"Brain drain" of health professionals: from rhetoric to responsible action

The question of the "brain drain" of health professionals has re-emerged since last exposed in 1970s. This paper is based on exploratory studies in Ghana, South Africa and the UK, a literature review and subsequent tracking of contemporary events. It reviews what is currently known about professional migration in the health sector and its impact on health services in poorer countries. The relevant responsibilities at the global level and source and recipient country levels are then reviewed. It is concluded that that the situation is more complex than portrayed by some of the rhetoric and that meaningful dialogue and consideration of responsibilities is needed. In addition, better information is needed to monitor migration flows; source countries need to improve staff attraction and retention strategies; and recipient countries need to ensure that they do not become a permanent drain on health professionals from the developing countries.     

Amenorrhea associated with contraception-an international study on acceptability

Surveys undertaken in the 1970s and 1980s suggested that amenorrhea was unacceptable to most women, especially in developing countries. More recent research suggests that increasing numbers of women in the developed world prefer to menstruate less often. In a questionnaire survey of 1001 women attending family-planning clinics and 290 contraceptive providers in China, South Africa, Nigeria and Scotland, only among black women in Africa did the majority like having periods. In all other groups, most women disliked periods, which were "inconvenient" and associated with menstrual problems. Given the choice, the majority of Nigerian women would prefer to bleed monthly. Elsewhere, women would opt to bleed only once every 3 months, or not at all. In all except the Chinese centers, the majority of women would be willing to try a contraceptive which induced amenorrhea. Providers tended to overestimate the importance of regular menstruation to their clients. This is an important observation for scientists and funding agencies involved in developing new methods of contraception.     

Blood transfusions in the early years of AIDS in sub-Saharan Africa

Blood transfusions transmit HIV more effectively than other means, yet there has been little examination of their role in the origins and early course of AIDS in sub-Saharan Africa. We review historical data in archives, government reports, and medical literature from African and European sources documenting the introduction, establishment, use, and growth of blood transfusions in sub-Saharan Africa. These data allow estimation of the geographic diffusion and growth of blood transfusions between 1940 and 1990.By 1955, 19 African colonies and countries reported transfusion programs-with national rates of 718 to 1372 per 100 000 by 1964, and urban rates similar to those in developed countries. We estimated 1 million transfusions per year in sub-Saharan Africa by 1970 and 2 million per year by the 1980s, indicating that transfusions were widely used throughout sub-Saharan Africa during the crucial period of 1950-1970, when all epidemic strains of HIV first emerged in this region.     

What is needed for health promotion in Africa: band-aid,live aid or real change?

Health Promotion in sub-Saharan Africa (SSA) is currently facing many difficult challenges. Health status is worse than in any other region, with the midpoint data indicating that that SSA is not on track to achieve any of the Millenium Development Goals. This paper explores the history of health promotion in Africa, from before Alma Ata, through the 1970s, 1980s and 1990s, and up to the present. Using examples from Mozambique, Zimbabwe and South Africa during their transitional periods, and health promotion approaches adopted to tackle HIV/AIDS, diarrhoea and non-communicable diseases, the paper shows how the focus has shifted away from the ideals of the Ottawa Charter to an individualistic behaviour change approach. The reasons for the shift reflect political choices of governments that have favoured technocratic approaches over harnessing the popular mobilisations that have accompanied national struggles. The experiences of global movements, such as the Global Equity Gauge Alliance are considered as a way of enhancing local health promotion initiatives which, as presently conceived, are limited in their ability to address equity and the broader determinants of ill health.     

Evolution of Seventh Cholera Pandemic and Origin of 1991 Epidemic, Latin America

Thirty single-nucleotide polymorphisms were used to track the spread of the seventh pandemic caused by Vibrio cholerae. Isolates from the 1991 epidemic in Latin America shared a profile with 1970s isolates from Africa, suggesting a possible origin in Africa. Data also showed that the observed genotypes spread easily and widely.     

