsewhere in Africa and around the world, e.g., inappropriate medicines, expired products, and inadequate labelling. Stronger collaboration among different partners in Francophone Africa is needed to disseminate important information about drug donations. Notably, copies of the 1996 inter-agency Guidelines for Drug Donations, published by WHO, had not reached many of the participants.
One of the presentations focused on the very large number of drugs that are available on the informal (parallel) market. These medicines, which may be ineffective, inappropriate or even dangerous, are usually sold by men and women who do not have adequate knowledge and training. To combat this informal market, consumers must have more and better drug information and consumer education. Governments also have to be willing and able to regulate the supply and sale of pharmaceutical products in their countries.
Participants decided to form a formal network to share information and carry out joint activities, e.g., training. At the country level, plans were drawn for the creation of national networks for information dissemination. To help ensure the successful growth of this network, all of the participants were encouraged to keep in touch with the new contacts they had made during the meeting.
The workshop report in French will be available from the Pharmaceutical Programme office in Nairobi. Please contact Dr. Eva Ombaka, WCC/CISS Pharmaceutical Programme, PO Box 73860, Nairobi, Kenya; Telephone: 254 2 444.832 or 445.020; Fax: 440.306; or e-mail: CISS@net2000ke.com.
Contributors: Elizabeth Dena - World Council of Churches/Community Initiatives Support Services and Beryl Leach, Coordinator - HAI Africa. (42/99)
Raising awareness
The devaluation of the CFA franc in early 1994 caused drug prices to increase dramatically; this has forced many consumers in Bénin to turn to cheaper medicines available in informal street markets and on the black market. ARAMBE KAFU ATA, a consumers association based in Cotonou, Bénin, estimates that informal/black market purchases of pharmaceutical drugs and over-the-counter remedies have increased 86 percent since the devaluation.
To raise governmental and consumers' awareness of the dangers of informal/black markets for medicines, ARAMBE launched an information campaign which included a seminar in Abomey-Calavi, Bénin from 27-29 April 1999 for 150 participants (police, customs agents, military, forest and water ministry and others) from Ouémé and Atlantique Provinces in Bénin. Minister of Public Health, Mrs Marina D'Almeida Massougbodji presided over the seminar.
Presentations covered the role of the police in combating fake drugs; the essential drugs concept; generics drugs and prices; and an explanation of what is a drug. Videos highlighted the dangers of skin bleaching and self-medication. Participants met in working groups to discuss and make concrete suggestions and recommendations on how to fight against the informal/black market drug selling that has taken on alarming proportions in Bénin.
Participants made the following suggestions:
- The government should be more vigilant and take more responsibility for enforcing current national laws concerning the supply and sales of pharmaceutical drugs.
- The government should use all available means to reduce illicit drug selling.
- ARAMBE should continue to provide information to consumers about the risks and complexities of pharmaceutical drugs.
- Health workers should prescribe more generic drugs.
- Information sessions should be organised in the different barracks [of enforcement agencies] in Bénin.
ARAMBE is organising another seminar with the same target group, which will be held in Parakou for participants from Borgou, Mono, Zou, Borgou and Atakora Provinces.
Bénin has a population of approximately 5.8 million (World Bank 1997), and per capita income is estimated at US$380.
For more information, please contact ARAMBE - Association pour la recherche de l' amélioration des conditions de vie au Bénin, 03 BP 2820, Cotonou, Bénin; Tel: (229) 321264; Fax: (229)306315; Email: arambekafu_ata@yahoo.com.
Contributor: Jacques Arbi Akerekoro, Executive Director, ARAMBE KAFU ATA; HAI Africa Voluntary Subregional Co-ordinator for Western Francophone Africa. (43/99)
Europe
The Netherlands
Globalisation & Access to Medicines
HAI Europe, Médecins Sans Frontières and Consumer Project on Technology will co-organise a 1½ day seminar on 25-26 November promoting improved access to medicines and on the implications of multilateral trade agreements. The conference will follow up on key issues within the Revised Drug Strategy resolution adopted at this May's World Health Assembly (see HAI News June 1999.) The conference will directly precede HAI Europe's annual meeting and will be held one week before the next Ministerial Conference of the World Trade Organization in Seattle (US) where NGOs hope to put trade and health issues high on the agenda.
