[Prevalence of anemia in clients of a family planning clinic in Merida]
305 low income women living in marginal areas and without access to any kind of social security participated in a study of the prevalence of anemia conducted at a family planning clinic in the state of Yucatan, Mexico. The women were reproductive age, had a minimum of 2 children, and had not used oral contraceptives or injectable methods for a minimum of 3 and 6 months, respectively. 41 women were aged 15-19, 81 were 20-24, 70 were 25-29, 67 were 30-34, 33 were 35-39, and 13 were 40-44. 73 were illiterate, 192 had incomplete primary educations, 31 had complete primary educations, and 9 had higher educations. The majority of women had no history of serious pathology except that 270, or 88.5%, reported intestinal parasites. The average hemoglobin level was 10.88 g/dl with a standard deviation of 1.48. The majority of the women had hemoglobin values between 9-11.9 g/dl; 76% therefore were anemic according to a criterion of the World Health Organization (WHO), which considers 12.0 g/dl of hemoglobin as the lower limit in nonpregnant women. 48 women, or 20.68%, had iron deficiency anemia according to WHO definitions. Other findings of the hematological studies were an average hematocrit of 36%, serum iron level of 84.4 ug/dl, and an index of saturation of 23.8%. The women had a considerably higher rate of anemia than a group of young, healthy, childless, and well norished women studied in the same city. The higher frequency of anemia should be considered in prescribing contraceptive methods. (summary in ENG)
The changing employment pattern in the developing world.
The research of Michael Hopkins, carried out under the International Labor Organization (ILO) World Employment Program reaches the conclusion that industry and, especially, services are rapidly outstripping agriculture as the main providers of jobs and major contributors to gross domestic product (GDP) in the developing world. The background data for this analytical survey come from 92 developing countries and cover some 2254 million people or 97% of the developing world's population. The findings show that in the 1960-80 period, agriculture's share of GDP in the 92 countries almost halved, falling from 31-17%. Its share of the labor force, meanwhile, dropped from 72.6-59.1% during the same period. At the same time, industry boosted its GDP share in developing countries from 30-39% and its contingent of the labor force from 13-20%. Industry's great leap forward in the developing countries came in the 1960s, in the heyday of import substitutions, when its share of the GDP soared from 30-38%. Third world industrial expansion slowed considerably during the 1970s when its portion of GDP increased only by 0.5%. For most developing countries, the growth sector over the 1960-80 period has been that of services, which gained momentum in the 1970s and by the end of the decade accounted for about 44% of the developing world's GDP. The services share of the labor force also increased from 14.5-21%. Hopkins warns that the pace of change in the structure of the 3rd world labor force has to be reckoned against a worldwide recession, which has impeded economic growth and increased unemployment, and the persistence of widespread underemployment and poverty in many areas of the developing world. If growth rates continue to lag in the 3rd world, unemployment rates could rise substantially in the next few years. From now until the year 2000, the unemployment situation could worsen unless a growth momentum is restored along with greatly improved income distribution. The unemployment figures alone fail to provide a true picture of the job situation in the third world, for they fail to reflect the acute underemployment and poverty which exist there. Hopkins's extrapolations from available data reveal an increase in underemployment in developing countries (excluding China) from 421 million to 448 million persons over the 1974-82 period.
In postindependence Africa new and more efficient strategies were required to support educational expansion. Political independence was accompanied by an increased demand for education to meet the growing labor force needs of the emerging countries in Africa. It was considered that education, as a means for human resource development, was a viable capital investment necessary to support both social and economic development, yet in many African nations, the educational systems and the traditional teaching methods inherited from colonial rule were not adequate to satisfy the increased demand for trained personnel. In response to the need for educational reforms and expansion, governments of many African countries invested heavily in the development of their education systems. During the 1970s it is estimated that Africa spent between 15-20% of the national budget on education. That high level of expenditure was justified by the increased demand for education. The educational expansion efforts also increased shortages of qualified and competent teachers, shortages of adequate equipment, and physical facilities. New strategies and resources with required to solve these increasing problems. Many African countries began to experiment with the use of mass communication technologies to support their educational reform efforts. There was generally consensus that the mass media, particularly radio and television, had certain qualities that could be exploited either to replace or improve conventional methods of teaching. By the late 1960s at least 16 African countries were using educational broadcasting of 1 form or another. International aid agencies, govermental donor agencies, and private foundations in the industrially advanced countries provided the support base for many African countries in their efforts to use radio and television for educational improvement. Most of these efforts failed to make any significant impact on educational development in Africa. Educational analysts have generally concluded that post-independence educational reforms in Africa failed to achieve thier aims. Some recommendations are offered with the objective of contributing to the ongoing international effort to search for more effective approaches in using communication technologies to support educational development in Africa. Technical assistance programs supporting educational use of modern communication technologies should be perceived in the context of international cooperation, with a 2-way flow, rather than in the context of a donor recipient relationship. Greater emphasis should be placed on thorough country by country assessment of educational needs and problems in order to provide an adequate basis for designing project objectives and project contents to satisfy specific needs. Needs assessment should be tempered with pragmatism and flexibility in approach. Training and orientation for foreign and local exports and increased local participation are among the recommendations.
Use of laparoscopy to determine the microbiologic etiology of acute salpingitis.
To determine the microbiologic etiology of acute salpingitis, laparoscopy was used in 26 patients to obtain specimens for a variety of microorganisms directly from the fallopian tubes. Simultaneous culdocentesis was performed to obtain peritoneal fluid for microbiologic analysis. A variety of microorganisms were isolated from the fallopian tubes and cul-de-sac aspirate. However, the organisms isolated from the fallopian tube were not consistent with the cul-de-sac isolates. It appears that direct culture from the fallopian tube may be necessary to determine the microbiologic etiology and pathogenesis of acute salpingitis. N. gonorrhoeae was isolated from the cul-de-sac in 32% of cases and the fallopian tube in 19%. In patients with endocervical gonorrhea, the gonococcus was isolated from the fallopian tube in 38.5% of the cases. Aerobic and/or anaerobic bacteria were present in the cul-de-sac aspirate in 46% of patients and in the fallopian tube in 38%. (author's)
Genital infections in Swaziland.
The relative frequency of the sexually transmitted diseases (STD) problem presenting as urethral discharge, vaginal discharge, genital complaints, genital ulceration, and inguinal adenopathy (bubo) seen at outpatient departments of the Mbabane Government Hospital in Swaziland were estimated and their etiology was determined. Collection of this type of data is a 1st step towards the development of treatment and control strategies for STD in any country. The data of the STD presenting problems was recorded during the January-February 1978 period. During a 3-week period, in addition to a clinical examination a number of diagnostic tests were performed to establish the eitology of the STD problem. Over a 5-week period, 249 patients were seen with an STD problem--urethral discharge, vaginal discharge, or genital ulceration. No figures were obtained on patients who presented only inguinal adenopathies. In males, 42% presented with urethral discharge, 51% with genital ulceration, and 7% with both problems, showing clearing the high frequency of multiple STD in these patients. 71% of females presented with vaginal discharge and/or genital complaints, and 29% with genital ulcers, in some cases combined with vaginal discharge. 82% of the males with urethral discharge had gonorrhea, 14% had nongonococcal urethritis, and 4% had no urethritis. Of the 65 females with vaginal discharge and/or genital complaints, 21.5% had gonorrhea, 24.6% trichomoniasis, and 23.1% candidasis. In patients with genital ulceration the clinical diagnosis was syphilis in 26%, herpes in 4%, and the remaining 70% were diagnosed as chancroid. Lymphogranuloma venereum and probably also granuloma inguinale were seen, but as the distinction on clinical grounds is difficult all these cases were classified as chancroid. On the basis of these figures for a 5-week period, it can be estimated that at the outpatient department of the Mbabane Hospital (with catchment area of 40,000 population) between 2500 and 3000 patients are seen annually with STD problems. This illustrates the great burden imposed on the health services by STD control in African countries.
The neglected male [editorial]
Infertility should not be considered a condition that affects the male and female separately. The concept of evaluating and managing infertile couples as a unit is becoming well established among sophisticated physicians. The investigation and management of male related infertility continues to be a cause for concern among both physicians and the lay public. Generally, the male partner of an infertile union is neglected. Most physicians refer their infertile males to a urologist for initial evaluation or management of specific problems. A few urologists who have the expertise and experience to manage male infertility can be found in most large communities and medical centers, and some of these physicians have limited their entire practices to infertility. Many urology residency programs are deficient in subjects related to male reproductive biology and endocrinology. Urologists who graduate from such programs are unprepared to provide care for infertile men. The result of this system is that the male partner of the infertile couple is neglected by both the gynecologist and the urologist. In many localities it is common to see men who have been under the care of a physician for months and at times years without the benefit of adequate evaluation or treatment. The use of long discarded therapeutic modalities such as thyroid preparations for the treatment of oligospermia continues unabated. Another problem is the lack of laboratory facilities and trained technicians for semen analysis. Knowledge of the physiology of the male reproductive function is still rudimentary, and diagnostic tools are crude. Satisfactory tests to assess the capability of sperm to effect migration and survival in the female reproductive tract and fertilize the ovum have not been developed. The level of training of both gynecologists and urologists in reproductive sciences must be improved. Semen analysis should be performed in laboratories equipped to process the sample by trained technicians who will provide the physician with a comprehensive support. Research in male reproductive biology must continue with the purpose of elucidating parameters which indicate functional disorders of spermatozoa. Several new techniques have recently been developed for the investigation of functional defects in human spermatozoa.
The problem of infertility in western Equatoria.
A survey was conducted to investigate the problem of infertility among the tribes of Western Equatoria. The selection of these tribes was motivated particularly by reports of the magnitude of the problem of infertility and depopulation in this area. The total population of all the Chiefdoms surveyed in the 1962-63 period was 100,8484; the total number of married women surveyed was 7111. The incidence of infertility was very high among the tribes in the Zande and Moru districts ranging from 24% among the Avokaya to 60% among the Zande. The Zande and Makraka tribes showed exceptionally high infertility rates, 51% among the Zande and 47% among the Makraka. There was no problem of infertility among the tribes of Yei district except the Makraka. The Fajulla, Kakwa, and Kaliko were very fertile. Analysis of the obstetrical and family histories of 353 unselected Makraka couples yielded a primary infertility rate of 47% and a secondary infertility rate of 16%. All the women who were studied showed an extreme desire for children, and they willingly accepted repeated and painful examinations. Bimanual pelvic examinations were performed on 198 unselected women to detect evidence of pelvic inflammation or other abnormalities. The diagnoses of chronic pelvic infections were based on the history of the presence of vaginal discharge together with palpable tender adnexal abnormalities. The adnexal inflammatory tuboovarian masses were gross in 16 women (10%). Among the fertile women, 8 (22%) showed signs of infection. Tumors (other than inflammatory) were found in 17 infertile women (11%) and in none of the fertile women. Cervical erosion was encountered in 16 women (13.2%). The position of the uterus was checked in all cases and was retroverted in 16 of 36 fertile women and 60 of 153 infertile women (40%). Lateral displacement was occasionally found in association with adnexal inflammatory masses and tumors. The uterus was very small and conical in 5 infertile women. The Kahn serological test for syphilis was performed in 285 women; 28 (10%) were serologically positive for syphilis. The positive cases were equally shared by the fertile and infertile women. The clinical investigations performed on 241 infertile women and 228 men (from the Zande and Makraka tribes) included general physical examination, gynecological examination of the pelvic organs, vaginal and cervical smears, tubal insufflation, examination of the male genital organs, urethral smears, and semen analysis. The following were among the most clinical findings associated with infertility. In the female there was a high incidence of pelvic inflammatory lesions in 49% and blockage of the fallopian tubes in 58.2%. Gonococci were detected in 0.9% of the smears. In the males there was deficient semen in 60.5% associated with hydroceles (11.9%), varicoceles (4.4%), epididymoorchitis (6.6%), and clinical testicular atrophy (7%). The physical causes of infertility could be due to venereal diseases, postpartum pelvic infections, and filariasis.
Epidemiology and aetiology of urethritis in Swaziland.
The annual incidence of urethritis can be estimated to be at least 3750/100,000 population in Swaziland. In a study of 109 males with symptomatic urethritis, 80% had gonorrhea, 6% nongonococcal urethritis (ngu), and 14% were classified as having no objective urethritis (less than 5 polymorphonuclear leucocytes/highpower field in the urethral smear). The relative frequency of gonorrhea was 80-95% and of nongonococcal urethritis 5-20% according to which criteria are used for patient selection and/or diagnosis ngu. Chlamydia trachomatis was cultured in 3.4% of the cases with urethritis, comprising 1 positive culture in 70 patients with gonorrhea, 1 in 5 with ngu, and 1 in 12 with no objective urethritis. 71% of patients with a comparable percentage in each diagnostic group, had chlamydial antibodies when tested by the microimmunofluorescence test to pooled chlamydial antigens. Interpretation of the chlamydial serologic results indicates that lymphogranuloma venereum is probably endemic in the country, and that oculogenital chlamydial infections are not a problem; this corresponds with the low isolation rate of Chlamydia trachomatis in the urethritis cases. The study shows that the epidemiology and causes of urethritis are clearly of a different pattern to that seen in industrialized countries. This type of study is a sound basis for a simplified but effective urethritis control program which can be implemented in the paraurban and rural health centers in developing countries. (author's)
Post-mortem compared with clinical diagnosis of genito-urinary tuberculosis in adult males.
5424 necropsies performed on men aged 16 and over from 1935-44 were analyzed with regard to age; race; death from tuberculosis; unhealed tuberculosis in those dead from other causes; the relationship between pulmonary, renal, and genital tuberculosis; and comparison of the necropsy with the clinical diagnosis of genito-urinary tract tuberculosis. The incidence of genito-urinary tuberculosis was greater among the 565 nonwhites and among men under age 40. Tuberculous lesions were found in the genito-urinary organs in 3.1% of necropsies, in 4.5% of persons harboring unhealed tuberculous lesions who died from other causes, and in 26% of those who died from tuberculosis. 85% of men with tuberculous lesions in the genito-urinary system had caseous or cavitating pulmonary foci. 45.9% of those presenting tuberculous lesions in the genito-urinary system died from generalized miliary tuberculosis compared with only 3% of those with no tubercular foci. It is hypothesized that individuals who develop genito-urinary tuberculosis have an impaired resistance to infection in general. Renal lesions were twice as frequent as those in the prostate and 3 times as frequent as those in other genital organs. In tuberculosis of the genital system, the prostate, seminal vesicle, and epididymis were all involved in 63% of cases, the prostate alone in 29%, and the seminal vesicle or epididymis alone in no cases. Involvement of the prostate is believed to succeed renal involvement in a high proportion of cases. The 6 patients who had an epididymectomy prior to death all died from tuberculosis, with both prostate and seminal vesicles affected, indicating that the procedure is not effective in genital tuberculosis. A clinical diagnosis of tuberculosis was recorded in 80% of patients with genito-urinary tuberculosis, but genito-urinary disease was recognized in only 18%. Only half the patients with tuberculous renal cavity and 40% of those with necrotic but unexcavated renal lesions presented urinary symptoms. Determination of the sequence in which organs of the genito-urinary system are affected will require a meticulous search for minute tuberculous foci prior to clinical manifestation of disease or development of lesions noted at necropsy. Such study will permit confirmation of the assumption that tuberculous lesions of the genital organs are not secondary to tuberculous lesions in the kidney.
In utero infection of the fetus by herpes simplex virus.
Case histories are presented of 2 premature infants with herpes simplex virus (HSV) infection occurring in utero, probably as a result of transplacental transfer of the virus. Case 1, a 969 gm girl who died at 71 hours of age, was noted at birth to have vesicles and bullae filled with clear or serosanguineous fluid. Viral cultures of the skin lesions were positive for HSV. A significant amount of immunoglobulin M (IGm) was present in the infant's serum and the neutralizing antibody (NA) titer to HSV was 1:8, suggesting that the fetus produced antibody in utero. The mother's serum contained 240 mg % of IGm, with a NA titer of 1:32. The father's serum NA titer was 1:64. Case 2, a 1960 gm infant, showed small, circumscribed areas of erythema at 1 hour of age. The skin lesions progressed until death on day 11. A diagnosis of generalized HSV was made, and HSV was isolated from the brain at autopsy. This infant's serum did not contain neutralizing antibody to HSV. Neither infant was exposed to an infected mother, father, or hospital worker. Such exposure accounts for 40% of neonatal HSV disease. The presence of lesions at birth in these 2 cases rules out postnatal exposure since HSV has a minimum 4 day incubation period. An animal study has indicated that transplacental transmission of HSV is the route of infection in utero. Maternal viremia associated with subclinical infection may be a significant source of herpes virus. Another possible source of infection is ascent of HSV from the maternal genital tract, particularly when manipulative procedures are attempted during the pregnancy. Treatment of HSV infection in newborns with gamma globulin or convalescent serum is nonspecific and ineffective. Prevention of contact with infected individuals remains the most important factor for control of herpetic infection.
Bacteriologic observations derived by culdocentesis in 17 women with gonococcal endometritis-salpingitis from whom 1 or more bacteria were isolated are reported. Neisseria gonorrhoeae was cultured from the cul-de-sac in 11 cases and identified by Gram stain in 1 additional case. N. gonorrhoeae was the only isolate in 5 of these patients. Concomitantly with N. gonorrhoeae, aerobic bacteria were recovered in 2 cases and multiple anaerobic bacteria in 4 cases. In the remaining 6 cases, only aerobic and anaerobic organisms were isolated. Analysis of the Gram stain of the endocervix revealed the presence of intracellular gram-negative diplococci in 10 of 11 smears where N. gonorrhoeae was isolated. Diplococci were not demonstrated when N. gonorrhoeae was absent from the culdocentesis fluid. The data tend to refute the concept of a polymicrobial etiology for pelvic inflammatory disease, suggesting instead progressive anaerobic superinfection with nonrecovery and probable elimination of N. gonorrhoeae. The presence of aerobic/facultative anaerobes with obligatory anaerobes argues against an end-stage anaerobic environment.
Paired sera from 60 consecutive patients with acute salpingitis, confirmed by laparoscopy, were examined for serum antibodies to Chlamydia trachomatis, Mycoplasma hominis, and Neisseria gonorrhoeae. By a microimmunofluorescence (MIF) test, IgM or IgG antibodies to C. trachomatis or both were present in sera from 80% of the patients; by indirect hemagglutination (IHA) tests, antibodies to M. hominis and N. gonorrhoeae pilar antigens were present in 40% and 18% respectively. In a control group of 50 pregnant women, antibodies to the same 3 organisms occurred in 8%, 8%, and 6%. Evidence of current chlamydial infection was found in 35 (58%) and of current gonococcal infection in 5 (8%) of the 60 patients by culture or serological tests, or both. The results of chlamydial antibody tests correlated with the severity of the tubal inflammation (shown by laparoscopy) and the duration of lower abdominal pain before attendance. The predictive values of a positive and a negative MIF test result were 44% and 83% respectively and of the IHA gonococcal antibody test, 36% and 100% respectively. Significant rises in titer of antibodies to M. hominis were found in 12% of the patients. A 4-fold or greater rise in titer indicated probable double infections with chlamydia and mycoplasmas in 7% of patients. Thus, at the present, gonococcal salpingitis appears to form only a small proportion of all cases of salpingitis in southern Sweden, and in patients with nongonococcal salpingitis infections with C. trachomatis and M. hominis commonly occur. (author's modified)
In the Scandinavian countries, Chlamydia trachomatis seems to be the most common cause of sexually transmitted diseases, including acute pelvic inflammatory disease (PID). Chlamydial infection of the female genital tract may induce cervicitis. A correlation between the occurrence of C. trachomatis and cervical dysplasia has been found. The organism may reach the uterine endometrium via the cervical epithelium, producing endometritis. From the uterine mucosa, the infection may spread canalicularly to the fallopian tubes, where it may induce PID. Chlamydial infection is also associated with perihepatitis (Fitz-Hugh Curtis syndrome). In addition, chlamydial genital infection seems to be an important cause of sterility. Experimental infection in grivet monkeys with C. trachomatis results in cervicitis, endometritis, PID, and perihepatitis. (author's)
Antibodies to Mycoplasma hominis in patients with genital infections and in healthy controls.