The implications of work organization for occupational health policy: the case of Canada

This article examines occupational health and safety developments in Canada during the decade of the 1970s when most government jurisdictions replaced former factory Acts with new health and safety legislation recognizing the right of workers to be involved in work environment matters. During the latter part of the 1970s, health and safety "activists" and trade unionists began to perceive the need for a wider conception of occupational health and safety. Canadian reformers were influenced by Scandinavian developments, especially the research of Dr. Bertil Gardell and his associates. Unfortunately, during the late 1970s Canada experienced a recession and a political shift to conservatism. Consequently, during the 1980s there have been no meaningful workplace health and safety reforms. Further, the article suggests that there is strong resistance by management and government to extension of worker rights in occupational health and safety. All major political parties ground their work environment policies in utilitarian concepts that trade worker health and safety for economic considerations. The author, therefore, argues for the development of an "ethics of the work environment" based upon egalitarian principles, and the transformation of the primary work group into a community of workers who can shape the character of their work environment. Ideally, the relationship between the major "actors" in our industrial relations system ought to be based on obligation instead of the present language of worker protest based on rights. Nonetheless, there is a need to extend and deepen worker rights in the workplace. Finally, the author argues that the appropriate relationship in industry to reflect a democratic work environment is "partnership"--the coming together of the primary work groups as equals.     

A "scorpion fish" (Trachinus vipera) sting: fishermen's hazard

"Scorpion fish" is a nickname given by fishermen to members of the Trachinidae family as a result of their unusual stinging mechanism. These fish are found throughout the eastern Atlantic region from the North Sea through the Mediterranean and Black Seas and along the western coast of Northern and Central Africa. They are characterised by poisonous glands located at the base and sides of the spines of their anterior back fin and at the base of a spine located on the gill cover. Because of the unusual location of the glands, fishermen handling these fish frequently suffer local injuries. A case of necrosis of the tip of the middle finger after a "scorpion fish" sting is described.     

Global nutrition transition and the pandemic of obesity in developing countries

Decades ago, discussion of an impending global pandemic of obesity was thought of as heresy. But in the 1970s, diets began to shift towards increased reliance upon processed foods, increased away-from-home food intake, and increased use of edible oils and sugar-sweetened beverages. Reductions in physical activity and increases in sedentary behavior began to be seen as well. The negative effects of these changes began to be recognized in the early 1990s, primarily in low- and middle-income populations, but they did not become clearly acknowledged until diabetes, hypertension, and obesity began to dominate the globe. Now, rapid increases in the rates of obesity and overweight are widely documented, from urban and rural areas in the poorest countries of sub-Saharan Africa and South Asia to populations in countries with higher income levels. Concurrent rapid shifts in diet and activity are well documented as well. An array of large-scale programmatic and policy measures are being explored in a few countries; however, few countries are engaged in serious efforts to prevent the serious dietary challenges being faced.     

Status of human monkeypox: clinical disease, epidemiology and research

Monkeypox, a vesiculo-pustular rash illness, was initially discovered to cause human infection in 1970 through the World Health Organization (WHO)-sponsored efforts of the Commission to Certify Smallpox Eradication in Western Africa and the Congo Basin. The virus had been discovered to cause a nonhuman primate rash illness in 1958, and was thus named monkeypox. The causative agents of monkeypox and smallpox diseases both are species of Orthopoxvirus. Orthopoxvirus monkeypox, when it infects humans as an epizootic, produces a similar clinical picture to that of ordinary human smallpox. Since 1970, extensive epidemiology, virology, ecology and public health research has enabled better characterization of monkeypox virus and the associated human disease. This work reviews the progress in this body of research, and reviews studies of this "newly" emerging zoonotic disease.     

A "scorpion fish" (Trachinus vipera) sting: fishermen''s hazard.