Participants will include representatives of public interest, NGOs, WHO, policy-makers, members of the European Parliament, drug policy experts, health economists, academics, researchers and pharmaceutical manufacturers.
For more information about the meeting and to receive a draft programme, please contact Bas van der Heide, HAI-Europe, J. van Lennepkade 334T, 1053 NJ Amsterdam, The Netherlands. Email: info@haiweb.org Fax: (31-20) 685 5002. (44/99)
Expert seminar on drug donations
Assessing and improving current drug donation practices was the theme of a recent European symposium co-organised by HAI groups - Wemos, DIFAM and PIMED. For two days in June, experts on donations from sixty organisations in 16 countries in Europe, North America and Africa met to discuss ways of raising awareness and improving donations. Speakers described recent problems caused by donations shipped to Albania to aid Kosovo refugees and to victims of Hurricane Mitch which devastated parts of Central America. Said Mark Raijmakers, coordinator of the NGO Consortium on Appropriate Drug Donations, "Although the guidelines for drug donations have the potential to improve the quality of drug donations, major educational efforts are needed to actually implement these guidelines." The consortium has set up a new website on donations: http://www.drugdonations.org
To order a copy of the conference's proceedings or a copy of a new video on donations targeted at groups involved in donations work, please contact: Mark Raijmakers, Wemos, Postbus 1693, 1000 BR Amsterdam, The Netherlands, tel: (+31-20) 468 8388, fax: (+31-20) 468 6008 or e-mail: mark.raijmakers@wemos.nl (45/99)
WHO and sponsorship
WHO's Director-General recently responded to HAI's letter issued during the 52nd World Health Assembly which criticised WHO's increasingly close contact with the pharmaceutical industry and the lack of guidelines supervising such interactions (see HAI News, June 1999, page 12). In her response, Dr Brundtland promises that "in developing partnerships, WHO's position as an impartial holder of health values will be ensured." However, the guidelines framing WHO's work on sponsorship remain unpublished and it remains to be seen how substantial they will be in preventing conflicts of interest that may have consequences for health. Dr. Brundtland also states that HAI will receive a copy of the guidelines once they are published and circulated for review among Member States and interested parties. HAI encourages all interested parties to take part in this debate on sponsorship as the organisation develops its policy in this extremely important area.
To receive a copy of Dr. Brundtland's letter and HAI's critique, contact the HAI Europe office or visit the news page of its website http://www.haiweb.org/news/news.html
HAI also invites all interested network partners to contact the European office to receive a copy of the guidelines once they are available. (46/99)
Estonia
Regulators post "dirty laundry"
The Estonian State Agency of Medicines launched a new website page in March which aims to make public all violations of advertising regulations and incidents of unethical drug promotion. Each violation is listed according to company and the corresponding law it has broken. The site also includes a listing of drug companies that repeatedly violated the advertising regulations or used unethical practices before the launch of the web page. To view the page, go to: http://www.sam.ee/violations/violations.html
News on Europe and North America contributed by Lisa Hayes, Publications & Information Officer, HAI-Europe. (47/99)
Asia-Pacific
Pakistan
Managing childhood illnesses
The Health and Nutrition Development Society (HANDS), Karachi, implemented a study to improve the management of sick children by private practitioners in rural/peri urban communities in Karachi, Pakistan. This project was carried out with the collaboration of the Community Health Sciences, Aga Khan University and BASICS - Basic Support for Institutionalizing Child Survival, Washington.