To examine the relationship of Mycoplasma hominis to lower genital tract (LGT) infections, 355 sera from 52 women with acute salpingitis, 70 women with infection confined to the LGT, and 154 healthy women were analyzed for antibody to M. hominis by means of the indirect hemagglutination (IHA) technique. These results were compared with the finding of M. hominis in cultures. The distribution of IHA antibody to M. hominis among women of different ages (1-73 years) was found to be highly correlated with the occurrence of the organism in the LGT and with the prevalence of genital infections. 16 of the salpingitis patients from whom more than 1 serum specimen was collected had IHA antibody to M. hominis at a titer of 1:16 or greater. The organism was isolated from the cervix in all 16 of these cases and from the fallopian tubes in 3 patients. Overall, M. hominis was isolated from 36 (69.2%) of the 52 women with acute salpingitis and 25 of them had a titer of 1:16 or more. Antibody to M. hominis was found in 59.6% of the women. Among the women with LGT infection, M. hominis was recovered from 38.6% and IHA antibody to the organism at a titer of 1:16 or greater was found in the sera of 27%. Anitbody to M. hominis was noted in 10.5% of the sera of the 57 nonpregnant healthy women of childbearing age, 8.5% of healthy pregnant women, and in none of the prepubertal or postmenopausal healthy women. The organism was isolated from 14.9% of the healthy pregnant women, but from insignificant numbers of the prepubertal, menstruating, and postmenopausal cases. Overall, M. hominis was isolated from 73 women in the study and their sera contained antibody to the organism at a titer of 1:16 or greater in 42 instances (57.7%). The corresponding figure for the 203 women from whom the organism was not cultured was 16 (7.9%). The difference between these 2 incidences was highly significant (p>0.001). Of the 16 women whose sera contained antibody to M. hominis but from whom the organism was not cultured, 8 had signs of LGT infection and 4 had a recent history of infection. Additionally, 73 sera from male venereal disease clinic patients and from healthy men were compared. Antibody to M. hominis was found in 30% of sera from the former group but in only 4% of the latter group. (summary in FRE)
Chlamydia trachomatis infection in patients with acute salpingitis.
The prevalence of Chlamydia trachomatis in the cervix and fallopian tubes of patients with acute salpingitis was examined. Cycloheximide-treated McCoy cells were used as the growth medium. For purposes of comparison, women with infections confined to the lower genital tract and women without signs of genital infections were also studied. C. trachomatis was isolated from the cervix in 19 of 53 patients with acute salpingitis, in 1 of 18 lower genital tract infections, and in none of 12 without signs of genital infection. C. trachomatis was recovered from 6 of 20 valid specimens from the fallopian tubes of the patients with acute salpingitis. Our results indicate that chlamydia is a common etiologic agent in acute salpingitis. (author's modified)
South India: yesterday, today and tomorrow: Mysore villages revisited.
An interdisciplinary approach to the study of development at the micro-level was employed in an effort to examine the interaction between economic and other variables within a social system. The 1st field work was conducted in South India in 1954-56, when the impact of irrigation on the economic and social organization of 2 villages within a regional economy was studied. Dalena, a dry, and Wangala, a wet village, are situated close to each other within the same culture area near Mandya town in Mysore State, South India. These particular villages were chosen because of their multicaste compostion and because they were then still outside the sphere of the Community Development Project. Results wre published in 1962. The villages were revisited after a lapse of 15 years, and this study enables an identification of the trends of change in these 2 South Indian villages, and within the different sections and economic strata in each of them, and an analysis of the various economic, political, and social factors and their interactions responsible for the observed changes. The sample was random insofar as the actual households in the sample were selected at random, but it was at the same time stratified in as much as households had been previously put into economic categories on the basis of landholding and the size and age composition of the household. The Wangala sample was made up to 64 of the 192 village households; of the sample of 51 of Dalena's 153 households, 3 had to be discarded. Dalena's population has increased at an average annual rate of at least 2.5% over the last 15 years. Family planning, although widely advocated in Mandya district, has not been accepted by many villagers, natural population increase must be expected to continue at least at its present rate. Unless migration takes on unprecedented proportions, Dalena's population is likely to double within the next 30 years. There is little chance that within this period canal irrigation will bring water to Dalena, though there is a possibility of more efficient pump irrigation being introduced to irrigate the village dry land and thereby increase agricultural reproductivity. If this were accompanied by the introduction of high yielding varieties of millet and paddy seeds comparable in result with the high yielding wheat varieties, Dalena might be able to produce overall sufficient crops to feed its population for the next 10-15 years, but in view of past trends such expectations seem optimistic. More realistic is the assumption that population will continue to grow much faster than the increase in village food production. Wangala's population also must be expected to continue growing. Wangala men are even less interested in family planning than are their Dalena counterparts. Wangala's population will problably double in about 25 years. If in the meantime a high yielding variety of paddy can be successfully introduced this will obviously increase the carrying capacity of irrigated land. Although Wangala has been incorporated in the cash economy, farmers are still only secondarily cash croppers. Their basic concern is to grow sufficient subsistence food.
Article 19 of the Constitution of the International Labor Organization (ILO) provides that Members shall report to the Director General at appropriate intervals on the position of their law and practice in regard to the matters dealt with in unratified Conventions and Recommendations. The reports summarized in this volume concern the Migration for Employment Convention (Revised) (No. 97) and Recommendation (Revised) (No. 86), 1949, Migrant Workers (Supplementary Provisions) Convention, 1975 (No. 143) and Migrant Workers Recommendation, 1975 (No. 151). The governments of member States were asked to send their reports to the ILO Office by July 1, 1979, and this summary covers country reports received by the Office up to November 1, 1979. Reports are included for the following countries: Argentina, Austria, Belgium, Benin, Bolivia, Botswana, Brazil, Cameroon, Colombia, Congo, Cuba, Cyprus, Czechoslovakia, Dominican Republic, Egypt, El Salvador, Fiji, Finland, France, Gabon, German Democratic Republic, Guyana, Hungary, India, Japan, Kuwait, Lebanon, Luxembourg, Madagascar, Malaysia, Mali, Malta, Mauritius, Mexico, Mongolia, Morocco, Netherlands, Niger, Nigeria, Norway, Pakistan, Panama, Peru, Philippines, Poland, Portugal, Romania, Rwanda, Senegal, Sierra Leone, Singapore, Spain, Sri Lanka, Sudan, Surinam, Swaziland, Sweden, Switzerland, Tanzania, Turkey, USSR, UK, Uruguay, Venezuela, and Zambia.
In vitro fertilization's future looks bright.
The 1st birth of a human "in vitro baby," in England in 1978 was followed by successful pregnancies in Australia, England, and the US. At this time, more than 100 women are pregnant after in vitro fertilization procedures, and there have been about 40 live births. Conventional methods to predict ovulation--basal body temperature graphs, cervical mucus changes, vaginal cytology, and serum hormone parameters--can predict only approximate time, and more precise methods of timing are essential to success. To ensure the recovery of mature oocytes, ovulatory function is monitored with real time ultrasound and rapid estrogen determinations. Real time is good for watching follicular changes on a daily basis. The 1st scan is performed with a real time sector scanner 1 day after the last clomiphene dose. At that time, the dominant follicle or follicles visualized should be at least 14 mm in diameter. If no follicle is adequately developed, therapy is extended 1-3 days, with the addition of hMG. Daily monitoring is continued until the follicle reaches 18 to 20 mm in diameter. At this point, blood samples are obtained twice daily and estradiol is measured by rapid radioimmunoassay. Once the preovulatory surge of estradiol appears 4000 IU of human chorionic gonadotropins (hCG) is given, and laparoscopy is performed precisely 36 hours later. This timing is essential because the eggs will be released spontaneously 38-40 hours after the hCG injection. Mature oocytes were obtained in 23 of 23 treatment cycles. This method, which combines ultrasound monitoring of the follicles' growth with the production of estradiol, ensures that the aspirated oocytes are mature and capable of fertilization. As long as luteinizing hormone (LH) levels are basal, the laparoscopy is performed. The male partner supplies a semen sample by masturbation approximately 5-7 hours after successful oocyte recovery. The sperm count and motility are estimated, and if these parameters are adequate, a 0.5 mL aliquot of the semen is washed in Ham's F-10 solution by a 2 wash technique. After removing the seminal plasma, the spermatozoa are incubated for an additional 40 minutes. Then 500,000 motile spermatozoa are added to each oocyte culture tube and incubated for 18 hours. The embryos are deposited by injecting 0.05 mL of Hepes buffer solution through a catheter. After 10 hours in Trendelenburg position, the patient leaves the hospital to remain at bedrest for the next 36 hours. Before 1981, overall pregnancy success ranged from 1% to 8% worldwide. Today the worldwide pregnancy statistics are between 17-20%. Before the rate of successful pregnancies can be increased further, several factors need to be improved.
Malarial infection of the placenta and foetal Nutrition.
The data in this study of malarial infection of the placenta and fetal nutrition were otbained from consecutive live singleton births to African women, mostly of the Sukuma, Nyamwezi, and Luo tribes at the Government Hospital, Mwanza (East Africa). Thick smears were made from the maternal side of the placenta and the sex and birth weight of the child noted. The slides were stained with Giemsa stain and each examined by 2 laboratory technicians for at least 1/2 hour by each, i.e., 1 hour in all, before being pronounced negative. Of a total of 400 smears, 21.5% contained malaria parasites and of these 82.6% were Plasmodium falciparum, 14.0% P. vivax, and 3.5% mixed infections. The placenta frequently contained large numbers of schizonts in various stages of growth although the peripheral blood of the mother may have few or no parasites present. Conditions in the placenta would seem to be suitable for the multiplication of malaria parasites in isolation from the rest of the circulation. Some placental smears were so closely packed with segmenting parasites that the appearance resembled that seen in the peripheral blood in cerebral malaria. Biochemical determinations were begun after the placental smear examinations had been under way for some time. Cord blood was taken during the 3rd stage of labor and a sample of venous blood obtained from the mother within a few hours of delivery. Whole blood was taken for hemoglobin, packed cell volume, and ergothioneine determinations, the latter after storage in the deep freeze. In plasma, estimations of proteins and vitamin A were carried out, deep freezing until required. The data of the Nigerian workers and these results are presented in table form for comparison. All showed a lower mean birth weight in the infected group. After division of the data on the basis of sex of the fetus the mean birth weight in the infected males was actually higher than in the noninfected. This tended to minimize the lowering effect of the female group when the sexes were considered together. Sex differences were not apparent for the biochemical data and the pooled results for mean corpuscular hemoglobin concentration, plasma vitamin A, red cell ergothioneine, and plasma proteins did not show any differences between infected and noninfected groups. Vitamin A was selectively absorbed by the fetus in the presence of maternal deficiency.
The occurrence of classic Mycoplasma, T-strain Mycoplasma, bacteria, and Trichomonas vaginalis in the uterine tubes of laparoscopized patients with acute salpingitis was investigated. Cervical and urethral specimens were also obtained. Women with infections confined to the lower genital tract and healthy females were investigated also. The 50 patients in the salpingitis group presented with a history and clinical signs suggestive of acute salpingitis. In all cases the diagnosis was confirmed by laparoscopy. In 50 women with infections confined to the lower genital tract, 2 of the following signs had to be present as diagnostic criteria: purulent or sanguino purulent discharge from the cervical os, abnormal pain on bimanual palpation of the cervix, or reddened vaginal mucosa. None of the group of 50 noninfected controls had any symptoms referable to infection in the genital tract. M. hominis was isolated from the cervix in 62% of the cases of salpingitis, in 46% of the cases of infection of the lower genital tract, and in 4% of the healthy women. M. hominis was isolated in pure culutre from the fallopian tubes in 12.9% of the patients with salpingitis who harbored M. hominis in the cervix. No significant difference was demonstrated in the occurrence of T-strain Mycoplasma in women with (50%) and without genital infections (44%). In 2 cases of salpingitis, T-strains were recovered from the uterine tubes. N. gonorrhoeae was cultured from the cervix in 34% of the patients with salpingitis but from the uterine tubes in only 4 cases. In only 3 cases were bacteria, apart from N. gonorrhoeae, isolated from the fallopian tubes in cases of salpingitis. T. vaginalis was recovered from the uterine tubes from 1 patient with infection of the lower genital tract, but there were no isolations from any of the patients with salpingitis. In addition to providing an objective means of diagnosing acute salpingitis, laparoscopy has offered excellent possibilities for obtaining samples directly from the fallopian tubes.
Impact of VD on the fertility of the U.S. black population, 1880-1950.
Despite the absence of hard data about venereal disease (VD) and fecundity changes in the black population, it is possible to go beyond speculation and suggestion to areas of circumstantial evidence concerning these variable sand their relationship. The only detailed effort in this direction appears to be the work of Reynolds Farley. In "Growth of the Black Population" (1970), Farley examines variables that might be used to explain the black fertility decline between 1880 and 1936. He concludes that this decrease appeared to be brought about by alterations in health conditions which were unfavorable to fecundity. The principal fertility inhibiting pathologies which Farley studied were pellagra and VD. Farley sees changes in VD prevalence as an important determinant of the fertility decline before the Depression and the following rise in the birthrate. Discussion examines some of the arguments used to support this conclusion and will offer a more conservative interpretation regarding the importance of VD as it relates to the history of the black population. Attention is directed to 3 questions: did VD actually become more prevalent between 1880 and 1935; was the sudden increase in fertility around 1936 preceded by the effective control of VD in the black population; and what was the quantitative physiological impact of VD on black fertility. Farley's effort to show that VD prevalence increased from 6.5% to 25.2% between 1918-40 damages his argument that an increase in VD prevalence was an important determinant in the trend toward lower fertility rates. Almost 80% of the black fertility decline between 1880 and 1936 occurred prior to 1918. In sum, it is difficult to infer from these sources that VD prevalence increased anywhere near 4 fold between 1918-40. A considerably lower figure seems likely. It is unlikely that the quality of treatment before the mid 1940s was at a level which could be expected to substantially reduce the prevalence of syphilis or gonorrhea. Regardless of treatment quality and government programs, the question is how likely were rural and urban blacks to avail themselves of proper treatment. It appears that during the late 1930s and early 1940s the level of public knowledge about such matters as where to receive treatment was unequivocally poor, particularly among blacks. The sudden rise in fertility around 1936 does not appear to have been preceded by the effective control of VD in the black population. Even if the unrealistic assumptions of a zero to 25% syphilis prevalence increase and a zero to 50% gonorrhea prevalence increase are accurate, such increases could account for only about 20% of the observed natality change.
The politics of the barrios of Venezuela.
In the barrios--the squatter settlements--clustered in and around every city in Venezuela live most of the hundreds of thousands of poor peasants who have migrated to the cities from rural areas during the last 25 years. This study provides background information regarding this migration and examines the physical, economic, and social conditions of the barrios; analyzes the political behavior and attitudes of the barrio residents, describing how these people have been affected by the urban environment and particularly by the process of modernization, by the municipal and state governments, and by the political parties; assesses the role that the barrios have played in national politics; and reviews certain problems related to their current political status. The study is an outgrowth of work over the 1961-64 period with a private, nonprofit, urban community development organization called ACCION en Venezuela. There were 4 main sources for the material on which the study is based: observations of the daily political behavior of the barrio residents; innumerable conversations with men and women of the barrios along with officials, social workers, and other outsiders who were in contact with barrio residents; the project reports of the ACCION workers; and individual censuses taken by barrio leaders in conjunction with ACCION workers. The number of inhabitants of most barrios ranges between 1500-2500. The density of population varies considerably. When one compares the living conditions of families in different barrios, it is clear that some have been more fortunate than others. Their private and community facilites are in widely varying stages of development. The 2 factors most responsible for the variations are the terrain on which a particular barrio is built and the age of the barrio. The Revolution of January 1958 ushered in a new and totally unprecedented phase of barrio development. Restrictions on land settlement were immediately lifted, and families poured out of their crowded ranchos to grab vacant land on the outskirts of the cities as quickly as possible. The process by which a barrio is formed determines to a high degree the subsequent political life and activities of the residents. Most of the factors which later play an important role in community affairs are introduced at the inception of a barrio. With a few exceptions, barrios are created by the illegal possession of public or private land--a mass movement popularly termed an "invasion." In some instances, the settlement process is slow and may take several months to complete, but in most barrios created since 1958 the settlement may take several months to complete, but in most barrios created since 1958 the settlement process is completed within a few days. As the barrio people are increasingly affected by the process of modernization taking place in their various cities, social and economic differences develop among them. One can detect a definite evolution of the political convictions of the barrio people as they come increasingly under the influence of modernization and industrialization.
Ethnic differences in mortality in the nineteenth century: a case study of Philadelphia, 1880-81.
Comparisons of the mortality levels of Philadelphia's population differentiated by race and place of birth show that only the black/white differential in mortality is substantial in 1880. The native white population and the German population had levels of mortality which were very similar to each other and only slightly lower than that of the Irish population. The life chances of the ethnic groups were consistent with the occupational status of the groups. However, an indirect standardization procedure indicated that the mortality levels of white men could be explained by their occupational status, while black men had considerably higher mortality than would be expected from their distribution by large occupational categories. Members of ethnic groups did not face consistently worse life chances in areas inhabited by many other members of the same group. This result is probably explained by both the low levels of ethnic segregation and the lack of effective medical and public health services in the 19th century city. All ethnic groups did face worse mortality conditions when living in areas inhabited by many low status people. This mortality differential appeared to be largely a result of the individual level correlation between occupational status and mortality, but a small ecological effect on life chances was also observed. (author's modified)
Slums and squatters in South and Southeast Asia.
Discussion relies on a review of the data available in terms of slums and squatters in Asia and in other developing countries, focusing primarily on the question of whether slums and squatters are developmental or not. The question is divided into what slums and squatters mean in terms of economic and social (including political) development. The economically relevant questions asked include: do squatters and slum dwellers contribute to production of goods and services; are they integrated with the urban and/or national economic system; and do they contribute to capital formation; and are squatters and slum dwellers upwardly mobile economically. For social development, relatively simple indices were used: social stability or the absence of disruptive events such as revolutions and riots in the urban areas; social and political participation of squatters and slum dwellers in community, city, and national affairs; integration of squatters and slum dwellers with the larger society; and openness of squatters and slum dwellers to external influences and values. Throughout the limited literature on slum dwellers and squatters in South and Southeast Asia, there is an air of optimism, based in part on a distinction between urban processes in South and Southeast Asian cities and those that occurred in the West. Mainly, it is founded on actual studies and surveys that have attempted to view the slum and squatter communities as they are related to the larger urban and national processes of which they form a part. The evidence suggests that slums and squatter communities contribute to economic production in several ways. They appear to be more closely integrated with the larger economic system than a structural and sectoral economic analysis tends to show. Living in the slums and squatter areas offers many opportunities for saving and for capital formation. Also, there is evidence of economic social mobility in the slums. Socially, slum and squatter areas do not appear as disruptive and unstable as their physical appearance often suggests. The value system of slums continues to be largely rooted in a traditional rural origin and it tends to be conservative even as it emphasizes personal and community improvement. Survival of the rural value system accounts for high social and political participation, yet as slum and squatter communities grow older, organizational behavior akin to labor unions and other more structured organizations replace the traditional practices. The politicalization of the slum contributes to its greater integration into the larger polity and society. Empirical studies and surveys of a comparative nature are required to validate these optimistic assertions of the nature and function of the slum and squatter community in South and Southeast Asia.