"Scorpion fish" is a nickname given by fishermen to members of the Trachinidae family as a result of their unusual stinging mechanism. These fish are found throughout the eastern Atlantic region from the North Sea through the Mediterranean and Black Seas and along the western coast of Northern and Central Africa. They are characterised by poisonous glands located at the base and sides of the spines of their anterior back fin and at the base of a spine located on the gill cover. Because of the unusual location of the glands, fishermen handling these fish frequently suffer local injuries. A case of necrosis of the tip of the middle finger after a "scorpion fish" sting is described.     

The "Pill scare" and fertility in England and Wales

In 1977 the published results of 2 major studies indicated that the use of oral contraceptives (OC)s increased the risk of death from cardiovascular disease. The studies were the Royal College of General Practitioner's (RCGP) Oral Contraception Study, and the other was the University of Oxford/FPA contraceptive study. Manufacturers' sales of OCs fell from their 1976 peak in 1977, and in 1978 fertility began to rise once more and continued to do so until 1980, when the increase evidently began to run out of steam. It is argued that the way people responded to the adverse findings about OCs may well have played a part in the recent rise in fertility. It is acknowledged, however, that in this complex field other factors will be involved and what is important is the extent to which each contributed to the rise. Between 1964 and 1977 the number of births/1000 women of childbearing age declined from 93.0 to 58.7 in England and Wales. OCs were introduced in 1961 and use grew steadily until at least 1975. A survey conducted in 1975 shows that OCs were easily the most popular method during the mid-1970s. The whole of the reduction in the rates at which pregnancies of higher orders occurred over the period seems to have been in unplanned pregnancies. It is worth noting that the decline could have been realized without modern contraception. The low general fertility rate of 1977 of 58.7 was only slightly lower than that for 1939 (61.3). It may be possible that whenever any commonly used effective method of birth control ceases to be available for some reason, the period of adjustment to other methods is accompanied by a temporary rise in fertility. The sequence of events of adverse publicity, i.e., decline in OC use and rise in fertility in England and Wales after 1976, could be an example of mere coincidence. 2 earlier sequences of the same kind suggest that it has not. There were earlier "Pill scares," all of which possibly the most important was that of 1969. Preliminary warnings of the findings of the Committee on the Safety of Drugs in 1969 was succeeded by a flattening of the upward curve in sales of OCs between 1969 and 1970 and a disruption in the downward movement of fertility followed in 1970-1971. Also, in the U.S., where OCs were the subject of Senate hearings, there was a small but perceptible decline in use accompanied by a small but perceptible rise in fertility. Other possible explanations are reviewed.     

Debt crisis, health and health services in Africa

In the early 1960s when most of Africa became independent, the hope for the resolution of the related problems of poverty, illiteracy and disease became the primary agenda of its sovereign states. There were indeed initial gains in various aspects of social infrastructure, especially education and medical services. Beginning from the mid 1970s, but particularly since 1980, this initial progress is, however, being reversed as Africa totters under an excruciating debt burden and accompanying austerity programmes. This essay provides a kaleidoscope of this ominous decay with particular reference to health and health services. Several proposals for the way forward are discussed.     

Legal review: informed consent--a shift from paternalism to self-determination?

This shift from a paternalistic standard for determining how much information should be disclosed to a person to a standard that values the self-determination of a person is consistent with the philosophical change in decision-making in a variety of areas of health care. Haber begins his article with a discussion of the psychiatry profession's proposed change in terminology from "patient" to "client." He argues that such a change would be more than semantic: It would serve the moral purpose of increasing such a person's autonomy. The right of patients to see their own medical records was formally recognized as part of the Patient's Bill of Rights in 1972 and has since been recognized by courts and incorporated into many state statutes. Likewise, the refusal of medical treatment has become a right more commonly recognized by the law throughout the 1970s and 1980s. For example, "living wills" are now a common vehicle for patients to express their views regarding the right to refuse treatment. Courts have recognized this right in cases of Jehovah's Witnesses refusing transfusions, the right to have life-sustaining procedures discontinued, and the restrictive involuntary commitment statutes that arose in the 1970s. Both the risks and benefits of medical treatments have increased with the forward march of technology. Patients have the right to choose to participate with their physicians in their own health care decision making; the trend toward the reasonable patient standard in medical malpractice suits that relied on negligent failure to obtain informed consent reflects a recognition of that right.     

