Correspondence
offers pregnant women first-trimester and second-trimester screening for fetal abnormality—but unlike the others, Queensland does not offer the care needed when a diagnosis of abnormality is made. Victoria and the Australian Capital Territory have completely decriminalised abortion, South Australia and Western Australia have reformed their laws, and New South Wales has case law which has liberalised practice in that state (although abortion remains in the Crimes Act). But in Queensland (population 4·5 million), abortion remains in a medical and moral grey area, and access to abortion is very difficult for many women, particularly rural women. There is known to be quite extensive abortion “tourism” from Queensland to other states. A further difficulty for many Australian women is the unequal availability of mifepristone for medical abortion from state to state. The drug is still not marketed nationally; individual doctors must apply to the Commonwealth Therapeutic Goods Administration to import and use it, and only for serious medical indications, 5 years after WHO declared it an essential drug even for developing nations.3 There is anecdotal evidence that drugs for medical abortion are being bought over the internet on possibly a large scale in Australia. National figures for abortion rates are not kept in Australia—another major omission in the health services. However, estimates put them at more than three times those of countries such as Belgium and the Netherlands.4 Until Australian women have uniform access to safe legal abortion services, including the drugs widely used overseas for medical abortion, we cannot begin to work on measures to try to reduce these rates.5 We declare that we have no conflicts of interest.
*Caroline M de Costa, Darren B Russell, Michael Carrette
[email protected]
www.thelancet.com Vol 375 March 6, 2010
Department of Obstetrics & Gynaecology, James Cook University School of Medicine, James Cook University, PO Box 902, Cairns, QLD 4870, Australia (CMdC); Sexual Health Clinic, Cairns Base Hospital, Cairns, QLD, Australia (DBR); and Cairns Private Hospital, Cairns, QLD, Australia (MC) 1 2
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Elks S. Bligh refuses abortion law reform. The Australian Dec 29, 2009. Douglas H. Abortion reform: a state crime or a woman’s right to choose? Crim Law J 2009; 33: 74–86. Gibson L. WHO puts abortifacients on its essential drugs list. BMJ 2005; 331: 68. Chan A, Sage LC. Estimating Australia’s abortion rates 1985–2003. Med J Aust 2005; 182: 447–52. WHO. Safe abortion: technical and policy guidance. Geneva: World Health Organization, 2003.
Snake bite: simple steps to prevention and reduction of morbidity We read with interest David Warrell’s Seminar on snake bite (Jan 2, p 77)1—a time-sensitive, life-threatening event often faced by farmers and farm labourers and included in WHO’s list of neglected tropical diseases. In India, ignorance of conventional treatment of snake bite by doctors delays proper treatment and contributes to morbidity and mortality. Mortality is further increased by inadequate administration of the initial dose of snake antivenom, particularly for bites involving elapid and Russell’s viper snakes. The absence of simple methods of tracheal intubation and ventilation by a bag valve mask or artificial ventilator in neurotoxic envenoming further add to mortality.2 Antivenom is always in short supply, but appropriate training of medical officers regarding indications and doses of antivenom can help regulate use.3 Antivenom should be made available free of charge in private hospitals with ventilation facilitates. Such a policy would be cheaper than having to provide benefits and cash compensation to orphans or deserted family members of snake bite victims as a result of poor facilities or medical negligence.4
Figure: Child using an open toilet
A bamboo cot and scrupulous use of a mosquito net can prevent snake bites, scorpion stings, and mosquito bites alike.5 Wearing of shoes with enclosed toes (rather than sandals) can prevent snake bites after dark. Indoor toilets should be made compulsory at the time of issuing permission for new housing construction (three patients recently died in our region after being bitten while using an open toilet [figure]). And supportive treatment including mannitol, diuretics, acetylcysteine, and neostigmine should be made available since they might help to arrest renal damage and increase neuromuscular transmission in viper and elapid envenoming, respectively.4 We declare that we have no conflicts of interest.
*H S Bawaskar, P H Bawaskar himmatbawaskar@rediffmail.com Bawasakar Hospital and Research Center, Mahad Raigad, Maharashtra 402301, India 1 2
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Warrell DA. Snake bite. Lancet 2010; 375: 77–88. Bawaskar HS, Bawaskar PH. Envenoming by common krait (Bungarus caeruleus) and Asian cobra (Naja naja): clinical manifestations and management in a rural setting. J Wilderness Envir Med 2004; 15: 257–66. Bawaskar HS, Bawaskar PH. Call for global snake-bite control and procurement funding. Lancet 2001; 357: 1132–33. Bawaskar HS, Bawaskar PH, Punde DP, Inamadar MK, Dongare RB, Bhoite RR. Profile of snake bite envenoming in rural Maharashtra, India. J Assoc Phys India 2008; 56: 88–95. Bawaskar HS, Bawaskar PH. Malaria vaccine. Lancet 1996; 348: 1329.
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