Slums are for people. The Barrio Magsaysay Pilot Project in Philippine Urban Community Development.
This study of Barrio Magsaysay, a pilot project in Philippine Urban Community Development, raises certain questions, including: what, in reality, is a slum; what physical, social, and psychological factors mark an area as a slum and another as a run-down, but viable community with character; what value judgments are expressed when an area is termed a slum; and how do these value judgments affect the ability to do something about the slum problem. An attempt is made in this book to take a second look at urban slum squatters, especially in the developing countries. It provides a close-up view of 1 community in the Philippines. The 10 chapters cover the following: slums and squatters (the extent of the problem, dealing with slums in terms of on-site housing, relocation, reasons for relocation and on-site housing failures); the Barrio Magsaysay Project (rural community development precedents and urban community development--basic urban community development approach, advantages and disadvantages of urban community development, program initiation, theoretical moorings, action research orientation, training the urban community development workers, and previous training), physical characteristics and legislative history of the Barrio Magsaysay; the people--general profile, age, education, income, and length of stay in Barrio Magsaysay); community leadership; entry (research survey, service impact, political officials, traditional government workers, social activities, economic appeals, and appeal to main community interest); interagency cooperation; urban community development projects (service impact projects, community organization projects, and income-producing projects); savings and slum life; and the future of urban slums. The research findings in Barrio Magsaysay revealed the existence of a sense of community among urban squatters and slum dwellers. Research surveys pointed to the fact that slums are the real "transitional societies" that social scientists have been describing in their analytical models. For most slum dwellers are rurall migrants in the process of becoming rural men. The slum and squatter problem at this time is not dependent on overpopulation. The main cause is the maldistribution of the population into certain growth points. Policies and action programs are most urgently needed because the rural programs of the government are already bearing fruit, and 1 side effect of their success would be rural-urban migration. With roads improved, the people displaced from agricultural employment will find their way to the cities. Clearly, solving 1 set of problems creates another.
Statistics of international migration.
This discussion of statistics on international migration considers the need for data on international migration, recent patterns of international migration, sources of the data; and national definitions of international immigrants and emigrants. Primarily, the text is based on 3 studies prepared by the Department of International Economic and Social Affairs on the UN Secretariat. Due to the large numbers involved and, more particularly, because the sex and age structure of migrants frequently differs substantially from that of the rest of the population, migration can have pronounced effects on population composition, the rate of natural increase, and the supply of human resources. Information on the number, sex, and ages of individuals entering or leaving a defined area during a given period of time, together with data on the number of persons enumerated in that area at the beginning of the time interval and the births and deaths occurring during the interval, is important for the estimation of the size and structure of the population at the end of the interval and for the preparation of population projections. Thus, the data on migration forms an integral part of the totality of a country's demographic statistics. For the calculation of merely crude rates of population increase, it is sufficient to have only the net difference between the numbers moving into a territory and the numbers moving out of it. Absolute numbers alone are not sufficient for preparing population projections and for the examination of the impact of migrants on the various economic, social, and cultural aspects of normal life and of the concurrent effect on the migrants themselves. Since 1950 important changes have taken place in international migration patterns. Primarily, the main currents of migration are now from the less developed countries to the industrialized countries as a result of differential economic and demogrpahic conditions. It is conservatively estimated that in mid 1974 there were about 9.5 million immigrants from the world's less developed regions living in the industrialized nations of Northern and Western Europe, Northern America, and Oceania. Migration statistics are obtainable from border collection, from registration, and from field inquiries, and each of these sources is reviewed. The advantages and disadvantages of each of the 3 methods of obtaining information are identified. As a guide to users of the data presented in the statistical tables on migrant flow, 2 tables present available national definitions of immigrants and emigrants respectively along with analysis of the elements of the concepts used in the definitions. The tables are abridged from results of the study of national practices which was conducted by sending a questionnaire on national practices to each national statistical office. 116 countries reponded to the request for the national definition of an immigrant, and 96 countries supplied a definition of an emigrant.
International migration policies and programmes: the view since Bucharest.
Since the World Population Plan of Action was drafted in 1974, there have been important changes in the volume, direction, and characteristics of international migration flows. Discussion focuses on recent policy developments with respect to permanent immigration, labor migration in developed and in developing countries, undocumented/illegal migration, and refugees. The number of places for permanent immigrants is relatively small in all world regions. The 4 traditional immigration countries--the US, Canada, Australia, and New Zealand--have accepted a total of less than 1 million immigrants per annum in recent years. All of these countries revised their immigration policies beginning in the 1960s, with the policies becoming more "universalist" (in the sense that they accepted immigrants on a wider geographical basis) yet generally more restrictive. Utilizing quotas and, in some countries, "point systems" or numerical weightings, the policies of the traditional immigration countries remain heavily biased toward family reunion, but also give preference to immigrants with assets, education, and specific skills. Given the current economic prospects and domestic political concerns of these countries, their restrictive immigration policies are likely to remain in force in the foreseeable future. A clear and growing preference exists in all world regions for temporary rather than permanent workers. As the size of the foreign population in and outside the labor force has continued to increase in most of the countries of Western Europe, as a result both of family immigration and of natural increase, a major challenge facing the host governments has ben devising policies to promote the integration of these workers and their families without incurring domestic political resentment. In recent years there has been slow but steady progress in improving the economic and social position of foreign workers and in granting them limited political rights. The decision to halt migration after 1973, which had profound effects on the sending countries, was a unilateral decision that was made by the immigration countries. Until the 1970s, the capital rich countries in Northern Africa and the Middle East maintained a "laissez faire" position with respect to their labor shortages, permitting migrant workers from neighboring Arab countries to enter with a minimum of control. By the mid and late 1970s, the receiving countries needed increasingly large supplies of labor, which they obtained from a number of Asian countries. The future of the large numbers of foreign workers who remain in the receiving countries remains uncertain. The policies of the countries that export labor to the captial rich countries have focused largely on recruitment, although they cover a broad range of approaches, from the highly organized "project package" approach to simple manpower export. Illegal migration has become an area of active policy concern. There is a tendency for a large number of governments to be moving in the direction of stricter controls over illegal migration. Governments have at times reverted to a unilateral position in regard to refugees, lowering quotas, contributing less, or even completely revising their policies.
Economic development and urbanization.
The current rapid pace of urbanization in developing countries, and particularly in Asia, should be taken as a welcome indication of development, yet this rapid pace is regarded with alarm by many eocnomists, sociologists, and political scientists interested in the developing world as well as by political authorities in the countries involved. The search for an acceptable allocation of resources between large cities and small and between the development of urban centers and hinterland may conveniently begin with a review of arguments and theories critical of the current state of affairs, followed by an attempt to define an efficient urbanization strategy congruent with economic and social development goals. In appraising the overurbanization argument, it is necessary to separate fact from fiction. Asia's urbanization occurs under conditions of greater rural population pressure than was the case in 19th century Europe. Asia's current rate of industrial job creation barely surpasses the rate of population growth. Consequently, a large proportion of the inmigrants into urban areas goes into work in the "unorganized" industrial sector, into trade, tertiary activities, and varieties of more or less casual work. This being the case, the distinction between rural "push" and urban "pull" remains irrelevant. What causes migration is the difference between rural and urban livelihood opportunities. The fact that migration into urban areas continues shows that there is a continuing difference between levels. If restrictive measures were taken to slow down migration, the potential migrants would be condemned to a lower living standard. It is also too easy to overstate the drain of the hinterland argument. Overurbanization does not mean that the cities of the Indo Pakistani subcontinent are unduly favored. On the contrary a progressive deterioration of conditions in a number of major urban centers is all too visible. India and Pakistan face a serious problem of underinvestment in urban housing and in urban amenities. Given the limited resourcet in urban housing and in urban amenities. Given the limited resources and the rapid rate of urbanization, the problem is formidable. It is aggravated by the "urban bias" which makes for an uneconomically fast growth of cities. Were urban job creation relatively slower, and rural job creation relatively faster, the rate of urbanization and the need for urban investment would be correspondingly reduced. India and Pakistan work to defend a decent standard of urbanization in the face of growing needs and of limited means by enforcing minimum standards applicable to private and public urban construction. The long run remedy must be sought in a technological breakthrough, either in the construction field for the building of cheap permanent urban structures, or in the transportation field, to allow the suburbanization of low income poulation without an excessive burden of transport costs. An interim solution, increasingly albeit reluctantaly accepted in India, consists of the construction of "controlled slums." A rational urbanization policy requires an end to the urban bias in planning. s and the rapid rate of urbanization, the problem is formidable. It is aggravated by the "urban bias" which makes for an une
Compensatory financing facility.
This pamphlet describes the obejctives and modus operandi of the International Monetary Fund's compensatory financing facility. It summarizes the main features of the facility, analyzes the nature of export earnings fluctuations, and explains how the facility operates. The pamphlet includes 4 appendixes which reproduce the compensatory financing decision adopted in August 1979 and list purchases made under the facility until March 1980, illustrate the statistics required for a compensatory financing request, present an algebraic analysis of expert shortfalls, and compare the main features of STABEX with those of the compensatory financing facility. The facility was established by the Fund to provide additional assistance to member countries experiencing balance of payments difficulties arising from expert shortfalls, provided the latter are temporary and largely attributable to circumstances beyond the member's control. Ideally, the facility should enable the member to borrow when its export earnings and financial reserves are low and to repay when they are high, so that its import capacity is unaffected by fluctuations in export earning caused by external events. Assistance extended to the Fund under the compensatory financing facility is additional to other forms of Fund assistance. Because the facility's aim is to cushion the adverse effects which could otherwise have resulted from temporary export shortfalls, assistance under the facility should be provided as soon as the existence of a shortfall can be established. When the shortfall results primarily from a decline in the volume of exports, it is not always easy to determine whether it is due mainly to circumstances beyond the member's control or to inappropriate policies which need to be corrected. The member is generally given the benefit fo the doubt in borderline cases, especially if it has been cooperating with the Fund to find appropriate solutions to its balance of payments difficulties. As with any other drawing from the Fund, a member can draw under the compensatory financing facility only if it has a need to do so in terms of its balance of payments or reserve position or because of developments in its reserves. The amount that a member can draw under the facility is based on the net shortfall in its total export earnings.
AID's course in basic education.
In recent years, steadily declining resources along with an increasing awareness of other development problems gradually led to reduced emphasis on education in the US Agency for International Development (USAID). Commitment to education has stabilized over the past 5 years, but during the 1970s there was a precipitous decline in USAID's funding for human resources developnent in general and basic education in particular. Grant assistance dropped form about US$336 million for the 1960-65 period to about $234 million for the 1971-76 period. Loan assistance underwent a comparable, though less severe decline, dropping 45% form 1966-1976. For comparison, total education and human resources development assistance currently averages US$100 million to US$120 million annually. These trends were in part of a response to budget constraints and challenges in program emphases. Lacking evidence of the overall impact and significance of past USAID educational programs, the growth debate within USAID on whether involvement in the education sector was the best use of foreign assistance funds was not empirically well grounded. Thus, impact evaluations were conducted to assess the extent that completed USAID funded education projects left a lasting social, economic, or institutional imprint on countries in which they were done. The lessons derived from these evaluations are reflected in the Agency policy paper on Basic Education and Technical Training (December 1982) and are being applied to programs in education. The projects and programs evaluated included 2 in Africa, 4 in Asia, 1 in the Near East, and 4 in Latin America. They covered a wide range of USAID development activities over the last 30 years, including the founding of institutions and institutional processes; curricula reform; distance teaching; vocational and nonformal education for out-of-school adults; teacher training; construction and equipping of facilities; and 3rd country training for professional educators. USAID's total expense for these projects and programs was conservatively estimated at US$235 million. Projects and programs that have had the most pervasive impact involved a wide variety of well-financed interventions aimed at solving several interrelated sector problems. Evidence on USAID contributions to economic and social change is sparse and should possibly be the focus of more systematic study. Evidence of institutional impact is much stronger and well documented by the evaluation reports. USAID efforts to reform school curricula appear to have had less than lasting impact. The relative ineffectiveness of curricula reform can be traced to several causes, 1 of which was simply the required investment in equipment, materials, and training. In sum, the impact evaluations confirm that in almost all developing countries there has been enormous progress in the education sector over the past 30 years, and that USAID contributed to this progress.
Impact of foreign remittances: a case study of Chavakkad village in Kerala.
Many Keralites are working abroad and their families depend to a great extent on the money sent by them. This study attempts to examine the impact of foreign money in Kerala (India) based on a survey of 95 households in Chavakkad village. The village was selected as the study area because a large number of persons have left the village for Gulf countries. The area is backward and the main occupation of the people is agriculture. The only industrial activity worth mentioning is beedi making, which provides employment to about 5000 persons. 1 to 3 persons had gone abroad from the 95 households, and the total number of persons abroad was 136. An inquiry as to the previous job of the persons working abroad revealed that 49 of them were unemployed before going abroad. The remainder were employed as beedi makers, tailors, small businessmen, helpers in shops, hotel workers, drivers. 14 persons refused to provide information on previous jobs. Many of the migrants were able to go abroad because of the help provided by persons already at work abroad. 34 persons were helped by relatives, 23 by friends, and 21 went by launch. 21 persons went to Gulf countries in launch from Bombay without any travel documents, but later they obtained the visa and the necessary documents. The 136 persons had gone abroad since the early 1950s but 94 of the 136 had left in the 1970s. Of the 136 persons, 19 were working as construction workers, 18 as hotel workers, 15 in partnership small business, 9 as military helpers, 9 as tailors, 8 as drivers, 4 each as clerks, typists, and houseboys. Other jobs include petrol bunk helper, welder, and carpenter. Money was not received from abroad regularly every month. In a majority of cases, money was sent once in 2 or 3 months. In some cases, money was also sent through a friend who comes home for vacation. 59 persons sent a sum ranging from Rs. 500 to Rs. 750, each per month, to their respective families. 15 persons sent a sum ranging from Rs. 1000 to Rs. 1250, each permonth. Of the 102 persons sending money, most were sending Rs. 400 or more per month. The families receiving money enjoyed fairly good consumption levels. The monthly consumption expenditure varied between Rs. 250 and Rs. 1000. The majority of the households possessed either a radio or a transistor. There has been substantial investment in land and houses. The increasing demand for land has resulted in an increase in the price of land within a 5-year period. The entire income earned by the persons working abroad is either being used for consumption or invested in land and houses.
In accordance with article 19 of the International Labor Office (ILO) Constitution, the Governing Body decided at its 201st Session (November 1976) to request reports on the Migration for Employment Convention (Revised), 1949 (No. 97), and the Migrant Workers (Supplementary Provisions) Convention, 1975 (No 143) from governments which have not ratified them, as well as reports on the Migration for Employment Recommendation (Revised), 1949 (No. 86), and the Migrant Workers Recommendation, 1975 (No. 151). These reports, dealing with the state of law and practice in relation to the standards laid down by the instruments in question, and the reports supplied under article 22 of the Constitution by govenments that have ratified 1 or both of the Conventions, have enabled the Committee of Experts to make a general survey of the situation. Reports have been received from 109 countries either under article 19 of the Constitution of the ILO on Conventions Nos. 97 and 143 and Recommendations Nos. 86 and 151 or under article 22 on the 2 Conventions when they have ratified them. An appendix provides detailed information on the countries that have communicated reports. The plan adopted for this present survey is as follows: preliminary measures of protection--information and assistance and recruitment, introduction, and placement of migrant workers; protection against abusive conditions (migrations in abusive conditions, the illegal employment of migrant workers, and minimum standards of protection); equality of opportunity and treatment and social policy; and certain aspects of the employment, residence, and departure of migrant workers. The vast range of subjects covered illustrates the complexity of the subject of migration for employment. The measures needed for the protection of migrant workers extend beyond their period of actual employment and must cover the initial phase of information, recruitment, travel, and settlement into the country of employment and the regulation of rights arising out of the employment but continuing after its termination. During the period of employment, they go beyond measures dealing exclusively with conditions of work to cover various other aspects of conditions of life which affect the context in which the migrant worker has to work and form the broader framework of the conditions of work and life of migrant workers. Thus, it is possibly understandable that few governments have covered all the subjects dealt with in the instruments in their reports. Convention No. 97 has been ratified to date by 34 countries and Convention 143 has been ratified by 8 States. Problems exist in many member States in affording to migrant workers the guarantees provided for in the instruments.
The fiesta system in the northern Bolivian highlands was analyzed. As social interaction is simplified in the fiesta system, the latter provides a useful tool for analyzing complex or changing social relationships. Fiestas in the northern highlands of Bolivia are based on a variety of systems of sponsorship combined with a system of reciprocal presentations. Sponsors who agree to accept a specific commission, or "cargo," are aided by relatives, friends, community, or neighborhood members, and by persons who want to "pass" a cargo at some later date. Most fiestas include 2 types of sponsors: the prestes and the dance group leaders. Sponsorship obligations often accompany political office. Because Aymaras and Mestizos are involved in wide networks of social relationships, they participate in fiestas at considerable distances from their homes. The relationships between the ritual and social dimensions of a small fraction of this network are analyzed, i.e., the fiesta participation of Aymara peasants from Compi, a Lake Titicaca community. Such an analysis entails a step by step description of fiestas in Compi itself, followed by those in the county capital and ending with the fiestas in the city of La Paz where many Compenos have migrated. The analysis revealed that the relationship between the center and the periphery of old La Paz is very similar to that of counties and their surrounding free communities. Similarities in La Paz market fiestas and town fiestas demonstrate that La Paz constitutes merely 1 of a multitude of interconnected market sites, albeit a more complex one. The dance group formation in voluntary associations reveals that La Paz is not a closed system, because these associations maintain intimate ties with the home towns of their members. La Paz fiestas are not unique in kind. The city's fiesta system viewed as a whole is distinguished not so much by individual ritual patterns as by the concentration of such a large number of different patterns and the extent of their linkages outside the city's boundaries. 1 La Paz informant compared the fiesta system to a root growing in many directions at the same time. The analysis of fiestas indicates that it is through such linkages and parallels with institutions in smaller settlements rather than by seeing cities, towns, and peasant communities as separate, bounded entities, that changing Andean social systems can best be studied.
The Cochabamba-Santa Cruz highway in Bolivia.
In Bolivia geographic facts must dominate any discussion of possible strategies for development and the place of transportation in that development. The country is divided between the cold, highly populated, poverty stricken Andean highland region in the western third of the country and the flat eastern lowlands, mainly lush, unpopulated jungles, in the remaining two thirds. Clearly, this geography limits the choice of development policies which are feasible and makes problematical the success of those attempted. The geography makes transportation between regions difficult, and it also makes the provision of better transportation facilities very expensive. It is a prime objective of Bolivian policymakers to open up the lowlands to exploitation by Bolivians. The exploitation of the lowlands by Bolivians has and will require transportation linkage with the highlands. An attempt is made to evaluate the costs and benefits of 1 such linkage, the Cochabamba-Santa Cruz highway, which was opened to traffic in 1954. The hope is that the methodology illustrated by this computation will have applications in other contexts, particularly cases in which the purpose of a facility is to open up an undeveloped and underpopulated area. The internal rate of return is used as a measure of benefit over costs. In this method a discount rate (internal rate of return) is chosen which equates the present value of the stream of costs with the present value of the stream of benefits. In calculating the costs it is necessary to take account of the fact that the benefits of the Cochabamba-Santa Cruz highway would have been smaller had it not been for the investment in feeder roads, in sugar mills, rice mills, and so on, which have been made in the area surrounding the Santa Cruz end of the highway. As it is impossible to separate out the benefits due to the highway alone, it is best to consider all of the investments as a cost "package." Th cost of the highway and associated investment in Santa Cruz (without discounting) is estimated to be between $73-83 million. Benefits, present and future, can be expected under the following categories: net increase in production for which the highway was a condition; higher standard of living available to those remaining in highlands because of higher average (and marginal) productivity; benefits from colonization, excluding present production of agricultural goods; stimulation of manufacturing because of higher demand and raw material supply; and balance of payments benefits. The net benefits have been calculated as currently running at US$11.3-11.8 million /annum.