A questionnaire was sent out to determine the knowledge about sick child management by health care providers. This was followed by a two-day workshop organised for community health workers to provide training on the standard protocols of common childhood illnesses - acute respiratory infections, fever and diarrhoeal diseases. Training materials and a guideline for quick reference were developed for health care providers.
Through a combination of interventions for five months and introduction of health care providers to the WHO case management guidelines, significant improvements were seen in the health care providers management practices for fever, acute respiratory infection and diarrhoea. The overall mean average in improvement in all practices was 33 percent.
Improvement in selected individual areas is given as follows:
|
Activity |
Improvement |
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Weighing children |
58.4% |
|
Fever diagnosis |
26.4% - 35.6% |
|
Fever management |
23.6% - 77.2% |
|
Acute Respiratory Infections (providing advise on cough managament) |
41.7% |
|
Diarrhoea management: Advising a soft diet Advising on ORS |
36.1% |
(48/99)
North America
USA
VP charged with opposing access to ED
The Consumer Project on Technology (CPT) has written to US Vice President Al Gore about his role in pressuring South Africa and other developing countries during their struggle to obtain access to essential medicines. The letter describes the huge impact diseases such as HIV/AIDS has had on the population and criticises current US trade policy which opposes the use of compulsory licensing and parallel importing among other measures aimed at reducing drug prices. The letter's author, James Love, director of CPT writes, "It is shocking that the US government is adapting such an aggressive trade policy on behalf of US pharmaceutical companies, when all of sub-Saharan Africa is confronted with a public health crisis of historical dimensions." (49/99)
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HAI Calendar 99 - International Society of Drug Bulletins (ISDB) International Meeting, Amsterdam, The Netherlands, 16-19 September, '99. - 3rd Planning Meeting for People's Health Assembly, Dhaka, Bangladesh, 4-7 September '99. - Workshop on Undergraduate Medical/ Pharmacy Education, Philippines, September '99. - European Drug Utilization Research Group (EURO DURG) Annual Meeting, Jerusalem, Israel, 1-3 October, '99. - International Conference on Globalisation & Access to Essential Drugs, Amsterdam, The Netherlands, 25-26 November, '99. - HAI Europe Annual Meeting, Amsterdam, The Netherlands, 26-28 November, '99. |
Children's vaccines - safety first
The World Health Organization (WHO) underlines the importance of continuing to use currently available children's vaccines.
WHO will continue recommending procurement of vaccines such as triple vaccine (DTP), diphtheria and tetanus (DT), tetanus toxoid (TT) and hepatitis B that contain thiomersal, a chemical compound containing mercury used in trace amounts as a vaccine preservative. These vaccines have been used safely throughout the world for over 60 years, helping to save many millions of children's lives.
For children in industrialised and developing countries alike, the risk of death and complications from vaccine-preventable diseases to unvaccinated children is real and enormous. "We support the continued use of current vaccines that protect the lives of millions of children each year," says Dr Michael Scholtz, WHO's Executive Director of Health Technology and Pharmaceuticals.
