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The Indian government has a national tuberculosis (TB) plan based on DOTS recommendations. The private health sector plays an increasing role in health care provision in India, and a public-private mix (PPM) project has been introduced to standardise TB diagnosis and treatment methods in Kerala, India. This study interviewed 45 private practitioners (PPs) to evaluate diagnostic, treatment and reporting practices, of whom 80% diagnose with sputum microscopy and 43% treat all of their patients according to the treatment regimens recommended by the DOTS strategy. This study demonstrates that the current management of TB by private practitioners in Kerala is still in need of improvement.

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The paper briefly outlines some of the ethical issues involved in community-based research particularly in developing countries. It focuses on informed consent, confidentially and the obligations to the community or its members who participate in the study. Most ethical guidelines are focused on the individual participants. Yet increasingly the community may be the unit of study. More attention will need to be directed towards developing guidelines for community-based research

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Globalization has led to an increase in the spread of emerging and re-emerging infectious diseases. International efforts are being launched to control their dissemination through global surveillance, a major hindrance to which is the failure of some countries to report outbreaks. Current guidelines and regulations on emerging and re-emerging infectious diseases do not sufficiently take into account the fact that when developing countries report outbreaks they often derive few benefits and suffer disproportionately heavy social and economic consequences. In order to facilitate full participation in global surveillance by developing countries there should be: better and more affordable diagnostic capabilities to allow for timely and accurate information to be delivered in an open and transparent fashion; accurate, less sensationalist news reporting of outbreaks of diseases; adherence by countries to international regulations, including those of the World Trade Organization and the International Health Regulations; financial support for countries that are economically damaged by the diseases in question. The article presents two cases--plague in India and cholera in Peru--that illuminate some of the limitations of current practices. Recommendations are made on measures that could be taken by WHO and the world community to make global surveillance acceptable.

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During 1980-1990 BRAC, a Bangladeshi non-governmental organization, taught over 12 million mothers how to prepare oral rehydration therapy (ORT) at home with lobon (common salt) and gur (unrefined brown sugar). This was followed by a strong promotion and distribution of prepackaged ORS by various agencies including the government. In 1993 we assessed knowledge of ORT preparation, its local availability and its use for the management of diarrhoea. Over 9000 households in 90 villages were revisited; 306 government outreach health workers, 296 drug sellers, and 237 village doctors were interviewed; 152 government facilities and 495 pharmacies/shops were visited. ORT prepared by mothers in a sub-sample of the households was analyzed for chloride content and interviewers collected information on use of ORT for diarrhoeal episodes occurring in the preceding two weeks. The data quality was assessed through a resurvey of sample respondents within two weeks of the first interview. Over 70% of the mothers could prepare a chemically 'safe and effective' ORS. A significant proportion of these mothers were very young at the time of the mass campaigns using house to house teaching, implying an intergenerational transfer of the knowledge on ORT. ORT was found to be used in 60% of all diarrhoeal episodes, but the rate varied with the type of diarrhoea, being highest for daeria (severe watery diarrhoea) and lowest for amasha (dysentery). Drug sellers and village doctors now recommend ORT much more frequently than before. Members of the medical profession (qualified and unqualified) still lag behind in prescribing the use of ORT. The availability of pre-packaged ORS in rural pharmacies has improved enormously. There is convincing evidence that the widescale promotion in the past of ORS for dehydration in diarrhoea has led to this marked improvement today. Nevertheless the use of rice-based ORS, culturally appropriate messages and the promotion of ORS with food offer opportunities to further improve the utilization of ORT.

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In urban and rural areas alike, people in India tend to prefer private medical care to the existing government health services. Nevertheless, the large private health care sector has hitherto been virtually alienated from activities of public health importance including priority disease control programmes. This study of 106 private general practitioners (GPs), practising in low socioeconomic areas of Bombay, shows a gross lack of knowledge and awareness among private doctors about leprosy and also about the National Leprosy Control Programme. The possible reasons are discussed. Effective involvement of GPs in the National Leprosy Control Programme should facilitate both integration and better implementation of leprosy control activities. The study also highlights some areas for future interventions at both primary and secondary health care levels and the need for a strategy, based on larger studies, to train and make private doctors participate in controlling diseases of major public health concern like leprosy.

