Monetary incentives and community-directed health programmes in some less-developed countries Sir—New campaigns on communitybased treatment or control measures are being launched against several major endemic diseases in less-developed tropical countries. Most campaigns are being sponsored by the World Bank and executed by the WHO, in partnership with ministries of health in the affected countries, major pharmaceutical companies, national and international donor agencies, and non-governmental development agencies. Among these campaigns are the African Programme for Onchocerciasis Control, the Global Programme for the Elimination of Lymphatic Filariasis, the Roll Back Malaria Programme, the Leprosy Elimination Programme, and other programmes to control schistosomiasis and tuberculosis, and to promote reproductive health. We have played an active part in the African Programme for Onchocerciasis Control since its inception in 1995. In essence, all these programmes are increasingly relying on community participation, control, and direction in the execution of the treatment or control measures concerned. For a programme to be successful, a sense of community ownership must be instilled from the beginning. The provision of monetary incentives (usually provided by external donors or national government health sources) is thought to motivate individual community members to treat their communities. However, our experience in programmes of community-directed ivermectin annual treatment for the control of onchocerciasis in Uganda over the past 7 years, has shown this belief to be a fallacy.1,2 In districts of Uganda where the community-directed distributors (CDDs) of ivermectin were given monetary incentives by the district health services, the communities failed to achieve the desired coverage of 90% of their annual treatment objective. We found that CDDs who received externally derived incentives were continually seeking increased remuneration with the threat of withholding their services. In addition, CDDs were not accountable to the community leaders, but identified themselves as agents of external donors or of government departments, thus alienating themselves from the community.3,4
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By contrast in districts where the responsibility for remuneration of CDDs was left to community members, the required 90% coverage rate was generally achieved. The CDDs were selected so that most treatment centres were conveniently located near the community that they were intended to serve. The numbers of people treated per CDD rose, with annual treatment being completed more quickly. Since CDDs were relatives or neighbours, they were interested in providing a community service rather than profiting financially from the exercise. CDDs were provided the necessary facilities to carry out their duties. For example, the community provided the CDD with a bicycle and food while he or she went to collect the ivermectin from the nearest designated centre and, if the need arose, community members would provide free labour in the CDD’s home or farm to make up for the loss of time spent on distribution activities. The use of subtle and unwritten social legal codes in a community is essential to the design of an effective communitybased health programme, and mobilisation of these systems must be from within the community. Unsatisfactory programmes result from ignorance and distortion of the local social support systems that should be the engines for social development.4,5 Our experience may be helpful to others charged with designing new community-directed programmes of this nature, especially in rural areas. *Moses Katabarwa, Dominic Mutabazi, Frank O Richards Jr Carter Centre, Global 2000 River Blindness Programme, PO Box 12027, Kampala, Uganda (e-mail:
[email protected]) 1
Katabarwa M, Mutabazi D. The selection and validation of indicators for monitoring progress towards self-sustainment in Community-Directed Ivermectin Treatment Programmes (CDITP) for onchocerciasis control in Uganda. Ann Trop Med Parasitol 1998; 92: 859–68. 2 Katabarwa M, Mutabazi D, Richards F Jr. The community-directed ivermectin treatment programmes for onchocerciasis control from 1993–1997 in Uganda: an evaluative study. Ann Trop Med Parasitol (in press). 3 Katabarwa M. Modern health services versus traditional ENGOZI system in Uganda. Lancet 1999; 354: 343. 4 Keesing RM, Strathern AJ. Cultural anthropology: a contemporary perspective (3rd edn). Orlando, Florida: Harcourt Brace College Publishers, 1998: p 288–301. 5 Mutabazi D, Duke BOL. Onchocerciasis control in Uganda: how can self-sustaining, community-based treatment with ivermectin be achieved? Ann Trop Med Parasitol 1998; 92: 195–203.