The effects of labor emigration on rural life in Malawi.
Great numbers of Malawians have emigrated from their predominantly rural country during the past 80 years to search for work throughout East, Central, and Southern Africa. The Ministry of Labor Report (1962-67) indicated that between 1948-62 a total of 544,000 men, 70,000 women, and 70,000 juveniles had gone to Southern Rhodesia; between 1953-67 approximately 360,000 men went to South Africa; and during those years roughly 69,000 men, 25,000 women, and 30,000 juveniles had made the journey to neighboring Zambia. Smaller numbers have traveled to Mozambique, Zaire, and Tanzania, but the total number of Malawians affected by emigration during the 20th century numbers into the millions. Early accounts of the exodus emphasized the suffering in rural areas resulting from the absence of so many men. This paper, while not denying this fact, suggests that the disastrous effects may have been exaggerated initially, that communal institutions absorbed some of the social shock, and that after the mid 1930s interterritorial labor agreements mitigated the worst economic consequences of emigration. The number of men who could be away from home at any 1 time without causing undue distress to village life has been the topic of diverse estimates. Van Velsen figured that 60-75% of Tonga adult men were absent but stated that there were no serious signs of disorganization in Tonga society. A Belgian Congo Commission reported that not more than 5% of the men could be absent for long periods without adversely affecting local life. Since most migrant analysts concur that the primary motive behind Malawian emigration is economic, encouraging the planning of cash crops must be the proper inducement for men to remain at home. Malawi's 1939 Labor Department Report stated that "emigration is unjust to women in every way," but the songs of the women reveal a less dogmatic attitude toward the traveling of their menfolk. Throughout the 20th century governmental authorities have sought ways to control "free flow" independent emigration which has been more popular than contractual arrangements. Malawians always preferred to choose their own employer rather than to offer themselves to the merices of recruiting agents, but controls were needed. The entire question of the internal effects of labor migration on Malawi's social and economic development needs further study. The relationship of migrants to the government's long range plans to replace traditional land tenure arrangements with private ownerhsip of land is a vital area of study.
It is contended that certain general patterns of city size distributions can be discovered by statistical analysis of changing absolute and relative population sizes for these cities. The 1st stage of the analysis is to determine the degree to which a system of cities may be said to conform to the Paretian hypothesis of lognormality in their size distribution. It was alleged by Pareto that the lognormal distribution of cities was in fact "normal" for a diversified economy subject to a wide variety of competing forces. He applied his analysis in the late 19th century to Italian cities and found a significant correlation between fact and hypothesis. Concern here is with the opportunity to test the conformance of city size distributions in 8 Latin American countries with the Paretian hypothesis. In the period since World War 2 it has become a matter of conventional wisdom to refer to the hyperencephalization of Latin America's system of cities. The data presented demonstrate that this situation of primacy is a recent phenomenon, i.e., a phenomenon of the 20th century. At the end of the colonial period only 1 country had developed an "excessively" primate pattern. The country is Mexico. The condition of lognormality in the 18th and early 19th centuries is not an idicator that the economies of the other 7 countries were then successfully integrated into a systematic hierarchy. There is some possiblity that such a condition could occur simply by chance, given particularly that the Paretian hypothesis already supposed the prior ranking of cities with regard to size. Yet, the conformance between hypothesis and fact was statistically significant. In the 19th and 20th centuries all city systems stopped being identifiably lognormal and became essentially primate. A hypothesis of growing openness of the economies was considered as a possible cause of the shift from lognormal to primate systems. The higher were per capita exports, the more the city size distribution diverged from the lognormal. The finding conformed to Berry's suggestion that as a system is subjected to the greater influence of a single force, the less it will succumb to general forces of entropy which, he contends, produce the lognormal city distribution. The case of Mexico is anomalous since Mexico was the 1st country in the sample to diverge from the lognormal pattern yet had quite low exports per capita. The data may unfairly understate Mexico's true position as a producer of exports. It may be fruitful to consider other causes for the rise of primacy among Latin American cities.
FPA Hong Kong extends services to refugees.
In the 2 years since the 1st Vietnamese refugees reached Hong Kong a total of 2575 births have been recorded, an average of 21/week. This is no surprise since 30% of the female population in the refugee camps is of childbearing age. Of the 22,109 refugees remaining in Hong Kong, 9212 or 38% are children under age 15. The Family Planning Association of Hong Kong, with these statistics in mind, launched a comprehensive project with funds from Population Concern and Oxfam to provide family planning information and clinic services to the refugees. At the start the Association had considerable difficulty convincing the authorities that the refugees needed family planning services. Eventually, the Association convinced the authorities and from June 1978 to February 1979, a total of 960 of the early refugees staying at that time in hotels, tenement flats, and colleges were visited. Last year the Association's field workers contacted 33,000 refugees now staying in camps, only 35 did not want any advice and only 108 wanted no more children. The project has 3 facets: publicity and education; person to person motivation; and clinic services. The working team consists of a project coordinator, a family planning advisor, a Vietnamese nurse, a fieldworker, and 2 Vietnamese fieldworkers. The Association conducts clinic sessions once or twice a week in each camp. 1 of the camps in which the Association project operates is Cape Collinson camp, where 250 refugees are held as prisoners. The women inmates seemed obviously pleased to see the family planning fieldworker with whom they discussed personal problems and from whom they obtained family planning information and contraceptive supplies. In the Chimawan prison camp on the island of Lantau, the Association launched a community-based program for distributing contraceptives. The inmates of Argyle camp and Kai Tak North camp go out to work during the day, the the Association runs its clinic in the afternoons and evenings to cater to those workers. There seemed to be more people attending the family planning clinic than the health clinic, suggesting the high regard the refugees have for the warm and friendly family planning workers.
Towards a system of recompense for international labour migration.
The discussion traces the forerunners of the concept of recompense and the reasons why foreigners are admitted and international migration occurs. It is on these fundamental factors that the idea of pay for another country's labor can and must be established. Attention is also directed to migration characterized by human resource transfer (scope, official or business migration, contract migration, settlement migration, free migration, and irregular migration) and they why, how and how much of recompense (justification, procedure, and amount). Recompense is meant to designate a payment for another country's human resources when one wants to use them. It stands a chance of becoming accepted and acted upon only if 2 conditions are met: it must related to economic or production requirements; and it must be powerfully supported in national and international political arenas. Jagdish Bhagwati was the first to articulate distinct links between the apparent inability of 3rd world countries to catch up with the developed nations and the large scale movement of professional, technical, and kindred workers from the 3rd world to the developed one. He proposed to levy a surtax on the income accruing to brain drain immigrants in developed countries with a veiw toward transferring the receipts to developing countries. It is the state as an institution rather than the migrant as an actor who crucially determines contemporary patterns of migration. A summary table provides a first impression of the kinds of movements that may be liable to recompense. An effort is made to make categories as homogeneous as possible and yet to make them mutually exclusively. Immigration countries should pay recompense to emigration countries whose citizens are admitted because they are needed for the purpose of employment. The philosophy of international distributive justice can be drawn upon to provide a secondary justification for recompense through an analysis of the differential gains from labor migation between immigration and emigration countries. Immigration countries have the undisputed right to close their borders to foreigners when it is in their interest to do so. Emigration countries are denied the right indefinitely to hold back citizens who are "bona fide" emigrants. Again, this provides a supplementary justification for recompense if viewed from the standpoint of international distributive justice. The economic and the legal inequities attaching to international labor migration lend strong moral support to the concept of recompense. A system of recompense needs to be solidly based to prevent a tug of war at the implementation stage.
Shadow households and competing auspices: migration behavior in the Philippines.
The concepts of shadow households and competing auspices are introduced and developed in an attempt to assist in clarifying the role of households and families in migration processes. The household is defined as including all persons committed to a set of residentially centered interpersonal relationships and can be analytically decomposed into a residential household component and a shadow household component. The shadow household consists of all former members who are not now living in a household but whose principal obligations and commitments are to that household. The concept of competing auspices is related to both the gravity theory of migration and the theory of intervening opportunities. It is hypothesized that intentions to move from point X to point Y are, "ceteris paribus," positively related to the presence of relatives and close friends who can help a person at point Y and negatively related to such links at any other point Z. All potential destinations are considered regardless of their location, and the attraction of a destination is measured by the availability and strength of auspices, rather than by sheer population size or economic opportunities. Auspices comprise only one of the many factors influencing migration decisions, but they are frequently an important consideration in the choice of destinations. The concept of competing auspices could be broadened to include other "pull" factors, if desired. The data are derived from a 1980 cross-sectional survey of 1744 adults in the province of Ilocos Norte in the Philippines. Data on remittances, correspondence, and future migration plans all pointed to a strong continuing commitment to the Ilocos Norte household among former household members and those who intend to move out in the future. The survey also confirmed the importance of auspices in potential destinations in both internal and international migration decision making. The presence of auspices also was found to be one of the most important determinants of migration intentions in multivariate analyses. The findings suggest that both shadow households and competing auspices are useful concepts in migration theory. Available data from Ilocos Norte are not ideal for quantifying and testing these concepts, but data from later stages of the Philippine Migration Study will provide additional indicators.
Present-day management of male infertility.
An overview is presented of the management of impaired fertility in men. Laboratory examination of semen, the primary determination of fertility status, is complicated by the lack of criteria of "normal" parameters. Most seminologists agree that fertility is compatible with a count below 20 million/ml, but the quality of motility and morphology is the critical factor. Consecutive semen analyses in the same person can also show great variation, so several specimens should be studied over a period of months. A definite cause for infertility can be found in less than 10% of cases. Half of those with a known cause are azoospermic due to an obstructive lesion of the conducting pathways or to total failure of spermatogenesis. Varicocele and immunolgoic aspects of infertility have attracted recent interest. New investigational methods have identified a substantial retrograde flow down the internal spermatic vein whenever a true varicocele is palpable. Suprainguinal ligation of the internal spermatic vein has been performed in these cases and estimates of improvement in the semen profile range from 30-80% of cases. However, many clinicians have reservations about the overall role of spermatic venous reflex in male infertility. When a significant titer of antibodies is noted, corticosteroids are generally administered. Despite little evident benefit, the trend toward prolonged treatment of infertility with pituitary hormones and stimulants continues. Increasingly, the infertile couple is being treated as a unit. Since specific measures seldom improve the semen profile, attention should be focused on improvement of opportunity for any effective sperm to achieve fertilization. There has been renewed interest in the cervical insemination cap method. About 14% of couples where the man shows seminal impairment conceived by this method, provided some of the sperm are of normal morphology. Artificial insemination with pooled stored sperm has produced disappointing results.
Epidemic kepone poisoning in chemical workers.
From March 1974-July 1975, 76 (57%) of 133 persons who had worked at a pesticide plant that produced Kepone, a chlorinated hydrocarbon insecticide, contracted a previously unrecognized clinical illness characterized by nervousness, tremor, weight loss, opsoclonus, pleuritic and joint pain, and oligospermia. Illness incidence rates for production workers (64%) were significantly higher than for nonproduction personnel (16%). The mean blood Kepone level for workers with illness was 2.53 ppm and for those without disease 0.60 ppm (p<0.001). Blood Kepone levels in current workers (mean, 3.12 ppm) were higher than those in former employees (1.22 ppm). Blood Kepone levels for workers in nearby businesses and for residents of a community within 1.6 km of the plant ranged from undetectable to 32.5 ppb. Illness attributable to Kepone was found in wives of 2 Kepone workers; there was no apparent association between frequency of symptoms and proximity to the plant in the survey of the community population. (author's modified)
Uterine specimens removed from 154 women who attended an infertiltiy clinic in 1967-70 were examined histopathologically. The majority of the women were in the 20-40 year age group. The presenting symptoms included infertiltiy in 56 cases, dysfunctional uterine hemorrhage in 30, and amenorrhea in 27. Postcoital bleeding was reported in only 8 cases; however, this is important since it represents cases of cervical tuberculosis that are often mistaken for carcinoma of the cervix. The endometrium was the site of the lesion in 120 cases. The fallopian tubes were found to be involved in only 11 cases, but this is considered an inaccurate figure because laparotomy was not used. In 1 case, tubercular infection was found in tubes removed due to ectopic pregnancy. The endometrium was in a proliferative phase in 86.6% of cases, secretory in 1.63%, and atrophic in 4.91%. Caseation was present in 6.5%. Genital tuberculosis was found in 6.48% of women with primary infertility and 6.52% with secondary infertility. 5% of the women had a healed pulmonary infection, 5% had abdominal tuberculosis, and 3.27% had adenitis. Treatment was most effective in women with menstrual disorders. Amenorrhea could not be cured in cases where the endometrium was completely destroyed.
Sexually transmitted diseases (STD) in tropical countries differ from those in more developed countries in 4 respects: 1) they are more prevalent, 2) their patterns differ, 3) their diagnosis and management must be modified and simplified due to technological and economic constraints, and 4) complications are more frequently encountered or are the presenting features. Rural and tropical areas show alarmingly high rates of gonorrhea and its complications (especially urethral stricture, epididymitis, pelvic inflammatory disease, and infertility), gonococcal ophthalmia neonatorum, and all stages of syphilis. The whole spectrum of each disease is usually seen, either because treatment facilities are not available, people do not utilize existing services, or treatment is not adequate. This book, aimed at medical practitioners and students in tropical countries, includes chapters on the incidence, clinical manifestations, differential diagnosis, and treatment of syphilis, endemic treponematoses, chancroid, gonorrhea, nongonococcal and nonspecific inflammatory disease and Reiter's syndrome, lymphogranuloma venereum, granuloma inguinale, and other sexually transmitted conditions. An initial approach to STD control should be to establish a model unit with up-to-date facilites for diagnosis and treatment and research and training in the national referral or teaching hospitals. This could be followed by more widespread services, including microscopy, in peripheral units, and more sophisticated testing, such as culturing the serology, at the district or provincial levels. Large cities with a considerable STD problem might consider separate STD clinics within the larger health centers. The private doctors who treat many STD patients should be drawn into the STD control program by offering them free facilities for diagnosis, contact tracing, and postgraduate education. Medical education on STD should also be directed at auxiliary health workers who provide much of the primary care in the tropics. Community education should focus on sexual behavior, condom use, avoidance of self-medication, symptom recognition, early reporting for treatment, and cooperation in contact tracing. Descriptive studies based on adequate district records and limited morbidity surveys should be carried out by community medical officers to determine STD prevalence and identify the groups at greatest risk.
Venereal problems in a developing country.
Venereal disease is a main public health problem, and it was recently placed on the priority list in Uganda. Mulago Hospital in Kampala was found as a venereal disease (VD) clinic at the beginning of the century by Sir Alber Cook. In 1972 about 32,000 new patients were seen in these clinics. During the 1st year of the reestablished clinic paramedical staff were trained to diagnose and treat venereal diseases. All patients with genital sores are examined by darkground microscopy for Treponema pallidum. The staff are also trained in contact tracing. The treatment is provided in the clinic by nursing staff and strict guidelines for treatment of the various venereal and paravenereal diseases are enforced. The main problem in any VD campaign is that of convincing women to come for early examination and treatment, as symptoms of acute gonorrhea are so mild in females they are usually unaware of the possibility of being infected. Another problem concerning women patients is that the microscopical demonstration of gonococci is often insufficient. Culturing of gonococci is essential in diagnosing gonorrhea in females. Since 1972 a central laboratory for this purpose has been established at Mulago Hospital. When in full operation, this laboratory should be able to examine 400-500 specimens a day and can offer its services to other hospitals and to the southern part of Uganda. Diagnosis of syphilis in women is also more difficult. About 75% of men with syphilis are diagnosed in the primary stage of the disease. In contrast, 75% of the females attending the VD clinic are initially diagnosed in the secondary stage of the infection. The importance of careful contact is obvious. A high proportion of false positive tests have been demonstrated in serological testing for syphilis. Many false negative reactions can occur even in secondary syphilis. The introduction of a general VD law in Uganda cannot be recommended at this time. A special legislation for prostitutes has proved to be quite useless in other countries. A single dose treatment with a very high cure rate is of special importance for clinics treating many thousand cases of gonorrhea each year. Gonococci have gradually developed increasing resistance to treatment with penicillin, but full resistance to penicillin has never been demonstrated. In contrast to Neisseria gonorrhoeae, Treponema pallidum is just as sensitive to penicillin as it was when the treatment of syphilis under this drug was introduced in 1943. Chancroid is a common disease in Uganda and the diagnosis is made purely on the clinical aspect of the genital sores and the presence of enlarged lymph nodes in the groin. Lymphogranuloma venereum was not very common in the clinic and granuloma inguinale was not diagnosed in the VD clinic.
Epidemiologic and experimental studies in drinking and pregnancy: the state of the art.
Epidemiologic and experimental studies of the consequences of maternal drinking during pregnancy confirm clinical reports that alcohol in high doses is teratogenic. Alcohol consumed in lower doses has been correlated with intrauterine growth retardation, increased risk of anomalies, behavioral decrements in infants and children, and increased risk of fetal wastage. While evidence linking these effects to moderate levels of alcohol use is growing, there is little agreement on the actual dose at which risks begin, due to the questionable validity of self-reported consumption. Many of the subtle effects correlated with lower amounts of alcohol--growth retardation, minor anomalies, and behavioral alterations--are the same effects which occur in severe degree with high amounts. Thus, a dose-response curve may be emerging, although its existence must be substantiated by further studies. (author's)
A normally progressing pregnancy has been established by implanting an 8-cell embryo into the uterine cavity of an infertile woman. The embryo was obtained by in vitro fertilization of a preovulatory egg aspirated at laparoscopy 28 hours after the beginning of the luteinizing hormone surge during the patient's natural menstrual cycle. Elevated levels of serum human chorionic gonadotropin and progressively increasing levels of total urinary estrogens and pregnanediol confirmed the presence of an early pregnancy. Ultrasound examination revealed an intrauterine gestational sac at 5 weeks, a 1 cm fetus with fetal heartbeat at 7 weeks, and an active, normally growing fetus at 13 and 16 weeks. Chromosome analysis at this time revealed no abnormality, and the alpha fetoprotein level was within normal limits. The patient is due to be delivered on or about June 28. (author's)
T mycoplasmas on spermatozoa and infertility.
The finding that pregnancy was achieved in 30% of couples after eradication of T mycoplasmas led to an investigation of the role of these organisms in infertility. Sperm samples from 7 infertile men with T mycoplasmas in their ejaculate and from 5 fertile controls without T mycoplasmas were analyzed. 1 portion of the sperm specimen was washed in phosphate-buffered saline (PBS). The washed spermatozoa and the supernatants were inoculated onto Shepard's A3 agar and incubated. The percentage of colonies originating from the spermatozoa was estimated. Some of the plates were fixed in 2.5% glutaraldehyde-5% sucrose solution, dehydrated in alcohol, gold shadowed, and examined in a scanning electron microscope. The remainder of some specimens was diluted in PBS, fixed in 2.5% glutaraldehyde, dehydrated in acetone, and examined by scanning electron microscopy. Growth was exhibited in 6 of the 7 cultures of men with T mycoplasma infection, but in none of the controls. 85-97% of the randomly selected T mycoplasmas isolated form the seminal fluid of the 5 cases originated from spermatozoa. Data were not available for the 6th case. Scanning electron microscopy indicated that the colonies originated from the anterior or middle piece of the spermatozoa. Moreover, some of the spermatozoa from the cases had rounded, bud-like outgrowths on the posterior part of the sperm head or on the middle pieces. These outgrowths were not observed in control specimens. These results suggest that T mycoplasmas are attached to sperm cells. However, it is not known whether the T mycoplasma cells adhere to the sperm cells during the passage of the ejaculate through the urethra or at an earlier point. It is possible that T mycoplasmas produce neuraminidase-like substances that interfere with fertilization or development of the fertilized egg. Investigations of this possibility are in progress.