On 7 July 1999, the American Academy of Paediatrics and the United States Public Health Service proposed phasing out of thiomersal as a preservative. They also made a recommendation to avoid thiomersal-containing hepatitis B vaccine for certain newborns, including the screening of pregnant mothers for the blood marker of the liver infection. WHO stresses that this is not an option for developing countries due to practical constraints and the high cost. WHO promotes the development of a single-dose presentation of hepatitis B vaccine that will not require a preservative. This "uniject" device is a disposable plastic pouch-and-needle, ideal for delivering the newborn dose in developing countries. It is presently undergoing field trials. WHO will continue working with industry and national regulatory authorities to eliminate thiomersal from vaccines as soon as possible. (WHO, Note for the Press No. 18, 9 July 99) (50/99)
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QUOTE The health of nations is more important than the wealth of nations. - Will Durant |
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Health Agenda for the Millennium Speaking at the 26th annual conference of the Global Health Council in Arlington, US, Dr Gro Harlem Brundtland, Director-General, WHO, called for a redistribution of healthcare resources. More financial support should go to developing countries which shoulder 90 percent of the global disease burden but have access to only 10 percent of the health resources going to health. Dr Brundtland urged the World Bank and IMF to look at health and social indicators in countries asking for financial assistance. The WHO Director-General called on medical and health professionals to "step out of professional confinements," become more involved in politics and take an active part in shaping the health agenda. (SCRIP No. 2450, UK, June 30, 99) [Editor's Note:HAI supports the WHO Director-General's call for social justice and equity in health. This should have priority in the health agenda for the millennium.](51/99) |
International Year of Older Persons:
Active Ageing Makes the Difference
Myth: Men and women age the same way
Women and men age differently. First of all, women live longer than men. Part of women's advantage with respect to life expectancy is biological. Far from being the weaker sex they seem to be more resilient than men at all ages, but particularly during early infancy. In adult life too, women may have a biological advantage, at least until menopause, as hormones protect them from ischaemic heart disease, for example.
Currently, female life expectancy at birth ranges from just over 50 years in the least developed countries to well over 80 in many developed countries, where the typical female advantage in life expectancy ranges from five to eight years. As a result, the oldest in most parts of the world are predominantly women. However, longer lives do not necessarily translate into healthier lives and patterns of health and illness in women and men show marked differences. Women's longevity makes them more likely to suffer from the chronic diseases commonly associated with old age. We know, for instance, that women are more likely to suffer from osteoporosis, diabetes, hypertension, incontinence, and arthritis than men. By reducing mobility, chronic disabling diseases such as arthritis have an impact on the capacity to maintain social contacts and thus on the quality of life. Men are more likely to suffer from heart disease and stroke, but as women age, these diseases become the major causes of death and disability for women too. The common view that heart disease and stroke are exclusively men's problems has obscured recognition of their significance for older women's health and more research is necessary in this area. (Source: Ageing: Exploding the myths, Ageing & Health Programme, World Health Organization)
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Strong bones in later life Osteoporosis is a diseases characterised by a loss of bone mass and density and the disruption of the normal bone architecture. Although widely seen as a "an old woman's disease", osteoporosis occurs in both men and women. Early detection is important. Normally, by the time any symptoms become apparent, the disease process is already far advanced. X- rays will only detect bone loss by the time 25 - 40 percent of bone mass is already gone. Techniques of bone densitometry now allow loss of bone mass to be detected at a very early stage. These methods give reliable and accurate estimates of bone density and should be used in all individuals who possess significant risk factors if the result will influence their clinical management. Unfortunately, the worldwide availability of bone densitometry equipment is highly variable. In countries such as Argentina, Australia, Japan and Lebanon, osteoporosis experts consider the national availability of bone mineral density (BMD) equipment to be adequate for the diagnosis of osteoporosis. Clearly, however, this is a matter of opinion, and even in countries with a relatively high availability, such as the United States, some experts believe it is still inadequate for proper diagnosis. The same can be said of the less affluent nations. By January 1998, for example, there were only four dual X ray densitometers available for the entire Indian subcontinent. The most important factor, however is the provision for reimbursement of the cost of BMD measurement. National health systems, such as in Netherlands and Switzerland, provide full reimbursement, but others only permit partial reimbursement, and others none. Some countries currently reimbursing BMD measurement are planning to stop doing so to cut costs. This seems to reflect a short-sighted approach to cost cutting. Osteoporosis is a slow, chronic disease, and the detection now will yield great financial benefits by preventing osteoporotic fractures in the longer term. Excerpt from Strong bones in later life: luxury or necessity?, Pierre D. Delmas & Mary Fraser, Bulletin of the World Health Organisation, Volume 77, Number 5, 1999, p. 419. |
• Quality of Patient Information Materials
by Angela Coulter, Vikki Entwistle, David Gilbert, published by King's Fund, United Kingdom, BP16.95, pp. 216.