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Humans have often used oral fluids to replace perceived losses of water, either instinctively or with a therapeutic orientation in the form of folk remedies. Replacement therapy with intravenous (IV) fluids was formally introduced in the last century for the treatment of patients with cholera. The modern implementation of oral replacement therapy was begun by pediatricians in the 1940s who used electrolyte solutions as maintenance therapy in mildly purging children with diarrhea. However, the scientific development of oral rehydration therapy (ORT) has occurred only in the last 30 years. Basic physiologic research in the 1950s demonstrated the cotransport mechanism of sodium and organic solutes (sugars and amino acids) in the intestinal cells, thereby establishing the scientific basis for ORT. The use of ORT based on scientific observations was first reported in 1964 from the Philippines by Phillips and coworkers. Research laboratories in Dhaka and Calcutta subsequently demonstrated that the mechanism of sodium and glucose cotransport remains intact in cholera patients and that oral solutions can successfully rehydrate and maintain hydration in these patients. Clinical studies carried out in Dhaka and Calcutta confirmed the efficacy of oral rehydration solutions (ORS) and showed that nearly 80% of IV fluid could be saved if patients were hydrated by the oral route. Further studies demonstrated the safety and efficacy of ORT in patients of all ages suffering from acute diarrhea of any cause. The use of ORT has substantially reduced morbidity and mortality from acute diarrhea, particularly after the World Health Organization adopted and promoted ORT on a worldwide scale. Researchers continue to search for better ORS formulations in terms of safety, efficacy, availability, and cost. Food-based ORS are a promising area of research. The use of a sound scientific method, the establishment of a close link between basic and clinical science, and the use of field studies have proved to be major assets in the development of ORT.

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Enteric infectious disease (EID), defined here as bacillary dysentery, viral hepatitis A, El Tor cholera, or acute watery diarrhoea, is an important public health problem in most developing countries. This study assessed the impact on EID of providing deep-well tap water (DWTW) through household taps in rural China. For this purpose, we compared the incidence of EID in six study villages (population, 10,290) in Qidong County that had DWTW with that in six control villages (population 9397) that had only surface water. Both the bacterial counts and chemical properties of the DWTW met established hygiene standards for drinking water. The incidence of EID in the study region was 38.6% lower than in the control region; however, the introduction of DWTW supplies did not significantly affect the incidence of bacillary dysentery. These results indicate that the construction and use of DWTW systems with household taps is associated with decreased incidences of El Tor cholera, viral hepatitis A, and acute watery diarrhoea. Since high construction costs have led many authorities to question the value of DWTW, we carried out a cost-benefit analysis of the programme. The cost of constructing a DWTW system averaged US $36,000 at 1983 prices, or US $10.50 per capita. The combined capital and operating costs of a DWTW system were US $1.46 per capita per annum over its 20-year estimated life. The benefits derived from reductions in cost of illness and savings in time to fetch water were 2.2 times the costs at present values Capital outlays were recouped in a 3.6-year payback period and the provision of DWTW proved highly beneficial in both economic and social terms.

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The annual economic burden of diarrhoea in four subdistricts in Indonesia averaged $2.27 per child aged under 5 years when health centre, hospital, and private expenditures were all considered. The community itself spent $1.03 per child or 46% of the total; 96% of community payments went to the private sector, and 4% were for fees at government health centres and hospitals. The widespread availability of oral rehydration therapy has led to only partial abandonment of ineffective or marginally effective medications; non-rehydration medications amounted to 44% of total treatment expenditures. Most medication costs were for antimicrobial agents, such as tetracycline in the government sector and iodochlorhydroxyquin in the private sector. If the use of tetracycline at health centres could be restricted to 10% of episodes treated instead of the present 88%, their costs could be reduced by 50%.

PIP: The annual economic burden of diarrhea in 4 subdistricts in Indonesia averaged $2.27/child under age 5 when health center, hospital, and private expenditure were all considered. The community itself spent $1.03/child or 46% of the total; 96% of community payments went to the private sector, and 4% were for fees at government health centers and hospitals. The widespread availability of oral rehydration therapy has led to only partial abandonment of ineffective or marginally effective medications; nonrehydration medications amounted to 44% of total treatment expenditures. Most medication costs were for antimicrobial agents, such as tetracycline in the government sector and iodochlorhydroxyquin in the private sector. If the use of tetracycline in health centers could be restricted to 10% of the episodes treated instead of the present 88%, their costs could be reduced by 50%.

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A representative country-wide rural nutrition status survey determined the extent and distribution of vitamin A deficiency in Sri Lanka in children 6 through 71 months of age. Trained paramedical personnel recorded the presence or absence of selected ophthalmological signs and symptoms associated with vitamin A deficiency in 13,450 children. The results of the country-wide clinical survey indicate that a vitamin A deficiency problem of public health importance may exist in two of 15 health areas. Serum vitamin A levels were determined on 346 survey children from two of 15 health areas and compared with clinical findings for these areas. The lowest mean serum vitamin A, 26.3 microgram/100 ml, occurred in children with clinical eye findings. A high prevalence of clinical eye findings, 34%, and the low mean serum vitamin A value, 28.2 microgram/100 ml, were found in the group of chronically undernourished children--children who are less than 90% of their expected height for age. The survey results enabled planned redirection of the distribution of vitamin A capsules to preschool children in Sri Lanka to areas shown to have the highest prevalences of ophthalmological signs and symptoms and/or the highest prevalence of chronic undernutrition.

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