The varicocele and male infertility.
Varicocele, found in 8-22% of the general population but in 21-39% of men attending infertility clinics, is now accepted as an important cause of male infertiltiy. The mechanisms by which varicocele affects fertility remain undetermined; however, decreased testicular size, abnormal testicular histology, and abnormal semen parameters have been noted in patients with varicocele. Sinc the size of the varicocele is not related to the degree of fertility impairment, care must be taken to detect subclinical varicocele. The presence of a small varicocele is suggested by an equivocal venous thrill during the Valsalva maneuver. This can be confirmed by noninvasive diagnostic tests in which the Doppler stethoscope is utilized. Before surgical intervention, other possible causes of subfertility (including factors in the female partner) should be excluded. If no other abnormality is found, and if both decreased sperm motility and increased numbers of tapered sperm and immature germinal cells in the semen are noted, varicocelectomy is indicated. The suprainguinal and high inguinal approaches are currently used for ligation and division of the internal spermatic vein. The safety of the suprainguinal division of the internal spermatic artery in the absence of prior dissection of the spermatic cord at a lower level has been demonstrated by experimental and clinical data. Reviews of the results of varicocele ligation in subfertile men have noted improved semen quality in 55-85% and pregnancy in 25-55% of wives.
Women alcoholics. A review of social and psychological studies.
Research on the social and psychological aspects of female alcoholism is summarized. The literature review is limited to English-language reports appearing since 1950. Women alcoholics, conservatively estimated to comprise 20% of the total number of alcoholics, are often lumped together with male alcoholics in both research and treatment efforts. However, women have been noted to show differences in the pattern and etiology of excessive drinking. In general, women alcoholics have a high incidence of alcoholic parents and are more likely than men to begin drinking heavily in response to a specific environmental stress such as divorce of death in the family. They tend to become problem drinkers at a later age than men, and many have more severely disturbed personalities. Female alcoholism has also been linked to low self-esteem and sex role confusion. However, women alcoholics are not a homogeneous group. There are distinct subgroups differentiated on the basis of race, socioeconomic class, and existence of prior psychological disorders. Some research has related the onset of female alcoholism to dysmenorrhea and menopause, and has pinpointed a relationship between eipsides of heavy drinking and premenstrual tension. Additionally, alcoholism has been found to be highly correlated with specific gyncological disorders such as repeated spontaneous abortion and infertility. However, it has not bee possible to separate out the effects of heavy drinking on physiological functioning from difficulties such as a hormonal imbalance that precede or cause the alcoholism. Future research efforts should extend the use of appropriate control groups. Areas in which more research is needed include the level of masculine identification among women alcoholics, the impact of the changing roles of women, and the characteristics of the various subgroups of female alcoholics, the impact of the changing roles of women, and the characteristics of the various subgroups of female alcoholics. Such research could be used to improve the low treatment effectiveness and poor prognosis that some studies have noted among women alcoholics.
Chlamydia trachomatis as a cause of acute "idiopathic" epididymitis.
To assess the etiologic role of C. trachomatis and other microorganisms in idiopathic epididymitis, 23 men underwent microbiologic studies, including cultures of epididymal aspirates in 16. 11 of 13 men under age 35 had C. trachomatis infection whereas 8 of 10 over age 35 had coliform urinary tract infection. Cultures of epididymal aspirates yielded C. trachomatis alone in 5 of 6 men under 35, and coliform bacteria alone in 5 of 10 over 35. These results suggests that C. trachomatis is the major cause of idiopathic epididymitis, and coliform bacteria the major cause of epididymitis in older men. Expressible urethral discharge and inguinal pain were more common in the chlamydial cases, whereas concurrent genitourinary abnormality and scrotal edema and erythema occurred more commonly in the coliform cases. The morbidity attributable to C. trachomatis is as serious as that attributable to Neisseria gonorrhoeae. (author's modified)
Etiology, manifestations and therapy of acute epididymitis: prospective study of 50 cases.
There were 50 patients with acute epididymitis who were evaluated prospectively by history, examination, and microbiologic studies, including studies for aerobes, anaerobes, Neisseria gonorrhoeae, Chlamydia trachomatis, and Ureaplasma urealyticum. Escherichia coli was the predominant pathogen isolated from the urine of men more than 35 years old, while Chlamydia trachomatis and Neisseria gonorrhoeae were the predominant pathogens isolated from the urethra of men under age 35. The etiologic role of Escherichia coli and Chlamydia trachomatis was confirmed by isolation from epididymal aspirates from a high proportion of men with positive urine or urethral cultures for these agents. Chlamydia trachomatis epididymitis accounted for 2/3 of idiopathic epididymitis in young men and was often associated with oligospermia. Of 9 female sexual partners of men with Chlamydia trachomatis infection, 6 had antibody to Chlamydia trachomatis, of whom 2 had positive cervical cultures for this organism and 2 others had nongonococcal pelvic inflammatory disease. Antibiotic therapy with tetracycline was effective for the treatment of men with Chlamydia trachomatis epididymitis and should be offered to the female sex partners. (author's)
Results of heavy drinking in pregnancy.
The outcome of pregnancy is reported for 23 women who had been drinking alcohol heavily and who were delivered in Belfast maternity hospitals during the last 4 years. 21 (91%) of the babies were small-for-gestational age and many had head circumference measurements <5th percentile. 10 babies (44%) had abnormal facies consistent with the 'fetal alcohol syndrome' and 10 babies had congenital malformations of the heart, palate, genitalia, and kidneys. Perinatal problems which included breech presentation, birth asphyxia, hypoglycemia, polycythemia, hypocalcemia, and withdrawal symptoms were frequently present. Most of the babies have shown delayed postnatal growth and 6 of 10 over age 1 have delayed development. (author's modified)
Mycoplasma hominis and postpartum febrile complications.
Patients delivering on the residents' service at Johns Hopkins Hospital between February 1, 1967 and May 15, 1967 who had oral temperature elevations greater than 99.6 degrees Fahrenheit or rectal temperatures greater than 100.4 degrees Fahrenheit between the completion of the 3rd stage of labor and discharge from the hospital were assessed for large colony mycoplasmas. A patient having entirely uncomplicated labor and delivery on the same day with uneventful postpartum hospitalization was selected as a control for each febrile patient, and 25 late 3rd trimster prepartum patients formed another control groups. Cervical cultures, blood cultures, and an acute-phase serum specimen were collected for each patient. Including all febrile patients, the overall rate of postpartum fever was 7%. After patients with other causes of postpartum fever were excluded, 37 patients with postpartum fever, 37 with uncomplicated deliveries, and 25 3rd trimester prepartum patients remained in the group. The postpartum groups were comparable in age, race, parity, and marital status. Mycoplasma hominis was recovered from the genital tract of 12 of 37 febrile patients, 4 of 37 postpartum controls, and 4 of 25 3rd trimester prepartum patients. Frequency of antibody response was also higher in febrile patients. M. hominis was recovered in 2 blood cultures from 1 febrile patient. No other patient had a positive blood culture. Results of serologic testing and evaluation of cultures in 16 patients and 16 controls demonstrated a significant association between M. hominis and postpartum fever. A significantly greater number of febrile patients had undergone cesarean section, but neither cesarean delivery nor prematurely ruptured amniotic membranes was associated with increased isolation of M. hominis.
Laparotomy for female infertility.
Laparotomy continues to be the only method available in India for dealing with female infertility. 45 consecutive cases of laparotomy for infertility were collected from among the new and follow-up patients who attended the Gynecological and Antenatal Clinic of Telco Maternity Hospital, Jamshedpur, India over the January 1977 to April 1979 period. Neither human pituitary gonadotropin nor ergobromocryptine were used in this unit. Only clomiphene citrate was used for treatment of infrequent ovulation. None of the patients had prior laparoscopy. All patients taken for laparotomy had transcervical dye test and transuterine injection of saline to check the tubal patency. All patients had healthy husbands. The proportion of primary and secondary infertility in this series was 62.22% and 37.77%, respectively. The single major indication for laparotomy was bilaterally blocked tubes on hysterosalpingogram which was present in 20 cases. Among other indications infrequent ovulation (with or without bilaterally enlarged ovaries) was present in 10 (22.2%) cases. All the 10 patients had clomiphene citrate in the usual regimen for 3 consecutive cycles in increasing doses up to 150 mg a day but without success. In terms of laparotomy findings, in no case was there any evidence of tuberculosis or pelvic endometriosis (apart from the case who had chocolate cyst). In all the 3 cases where the only abnormality was peritubal adhesions preoperative hysterosalpingograms were normal and in all of them laparotomy was performed as a final method of investigation. Of the 12 cases who showed bilateral cornual block in preoperative hysterosalpingogram, tubal patency tests at laparotomy showed unilateral blockage in 4 and no blockage at all in another 4. Of the 13 cases where no lesion was found, the indication of laparotomy was bilateral cornual block (4 cases) and in 9 cases it was performed simply as a method of investigation. In 10 of the 45 cases, the ovaries appeared to be like those found in Stein Leventhal syndrome.
Pattern of malformation in offspring of chronic alcoholic mothers.
Case histories are presented of 8 unrelated children born to mothers who were chronic alcoholics. These children showed a similar pattern of craniofacial, limb, and cardiovascular defects associated with prenatal-onset growth deficiency and developmental delay. This is the 1st report to document an association between maternal alcoholism and aberrant morphogenesis in the offspring. The mean duration of maternal alcoholism was 9.4 years. 3 of the cases were black, 3 were Native American, and 2 were white. The mean gestational age was 38 weeks. The degree of linear growth deficiency was more severe than the deficit of weight at birth, suggesting that a factor other than maternal undernutrition alone affected prenatal growth. Developmental delay, prenatal and postnatal growth deficiency, and short palbebral fissures were observed in all 8 children. 7 of the 8 children also demonstrated microcephaly and maxillary hypoplasia with relative prognathism. 6 had an altered palmar crease pattern, 5 showed cardiac and joint anomalies, and 4 had epicanthal folds. Although adequate nutrition was provided to the children during hospital admission and/or foster care placement, no catch-up growth was observed. After 1 year, the average linear growth rate was 65% of normal and the average rate of weight gain was only 38% of normal. By 1 year, head circumference fell below the 3rd percentile for height and chronological age in 5 of the 6 children in whom measurements were taken. Fine motor dysfunction was present in 5 of the 6 children tested, and most were delayed in gross motor performance as well. The similarity in pattern of malformation noted among these 8 children suggests a singular mode of etiology related to an as yet unknown effect of maternal alcoholism. Direct ethanol toxicity is the most likely possibility.
An evaluation of etiologic factors and therapy in 555 private patients with primary infertility.
Some 12 years ago a form was designed for the tabulation of information in the study of infertility and female endocrine disorders in an effort to collect data suitable for coding and mechanical sorting. This study deals with the records so tabulated of 555 consecutive private patients complaining of primary infertility. The evaluation of etiologic factors is obviously subject to individual bias in many instances. The final diagnosis was made with the use of all findings and, in some cases, a retrospective diagnosis, not possible at the patient's initial study, was made. An effort was made to use only therapeutic measures which were indicated by the physical or laboratory findings, but as the investigation and therapy of these patients was carried over a 12-year period, changes in therapeutic approaches occurred. Follow-up information was available for 542 of the 555 patients. Of the 542, 204 or 37.4%, were known to have achieved a pregnancy. This correlated wtih the age of the patients and the duration of the inferitliy to as great an extent as the etiologic factor responsible for that infertility. Of the 315 patients between the ages of 20-35 years with infertility of 1 or more years duration who had completed the study or had 5 or more visits, 143 or 46% achieved a pregnancy. 28 pregnancies terminated in abortions, 7 in premature delivery of a normal child, and 1 in an ectopic pregnancy. Surgical therapy for the entire group of 55 patients was as follows: 16 tubal plastic procedures; 7 myomectomies; 29 endometrial resections; 8 cervical procedures; 15 ovarian wedge resections, and 3 vaginal plastic procedures consisting of removal of a vaginal septum. There were 131 patients with infertility primarily due to tubal factors. The etiology of the tubal pathology was not determined in the majority of the cases. An effort was made to subdivide further the cases in the category of ovarian factors according to the estimated etiology of the ovarian failure: Stein-Leventhal Syndrome; unknown dysfunction; ovarian failure; nutritional insufficiency; chronic disease; metabolic disease; neurological and psychogenic disease. 65 patients, in addition to the 17 reported under tubal factors, had endometriosis. There wre a total of 54 couples in whom the infertility was judged to be due to male factors, with no additional factors found in the wife. 20 patients had infertility judged to be due primarily to a cervical factor. 9 patients had anatomical abnormalities of the uterus. In 3 patients age was found to be the etiologic factor, with no other factor detectable. In addition to 4 patients reported under ovarian factors, there were 15 patients in whom malnutrition was judged to be the sole cause of infertility. 11 patients, in addition to the 9 reported under ovarian factors, were diagnosed as having infertility due to psychogenic factors. 9 patients had infertility primarily due to intercourse problems, and 90 patients were classified as having infertility of unknown etiology.
Correlation between serum antichlamydial antibodies and tubal factor as a cause of infertility.
Although salpingitis frequently produces tubal damage and infertility, many women with tubal factor as a cause of their infertility do not have a clinical history of salpingitis. In order to investigate whether or not some such cases might be due to subclinical chlamydial infections, we measured antichlamydial antibodies in the serum of 172 women consecutively undergoing infertility evaluation. Only 16 (9.3%) had a prior history of salpingitis. 61 (35%) had antichlamydial antibodies (S+) and of these, 75% had tubal factor as a sole or contributing cause of their infertility, vs 28% of the seronegative (S-) women (chi square=34, P<0.001). There was no association between chlamydial seropositivity and any infertility factor other than tubal factor in multivariant analyses. Subclinical infections with Chlamydia trachomatis may be a major cause of tubal infertility in the US, and chlamydia serologic studies may be useful in identifying that subset of infertile women likely to have tubal factor. (author's modified)
Congenital syphilis in Lusaka--II. Incidence at birth and potential risk among deliveries.
To determine the incidence of congenital syphilis among infants born at the University Teaching Hospital in Lusaka, Zambia, cord blood was tested for reagin antibody in 469 consecutive deliveries (464 livebirths and 5 stillbirths) during the 1st 2 weeks of March 1981. The Treponema pallidum hemagglutination assay test was positive in 30 (6.5%) of the infant-mother pairs. Seroreactive mother were younger and of lower socioeconomic status than seronegative mothers, but marital status, education, and parity were comparable. The incidence of abortion and stillbirth in earlier pregnancies was significantly higher in seroreactive mothers (p>0.05). 396 mothers (85.3%) had attended antenatal clinics, but only 284 (71.7%) had been screened for syphilis. Of the 30 seroreactive mothers, 10 had a reactive test during pregnancy (only 8 of whom received treatment), 10 had negative tests, and 10 were not tested. 4 of the 30 seroreactive infants had clinical signs of congenital syphilis at birth. An additional 2 babies were stillborn, and 8 others required intensive care due to prematurity, asphyxia, or conjunctivitis. Although other infants in this group may have had subclinical or latent syphilis, follow-up was not attempted. On the basis of the high risk of congenital syphilis identified in this study it is recommended that: 1) every pregnant women be screened for syphilis early in pregnancy and again in late pregnancy in order to detect infection acquired in the interim, 2) both sexual partners receive simultaneous treatment to prevent reinfection, 3) cord blood be screened in infants of mothers who did not receive antenatal care, and 4) infants of women who did not deliver in a health care facility should be evaluated for syphilis either at primary vaccination or at earliest contact with a health facility.
An information handbook on infertility services.
The guide, based on information culled from several sources, helps Title 10 grantees assess the needs of their clients, the resources in their communities, and their own capabilities to provide infertility services. Such careful assessment is needed if Title 10 grantees are to plan an effective infertility service within their current family planning program. The guide is designed to do the following: acquiant Title 10 family planning grantees with the issues they must consider in planning effective infertility services; present a workable model of infertility service delivery which can be implemented in an area where need, resources, and expertise may all be limited; and assist family planning grantees in assessing the infertility service network that they plan and develop. The guide deals with the following: an overview of infertility; a comparison of infertility and contraceptive services; developing support networks in the community; analyzing needs and resources; infertility service delivery; referral and linkages with level 2 and level 3 providers; staff development and training; financial management of infertility programs; management information systems for infertility programs; developing an infertility service plan; and community education and marketing. Needs and resources for an infertility program should estimate the amount and kinds of service required by the community and the resources available, both within and outside the family planning program. The resources assessment will establish the degree to which new services are required and whether adequate service can be provided by better linking services that are already available. Leading factors of infertility in both men and women are general health related, psychogenic, endocrine, and environmental or occupational. Coordination between agencies offering services in the area will ensure that clients desiring services have access to the best possible care. Establishing appropriate linkages, referral networks, and contractual arrangements is 1 of the most important issues in program development. Once staff have developed an awareness of the problem and receptivity to providing a new service, they must acquire specific clinical and counseling skills. The operational plan for a comprehensive infertility service should focus on the system of service delivery, rather than on the details of clinical care. Most likely these will be responsibility of the infertility specialists.
Preliminary report on the Murle infertility study.
The study objectives were as follows: to define in specific terms whether there is retarded growth among the Murle tribe in Sudan; if this is the case, what are the factors contributing to this, i.e., infertility or subfertility, pregnancy wastage, child loss; what are the etiologies of this situation and the immediate predisposing causes; to determine by epidemiological, clinical, and laboratory methods the association of any of the contributing factors with specific endemic disease etiologies of infertility such as venereal disease; and to learn whether there are any psychological or genetic factors involved. About 360 families were interviewed in March 1976 and another 154 families in March 1977. The total number surveyed and analyzed was 390 families. The highest prevalence of primary infertility was 22.62% for the age group 20-29 at Pibor. The total infertility rate at Pibor was 41.3%. It was 34.6% at Kong Kong and 31.4% at Buma and 38.29% at Gumruk. The percentage of total infertility for the Plain Murle was 39.5%; primary infertility was 10.3% and secondary infertility was 27.11% at the age group 20-29. The total infertility rate was 38.4% for the whole Plain Murle. A comparative analysis was made between the infertility in the Plain Murle and the Hill Murle for all ages. The result was that there was no significant difference by both standard error of the difference and chi square. When pelvic infections in fertile and infertile women were compared, no significant difference was found, indicating that infection has not been proved to be the cause of infertility in this sample. The incidence of pelvic infection and cervicitis was high in both groups, and the etiology has not been investigated as yet. Culture of the organism, biopsies, and tubal insufflation is required to elucidate the role of tubal blockage, resulting from a specific infection. Laboratory investigation was primarily limited to parasitological work, with special attention directed to malaria and filariasis. In sum, in this series there was a high rate of infertility amounting to 51% for the entire sample. Primary infertility constituted 10% and secondary infertility 41%. 60.45% of the primary infertility cases were encountered in Pibor. The high rate of secondary infertility might suggest postpartum or postabortal infection. In the whole series, the pregnancies per woman was 2.4, with a pregnancy wastage and child loss of 31.54%.
