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PubMed2005

Ethical issues in pediatric intensive care in developing countries: combining western technology and eastern wisdom.

Application of traditional ethical principles in developing countries may not, indeed should not, conform to the western philosophy and ideology. The principle of distributive justice is of utmost importance when critical resources are scarce. There is no ethical imperative, nor is one followed even in the most advanced countries, that every citizen is entitled to the very best available care. However, a society must establish a uniform code of ethics that can be applied nationally, whereby all citizens are eligible for a minimum acceptable level of care. The traditional principles of autonomy, beneficence, nonmaleficence and justice are still applicable in structuring an ethical framework that is most suited for the country's needs and resources.

Attitude to Death↗

PubMed1982

Pituitary tumours and blindness: continuation of the pre-Harvey-Cushing era in developing countries.

Of the 11 patients with pituitary or suprasellar tumours seen at Muhimbili Medical Centre, Dar es Salaam, from January, 1980, until July, 1982, 6 (54.5%) were totally blind, 3 (27.3%) were blind in one eye and had severe visual impairment in the other, and 2 (18.2%) had marked visual field abnormalities but normal visual acuity in one eye. Blindness in most of these patients highlights the absence of neurosurgical services in many developing countries. In addition there is little prospect of countries like Tanzania establishing neurosurgical services in the foreseeable future. The only help for patients with neurosurgical problems is from referral overseas. This, however, is possible for only a limited number because of costs, unless neurosurgical units in developed countries offer their services at nominal cost. Such an offer would not only benefit patients who would otherwise die but would also help to further the interests of neurosurgery in the helper country.

Adenoma, Chromophobe↗

PubMed2003

The ethical aspects of biomedical research in developing countries.

The European Group on Ethics is made up of 12 independent experts appointed by the European Commission. It is a multidisciplinary body that advises the Commission on ethical aspects of science and new technologies in connection with the preparation or implementation of EU legislation or policies. Its latest, 17th, opinion is reproduced below: since the current EU framework programme of medical research encourages partnerships with developing countries, it concerns the ethics of such research.

Advisory Committees↗

PubMed1977

Profile of epilepsy in a developing country: a study of 1,000 patients based on the international classification.

The present prospective study undertaken in a specialized neurological center of a developing country deals with 1,000 epileptic patients classified in accordance with the International Classification. Eighty-one percent of the patients could be classified, with a lower incidence in the younger age group. Partial epilepsy was found to be far more common than generalized epilepsy (80% versus 20%). Primary generalized epilepsy was seen in 15% and secondary generalized in 5%. Partial epilepsy with elementary symptomatology was seen in 58% and complex symptomatology in 7%. Secondarily generalized seizures were seen in the remaining 15%. Primary generalized epilepsy and partial epilepsy with complex symptomatology were more common in adults. Secondary generalized epilepsy and partial epilepsy with secondarily generalized seizures were more common in children. Partial epilepsy with elementary symptomatology, however, did not vary significantly with age. The higher incidence of partial epilepsy in our patients, compared to the West, could be due to greater frequency of CNS infections and birth injuries, which are common childhood hazards in the developing countries.

Adult↗

PubMed1999

Reducing perinatal HIV transmission in developing countries through antenatal and delivery care, and breastfeeding: supporting infant survival by supporting women's survival.