Dispelling "heterosexual African AIDS" in Namibia: same-sex sexuality in the township of Katutura

This paper questions international public health theories that characterize AIDS in Africa as an unambiguous heterosexual epidemic. It does so by describing the daily sexual lives of a community of Namibian youth who engage in same-sex sexual practices. The author outlines how the ongoing vilification of "homosexuals" by ruling State officials serves as a stigmatizing backdrop against which young people experience and practice their sexuality. Drawing upon 20 months of ethnographic research, the paper discusses the HIV sexual risk perceptions and practices of young men, highlighting the complexities in sexual subjectivity that form within the cultural politics of competing masculinities, state-sponsored anti-homosexual rhetoric and transnational queer rights protest. Bounded and monolithic notions of gender and sexual identity do not lend themselves to HIV risk and vulnerability analysis in this community.     

The class of 1970: making connections with change

Whatever happened to the class of 1970? For the most part, they're still right here in our midst. But a lot has changed since the young people (mostly young men) who took their MHAs from health administration programs left school. Although many started out with their eye on the hospital CEO prize, the 1970 grads have fanned out across the health care profession spectrum--and beyond. The kinds of changes in the health care field the 1970 MHA graduates have seen are the ones that have transformed health care in just two decades. PPS, managed care, the indigent care crisis, downsizing, the growth of systems, greater physician scrutiny and an avalanche of regulations of all types have fundamentally altered the health care career map. The 1970 grads will tell you--in their own words--what two decades of revolution have meant to them--and to all of us.     

Mortality of middle aged white South African gold miners

A cohort of 3971 white miners in South Africa, born between 1 January 1916 and 31 December 1930 who were alive on 1 January 1970 and currently working in the East Rand-Central Rand-West Rand mining areas, was followed up for nine years, when the 3426 survivors were aged from 48 to 62. Fifteen (0.4%) had been lost to view and 530 had died (13.4% of the 3956 whose vital status was determined). Based on the occupational histories of a 30% sample of the cohort it was known that the vast majority were gold miners. An estimated 93% had worked more than 85% of their mining service in gold mines. Standardised mortality ratios were calculated as the ratios of the deaths observed in the cohort to those expected on the basis of concurrent mortality in the reference population--the total white male population in the Republic of South Africa. There was little sign of a "healthy worker effect"; of several possible reasons, one is that the white miner in South Africa had adopted certain unhealthy life styles, another is that the reference population was otherwise inappropriate. The SMR for all causes of death (117.6) was raised because of excess mortality due to the following causes: lung cancer (161.2), chronic respiratory diseases (165.6), and acute and chronic nephritis (381.0). A case-referent analysis was carried out on those miners in the cohort who had spent at least 85% of their service in gold mines. For lung cancer, smoking was the main contributory factor towards disease. For chronic respiratory diseases bronchitis, emphysema, asthma, pneumoconiosis, and pulmonary heart disease), smoking was also the main risk factor, but there was an association wih cumulative dust exposure. Raised blood pressure, smoking, and adiposity were associated with ischaemic heart disease as was the duration of service underground. Study of comprehensive medical histories in all 530 deaths, including necropsy in most cases, showed that none was directly due to pneumoconiosis or to tuberculosis.     

Recent trend of increase in proportion of low birthweight infants in Japan

BACKGROUND: The proportion of low birthweight babies (LBW: 1500-2499 g) in Japan decreased steadily from 1950 to the 1970s. However, since then it has started to increase consistently, the reason for which has not been discussed in detail. METHODS: Trends of birthweight and the two known factors for low birthweight (maternal smoking, and pre-pregnancy weight) were analysed with vital statistics, national nutritional and smoking prevalence survey data. RESULTS: Increase in term LBW due to intrauterine growth retardation, is the major risk factor for the overall increase since the 1970s. The increase of smoking prevalence in women in their thirties started in the 1970s, while that for women in their twenties started in the 1960s. The decrease of body mass index for women in their thirties also began in the 1970s, while that for women in their twenties began in the 1960s. The ratio of delivery to mothers in their thirties to mothers in their twenties has increased more than threefold compared to the late 1970s. CONCLUSIONS: Since the 1970s increase in smoking prevalence and decrease in body mass index in young women, especially those in their thirties, appeared to be the major factors involved in the increase in LBW babies.     