The experience of a community surveillance program aimed at detecting gonorrhea in women in Memphis-Shelby County, Tennessee, is reported. This report, presenting data from 1975-76, updates an earlier report from the 1973-74 period. Data from both periods are compared in an attempt to determine the program's impact on the rate of women with gonorrhea and on the number of hospital admissions for pelvic inflammatory disease (PID), the most serious complication of gonorrhea. The total number of tests performed in the community increased from 113,063 in 1973-74 to 140,201 in 1975-76. The percentage of women with positive cultures was 5.1 in the earlier period and 5.0 in the latter period. The total number of positive cultures at the City of Memphis Hospital declined by 7.4% from 3097 in 1973-74 and 2868 in 1975-76. This decline is largely due to a reduction in the number of positive cultures identified in the emergency room. Despite this decline, the emergency room continued to provide the highest number of positive cultures (16.5% in 1975-76) and the highest ratio of positive cultures to number of tests. City of Memphis Hospital as a whole provided 40.6% of the positive cultures in only 31.5% of total tests. The number of cultures obtained from other community health services increased by 54.5% from 2709 to 4185 in the 2 study periods. This increase is largely attributed to the establishment of new family planning clinics in poor areas and increased participation in the surveillance program among private physicians in these areas. The 3 year moving average incidence of PID recorded in the City of Memphis Hospital discharge at diagnosis showed a dramatic decline between 1968 (the year the surveillance program was initiated) and 1976, suggesting that the program has effectively prevented much infection from progressing to PID. Moreover, the unchanged incidence of gonorrhea observed in the 2 study periods indicates that the infection rate has stabilized. This is in contrast to the continuous upward trend observed on a national level.
Culture and serology studies have shown Chlamydia trachomatis (CT) to be 1 of the causes of acute salpingitis (AS). In the present investigation, results of cervical cultures were correlated with serum antibody titers to CT in patients with laparoscopically verified AS. Serum samples from 206 patients, including paired sera from 80, were assayed. Of 206 patients, 118 had chlamydial IgG antibody titers of 1:64 or more. Patients with negative cultures for CT and an IgG titer of 1:64 or more had a significantly higher geometric mean titer than corresponding patients with positive cultures. In paired sera, a seroconversion or a 4-fold or greater rise in IgG titer to CT was demonstrated in 35%, while a further 11% had detectable IgM antibody in a titer of 1:8 or more. The overall isolation frequency of CT was 33%, compared with 19% for Neisseria gonorrhoeae. (author's)
Problems posed by potential gonococcal vaccines viewed from the vantage point of a control agency.
Progress in the characterization of Neisseria gonorrhoeae and other bacterial pathogens has suggested that immunoprophylaxis for gonorrhea may be possible despite the well-known propensity for reinfection. Pili, outer membrane proteins, a capsular polysaccharide, and the lipopolysaccharide may be important gonococcal virulence factors, and immune components (probably antibodies) to more than 1 of these antigens may be required to confer immunity. A study of antigenic polymorphism of these structures should identify disease isolates more precisely and provide information about the relationship between variants of these gonococcal structure and gonococcal virulence. (author's)
Sexually transmitted diseases and infertility.
3 primary mechanisms exist by which sexually transmitted disease (STD) can adversely affect fertility: pregnancy wastage, which may occur in the presence of maternal infections with some STD because of direct effects on the fetus or fetal membranes; neonatal deaths, which may occur as a result of in utero infection or infection acquired during the passage through the birth canal; and post inflammatory reproductive duct scarring with obstruction can result when STD infections remain untreated are inadequately treated or treated too late. Many infections and noninfectious factors have been associated with perinatal wastage, including STD, bacteriuria, malaria, race, socioeconomic status, and pregnancy as a teenager. These factors are often associated with each other. Syphilitic infections have severe adverse effects on pregnancy outcome. Nearly 40% of pregnant women with recently acquired syphilis will have spontaneous abortion or stillbirth or their infant will die within a month of birth. Another 40% will have infants which will survive but will have congenital syphilis. The control of pregnancy wastage and congenital syphilis may be approached by focusing on antenatal screening and/or treatment as well as by reducing the incidence of syphilis in the general population. The risk of transmission of genital herpes simplex virus (HSV) infections from a mother with genital HSV infection to her infant at the time of delivery is about 50%. Nearly 60% of infected infants die and most survivors have severe brain damage. In the US the incidence of genital herpes increased nearly 10 fold in the last 15 years. Gonococcal infection during pregnancy increases the risk of chorioamnionitis, premature rupture of membranes and prematurity. In addition, a recent study identified a 10 fold increase in perinatal deaths associated with chlamydia infections during pregnancy. Mycoplasma hominis ureaplasma urealyticum colonize the genitalia as a result of sexual intercourse and can be recovered from more than 50% of sexually experienced persons. Spread of STD agents from the lower to the upper genital tract may be prevented by early treatment of the infection. The ability of the STD agents to spread to the upper genital tract may also be a characteristic of the infecting organism. Recent data suggest that some strains of gonococci are more likely than others to cause ascending infections. The early approach to the infertility problem should include an evaluation of the area's specific epidemiology of both infertility and STD. From the standpoint of STD related infertility, the 1st step in prevention is to identify the type of infertility problem, e.g., pregnancy and perinatal wastage or reproductive duct obstruction.
The effects of starvation on the physiological aspects of sexual function are examined in a review of animal studies and investigations during periods of war and famine. Reports of war or famine edema have noted a high incidence of amenorrhea. The onset of menstruation appears to be delayed when there is a food shortage, and adult sex organs often undergo atrophy under conditions of severe starvation. The male testis is considered to be somewhat more resistant to starvation than the female ovary, which shows considerable reduction in size and weight. Moreover, excretion of male sex hormones is lowered in undernourished subjects. Sperm motility and the length of time sperm remains motile are also affected by semistarvation. There may be important sex differences in resistance to starvation. Several famine studies have noted a significant excess of male over female deaths; however, it is difficult to segregate physiological from sociological factors. A real decline in the birth rate has been recorded during many periods of food shortage.
The effectiveness of danazol on subsequent fertility in minimal endometriosis.
65 patients with minimal endometriosis were studied for the purpose of prospectively comparing conservative medical management in the form of danazol with no therapy in the treatment of this disease. After completion of the basic infertility evaluation and correction of additional factors affecting fertility, a diagnostic laparoscopy, dilatation and curettage (D and C), and tubal lavage were performed. A randomly selected card determined whether the patient received no treatment for 6 months or danazol for 6 months followed by no treatment for 6 months. The dosage of danazol was 800 mg daily for the 1st 2 months, 600 mg daily for the next 2, and 400 mg daily for the final 2 months. The mean of both the danazol-treated group and the group receiving no danazol was 31 years. Conception occurred in 30% of the danazol-treated patients and 50% of the untreated patients. These results suggest that infertile patients with minimal endometriosis should be given an opportunity to conceive after laparoscopy, D and C, and tubal lavage. This would seem particularly true in older patients, where a 6-month delay in permitting attempts at conception represents a significant interval time. (author's modified)
Emotional aspects of infertility.
The psychologic aspects of infertility in men and women are reviewed, neuroendocrinologic factors thought to affect reproduction physiologically are described, and awareness of the stresses that infertility places on a couple's relationship is encouraged. Studies have found infertile women to be more neurotic, dependent, and anxious than fertile women, experiencing conflict over their femininity and fear associated with reproduction. In contrast to these reports, a double blind study could not determine the difference in the psychologic makeup of women who were infertile because of demonstrated somatic causes and those women in whom no somatic cause could be found and who were considered infertile on an emotional etiologic basis. Other studies have similarly come to negative conclusions regarding the relationship between psychologic factors and infertility. The 1st set of studies failed to consider the stress that infertility itself places on the couple. Emotional factors may negatively affect fertility in the male. Up to 10% of infertile males have had improvement in their semen analysis after cessation of all treatment for a prolonged period of time. The concept that emotional stress might lead to oligospermia was further supported in a report describing testicular biopsies obtained from men awaiting sentencing after raping and impregnating women. A more obvious effect of the emotional stress infertility places on the male is the occurrence of impotence. It has been estimated that up to 10% of infertilty may be partially or completely explained on the basis of male sexual dysfunction. The gradual unraveling of the complexities of neuroendocrinology have permitted increased understanding of the role that stress might play in infertility. Catecholamines, prolactin, adrenal steroids, endorphins, and serotonin all affect ovulation and in turn are all affected by stress. Such stress might result from infertility or habitual abortion. Infertility is frequently perceived by the couple as an enormous emotional strain, and counseling may prove helpful as a part of the initial infertility evaluation, an adjunctive measure during treatment, or a final measure to help patients cope with acceptance of their infertility problem. Although statistical evidence is overwhelmingly against the relationship of adoption and subsequent conception, it does appear that a small percentage of patients do achieve pregnancy following adoption. Possibly this can be explained by a reduction in stress, and subsequently, alterations in the neuroendocrinologic characteristics of the infertile couple.
At this time what might be termed the 5th epidemic of interest in the chlamydiae, a diverse group of microorganisms containing a number of pathogens that are important in both human and animal diseases, is occurring. Focus in this discussion of chlamydial infections is on taxonomy, microbiology, and latency. The chlamydiae, due to a unique developmental cycle that differentiates them from all other microorganisms, have been placed in their own order--the chlamydiales. There is 1 genus chlamydia and 2 species--Chlamydia psittaci and C. trachomatis. All members of the genus share a common antigen. The species can be differentiated on the basis of inclusion type. C. trachomatis inclusions stain with iodine; C. psittaci inclusions do not. Additionally, C. trachomatis is sensitive to sulfonamides, and C. psittaci is resistant. A table lists the human diseases caused by chlamydia. C. psittaci includes the organisms responsible for human psittacosis and for the avian infections that may ultimately cause the human disease. Additionally, different strains of C. psittaci cause a wide variety of diseases of animals. Economically prominent among these are abortions, arthritis, and other systemic infections in sheep and cattle. C. trachomatis includes the organisms responsible for trachoma, inclusion conjunctivitis, genital-tract infections, and lymphogranuloma venereum. With the exception of a few strains of rodent pneumonitis, the C. trachomatis strains are human pathogens with the human as the sole natural host, whereas C. psittaci strains appear to involve human diseases only as zoonoses. C. trachomatis strains of human origin are more homogeneous. The chlamydiae are obligatory intracellular parasites once considered to be large viruses sensitive to the action of some antimicrobials or antibiotics, but a more sophisticated definition of viruses and bacteria has permitted the recognition that the chlamydiae are bacteria like and definitely not viruses. They differ from the viruses in having 2 nucleic acids and in having a discrete cell wall, quite analagous in structure and content to those of the gram negative bacteria. The chlamydiae have a restricted metabolic capability and multiply within the host cell by binary fission. They undergo no eclipse phase. They are susceptible to antibiotics. Careful study of any natural chlamydial host shows a substantial degree of latent or inapparent infections. There is no convincing evidence that chlamydiae persist in the intact host in a nonreplicating form. It is more likely that latent or subclinical infections represent persistent low levels of multiplication held in check by host defense mechanisms. C. trachomatis infections of the genital tract represent the major focus of current interest in the chlamydia. Chlamydia recovery has been associated with nongonococcal urethritis at a statistically significant level. The implications of the double infection with chlamydiae in gonorrhea are clear; chlamydiae are responsible for approximately 70% of postgonococcal urethritis.
Are chlamydial infections the most prevalent venereal disease?
We studied 2 populations (more than 1600 patients) to determine the prevalence and clinical associations of genital tract infections with chlamydiae and herpesviruses. Baseline isolation rates for asymptomatic women having routine pelvic examinations were much lower than rates for symptomatic women. In both groups, chlamydiae were more prevalent than herpesviruses. Chlamydial infection was associated much more commonly with cervicitis (36.6%) than with vaginitis only (4.1%). Among 282 symptomatic men, the cultures of 19.9% yielded chlamydiae, and 4.3% herpesviruses. Chlamydiae were recovered from 35.5% (27 of 76) of specimens from men with nongonococcal urethritis, and from an even larger proportion, 57% (24 of 42) of the specimens from men with frank discharge. (author's modified)
This discussion of chlamydial infections focuses on the diagnosis of nongonococcal urethritis, treatment of chlamydial urethritis, chlamydial infection in the female genital tract, the spectrum of chlamydial genital tract infections, and lymphogranuloma venereum. Routine workup of men with urethritis always begins with tests for gonococcal infection. Once this possiblity is ruled out, an effort may be made to establish infection with H. hominis, Trichomonas vaginalis, or Candida albicans, but these efforts are ususally not rewarded and are probably not justified. Initially, the clinician should establish the diagnosis in a patient who has discharge or complains of dysuria or frequency, by demonstrating polymorphonuclear leukocytes in direct smear of the discharge or by quantitative first void urinalysis. A standardized procedures should be used to provide an objective measurement of urethral inflammation and an index of response to therapy. Treatment of chlamydial urethritis can be highly effective, and successful treatment implies microbiologic cure and reversal of the signs of urethritis, i.e, failure to demonstrate leukocytes in either urethral scrapings or urine. Partners of patients with chlamydial infection must be treated in parallel with the patient. The failure to treat nongonococcal urethritis as an venereal disease is a major reason why the disease has gained a reputation for difficulty in treatment. Successful treatment of chlamydial infections requires attention to the appropriate choice of drug and recognition of the unique characteristics of the organism to assure success. Several studies have found chlamydiae to be among the most commonly recovered pathogens in women attending clinics for sexually transmitted diseases. Many workers have reported higher recovery of chlamydiae from women with cervicitis than from women with no abnormal findings. Screening studies have clearly shown that chlamydiae can be recovered from clinically normal cervices. It is likely that chlamydiae are capable of causing cervicitis without assistance or interaction with other pathogens. The baseline carrier rate for chlamydiae in the cervix is unknown. The role of chlamydiae in disease of the female genital tract other than cervicitis is currently the subject of active study. Women with cervical atypia have been shown to have a high rate of exposure to chlamydia. Epididymitis is recognized as 1 of the possible complications of lymphogranuloma venereum, and Heap has provided serologic evidence of chlamydial infection in 2 cases studied recently. Lymphogranuloma venereum is a venereal disease caused by C. trachomatis. There have been no noteworthy improvements in the treatment of lymphogranuloma venereum. Response to therapy is usually better in acute cases. Lymphogranuloma venereum, particularly in the chronic stages, results in profound changes in serum globulin levels.
Excessive perinatal mortality in a small town associated with evidence of toxoplasmosis.
The small town of Barton on Humber in North Lincolnshire district, England experienced a stillbirth rate of 59.6 for the years 1956, 1957, and 1958. During the same 3 year period the neighboring town of Brigg had a stillbirth rate of 9.0 and the surrounding rural district had a rate of 28.1. The differences in numbers of stillbirths occurring in these districts were statistically significant. This discussion describes the investigations made to determine the cause of the excess of stillbirths experienced in Barton on Humber. As it was already apparent by the end of 1957 that the excessive mortality in Barton was unlikely to be due to chance, a preliminary survey was begun. The county medical officer of health arranged for the midwives to complete a questionnaire focusing on all stillbirths and early neonatal deaths occurring in the 3 county districts. From the questionnaires it soon became evident that the fetus was either malformed or macerated in almost 2/3 of all stillbirths in the area, suggesting that the factors responsible must be nonobstetric and that an inquiry must consider possible genetic and environmental influences if it was to be successful. 19 women who were residents of Barton on Humber and had stillborn babies during 1956, 1957, and 1958 were identified and traced. For each of these women, 2 "control" mothers of live babies born in the same months were selected. A questionnaire was designed to obtain information regarding past obstetric history, consanguinity between parents, occupation of father, details of work outside the home, illnesses during pregnancy, dental treatment, anesthetics, x rays, medical treatment, recreational habits, contact with animals, and details of the pregnancy under review. In only 3 of the 19 stillbirths is it possible to state the cause with any certainty. In 1 case the fetal heart stopped after the mother was injured in a fall at the 27th week of pregnancy. In another patient the transverse lie of the fetus was due to a large fibromyoma which filled the placenta and to which a low lying placenta was adherent. In a 3rd case there was a placent previa and the cord encircled the baby's neck. The most notable difference between the 2 groups of mothers was in respect of toxoplasma dye test titres. As stillbirth may be caused by toxoplasmosis, either primarily as a result of the infection or secondarily as a result of obstetric difficulty due to hydrocephaly or malpresentation, the finding of a significant excess of toxoplasma dye test titres of mothers of stillbirths supported by a relatively high incidence of hydrocephaly suggests that toxoplasmosis may have caused a proportion of these stillbirths. There was a significantly higher incidence of cytoplasm modifying antibody to Toxoplasma gondii in the women whose babies had been stillborn, when compared with the other mothers.
The clinical management of repeated early pregnancy wastage.
This review of the current literature on the clinical management of repeated early pregnancy wastage focuses on several etiologic factors (i.e., genetic, medical, immunologic, endocrine, psychogenic, environmental, occupational, infectious, and uterine) which have been noted to result in repeated pregnancy wastage. Suggestions for further clinical study are outlined where appropriate, and a rational approach to clinical evaluation and management is provided, based on the interpretation of the state of the art. The frequency of clinically recognized spontaneous abortion in the general population has been estimated to range between 15-20%. The actual spontaneous abortion rate is difficult to determine due to the fact that some patients do not seek medical services and abort completely at home. Despite the present uncertainty concerning the actual risk of recurrent abortion, most clinicians agree that repeated early spontaneous pregnancy wastage (i.e., repeated pregnancy loss) is defined as the occurrence of 3 or more pregnancy losses prior to the 20th week of gestation. From cytogenetic studies of aborted products of conception, chromosomal abnormalities account for between 50-60% of spontaneous abortions in the 1st trimester of pregnancy. Most of the chromosomal aberrations involved in spontaneous abortions have been presumed to be due to random events that are not necessarily repetitious. Sporadic chromosomal errors account for approximately 30% of spontaneous pregnancy losses, and repeated pregnancy loss under these conditions would therefore occur as a matter of chance and would not be predictive of future pregnancy loss. Several medical diseases have been implicated in causing habitual abortion, and these include systemic lupus erythematosus, congenital cardiac disease, and renal disease. The severity of the disease correlates best with fetal wastage. An absence of blocking antibodies within the serum of women with repeated abortions was reported by Rocklin et al. A review of the literature shows that only an association exists between psychologic disturbances and habitual abortion. Intrauterine infection may result in early pregnancy wastage, and fetal death may result from an acute overwhelming infection. It has long been recognized that congenital anomalies of the uterus have been responsible in some instances for reproductive failure. The gynecologist must consider the time of initiation of an evaluation of a patient with reproductive loss. Any evaluation must include a complete history and a karyotypic analysis with fluorescent banding of both partners, a hysterogram, and a properly timed endometrial biopsy. In the authors' experience, about 50% of patients with repeated pregnancy loss have no discernible etiologic factor. Subsequent early pregnancy should be carefully monitored in these patients. When no etiologic factor is identfied, a 60-80% fetal salvage rate may be expected.
Tuberculous epididymitis: a review of 170 patients.