Pamphlets and recently, audiotapes and videos have become a usual, visible, and promoted source of information for patients in general practice, in specialist consulting rooms, and in outpatient clinics. These information aids have been produced by a wide range of organisations in response to increasing patient expectations for factual or experiential information about investigations, illness and its causes, treatment options, support services and likely outcomes. The quality, availability, acceptability, and effectiveness of information sources developed by authoritative bodies is commonly assumed.
The King's Fund, United Kingdom has now produced an excellent manual examining what information materials patients prefer and how well currently available materials meet their needs. The manual makes useful and generally applicable recommendations for the development of good quality patient information sources. The first section summarises the uses, accessibility, and content of such materials, highlighting the limited work on quality control of their content.
In the next section material for 10 common health problems was assembled for analysis - at least five examples for each health problem that met minimum criteria including reference to more than one treatment option and to treatment outcomes. Focus groups of five to nine patients with experience of the particular health problem were convened to review their information needs and the selected materials. In addition, two or more clinical or academic experts in each health area reviewed the selected materials and rated each for specific characteristics. The results of these reviews are summarised in 30 pages, and there is then an eight page chapter of recommendations. The last 150 pages contain detailed commentaries on the reviewed materials for each of the 10 health problems and a comprehensive list of references.
The book is an excellent guide to the process of development and appropriate content of patient information materials. Criteria for evaluating the quality of patient information materials are presented, and a comprehensive list of common questions asked by patients that should guide content is presented. Adopting the book's recommendations would greatly enhance the quality, value and availability of useful patient information materials.
· World Health Report 1999: Making a Difference
published by WHO, Geneva, Sw.fr.15.- (Sw.fr.10.50 for developing countries), 1999, 121 pp.
The report explains how lessons learned from past successes and failures can guide a more targeted and pragmatic approach to current and emerging health challenges. Part one of the report reviews the decline in mortality in the 20th century. Nevertheless, while there has been remarkable progress in health standards, over a billion people have not shared in these health gains. The threat posed by infectious diseases is being accompanied by the growing prominence of non-communicable diseases. Relatively inexpensive tools for dealing with these problems are illustrated in this section.
Part two deals with three specific approaches for improvement in health standards. Selected experiences are drawn together in advocating a 'new universalism' as a framework for guiding health system development to meet future challenges. The report also focuses on WHO's Roll Back Malaria project and Tobacco Free Initiative, and indicates how timely action can make a difference.
Available from: World Health Organization, 1211 Geneva 27, Switzerland.
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Quotable Quotes Retail Drug Prices: The Law of the Jungle Health Action International's comment that "drug pricing resembles the law of the jungle where might is right", is one of the many "quotes of the year" in SCRIP's Review of 1998. This is supported by some other quotes describing the pharmaceutical marketplace. "Hand to hand combat" was how COR Therapeutics president and CEO, Vaugh Kailan described its competition with Merck & Co in the antiplatelet market. Jack Key of the Canadian Drug Manufacturers' Association warned it was "ready to take the gloves off to fight the federal government on its proposed changes to Canada's patent law". Gordon Johnston, deputy director of the US FDA's office of Generic Drugs, described Andrax's market exclusivity case against FDA and two other generic companies, Biovial and Faulding as, "mother of all suits". While few women would agree with the statement by Dr William Dere, Lilly's director of endocrine research, that "a premenopausal rat cannot be considered a relevant model for a premenopausal woman", many people would take issue with IFPMA director-general, Harvey Bale who asked: "What is the difference between public health and commercial interests? There isn't any." (SCRIP magazine, UK, Feb 99) |
HAI News Editors: Kiran Sagoo and Dr. K. Bala
Production: Lin Min Min
HAI News is produced six times a year by the Regional Office for Asia and the Pacific of Consumers International (CI). For more information about the publication or to subscribe, contact HAI-Asia.