Mortality of middle aged white South African gold miners.

A cohort of 3971 white miners in South Africa, born between 1 January 1916 and 31 December 1930 who were alive on 1 January 1970 and currently working in the East Rand-Central Rand-West Rand mining areas, was followed up for nine years, when the 3426 survivors were aged from 48 to 62. Fifteen (0.4%) had been lost to view and 530 had died (13.4% of the 3956 whose vital status was determined). Based on the occupational histories of a 30% sample of the cohort it was known that the vast majority were gold miners. An estimated 93% had worked more than 85% of their mining service in gold mines. Standardised mortality ratios were calculated as the ratios of the deaths observed in the cohort to those expected on the basis of concurrent mortality in the reference population--the total white male population in the Republic of South Africa. There was little sign of a "healthy worker effect"; of several possible reasons, one is that the white miner in South Africa had adopted certain unhealthy life styles, another is that the reference population was otherwise inappropriate. The SMR for all causes of death (117.6) was raised because of excess mortality due to the following causes: lung cancer (161.2), chronic respiratory diseases (165.6), and acute and chronic nephritis (381.0). A case-referent analysis was carried out on those miners in the cohort who had spent at least 85% of their service in gold mines. For lung cancer, smoking was the main contributory factor towards disease. For chronic respiratory diseases bronchitis, emphysema, asthma, pneumoconiosis, and pulmonary heart disease), smoking was also the main risk factor, but there was an association wih cumulative dust exposure. Raised blood pressure, smoking, and adiposity were associated with ischaemic heart disease as was the duration of service underground. Study of comprehensive medical histories in all 530 deaths, including necropsy in most cases, showed that none was directly due to pneumoconiosis or to tuberculosis.     

Marriage,divorce, and living arrangements: prospective changes

An analysis of current marriage patterns in the United States is presented based on official data. "The population base for first marriages reached a peak in 1982, and the corresponding peak for divorces will be reached in about 1990. Both first marriage and remarriage rates have been declining among those in critical age groups and may be expected to continue to do so, barring unforeseen developments. About one-half of the first marriages of young adults today are likely to end in divorce. For second marriages, the projected level is closer to 60%. The divorce rate is highest for those with an incomplete college education and is especially low for those with four years of college." It is noted that "about three-fourths of young divorced persons are likely eventually to remarry. The number of unmarried couples tripled during the 1970s and may double again during the 1980s. One-parent households are expected to continue increasing rapidly while two-parent households actually decrease. But even if the recent trends continue at a moderated rate, the vast majority of Americans in 1990 will probably still be living in homes of married couples with or without children or in homes of lone parents and their young children."     

The politics of employment-based insurance in the United States

Analyses of the corporatization of U.S. health care typically focus on the political struggle between corporations and traditional health care providers, e.g., physicians. A neglected area of study is the struggle between corporations and their employees over the employment-based health insurance system. Yet, since this system is currently the primary mechanism for financing health care in the United States, an analysis of its historical development is critical to any understanding of the corporatization of U.S. health care. It is argued here that the employment-based health insurance system was a part of a political compromise between capital and labor that emerged after World War II. In exchange for control over production and increased worker productivity, corporations agreed to provide workers with steady wage increases and an expanded system of fringe benefits, or "corporate welfare." But, by the late 1970s, rising health care costs created a corporate health care financing crisis that has prompted corporations to cut back employee health insurance coverage. The relative inability of workers to resist such cutbacks reveals the extent to which, by linking health care to wage labor, the "corporate welfare" system has made the U.S. working class more vulnerable to corporate power.