A current series of 129 patients with tuberculous epididymitis was compared with a series of 41 cases reported by 1 of the authors in 1948. A close association between renal and genital tuberculosis was observed in both series (40% in the earlier group and 65% in the current series). Little difference was noted between the 2 groups in terms of clinical features. The majority of patients in both groups were in the 20-40 age group. A previous history of tuberculosis was given by 70% in the earlier group and 76% in the later group. 113 patients in the later series had widespread disease involving all 3 parts of the epididymis. Thickening of the vas deferens was noted in 74% of the earlier cases and 50% of the more recent cases, but beading and secondary hydrocele were rarely observed. The current treatment method involves 6 months of intensive chemotherapy in a sanatorium followed by outpatient treatment over a period of 2 or more years. 39 of the 41 earlier patients required epidiymectomy; however, since the advent of chemotherapy, this procedure has been indicated only in cases of gross thickening of the cord and vas, a large caseating abscess, or failure to respond to treatment. 12 recent patients were treated by chemotherapy alone, and the epididymis either returned to normal or became a fibrous cord. Orchidectomy and division and ligation of the contralateral vas, which render patients permanently sterile, are considered unnecessary in most cases. Chemotherapy has made subsequent epididyitis on the opposite side unlikely. The 2 fundamental techniques of epididymectomy include preservation of the blood supply of the body and exteriorization of the stump of the vas deferens. Follow-up of patients in both series indicated minimal morbidity and no postoperative mortality. The route of infection is considered to be via the blood stream in the majority of cases. This theory allows tuberculous epididymitis to conform with other secondary manifestations of tuberculosis. No evidence has been found for infection via the lumen of the vas or via the lymphatics.
Effect of graded doses of ionizing radiation on the human testis.
A portable unit was developed to provide uniform irradiation of the human testes. The device had built-in radiological protection and provided a dosage independent of the subject geometry, uniform to within +or- 5%. Single doses, between 8-600 rad were administered to the testes of human subjects. Observations were made both before and following irradiation. Parameters evaluated included sperm concentration, motility and morphology, seminal fluid volume, plasma and urinary gonadotropin and testosterone levels, urinary estrogens, and comparison of testicular biopsies taken before and after irradiation in the same subject. Dose-response relationships and recovery times were determined for each dose range studied. (author's modified)
To explore the association of lepromatous leprosy with immunologic deficit and the formation of autoantibodies, the sera of 35 randomly selected leprosy patients (30 men and 5 women) ages 21-58 years was examined. 50 normal fertile men were used as controls. Microscopic sperm agglutination in gelatin, sperm immobilization, tanned red cell hemagglutination, and antihuman globulin consumption tests detected antispermatozoal antibodies in 41%, 37%, 23%, and 82%, respectively, of the leprosy patients. The corresponding percentages among controls were 2%, 0, 0, and 16.6%. All 4 tests were positive in serum from 1 female patient with borderline leprosy. No signigicant difference in sperm antibody detection was noted between the lepromatous and tuberculoid forms of the disease. When the results of the spermagglutination in gelatin, sperm immobilization, and tanned red cell hemagglutination tests were compared, perfect correlation between all 3 tests was found in 57% of the sera. Head-to-head sperm agglutination was the predominant morphologic type (52%). Sepcific gamma globulin in the sera of 19 of 23 leprosy patients was adsorbed to the surface of the normal donors' spermatozoa when the latter was incubated with the test sera. The consumption of antihuman globulin was more intense in the sera of lepromatous patients than tubercluoid patients. The etiology of the formation of circulating sperm-specific antibodies in leprosy patients appears to be different from that in infertile and vasectomized subjects. Inflammation of the testis and genital tract may cause obstruction, with the formation of antibodies. Antibody synthesis may be further accentuated by the adjuvant-like action of M. leprae. It has been suggested that antisperm antibodies cause infertility, but there is debate as to whether it is immobilizing or agglutinating antibodies that interfere with host fertility. Further research is needed on the role of the circulating sperm antibodies on fertility in lepromatous patients. (summaries in SPA, FRE)
The search for chlamydiae agents in human excretions and secretions has led to rapid expansion of the clinical spectrum of C. trachomatis infection. Inclusion conjunctivitis, a chlamydial infection acquired during passage through the birth canal, occurs in 40-50% of exposed infants. This infection is of concern due to the recent recovery of C. trachomatis from the nasopharyngeal and tracheobronchial aspirate of infants with the distinctive pneumonia syndrome. Chlamydiae have also been recovered from the nasopharynx of infants with inclusive conjunctivitis but no respiratory manifestations. The organism is further believed to be involved in excess secretory otitis media and nasopharyngeal obstruction. Prospective studies are needed to determine what percentage of infants with inclusive conjunctivitis contract respiratory tract infection and what percentage with respiratory infection have antecedent inclusion conjunctivitis. Trachoma, a chronic conjunctivitis caused by C. trachomatis, is self-limiting but may leave a residuum of permanent lesions that can cause blindness. Treatment campaigns are aimed at pervention of blinding lesions and include mass application of topical antibiotics for active disease. Trachoma will probably respond better to improvements in economic development and hygienic conditions than to vaccination or chemotherapy alone. Human psittacosis, an infection with C. psittaci, is contracted through exposure to infected birds and produces either a respiratory or systemic disease. Due to a lack of monitoring, imported birds handled at US treatment centers may not be treated effectively and those having occupational contact with these birds are at risk. Mammalian chlamydiae are not considered a serious threat to human health. Sufficient criteria for identification of chlamydiae are needed for tissue culture systems. Although initial identification will be based on cytologic results, it could be augmented by Giemsa stain confirmation of the inclusions that stain with iodine. Serial transmission of the isolated organism should be a minimal criterion. The use of complement fixation or microimmunofluroescent tests to provide group-specific serologic identification should be applied.
Socio economic consequences of migration in the Philippines.
The structural consequences of migration in the Philippines were examined by looking at both an area of origin and an area of destination: the Ilocos region, to represent a rural outmigration area in the Philippines; and Metro Manila, the major urban destination area in the country. The effects of migration are often manifested at 3 levels: the community; the household; and the individual. Focus here is primarily on the effects of population movements at the community level. In the process, some policy alternatives for coping with the consequences of population shifts are outlined. In addition to available secondary data from census reports and other related documents, some of the preliminary findings of a baseline, cross section survey in the province of Ilocos Norte are presented. The survey involved interviews with over 1700 adults aged 18-64 and formed part of a broader research effort designed to examine the determinants of migration, the adjustment process, and the flows of migrants from a rural area of outmigration in the Philippines to the major urban destination area in that country (Metro Manila) and a major place of destination in the US (Honolulu). What is really problematic in regard to outmigration from the Ilocos has to do with a process of selectivity that appears to be occurring. Outmigration from the Ilocos in the prewar period was heavily male dominant, and this male dominance resulted in highly imbalanced sex ratios. Outmigration from the Ilocos also seems to be selective of the relatively young and single persons. The results of the original survey in the Ilocos showed that intended migrants are generally younger than intended strayers, and that this difference was particularly more pronounced for internal migrants. An adverse consequence of this process of age selectivity which is not difficult to anticipate was the degradation of the age structure of the region's population which, in the long run, could increase its dependency burden. What is more problematic is that outmigration from Ilocos appears to be selective of the well trained and the skilled, i.e., the population with the greatest potential for labor. The survey results revealed that intended migrants had a higher educational attainment than intended nonmigrants. The socioeconomic effects of migration in Metro Manila relate mostly to development problems associated with unregulated urban growth. These problems include such urban phenomena as unemployment and poverty, the straining of urban services, congestion and overcrowding, housing shortage, and generally less satisfactory physical conditions. These problems have reached alarming proportions in Metro Manila where urban growth has outpaced the provision of basic government services. The government has implemented such programs as regional development aimed at rectifying imbalances among regions; industrial dispersal through mini-industrial estates in selected areas of the country; and integrated area development projects. A wide gap often exists between official pronouncements of policy and intent and acutal accomplishments.
Women, migration and the decline of smallholder agriculture.
It is argued in this discussion that the migration of males to cash earning opportunities off the farm is a major ingredient endangering smallholder agriculture, particularly the production of local food. The reasons smallholder agriculture appears to be losing ground, and the effects on the food supply and the nutritional status of the poor are examined, with emphasis on women's role in small farm systems and particularly their preeminence in food production. Evidence is cited that the absence of able bodied men places great burdens on the women left behind to carry on the agriculture work and care of their families. Both the family farm and the community suffer from the loss of labor when young men leave to work as wage laborers in agriculture or in distant cities or countries. With cash remittances, the family left behind must shift production and consumption patterns. A dependency on remittances develops, resulting in loss of self sufficiency both in food production and material necessities. Accompanying this new cash created dependency is a breakdown in the work sharing systems that have been a factor holding the community fabric together and a reluctance to take up agriculture again if the migrants return. Agricultural development programs at times threaten both rural economies and smallholder agriculture. When agricultural production is directed towards export, foreign exchange earnings frequently go for purchased luxury goods and imported food for urban consumers. Modernization and mechanization usually mean less employment in agriculture. For individuals who continue to work in the agriculture sector, a changeover to purchased food from traditional home produced food often results in lower nutritional levels. Projects of the world food supply indicate that there will be serious shortages, particularly for the 3rd world countries. A body of development literature exists that documents women's contribution to agricultural production. The view that emerges is that women predominate in food cropping, subsistence agriculture, and hoe cultivation. Men are in control when production is commercial, based on a mechanized system or on the plow. Recognition of the role women play as food producers continues to be inadequate for responsible development planning. Major works on agricultural development overlook totally this key factor in production, yet numerous studies exist documenting women's capabilities in farm production and management--if they have sufficient support and inputs. Because of the important role women play in family farming, the forces undermining small farm systems deprive women of an important source of economic productivity. Any policies designed to increase food for the poor will fail unless they consider women's role as food producer and, preeminently, as producer of food for the poor.
Principle factors influencing migration: an analysis of individuals and households in Bicol.
The study objective was to examine the causes of, and the issues and factors related to, the "maldistribution" aspect of the Philippine population problem. An in depth follow-up of an earlier study, the sample included 528 randomly selected households in Bicol, which came from households in selected outmigration areas and included 19 cases of movers and 2 cases of stayers. The study made use of secondary data in relation to the region's main characteristics--its economy, the problems in the area, and the migration experience in the region. The primary data collected included variables that were examined at 3 different levels--community, household, and individual. The following were among the study findings: the Bicol region is essentially an outmigration area; "negative selectivity" appears to occur--heavy losses were in the younger ages up to the early 40s and among persons of higher skills and educational level; the favored destination, especially for the rural migrants, was another rural area; on the whoe the migrant's motivations for moving were usually linked with his relationships with the family and the community; case histories supported the contention that there is no single reason and often no explicit decision for migration; many migrations had a strong family basis, ranging from marriage and accompanying a family head to contracting members of the family for outside employment; the consequences of the outmigration in Bicol were the depletion of the region's manpower resources due to the degradation of the age structure of the population, the increase in the region's dependency burden as a result of chain migration, and a slowing down of the region's economic growth and development due to the relative deterioration of the skill structure of the region; and the cases showed that the outmigrant was the recipient of economic aid from his relatives in Bicol. At the level of the individual, 3 propositions may be made: geographic mobility of fathers leads to geographic mobility of children; social mobility of parents is related to the children's propensity to migrate and geographic mobility does not generally lead to social mobility. Policy implications of the findings include the following: the importance of the family and the community in designing programs to cope with the migration problem must be recognized; rural resettlement schemes need careful study in view of the strong rural to rural migration stream; and the government should consider giving more support to conservative migrants and stayers, both of whom tend to remain in the primary industries of farming and fishing.
Expectations and reality: a case study of return migration from the United States to Southern Italy.
A summary of Italy's emigration flows shows that Southern Italy sent her people abroad in great number, and, at the same time, return migration to Italy has been characteristic of a minority, e.g., an estimated 3000 from the US alone, 1964-68. Italy's modernization proceeded unevenly, the South remaining agricultural and for the most part, economically backward. Any form of identification with Italy as a country did not affect the Southern peasant thus preparing his/her way to emigrate as soon as any opportunity presented itself. Due to all the conditions which facilitated emigration from Italy on an individualistic and nonideological basis and without an understanding of the economic forces pushing the emigrant out, and in view of the lack of understanding of how the New World economy of the US was constituted, it is no surprise that the return migration of some remained as much ad hoc and based solely on individual motivations as was the emigration. The 2 fundamental approaches to the concept of immigrant both start by considering the immigrant in his/her new situation. 1 approach views the immigrant's success in the new situation as dependent upon acquiring values and patterns of behavior which would resolve his/her problems in the new society. According to the other approach, in order to resolve the problems of his/her new situation the immigrant must become critically aware of the consequences of his/her actions. The 1st view of conceiving integration has been prevalent, particularly in the study of international migration. And, mass migration from Italy, from the emigrant's perspective, is connected to a repeatedly unsuccessful search for economic success and failure to reach prevailing cultural objectives. The act of emigration, of abandonment, may thus be seen as the resolution of the disparity between the means at the emigrant's disposal and the objectives he/she seeks. The great majority succeed but some fail, and if they have a home and family to return to, they begin to think of returning. Returned migrants interviewed experienced an abrupt passage from a rural to an urban and industrial world. Few of the immigrants whose background was in a fa rm occupation engaged in farming upon arrival in the US. The factor determining whether the immigrant surmounts the problems of the 1st phase of his/her experience is his/her work. If the work the immigrant has found makes him/her part of the production process, the money earned makes him/her part of the consumption process. And, this is the 1st turning point in the experience as an immigrant. A return of conservativism is given when the immigrant continues to consider his/her earnings and investments in terms of the traditional scheme appropriate to the home country. Return of innovation is the term given to those who were unwilling or unable to accept fully their expected position in the new society and tended to detach themselves, even to the point of return to the mother country. The consequences of returns to the native society are summarized. In sum, it appears that returned migrants cannot function as vehicles of social development.
Wave of Middle East migration raises questions of policy in many countries.
Since 1973 the increase in revenues from petroleum has resulted in a substantial migration of workers to the oil exporting countries of the Middle East. Discussion focuses on the policies being used to minimize the costs and maximize the advantages of emigration, including description and evaluation of measures and proposals for further action. No action seems to have been taken to regulate the present wave of Middle Eastern emigration, probably because in its initial stages it proved an unmixed blessing for the labor exporting countries. Steps should have been taken to protect the emigrants. Their living conditions are unsatisfactory in some host countries, and frequently they are exploited by the unscrupulous middlemen who arranged their employment and wages. No effective international agreements, multilateral or bilateral, have been concluded to deal with these problems. A policy response is required as labor shortages emerge in the later phases of emigration, especially as the balance of payments situation improves and reserves rise. An appropriate strategy should combine both supply and demand management measures. It should avoid overambitious antiinflationary objectives. For the majority of the labor exporting countries discussed here, foreign exchange earnings from migrants have reached sizable amounts, exceeding, for example, $1 billion in Egypt, India, Pakistan, and the Yemen Arab Republic. Countries are maximizing those receipts by resorting to compulsion and surrender requirements. Emigrants should be coaxed and not compelled to remit currently a high proportion of savings and to invest a low percentage in the country where they work or in 3rd countries. Remittances by workers during the period of their stay in foreign countries are made for family maintenance and for investment. The most effective way to satisfy emigrants that they will be able to reexport their assets is to remove all restrictions on payments. Going beyond general policies to create a favorable investment climate, almost all labor exporting countries are providing facilities and incentives for specific transactions of interest to emigrants. Policies which create a favorable investment climate and facilitate the construction of housing can be helpful in attracting emigrants back to their country of origin.
Demographic responses and population change.
Most Western societies have gone through a process of population change during the past 100-150 years. 1 important aspect is the so-called demographic transition: the shift from high to low birth and death rates, and accelerated growth resulting from the lag between falling mortality and falling fertility, in national populations. Equally important has been the "rural-to-urban" transition, which involved the migration of millions of people from rural areas. It is hypothesized that, following the suggestion of Davis (Theory of the Multiphasic Demographic Response), the adjustment in reproductive behavior made by a community in response to a rising "strain," such as that resulting from higher natural increase, is likely to differ depending upon the ease with which the community can relieve the strain throughout migration. Relationships among such characteristics of modernization as intensity of industrialization, speed of urbanization, structural changes in the agricultural system, and declining fertility are implied. Case studies of England and Sweden lend support to the hypothesis that more rapid urban-industrial development, larger scale movement from rural areas, and a delayed decline in the rural birth rate distinguish the English transition. (author's)
At a homecoming in Ghana: few amenities, much worry.
Thousands of Ghanaians are returning to Ghana after being expelled from Nigeria. Their difficulties are not over when they arrive, however; reabsorption will be extremely difficult. Thus far, 350,000 Ghanaian nationals have been processed. The US is helping in this effort by providing 60 tons of food for a relief effort. These illegal aliens were expelled from Nigeria because of the shrinking oil economy and because of domestic political pressure. Ghanaian officials have estimated that 1.2 million Ghanaians will be returning; if this is so, Ghana will have to import 126,000 tons of grain to feed them. If this figure is accurate, too, it means that Ghana will have a 10% population increase in the span of 2 days. The administration intends to assure that these returnees do not remain in the major cities but rather go to the towns and villages where they will be absorbed more easily. The major concern of Ghanaian officials is not outbreak of disease but rather that the young men returning may have learned the ways of violence in Nigeria. The government is also concerned about the political effects of the population influx as there have already been signs of discontent. While many of those returning are skilled and ambitious, it is difficult to utilize those individuals in light of the condition of the economy. There is concern that they may form an uncontrollable constituency since they have become accustomed to relative wealth in Nigeria which cannot be matched in Ghana.
The manpower boomerang hits Jordan.
Jordan's main source of wealth, a surplus of skilled manpower, obtained sufficient funds from its employment in neighboring countries to compensate for shortages of other resources, and until 1974 the wheels of economic and social progress turned fairly smoothly. At that time Jordan began to realize that the export of skills to the oil producing countries had begun to boomerang. What had started as a source of valuable revenues turned into a drain on human resources Jordan could no longer afford to lose. Currently, it is estimated that 120,000-150,000 Jordanians are working in the oil producing countries, including 14,750 teachers. Figures provided by the engineering, medical, and pharmacists' professional unions show that 66%, 34%, and 24% of their respective registered members left the country in 1976. To combat the shortage of skilled manpower, Jordan has had to import labor from Egypt and Pakistan. The problem now facing the country is not solely that of the cost of preparing professional and skilled labor but also one of lost or delayed development momentum, pressure for higher wages by local workers unrelated to productivity increases, an increasing tendency towards luxury consumption, and the import of manpower. Both the authorities and the private sector have made strenuous efforts to curb the chronic exodus of manpower. Inducements have been introduced to persuade workers to stay. These include a 50% exemption from the income tax on annual net earnings and tax exemption on some consumer goods and household appliances for civil servants. Private sector employees, who unlike civil servants are free to negotiate wage increases any time rather than rely on a predetermined fixed annual increment, are granted a 25% exemption from income tax. Little or no improvements have resulted from these measures, because they were still outweighed by the attractive salaries and fringe benefits which continued to lure professionals and skilled workers to migrate, mainly the newly graduated. Additionally, the vocational institutes were expanded to accommodate more graduates from secondary schools. For training middle level managers, the Jordan Institute of Management was established in 1977. In June 1977 Crown Prince Hassan proposed the establishment of an International Labor Compensatory Facility to promote a more balanced relationship between the manpower exporting and importing countries, but to be gainfully operative any such facility requires the advice and support of international bodies and in particular that of the International Labor Organization.
Immigration: the other population issue.
