813

for an encore?" All sorts of interesting and worthwhile work waswaiting to be done. One rule I made was that from then on I wouldnot accept invitations that involved endless hours of boring com-mittee meetings. The interesting consequence is that I have neverbeen busier, and everything I do now is wholly enjoyable. Moreoverthis has proved to be a most productive period. In the three yearssince I left the chairman’s office, I have edited a large textbook and asmall monograph. Now, besides editing a journal, I am working onthree more books and am leading a more normal family life.

I hope others who read Catchpole’s article will find his and mythoughts reassuring.School of Medicine,University of Ottawa,Ottawa, Canada K 1N 9A9 JOHN M. LAST

PHARMACEUTICALS IN BANGLADESH

SIR,-In response to your Round the World item on

Gonoshasthaya Kendra Pharmaceuticals (July 4, p. 35) somepharmaceutical concerns have expressed their opinions (Sept. 5,p. 524, and Sept. 12, p. 586). Doctors, especially those who haveworked in Bangladesh, need to make their views known.Inappropriate and extravagant prescribing has been recorded in

many third world countries and drug consumption patterns do notalways parallel the pattern of the most prevalent diseases.2 2Promotional activities have created a demand greater than the need

and, despite the great increase in drug usage, there has not been aproportionate improvement in health.3 Expenditure on expensiveand inessential drugs means that a large segment of population willbe deprived of essential drugs. 60-80% of the populations of many

developing countries do not have constant access to essential

drugs. An essential drug list4 has been adopted by many developingcountries. 1,5The drug market in Bangladesh is, if anything, worse than the

description given by your reporter. The drug control department,with its limited manpower, has to supervise about 17 000 registeredpharmacies and countless other unregistered ones. Most drugs canbe bought over the counter. The sales of vitamins and alkalipreparations, tonics, and anabolic drugs far outweigh the sales ofother drugs. Drugs which doctors in the developed countries havestopped using because of dangerous side-effects are still sold. Anexample is the widespread use of iodochlorhydroxyquin, usually onself-prescription.The Gonoshasthaya Kendra, which has already established a

pioneer role in community health care in rural areas of Bangladesh, 6has now come forward with a venture to supply essential drugs atminimum possible cost to the population. This project, if success-ful, would not only improve drug availability and use in Bangladeshcountryside, but would also serve as a model from which otherdeveloping countries can learn.The drug companies are understandably concerned, but

Gonoshasthaya Kendra Pharmaceuticals cannot replace them as themajor supplier of drugs: all it can do is to set an example in theproduction of essential drugs at a low price and their properdistribution in deprived areas. The drug market in developingcountries is almost certain to grow2 and the manufacturing concernswill surely remain profitable, but following the lead of the

Gonoshasthaya Kendra Pharmaceuticals will mean much greaterservice to the country in which they operate.Gastrointestinal Unit,Western General Hospital,Edinburgh

Department of Orthopaedic Surgery,Princess Margaret Rose Orthopaedic Hospital,Edinburgh

M. HASAN

M.R.H.KHAN

1. Anon. Drug use in the third world. Lancet 1980; ii: 1231-32.2. Antezana FS. Essential drugs-whose responsibility? J Roy Soc Med 1981; 74: 175-773 Editorial. Desert-island drugs. Lancet 1978; i: 423-24.4. Anon. W.H.O. on essential drugs. Lancet 1978; ii: 977-78.5. Hanlon J. Are 300 drugs enough? New Sci Sept 7, 1978: 708-10.6. Anon. Gonoshasthaya Kendra. Lancet 1976; i: 26-27.

MALARIA PROPHYLAXIS WITH CHLOROQUINESIR,-The W.H.O. recommendation that chloroquine be used as

the drug of choice for malaria prophylaxis has done much toincrease the incidence of chloroquine resistant strains ofPlasmodium falciparum, and I read with dismay the report from DrBengtsson and colleagues in Sweden (Aug. 1, p. 249) of three casesof malaria in expatriates who had taken the recommended fourtablets of chloroquine a week as a prophylactic. Now Bengtsson etal. recommend that this be followed by a course of sulphonamides.Having worked for several years in East and Central Africa and the

Sudan in" areas of undoubted chloroquine resistance I am impressedjust how effective the long-tried prophylactics proguanil andpyrimethamine still are. I have occasionally seen proven falciparummalaria in people who had, allegedly, taken these drugs regularly,but invariably they responded to conventional doses of chloroquineused curatively.Chloroquine is not an efficient prophylactic drug and four tablets

a week could cause side-effects, notably to the eye, in expatriates onshort-term contracts. Chloroquine surely must be kept as the drugof choice for treatment of malaria for as long as possible. To use it asa prophylactic means that the only effective treatment is quinine, inthe event of genuine chloroquine resistance developing. Quininehas caused several deaths and complications in the past and I woulddread to see it return as the number one treatment drug.Furthermore physicians treating the indigenous populations inmalaria countries are abusing chloroquine and tend to prescribe it inunnecessarily large doses, usually by injection, thereby increasingthe risk of resistant strains, reducing the acquired immunity of thepopulation, and, ultimately, exposing them to the risk of

chloroquine resistant falciparum cerebral malaria which carries ahigh mortality.Abuse of antimalarial drugs is just as serious as that of antibiotics

and insecticides. -

11 The Avenue,Roundhay, Leeds 8 C. H. MCCLEERY

ANTENATAL CARE FOR GURKHA WIVES

SIR,-Your Sept. 19 editorial misses the point made by CaptainRasor in the Journal of the Royal Army Medical Corps in his articleon the obstetric problems in the wives of Gurkha soldiers serving inthe New Territories, Hong Kong. He was at pains to point out thatthe attitude of peasant Nepalese women to their obstetric care isdifferent from that of the wives of British soldiers. Unless cajoled toattend for antenatal care they report to the unit’s Family Hospitalfor the first time in established labour, too late to be safelytransferred to the British Military Hospital should complications befound. The result is that the perinatal mortality rate, at 21-5 5 per1000, is nearly double the rate for British wives (12-4 per 1000). Ifthreats for failing to report pregnancies sound harsh, they are onlymade with the interest of the Gurkha families in mind and in thehopes of providing proper antenatal care and of makingarrangements for complicated cases to be delivered in hospital.

109 Harley Street,London W1N 1DG

T. L. T. LEWIS,Hon. Consultant in Obstetricsand Gynaecology to the Army

MALNUTRITION’S ROLE IN BLINDNESS

SIR,-The study by Dr Sommer and his associates (June 27,p. 1407) on blinding malnutrition in West Java is a fundamentalcontribution to the epidemiology of nutritional blindness. Theseworkers report cases of classic corneal xerophthalmia, butmalnutrition in less florid forms can also contribute to blindness inchildren.Chronic malnutrition interferes with host defence mechanisms,

and milder degrees of conjunctival and corneal xerosis may wellenhance the susceptibility of the eye to infections. In many

1. Chandra RK. Nutritional deficiency and susceptibility to infection Bull Wld Hlth Org1979; 57: 167-77.