Diagnosis and frequency of brain death Sir—The diagnosis of death has been debated for centuries. 1 Finland was the first country in which the notion of brain death was legally accepted, alongside the traditional idea of death caused by cessation of cardiorespiratory functioning. The diagnostic criteria for establishing brain death were published by the Finnish National Board of Health in 1971. The corresponding criteria are used in over 30 countries, but there are few reports on the frequency of diagnosis of brain death and its impact on clinical practice, and especially, on the removal of organs for transplantation.2 In one report from the Meilahti University Hospital in Helsinki 37 cases of brain death were recorded during 4 years. Organs were procured in only ten cases (27%) of this series. 3 In a new study covering the same hospital in 1996, brain death was diagnosed 85 times—ie, in 11% of all deaths. Organs were removed from 27 (32%) of the brain dead patients, which is somewhat higher than that of 20 years earlier. The practice of reporting the cause of nonprocurement varied widely, and in one hospital no cause was reported in almost 40% of brain death cases. Organ removal was refused nine times, in seven cases by family members. Despite almost 30 years of nationwide clinical practice, there is no uniform method to record the diagnosis of brain death in patients. The Finnish National Board of Medicolegal Affairs has prepared updated instructions on diagnosis of death, and brain death in particular. These instructions stipulate that the diagnosis of brain death should always be recorded in a patient journal. Brain death should be given the ICD (International Statistical Classification of Diseases and Related health Problems) code of 93·90. The code should not be used, however, as the principal diagnosis or as the basic cause of death in the death certificate. This new practice may improve the follow-up of diagnosing brain death in hospitals and lead to increased procurement of organs for transplantation. *Jorma Palo, Susanna Viitala Department of Neurology, University of Helsinki, PO Box 300, 00029 Helsinki, Finland (e-mail: Jorma.
[email protected])
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Powner DJ, Ackerman BM, Grenvik A. Medical diagnosis of death in adults: historical contributions to current controversies. Lancet 1996; 348: 1219–23. Birkeland SA, Christensen AK, Kosteljanetz M, et al. Rise in organ donations. Lancet 1997; 350: 1558.
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Kaste M, Hillbom M, Palo J. Diagnosis and management of brain death. BMJ 1979; 1: 525–27.
Eradication of poliomyelitis Sir—T Jacob John’s (Sept 4, p 869)1 concern that poliomyelitis eradication might damage primary health care systems, particularly routine immunisation, has been shared by WHO since the inception of the initiative. In 1988, the World Health Assembly directed WHO to eradicate polio in a way that would support primary health care. Effective routine immunisation is valued both for its effect in protecting children’s health and for its role as the foundation for polio eradication. Accordingly, substantial resources to improve cold chain and to provide training to strengthen immunisation services have been mobilised through the polio eradication initiative in many countries, particularly in Africa and Asia.2 In India, for example, the eradication initiative has highlighted serious deficiencies in the routine immunisation system, particularly in the populous northern states where polio cases are concentrated.3 As a result, the Indian Ministry of Health and Family Welfare has mobilised support for routine immunisation including urgent repair and replacement of malfunctioning cold chain equipment. State and local level immunisation committees have been formed in the critical states of Bihar and Uttar Pradesh to address both funding and technical issues. Although polio eradication is only one of the many factors in effectiveness of health systems, national data have shown that routine immunisation coverage can improve as polio eradication activities are implemented. Cambodia is one clear example, where immunisation coverage for measles and diphtheria tetanus pertussis vaccines rose from 35% to 70% in measles, and from 37% to 68% in DTP from 1993 to 1997. 1997 was the year of the last polio case in Cambodia. Similarly, between 1995 and 1998, measles vaccine coverage increased in Nepal from 71% to 89%. Independent coverage surveys from India document that the measles vaccination coverage rose from 5% to 22% in Bihar, and from 24% to 39% in Uttar Pradesh between 1992 and 1997. The positive impact of polio eradication activities on several aspects of primary health care, including improved routine immunisation coverage and progress in disease surveillance, is clearly documented
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in the Philippines. 4 The most comprehensive study of the broad effect of polio eradication on primary health care showed that the effects of polio eradication were largely positive.5 With support from USAID and Danida, WHO examining the effect of polio eradication on health systems. The full report will be published early next year. One impact of this initiative is that vitamin A supplements are now given to children during national immunisation days, in more than 40 countries. *Harry F Hull, Rudolf H Tangermann R Bruce Aylward, Jon K Andrus *Department of Vaccines and Biologicals, World Health Organization, 1211 Geneva, Switzerland; and Regional Office for South-East Asia, World Health Organization, New Delhi, India 1
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John TJ. National immunisation days and global eradication of polomyelitis. Lancet 1999; 354: 869–70. Lee JW, Melgaard B, Hull HF, Barakamfitiye D, Okwo-Bele JM. Comment: ethical dilemmas in polio eradication. Am J Public Health 1998; 88: 130–31. Andrus JK, Banerjee K, Hull BP, et al. Polio eradication in the World Health Organisation south-east Asia region by the year 2000; midway assessment of progress and future challenges. J Infect Dis 1997; 175 (suppl): 89–96. Tangerman RH, Costales M, Flavier J, et al. Poliomyelitis eradication and its impact on primary health care in the Philippines. J Infect Dis 1997; 175 (suppl): 272–76. Taylor Commission. The impact of the Expanded Programme on Immunization and the Polio Eradication Initiative on health systems in the Americas. Washington: Pan American Health Organization, 1995.