In 1998, a joint UNAIDS/UNICEF/WHO working group announced an initiative to pilot test an intervention to reduce perinatal transmission of human immunodeficiency virus (HIV), based on new guidelines on HIV and infant feeding. This intervention for developing countries includes short-course perinatal zidovudine (AZT) treatment and advice to HIV-positive women not to breastfeed their infants, where this can be done safely. The present paper raises questions about the extent of the public health benefit of this intervention, even though it may be cost-effective, due to the limited capacity of antenatal and delivery services to implement it fully. It argues that it is necessary to provide universal access to replacement feeding methods and support in their safe use, not only for women who have tested HIV-positive during pregnancy, but also for untested women who may also decide not to breastfeed, some of whom may be infected with HIV or may acquire HIV during the breastfeeding period. It further argues that additional funding, more staff, staff training, and improved capacity and resources are also needed to integrate this intervention successfully into antenatal and delivery care. The intervention will prevent some infants from getting HIV even in the absence of many of these changes. However, a comprehensive approach to HIV prevention and care in developing countries that includes both women and infants would promote better health and survival of women, which would in turn contribute to greater infant health and survival. If combination antiretroviral therapy in the latter part of pregnancy and/or during the breastfeeding period can be shown to be safe for infants, preliminary evidence suggests that it might reduce perinatal HIV transmission as effectively as the current intervention and, in addition, might allow the practice of breastfeeding to be preserved.

Breast Feeding↗

PubMed2005

Continuous peritoneal dialysis in children: a single-centre experience in a developing country.

Continuous peritoneal dialysis (CPD) is the most commonly used modality of dialysis in children. Continuous ambulatory peritoneal dialysis (CAPD) has been an established form of therapy in adult patients with end-stage renal failure in India for more than a decade. There is a paucity of published experience of CPD in children from developing countries. We retrospectively studied children with end-stage renal failure (ESRD) that had been on CAPD over the past 10 years. Thirty patients with ESRD, mean age 13+/-8 years (range 5-21 years), male 18, were started on CAPD from 1994 to October 2004. The mean break-in period was 12+/-3 days. Of these 30 patients, 15 had a total of 21 episodes of peritonitis. The peritonitis rate was 0.58 episodes per patient year. E. coli was the commonest organism causing peritonitis. On outcome analysis, 7/30 (23.3%) patients received a renal transplant, while 11/30 (36.6%) continued on CAPD, awaiting a kidney transplant. Of the rest, eight (26.6%) patients died, two (6.7%) suffered technique failure and were changed to haemodialysis, and two (6.7%) were lost to follow-up after 2 months. The mean cumulative survival time of patient on CPD was 42 months. We conclude that CPD is a viable option for dialysis in ESRD children in a developing country and is a successful bridge between ESRD and renal transplantation.

Adolescent↗

PubMed1993

[Clinical and serologic study of Czecho-Slovak citizens working in developing countries from the aspect of risk of infection with Coxiella burnetii].

In the years 1984-1988 we observed, besides the routine examinations of history, clinical state, and laboratory tests, also the presence of antibodies to Coxiella burnetii antigens by means of microagglutination reaction (MAR). The examinations were performed in our citizens returning to Czecho-Slovakia from a long termed business stay in the developing countries. Antibodies to C. burnetii antigen 2 have been detected entirely in 91 serum samples, out of which 48 cases following their stay in Libya, 42 cases following their stay in Iraq, and 1 in Syria. Diagnostically significant antibody titres (64) were detected in 44 serum samples, in which the serological positivity was proved by complement fixation test (CFT) examination. Clinical symptoms in the history, responding to the acute form of "Q" fever, occurred in 44 serologically positive cases, 37 of which developed high antibody titres, which is considered to be a significantly high incidence. The results imply the necessity to become more concerned by the incidence of "Q" fever, its diagnostics and therapy, eventually prevention in our citizens working in a more exacting climate of some developing countries. (Tab. 1, Ref. 15.).

Antibodies, Viral↗

PubMed1992

The urge for an AIDS vaccine: perspectives from a developing country.

