In this months Bulletin

Exceptional training for unexceptional diseases

Physicians in many countries are trained almost exclusively in a hospital setting, where the severer or less common illnesses predominate. The result, as Guiscafré et al. (pp. 434441) point out with respect to Mexico, is that most physicians receive very little training in treating extremely common childhood diseases like acute respiratory infection (ARI) and acute diarrhoea (AD). The authors describe the activities of a clinical training centre set up in a hospital outpatient ward in Tlaxcalathe state with the highest infant mortality rate in Mexico  to remedy this lack. In the centres first four years, consultations for ARI and AD in the area increased by nearly 477% and 134%, respectively; 85% of the 350 government physicians and 45% of the 90 private physicians in the area were trained in the recognition and management of ARI and AD; under-one-year-old mortality from these diseases fell by 3646%; and 11 clinical research projects were undertaken by physicians trained at the centre. Enough to confound the initial reluctance of health authorities to support the centres creation.

Kids, culture and violent thoughts

Moral disengagement has been described as a process through which people can inflict suffering on others with a clear conscience. McAlister et al. (pp. 382387) describe a pilot study on cultural differences in moral disengagement. The study involved 3122 students aged 13 18 years resident in the USA and in four European countries  Estonia, Finland, Romania and the Russian Federation  who were asked to rate their agreement with statements relating to moral disengagement and justification of violence. Significantly greater proportions of US students than European students believed that war is necessary (20% vs 9%), that a person has a right to kill to defend property (54% vs 17%) and that physical punishment is necessary for children (27% vs 17%). The study is part of a larger ongoing project designed to help young people understand and resist moral disengagement.

Keeping pathogens out of food

Of the nearly 2 million deaths in children each year from diarrhoeal diseases, up to 70% are believed to be caused by food contamination. Ehiri et al. (pp. 423433) analysed food at different stages of handling in 120 homes in Imo State, Nigeria, where an extremely high child mortality rate coincides with a high frequency of diarrhoea in 424-month-old children. Using the Hazard Analysis Critical Control Point (HACCP) approach, they identified a number of points where food could be contaminated between purchasing and processing: storage at room temperature, reheating at too low temperatures, adding potentially contaminated ingredients after heating of food, and use of raw foodstuffs purchased from street vendors. These findings, the authors hope, could be used to make food handling safer in high-risk communities.

Cheaper kala-azar treatment does the job

For more than half a century, sodium stibogluconate (brand name, Pentostamt) has been the only medicine recommended for the treatment of visceral leishmaniasis (kala-azar) in English-speaking East Africa. Costing more than US$165 for a full course of treatment for one patient, however, the drug has remained beyond reach of most local health authorities and patients. Moore et al. (pp. 388393) report the results of what they believe is the first study in Africa to compare Pentostamt with a generic form of the drug, sodium antimony gluconate, that costs less than US$ 11 per patient. The study, involving 102 patients, showed the generic drug to be comparable in safety and shortterm efficacy to the commercial version. This finding, added to those of Asian studies in which the generic drug attained efficacy rates of over 90%, should please health authorities in East Africa, the authors suggest.

Better malaria management with pre-packaged drugs

In tropical Africa, poor management of drug treatment is one cause of escalating malaria costs. Yeboah-Antwi et al. (pp. 394399) describe a study conducted in Ghana on a possible solution. The study found that over a period of 20 weeks after switching to the dispensing of pre-packaged chloroquine tablets, three districts recorded total malaria costs and average patient waiting time 50% below, and patient compliance 20% above, levels recorded in three control districts that had stayed with the traditional individually dispensed tablets. In addition, pre-packaging of drugs facilitated staff management of drug supplies. An inexpensive, simple and therefore sustainable solution, if ever there was one, say the authors.

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