Paracelsus on wound treatment v
Sir—Jurica Baci´c and colleagues (Oct 2, p 1200)1 write that it was Ambroise Paré, chief surgeon to three French kings and the greatest figure in 16th century surgery, who “pointed out the usefulness of using boiling oil or burning for surgical wounds”. Throughout the Middle Ages and early Renaissance it was customary for physicians to prescribe treatments based on philosophical dogmas, such as the popular similia similibus curantur (the same is cured by the same). Thus, guaiac preparations from trees found in the West Indies were used to treat the syphilis allegedly brought to Europe by Columbus, and doctors nearly suffocated patients in acrid wood vapours because “Indian” wood ought to cure an “Indian” disease. The pouring of boiling oil into a wound is another example of dogma-based practice. Fever (calor febrilis) and localised heat (calor) have been recognised for thousands of years as the cardinal symptoms of inflamed
wounds,2 and wounds were burned (similia similibus) with a heated iron rod or boiling oil. Philosophical support for this mode of treatment grew with the introduction of firearms and the resulting gunshot wounds. Patients may not have been eager to undergo such a v therapy—indeed, Baci´c et al note that a 1313 contract between a patient and a “doctor of wounds” specifically excluded wound burning from the allowed treatment modalities. Nevertheless, boiling oil remained the treatment of choice until, according to v Baci´c et al, it was challenged by Paré in c1563. However, there are indications that a serious challenge was mounted a few decades earlier and was associated with another great name in medical history. 1993 was the 500th anniversary of the birth of Philippus Aureolus Theophrastus Bombastus von Hohenheim, otherwise known as Paracelsus.3–5 Among his scientific and medical contributions was the advocacy of clean, near-aseptic surgical technique and opposition to the use of boiling oil for cleansing gunshot wounds.4 His views were probably formed and applied during 1516–25, when Paracelsus spent a decade travelling in Europe, including two tours of duty as an army surgeon in Sweden and Holland.3–5 According to Davis,5 it was during this time that Paracelsus obtained first-hand battlefield experience for his classic book on military surgery, Grosse Wund Artzney von allen Wunden (1536). This book was one of only eight works by Paracelsus published while he was still alive. Three of the others confronted the use of guaiac vapours in syphilis2 and ridiculed the similia similibus dogma. Irrespective of whether it was Paré or Paracelsus who made the decisive contribution, alternatives to boiling oil for wound treatment were exploited long before the official dismissal took v place. Baci´c et al provide information about one such doctor, Magister Stjepan, who practised in Dubrovnik in the early 14th century. Andrej A Romanovsky Thermoregulation Laboratory, Legacy Holladay Park Medical Center, Portland, OR 97208, USA 1
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Baci´c J, Skorbonja A, Polanda-Bacic G. Three cases of bone and joint surgery in the 14th century. Lancet 1999; 354: 1200–02. 2 Majno G. The healing hand: man and wound in the ancient world. Cambridge: Harvard University Press, 1975. 3 Bernoulli R. Paracelsus—physician, reformer, philosopher, scientist. Experientia 1994; 50: 334–38. 4 Mann RD. Famous names in toxicology: Paracelsus—born 500 years ago. Adverse Drug React Toxicol Rev 1993; 12: 81–82. 5 Davis A. Paracelsus: a quincentennial assessment. J R Soc Med 1993; 86: 653–56.
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