AIDS is inexorably involving all parts of the country and all strata of society, with 10% of the urban and 3% of the rural population infected with HIV. It is increasingly a disease of women and children. The major cofactors for transmission are also sexually transmitted. For most developing countries, in spite of all education efforts, the "silent epidemic" of AIDS continues. AIDS is known but not understood; counselling modifies behavior in only 10-20% of at-risk persons. Under optimal conditions, HIV discordant females have seroconversion rates of 4.7% per year and pregnancy rates of 10.4% per year. The recent political unrest in Zaire and Haiti will further enhance the spread of AIDS in these countries. Despite these difficult periods, the work can and must continue. After all, during our 10th year of collaboration with a Haitian private research group, the Haitian government and Cornell University, Haiti has known seven different political rulers. Finally, I want to make a pledge on behalf of the millions of people who face a certain death from HIV infection and AIDS and who will never make the front page of any newspaper. For these people, you can make a difference. You must give us the tools to carry on this fight. The clinical trials must be done where they are most needed: the developing countries. Vaccines represent the only viable alternative despite the recognized obstacles of viral heterogeneity, immunogenicity, and delivery.

AIDS Vaccines↗

PubMed2002

AIDS research in developing countries: do the ends justify the means?

Concrete ethical standards for human research are clearly stipulated in both international and national codes of ethics, and are meant to protect human subjects, especially the most vulnerable. A recent clinical study conducted from 1994 to 1997 by Dr. Thomas C, Quinn, M.D. has fueled the debate raging in the scientific community regarding the ethics of clinical AIDS research in developing countries. Quinn's conducted a community-based, randomized, controlled study of 15,127 rural Ugandans to determine whether intermittent antibiotic treatment to reduce the prevalence of other sexually transmitted diseases would also reduce the rate of HIV transmission. Subsequently, the study identified 415 couples in which one partner was HIV positive and one was initially HIV negative and followed them prospectively for up to 30 months. Researchers were not permitted to inform the seronegative partner of the HIV status of the other partner. As a result, 90 of the initially HIV negative partners (21.7%) seroconverted during a follow-up period of 30 months. To allow for research studies in developing countries that are not permitted in the United States appears to make the Third World equivalent to a 'research sweat shop'. Developing nations offer easy access to patients, reduced costs, and less stringent regulations. This appears to create a double standard for medical research that is both ethically and humanly unacceptable, especially when other viable option exist. To allow relativism to seep into the international and national ethical standards will open the door to an idea that condones the possible abuse of those least able to protect themselves. Researchers have an ethical responsibility to uphold the integrity of these ethical standards. Failure to do so today may have a devastating impact on humanity in the future.

Acquired Immunodeficiency Syndrome↗

PubMed2000

[Reduced mother-to-child transmission of HIV-1 infection. Exclusive breast feeding and weaning--a possible model in developing countries?].

Antiretroviral therapy with zidovudine during pregnancy, delivery, and to the newborn in combination with Cesarean section has markedly reduced the rate of mother-to-child transmission of HIV-1 in industrialized countries. These strategies are not realistic in the less developed world. Nevertheless, short-term antiretroviral therapy during delivery and shortly after birth has proven feasible as a means of reducing the rate of vertical transmission in less developed countries, in some studies even in combination with exclusive breast-feeding. The risks and benefits of breast-feeding among HIV-1 infected mothers are discussed.

Anti-HIV Agents↗

PubMed1993

Musculoskeletal disorders of female workers and ergonomics problems in five different industries of a developing country.

An ergonomics survey was carried out using interviews based on Standardized Nordic Questionnaires for evaluating musculoskeletal disorders of 1,000 female workers in five different industries in Thailand, viz. garment, fertilizer, pharmaceutical, textile, and cigarette. A checklist used in an ILO study for examining ergonomics problems was used for identifying ergonomics problems. The results show that about 50% of the female workers experienced a high prevalence of musculoskeletal symptoms in their lower backs, particularly the textile workers. The musculoskeletal symptoms of each body region were significant in each industry during the last year and the preceding 7 days (p < 0.05). Other ergonomics problems in the survey industries included heavy manual handling, prolonged sitting and standing, awkward work postures, poor machine design and operation, high repetitive and monotonous movements, poor work organization, and unsatisfactory working environments. Based on the results of this survey, it became obvious that ergonomics problems related to occupational health and safety of female workers seem to fall into three categories: (i) poor working practices and workplace programmes without sufficient knowledge of ergonomics principles, (ii) lack of adjustment to local population of imported machinery and equipment and their use, and (iii) lack of appropriate work organization. The findings demonstrate the need and the importance for ergonomics intervention in industrially developing country using low-cost improvements and appropriate training methods. It also indicates that research in ergonomics applications is needed, considering the specific characteristics of the industrially developing country.

