1310

cancer. However, a considerable educational effort will be requiredto change medical behaviour in this sphere.1. Brahams D. The right to know in Japan. Lancet 1989; ii: 1732. Jospeh J. Cancer diagnosis "can stay secret". Times Nov 2, 1990.3. Kimura R. Bioethical and socio-legal aspects of the elderly in Japan. law in East and

West. Tokyo: Waseda University Press, 1988.

Fowler and the public health

In 1854 Dr John Snow, having satisfied himself that an outbreak ofcholera in London was due to faecal contamination of a water

supply, suggested removal of the handle from a pump in BroadStreet, Soho. This was done, and the outbreak came to an end

(sceptics said that the epidemic was already decliningat the time). The Broad Street Pump has come tosymbolise the efficacy of simple public healthmeasures based on good epidemiology. Since theAcheson Report,’ public health has undergone arenaissance in the UK, and on Nov 13 Sir DonaldAcheson, Chief Medical Officer at the Departmentof Health, saluted Sir Norman Fowler (formerSecretary of State for Social Services) for his

perspicacity in establishing the inquiry that gave riseto the report. Presenting Sir Norman with a small

model of the Broad Street Pump (as it might have been), Sir Donaldalso paid tribute to his courage in transmitting to 23 millionhouseholds a plain-language message about the avoidance of HIVinfection.

1. Committee of Inquiry into the Future Development of the Public Health Function.Public health in England London: HM Stationery Office, 1988.

Immunising against povertyThe World Health Organisation (WHO) has recently announcedplans to expand their programme for vaccine development that will,it is claimed, prevent 8 million deaths per year (see Lancet, Oct 6,p 870). These claims are at best misleading and at worst false,according to Dr John Seaman, a senior medical officer at Save theChildren Fund. In a BBC Antenna television documentary onimmunising against poverty, he described how the funding bysupranational organisations of immunisation programmes fails toaddress fundamental issues in health care in the developing world(see Lancet Oct 13, p 936). With Uganda as his example, Dr Seamandrew a distinction between disease and poverty. With developingcountries often acutely short of money because of falling crop prices,poverty has been exacerbated, with the health care system leftcrumbling.Only one-third of all childhood deaths will be prevented by

immunisation against tuberculosis, diphtheria, polio, pertussis,tetanus, and measles, and this proportion depends on a 90% uptakeof all vaccines. However, only 45% of the population of manyregions of Uganda have been immunised despite 2 years of intenseeffort. An especial difficulty is the geographical isolation of manycommunities with poor facilities for vaccine storage-solar fridgeshave been supplied to some areas but considerable logistical backupis required to ensure adequate maintenance. Dr Seaman claimedthat vaccination figures cited are unrealistically high becauserecords are often falsified and vaccines are thrown away-there is noproper audit of immunisation schemes. Diarrhoea, respiratory tractinfections, and malaria kill more children than diseases targeted byvaccines, but little has been done to improve the social andsanitation conditions that are responsible for these endemicillnesses. Many hospitals do not even have antibiotics and

analgesics--one hospital visited by Dr Seaman had onlychlorpromazine in its makeshift pharmacy. Dr Seaman also

suggested that money spent on growth chart recording, for

example, could be better directed to transport and simple medicalfacilities. Interviews with health workers awash with vaccinesrevealed their frustration at being unable to provide basic primarycare-the film showed rusty and dirty metal tables that womendelivered their babies on in a derelict labour ward. Despiteambitious promises,! there is no evidence in the field to suggest thatthese derisory facilities will be improved upon in the near future.

Dr Seaman read from a UNICEF report that "vaccines maycome to be seen as one of the greatest human investments evermade". This statement belies the realities of life in the developingworld. It is thus timely that UNICEF has chosen to focus onpoverty in the next decade (see p 1309).

1. Belsey M. Maternal health strategies to the year 2000. In: Bullough CHW, LennoxCE, Lawson JB, eds. Maternity care in developing countries. London: RoyalCollege of Obstetricians and Gynaecologists, 1990: 23-25.

In England Now

"Thought for the week" declared the Very Senior Partner. "Yourtask is to devise a name for the practice’s new information leaflet.Cardinal points: focus attention, spotlight interesting items, presentthem with an aperitif, put things in perspective. First impressionsare important-the accent is on novelty." The targets of hisoutburst gave him a sideways look. The VSP likes presentingcomplex concepts in capsule form. The scope of this challenge,which was plain for all to see, rapidly became one of the talkingpoints over the teacups, but by Friday little progress had been made.Despite his avant-garde style, the VSP is a significant form withinthe organisation and his insight in such matters is legendary. Hepoked his head round the door. "I’ll make a spotcheck later thisafternoon; answers on a postcard by Monday." The outlook for theweekend is rain and wind-you’ll have plenty of time. The newestrecruit to the practice looked dismayed: "Is this a foretaste of life tocome-compiling lists?". The eloquent lights of the chandeliertwinkled encouragingly; as a forerunner of the weekend’s work thedusty thesaurus was taken down off the shelf. There’s alwayssomeone who starts at the back-"zeotrope, verisimilitudes,vanguard", he intoned. And another who gets stuck in a certainsection—"forepiece, forerunners, forethoughts, fore..., no perhapsnot". Monday dawned, dispatch boxes flew open to reveal the fruitsof the weekend’s labours. The VSP, overwhelmed with his team’singenuity, disappeared to his consulting room to peruse the results.The door being slightly ajar he was heard to say "Conjectures andrefutations, dialectical digest-too stuffy. Scanners, trailers-sounds like a mobile public health campaign. Notanda..." As anerstwhile Latin scholar himself he had found a kindred spirit."Matters arising, platform, fulcrum, bulletin, gazette-unoriginal.But what’s this? Paracetamol capsules, nuggets (chicken), pinenutkernels, vanilla and almond extracts, briefs." The wise old headpopped round the door again: "Has anyone lost a shopping list?"

International Diary1990

An international symposium entitled Recent Trends in Nutrition is to takeplace m New Delhi on Dec 5-6: Nutrition Foundation of India, B-37Gulmohar Park, New Delhi 110 049, India.

1991

1 st international conference on Ultrasound in Obstetrics and

Gynaecology is to be held m London on Jan 7-10: Meeting PomtConferences Ltd, 42 Upper Richmond Road West, London SW14 8DD

(081-876 0102).

A meeting entitled Practical Issues in Breast Cancer Screening is totake place in London on Thursday, Jan 17: British Institute of Radiology, 36Portland Place, London WIN 4AT, UK (071-580 4085).

A course entitled Incontinence in the 90s-A MultidisciplinaryApproach to Management will be held in New Orleans on Jan 25-26:Kathleen T Melancon, Tulane Medical Center, Office of ContinuingEducanon, 1430 Tulane Avenue, New Orleans, Louisiana 70112, USA(504-588 5466).

4th international congress on Endovascular Therapies in VascularDisease will take place in Arizona on Feb 10-14: Erika Scott, CongressCoordinator, International Congress IV, PO Box 10 000, Phoenix, Arizona85064, USA (602-266 2200).

15th conference on the Nepal Medical Association is to be held in Nepalon Feb 13-16: Dr R. N. Sinha, 15th All Nepal Medical Conference, PO BoxNo 185, Biratnagar, Nepal, India.