Adult↗

PubMed2003

Antalya consensus on perinatal care: the report of the 2nd World Congress of Perinatal Medicine for Developing Countries, 1-5 October 2002, Antalya, Turkey.

The goal of antenatal care is to help the mother to maintain her well-being and achieve a healthy outcome for herself and her infant. Education about pregnancy, child-bearing and childrearing is an important part of antenatal care. Because of the perception that pregnancy is a physiologic event, even today lots of women do not seek medical care until a problem occurs during their pregnancy. There are still unacceptable differences in the extent of perinatal problems in developed and developing countries. Over the last century almost all countries have accepted antenatal care principles. However, insufficiency of resources and a lack of women's compliance have proved to be obstacles in developing countries and have compelled the application of various standard programs. Unfortunately, these programs are not sufficiently effective in preventing and treating maternal mortality. A safe pregnancy and delivery is a human right. Maternal mortality and morbidity should not be ranked with other diseases, because child bearing is not a disease. For this reason a global ethical consideration imposes an obligation upon society to avoid these almost totally preventable deaths. Ensuring access to family planning is an important way of decreasing maternal death. Maternal morbidity and mortality as well as perinatal mortality can be reduced through the synergistic effect of combined interventions, without first attaining high levels of economic development. These interventions include: education for all, universal childbirth, access to family planning services, attendance at birth by professional health workers, access to good quality care in case of complications, and policies that raise women's social and economic status and increase their access to property and the labor force.

Developing Countries↗

PubMed2006

Immune systems in developed and developing countries; implications for the design of vaccines that will work where BCG does not.

New vaccine candidates for tuberculosis are beginning to enter clinical trials. In this review we discuss issues surrounding the design of these candidates, and the way they were screened in animal models. First, screening vaccines for their ability to attenuate inevitably fatal tuberculosis in immunologically naïve mice might be leading to the selection of inappropriate candidates. We need to screen vaccines for their ability to stop the development of progressive disease, since this is what they must achieve in man. A solution to this problem is proposed. Secondly, we point out that some mouse models of tuberculosis in laboratories in developing countries, where exposure to environmental mycobacteria is large, mimic neglected aspects of human disease more closely than do low-dose infections in hyper-susceptible immunologically naïve mice in the USA or Europe. We need to think more about geographical differences in immunological experience, and these mouse models can help us. Thirdly, we conclude that in developing countries where BCG fails this is not because there is too little Th1 response, but rather because the Th1 response is rendered ineffective and immunopathological by other subversive mechanisms, including IL-4 responses and inappropriate regulatory T cell function. Therefore, we suggest that vaccines that will work in those countries might need to have immunoregulatory properties that can switch off pre-existing subversive mechanisms, and block their development in the future. The development of such vaccines, that might work where BCG does not, will require a greater understanding of the roles of the many types of regulatory T cell in tuberculosis.

Animals↗

PubMed2003

Setting up a palliative care clinic within a radiotherapy department: a model for developing countries.

Nearly 50% of all newly diagnosed cancer patients in India (and other developing countries) are terminally ill with advanced disease. These patients are usually neglected or often receive futile anticancer treatment(s), whereas what they really need is maximum medical management in the form of palliative care and psychosocial support. Since advanced and incurable cancer cases are mostly referred for radiotherapy (RT), a palliative care (PC) clinic was started in the Department of Radiotherapy, PGIMER, Chandigarh. The PC clinic staff consisted of one specialist doctor, a nurse and volunteers. Previous disease and treatment records maintained by the RT colleagues were noted. Proforma-based assessments were done in the PC clinic and focused on patients' Karnofsky Performance Status, physical symptoms, drugs prescribed, and the doctor's or patient's/relative's response to/satisfaction with the treatment in each case. Prospective data on 100 patients (March to August 2001) revealed that various distressing physical symptoms (cachexia, dyspnoea, constipation) had not been routinely assessed earlier. Despite previous treatment, adequate pain management as per the WHO ladder was needed in 67 of 88 (76%) patients when they were seen by the PC team. On the regular follow-up visits to the PC clinic, 42% and 50% of the patients/relatives reported a response to and satisfaction with the treatment at their second and third visits. We believe two conclusions are justified. (1) Attention to palliative care needs could result in good treatment outcome and high level of patients' and doctors' satisfaction. (2) Since a specialist PC set-up is lacking in most medical institutions in India, the RT department is the best suited to delivery of palliative care for patients with advanced cancer.

Developing Countries↗

PubMed2005

A hexavalent human rotavirus-bovine rotavirus (UK) reassortant vaccine designed for use in developing countries and delivered in a schedule with the potential to eliminate the risk of intussusception.

There is an urgent need for a rotavirus vaccine, because up to 592,000 infants and young children <5 years old die each year from rotavirus diarrhea, predominantly in the developing countries. We have developed a tetravalent human-bovine rotavirus (UK) reassortant vaccine with VP7 (G) specificity for serotypes 1, 2, 3, and 4, which has been shown to be safe, immunogenic, and effective in preventing severe rotavirus diarrhea. However, because of the emergence of VP7 (G) serotype 9 as an epidemiologically important serotype and the importance of VP7 (G) serotype 8 in focal areas, we are planning to add human-bovine (UK) reassortants with G8 and G9 specificity to the tetravalent vaccine, thereby formulating a "designed" hexavalent vaccine for universal use. In addition, we propose that the vaccine be administered orally in a 2-dose schedule, with the first dose given at 0-4 weeks of age and the second dose given at 4-8 weeks of age, when infants are relatively refractory to developing intussusception, thereby avoiding the age period when naturally occurring intussusception is most prevalent (i.e., ages 3-4 months through age 9 months). In this way, there may be the potential to eliminate or at least significantly decrease the risk of intussusception associated with rotavirus vaccination.

Administration, Oral↗

PubMed1993

Diagnosis of Helicobacter pylori infection in a developing country: comparison of two ELISAs and a seroprevalence study.

Serology to detect antibodies to Helicobacter pylori is not frequently used as a diagnostic tool in developing countries. When compared to a commercial ELISA, an ELISA constructed and validated in Thailand had a higher sensitivity (98% vs. 85%), specificity (76% vs. 66%), and negative predictive value (97% vs. 76%) for the detection of H. pylori infection among 104 patients with dyspepsia evaluated by endoscopy. The positive predictive value was 88% for both tests. Serum antibody levels fell significantly 5-8 months after eradication of infection in 8 Thai patients (P = .009). By 8 years of age, > 50% of Thai persons living in urban and rural locations were seropositive. The low negative predictive value of the commercial ELISA limits the usefulness of this assay as a diagnostic tool in Thailand and suggests a need to reevaluate H. pylori serologic tests when used in populations living in developing countries.

Adolescent↗

PubMed1994

Let pharmacists do more for health in developing countries.

It is desirable that the role of the pharmacist be expanded in developing countries, particularly with a view to coping with the problems of poor access to essential drugs and the irrational use of drugs. This objective requires improved collaboration between the medical and pharmacy professions.

Developing Countries↗

PubMed1990

A systems analytical framework for rural to rural migration studies in developing countries.

"This study is an attempt to examine a substantial and important migration type in developing countries, in this case, rural-rural migration. Its focus is on the development of an explanatory model to account for the determining factors for, and impact of, rural migration. Recognising the diversity of causal factors in rural migration in traditional societies of the world, the model proposes that the rural-rural migration phenomenon is better understood within the systems analytical framework."

Demography↗