More and more concern is being focused on the "other" population issue, that is, the movement of millions upon millions of persons across international borders in search of a better life. Never before in human history have migration levels approached those presently observed. Demographically, the potential migration pent up in today's world is enormous. Nothing is more natural than to expect the destitute masses of the underprevileged regions to move across international and continental boundaries into the better regions. Actual migration is also governed by economic costs, political barriers, ethnic attitudes, and limited horizons. With the emergence of nation states and political barriers, migration has become subject to control, yet an increasing number of persons are ignoring these constraints. The possibility dire consequences of migration seem less important in light of the spectacular advances in communication and transportation technology and the prospect of increasing poverty. This is becoming evident throughout the world in migration from Mexico and Central America to the US, from Guninea to Ivory Coast, from Colombia to Venezuela, and even from St. Vincent and St. Lucia to Barbados. An estimated 13 million refugees are currently living in countries other than their own, possibly temporarily but possibly permanently. In sum, an incredibly vast movement of humans is taking place in all regions of the world. The effects of these movements across borders are awesome and differ substantially from 1 region to another. Some 3rd world countries have exhibited considerable socioeconomic development in recent years. This is particularly the case for the OPEC nations. The question that arises is what happens when the economic bubble bursts and the need for foreign workers no longer exists. The US is becoming increasingly concerned about immigration issues, whether involving refugees and legal or illegal immigrants. Since the mid 1970s the US has been accepting over 100,000 refugees every year, and one can only speculate regarding the demands in future years given the unstable political situation in many regions of the world. The situation in Western Europe is similar though under somewhat different circumstances. Another difficult issue facing the more developed countries is that fertility has dropped to historical lows in almost every country. In the US fertility has remained well below replacement for over a decade. Without continued immigratin the population would begin falling after the year 2000. Many feel that numerical increases should come to an end in the US and be followed by an era of zero population growth at perhaps 275 or 300 million population. Massive economic and family planning assistance to developing countries is urgently needed if both population growth and emigration are to be reduced. The developed countries must be prepared to accept inevitable changes in the age, racial, and ethnic composition of their populations. The very size of international movements of all kinds--legal immigration, illegal movements, and refugees--necessitates a reexamination of the issue at this time.
Full term pregnancy following genital tuberculosis.
To evaluate conflicting statements concerning the permanency of infertility following genital tuberculosis, a comprehensive review of the literautre was conducted. The literature reflects differences in terms of the criteria that must be fulfilled to establish a diagnosis of genital tuberculosis. Histologic and/or bacteriologic examinations of uterine or tubal tissue or secretions are the only accurate methods. An absolute diagnosis cannot be made solely from a hysterosalpingogram, and menstrual blood examinations for tubercle bacilli may not always be accurate. It is also essential to distinguish between pelvic tuberculosis and genital tuberculosis. The former may involve the peritoneum, mesenteric or pelvic lymph nodes, intestines, and serosa of the tube. However, the mucosa of the tube or of the endometrium is not involved, as it is in genital tuberculosis. The literature contained 64 case histories of full-term pregnancies in women with prior genital tuberculosis, and these histories are summarized and evaluated individally. It is concluded that a diagnosis of genital tuberculosis cannot be substantiated in over half (33) of these 64 cases. The explanation for the occurrence of full-term pergnancy is sought for the remaining 31 acceptably substantiated cases. Although a common cause of sterility after genital tuberculosis is occlusion of the fallopian tubes, tubal occlusion is not complete in all cases and does not involve both tubes at the same time. 1 or both of the tubes remained patent in 15 of the 31 patients analyzed. Pregnancy may also occur after longterm therapy with antituberculosis drugs in patients with minimal tubal disease diagnosed at an early stage. This occurred in 13 of the 31 proven cases. The use of cortisone with these drugs may enhance the possibility of pregnancy in some cases. Most pregnancies in women who have had genital tuberculosis end in spontaneous abortion or an ectopic site. Women with advanced cases are premanently infertile.
Resolve is a national, nonprofit charitable organization which offers counseling, referral, and support groups to couples with infertility problems, and education and assistance to associated professionals. The Resolve newsletter provides news of the national organization and local chapters; articles and letters sharing experiences of infertile couples and suggesting strategies for coping with the emotional and psychological problems of infertiilty; request for contacts with other couples experiencing the same specific problems; a column announcing births and adoptions; and reviews of books on topics related to infertility. The December 1982 issue includes a discription of the various activities of the national organization, suggestions for coping with the holiday season and its emphasis on children, a woman's account of her slow public acknowledgement of infertiltiy and the difficulty and risks of discussing it with others, and a discussion of myths about pregnancy after infertility and the response of the organization to memebers who become pregnant.
Toxoplasmosis. Report of a WHO meeting of investigators.
This report of a World Health Organization meeting of investigators on toxoplasmosis held in Geneva in November 1968 reviews recent progress in the taxonomy, physiology, and immunology of Toxoplasma and the epidemiology, diagnosis, and therapy of toxoplasmosis, and makes recommendations for further research. The discussion of Toxoplasma and related organisms considers their distribution within the animal kingdom, host specificity, location in the host, morphology, immunology, behavior in experimental animals, and life cycles. Few studies have been done of the physiology and biochemistry of Toxoplasma, but available findings suggest that there is nothing unique about the respiratory physiology and biochemistry of Toxoplasma. The virulence of a given strain of Toxoplasma is usually estimated through laboratory experiments with mice. Most cases of toxoplasmosis among humans are subclinical, but symptomatic toxoplasmosis may occur in congenital infections, probably the most serious form. The disease is acquired by the fetus during an asymptomatic or mild primary infection of the mother and may result in stillbirth, various severe deformities, or minor damage. Symptomatic toxoplasmosis may also appear as a benign syndrome of acquired infection characterized by lymphadenopathy, a rare but more severe disease with fever, rash, malaise, muscular pain, pneumonia, myocarditis, and meningoencephalitis; uveitis which occurs in congenital toxoplasmosis; abortion occurring as a single event; or diffuse toxoplasmosis in patients receiving immunosuppressive therapy or suffering from immunopathy. Toxoplasma are widespread in warm-blooded vertebrates, whose disease closely parallels human toxoplasmosis. Available data indicate that human-to-human transfer does not occur except from the primarily infected woman to her fetus. There is no evidence that transfer usually occurs from animals and birds to man except by ingestion. Diagnostic methods include direct demonstration of Toxoplasma, a dye test, a complement-fixation test, indirect hemagglutination test, and indirect fluorescence test. The intradermal skin test becomes positive a few months after infection by Toxoplasma and probably remains positive throughout life. There is no evidence that administration of chemotherapeutic agents to infants with congenital toxoplasmosis affects the course of their disease.
Gonococcal pilus vaccine development project by Bactex.
Gonococcal pilus vaccine development project by Bactex includes a recently completed clinical trial involving approximately 3500 US army volunteers in Korea. Results of the double-blind, placebo controlled study, conducted during the 1st 8 weeks of 1983, are currently being analyzed. The findings will be confirmed by further testing and if the vaccine proves effective, Bactex plans to apply for a biological license. Bactex was founded in 1974 with the assistance of loans from the Center for Entrepreneurial Development at Carnegie Mellon University. The center at Carnegie, set up and funded by the National Science Foundation, serves to stimulate the transfer of technology from the academic community to industry. Similar centers have been established at MIT and the University of Washington, Bactex President and University of Pittsburgh microbiologist Charles Brinton told "The Blue Sheet" the company is developing additional human vaccines based on pilus technology. He noted that the firm also has a joint agreement with Schering's Animal Health Division for the production of animal vaccines. Under this agreement, Bactex developed a vaccine for neonatal diarrhea in piglets, which Schering began marketing about a month ago. In addition to the study in Korea, Brinton has tested the gonorrhea vaccine in approximately 230 volunteers at the University of Pittsburgh. The Korean trial was partially funded by the US Army Medical Research and Development Command. (full text)
An evaluation of 576 hysterosalpingograms on infertile women.
Tubal occlusion is a frequent cuase of infertility throughout the world, and in Ibadan, Nigeria, about 60% of infertile women have bilateral tubal occlusion. Although laparoscopy and chromotubation provide more information than hysterosalpingography, radiographic studies are valuable nonoperative procedures which detect tubal and uterine pathology. In African culture, infertility is an event for which women are usually blamed. Most investigative procedures are done on them. The purpose of this presentation is to report the findings resulting from hysterosalpingograms performed on 576 women whose main complaint was infertility. (author's modified)
Pelvic tuberculosis (TBC) was diagnosed in 20 patients studied during the period 1971-75. 14 patients were born outside the US. The most frequent presenting complaints were infertility (14 patients), pelvic pain (6), and amenorrhea (4). Only 5 patients gave a previous history of treatment for TBC. Results of pelvic examination were normal in 11 patients; results of chest x-rays were normal in 15. 15 patients had endometrial biopsies, 10 of which showed granulomatous endometritis. 15 patients had hysterosalpingograms, all of which yielded abnormal results, and 14 were indicative of TBC. Cultures were positve for Mycobacterium tuberculosis in 6 of 16 patients. Genital TBC should be considered as a possible cause of infertility, especially in foreign-born patients. Although a conclusive diagnosis can be made only from a positive culture or histologic specimen, hysterosalpingography is a very useful aid in establishing the diagnosis. (author's modified)
Infertility in women over the age of 36.
93 infertile couples with the female partner over age 36 were studied. Tubal factor was the most common etiologic factor in women ages 36-40 and unexplained infertility was the most common factor in women over age 40. It appears that in the aging infertile population, the ovulatory factor is not the most important cause of infertility. The overall pregnancy rate (33%) is lower and the abortion rate (31%) is increased with advancing age as compared with the general infertile population. The implication of aging as a cause of infertility is discussed. (author's modified)
Antibodies against testicular germinal cells in lepromatous leprosy.
Testicular germinal cell antibodies were found in 44 of 59 patients with lepromatous leprosy and in 4 of 10 patients with tuberculoid disease. A similar pattern was found in 12 of 262 controls and normal subjects. The antibody was found to be of the IgG class and 40 of 49 of these antibodies were shown to be complement fixing. Spermatozoal antibodies were detected in 12 patients, but no ovarian antibodies were found in any specimen. There was no close correlation between erythema nodosum leprosum and testicular antibodies. It was found that the characteristic of the testicular antibody in leprosy was its ability to be absorbed by Mycobacterium BCG suspension suggesting that this is another antibody induced by infection. A similar fluorescent pattern was seen in some patients who did not have leprosy, but in these cases, it could not be abolished with BCG. It is concluded that autoimmunity may be 1 of the factors involved in the pathogenesis of orchitis in leprosy. (author's modified)
Pattern of the infertility problem at Kenyatta National Hospital.
The data for this examination of infertility was obtained from 274 files with the diagnosis of infertility of patients attending gynecology clinic at the Kenyatta National Hospital for the January 1976 to April 1978 period. The files were randomly selected from the records office. The patients had been subjected to various investigations, including clinical examination at the clinic and later in the ward for those who were hospitalized, hysterosalpingography, laparoscopy, hydro tubation, diagnostic curettage, and an occasional laparotomy. The clinical examination included a history of previous illnesses, a social history, and a gynecological history taken at the 1st visit. A full physical examination was conducted for systemic illness. If no systemic illness was found, and no gross pelvic abnormalities had been detected, the patients were booked for hysterosalpingography. While the patient awaits the heavily booked hsyterosalpingography, the husband is booked for semen analysis. This investigation was carried out on all couples complaining of infertility. If the husband declined participation, nothing further was done for the couple. If no physical or gross pelvic abnormalities were revealed and if the husband's fertility was established, the next step was booking the patients for laparoscopy with hydrotubation and diagnostic curettage at the same time. Most of the patients presenting for infertility investigations were between 21-30 years old and accounted for 204 (74.4%) of the cases. Among those 204 cases, 49% had primary infertility. 24 patients had not had a single pregnancy by the age of 30 years and 15.3% were still complaining of either secondary or primary infertility. 45.9% of patients (126 cases) were subjected to hysterosalpingography. 42.8% of them had gross pelvic inflammatory disease and could not be investigated further. 28.6% had tubal damage that was considered favorable to further study. 27% of them had either normal Fallopian tubes or spill of the contrast medium was noted on 1 side. Of the 92 patients who underwent laparoscopy, 2 cases were unsuccessful because of technical problems, 78 patients had evidence of previous chronic inflammatory disease, and only 32 patients were considered for tubal surgery. Fibroids were detected in 4.8% of cases. Nearly half of these patients had blocked tubes and were not suitable for reconstructive surgery. 20 patients (7.3%) have been reported to be pregnant. In sum, the major cause of infertility was tubal damage due to pelvic inflammatory disease. Most of the patients had gross damage and only about 11% were suitable for tubal surgery.
Chlamydial and gonococcal infections in a defined population of women.
The annual incidence/1000 women of genital chlamydial and gonococcal infections during 1977-80 were 47.6 and 12.1, respectively, in a defined population of about 14,000 women ages 15-35. In sexually active women, who are obviously at risk for sexually transmitted diseases, the annual incidences of both infections decreased with increasing age of the women. Asymptomatic infection with Chlamydia trachomatis was more common than was similarly asymptomatic gonococcal infection. The risk of acute salpingitis in women with genital chlamydial infection (8.0%) was not significantly different from that of women with gonorrhea (8.6%). (author's)
VD education in developing countries. A comparison with developed countries.
No new method of control of sexually transmitted diseases is imminent. Reliance must be placed on existing methods including health education. Health education has a double role, being a primary method in its own right and being involved in the enforcement of all other tried methods. A comparison is made of the situation in countries with a developed or underdeveloped venereal disease control service, with respect to organization, statistical reporting, various agencies treating venereal disease, clinic and diagnostic facilities, personnel involved in venereal disease management, and other aspects. The vicious circle inherent in developing countries is outlined. A lack of awareness of the extent of the problem and the presence of other serious competing diseases lead to a low budget, thus to poor diagnostic and treatment facilities, and to a few cases being seen in the official clinics and hospitals. Thus, relatively small numbers of cases are reported and there is consequently, a continuing lack of awareness of the problem. There is emphasis placed on the importance of health education activities during this period, and a method of cutting through such a vicious cycle is suggested. There is a worldwide need for better training of physicians, paramedical workers, and nurses in the management of venereal disease, including case finding and health education. In a great many developing and developed countries, the bulk of such management is conducted by general practitioners and it is logical that they should be involved more closely in the program by providing them with assistance in diagnosis, contact tracing, and postgraduate education. As pharmacists are legally or unofficially involved in many areas with few facilities, it may be questioned how their contribution may be more effective pending the development of more extensive official programs. (author's modified)
Venereal diseases in the islands of the South Pacific.
The island territories of the South Pacific vary considerably in area and population size; Pitcairn has a population of 100 in 2 square miles whereas Papua New Guniea has a population of 2,990,000 in approximately 175,000 square miles. Today, the whole ocean is traversed by air routes. Recently, the prevalence of gonorrhea has decreased in the northern region but has increased in the eastern and western regions; the reported prevalence in all these regions exceeds 200 cases/100,000 population. In an area where yaws was once widespread, syphilis is being increasingly recognized. Although the figures for syphilis are clearly higher because of the greater use of serological screening, many of the reported cases are of early infection. Yaws has been eliminated from most of the South Pacific islands but is still present in the western region--more than 99% of the reported cases occurring in Papua New Guinea, particularly in the offshore islands. (author's modified)
Venereal diseases in the Pacific Islands. Papua New Guinea.
Papua New Guinea, which contains nearly 3/4 of the population of the 20 islands or island groups studied by the South Pacific Commission has a commensurate proportion of reported cases of syphilis and gonorrhea. It is a country with an exceptional interest in the venereologist as it exhibits all facets of venereal disease problems as experienced in the world. With the expansion of communication, syphilis has gained a foothold in what were areas previously endemic with yaws; moreover, some yaws still remain (particularly offshore in the islands)--the 2 conditions tend to be mutually exclusive. In the area surrounding the capital, Port Moresby, the prevalence of Donovanosis is unparalleled. (author's modified)
Growth and effect of Neisseria gonorrhoeae in organ cultures.
Neisseria gonorrhoeae is highly host-specific. Apart from the successful experimental infection of chimpanzees and infection of subcutaneous foreign bodies implanted in small laboratory animals, it has not been possible to infect or produce disease in species other than men. This almost total inability to infect laboratory animals has hampered studies on the mechanism of pathogenicity. We considered that the use of organ cultures, in which the relationships between tissues remain essentially undisturbed, would provide an alternative approach to studying the interaction between host cell and microorganism. The motility of cilia on ciliated epithelial surfaces provides an index of cell viability and loss of ciliary activity due to the effect of an organism that can be easily assessed. We have, therefore, inoculated follopian tube organ cultures with N. gonorrhoeae, a bacterium known to be responsible for some cases of acute salpingitis. In addition, we have inoculated the same bacterium into organ cultures of another ciliated epithelial membrane, namely the trachea. In this case, tissue was derived not only from human but also from other mammalian and avian sources. The cultures were examined for growth of the organisms and for damage caused by them. (author's) (Summary in FRE)
Nongonococcal urethritis (NGU) and its counterparts in women are the most common sexually transmitted disease syndromes in the US and Western Europe. Chlamydia trachomatis causes 40-50% of the cases of NGU and is a major cause of mucopurulent cervicitis and urethral infection in women, epididymitis in young men, pelvic inflammatory disease, acute perihepatitis, and neonatal conjunctivitis and pneumonia. Chlamydial infection also has been linked with Reiter's syndrome, infertility, cervical dysplasia, stillbirth, postpartum endometritis, and other syndromes. Tetracycline HCI is the treatment of choice for NGU and related syndromes, and for the sexual partners of infected patients. (author's)
Current view of the epidemiology of sexually transmitted diseases in the United States.
The annual incidence of reported cases of gonorrhea in the US has increased progressively from a low of 129/100,000 population in 1958 to 420/100,000 in 1974. An estimated 2,700,000 cases actually occurred in 1974. Neisseria gonorrhoeae was recovered from 196,114 (2.7%) of 7,233,041 women screened by federally supported programs during 1973-74. The male:female ratio of reported cases of gonorrhea dropped from 2.4:1 in 1971 to 1.5:1 in 1974, and the annual incidence curve of reported male cases has begun to level off. Results of a 9-city cooperative therapy monitoring study led to new CDC treatment recommendations in 1974. The incidence rate of pelvic inflammatory disease has paralleled that of reported gonorrhea. Strains of gonococci recovered from patients with disseminated gonococcal infection have been found to have characteristic auxotrophic requirements for arginine, hypoxanthine, and uracil, and such strains comprise a large minority of gonococcal isolates in the US. The reported incidence of early syphilis has increased somewhat since 1958, but the reported incidence of late syphilis, congenital syphilis, and death from syphilis has continued to decline. Transmission of syphilis among male homosexuals has become increasingly recognized. Nongonococcal urethritis accounts for about 60% of urethritis in men in some venereal disease clinics in the US and Chlamydia trachomatis has been recovered from approximately 40% of men with NGU in Seattle and San Francisco. Chancroid, lymphogranuloma venereum, and granuloma inguinale have become rare diseases, whereas genital herpes, hepatitis B, Phthirus pubis infestation, condyloma accuminata are common. Pilot sentinel surveillance systems have been initiated to further delineate the relative magnitude of these problems. (author's)
Etiological factors in tubal infertility.
An analysis was made of the history of 820 patients who underwent diagnostic laparoscopy for reasons of infertility. Events in the patient's history related to abdominal surgery, infection of the genital tract, and endometriosis were compared with the incidence of tubal disease at laparoscopy. Salpingitis, puerperal endometritis, gynecologic operations such as ovarian cystectomy, wedge resection, and operative correction of uterine retroversion and appendicitis complicated by perforation of the appendix, inflammatory mass, or appendiceal abscess, were all associated with a significantly higher incidence of tubal disease. In patients who had undergone an uncomplicated appendectomy, the occurrence of tubal abnormalities was not increased (42%) when they were compared with the group with a completely negative history (37%). Implications of these findings with relation to the prevention of tubal disease are discussed. (author's modified)
The interpretation and significance of the fractional postcoital test.
This investigation was designed to objectively determine the clinical usefulness of the fractional postcoital test. 43 normal subjects had midcycle cervical mucus collection at various times after insemination. There was a significant correlation between the number of motile sperm at the interval os level and the total sperm count within the cervical mucus. The median internal os count was 15 motile sperm/high power field with a lower 95% confidence of 5 motile sperm/high power field. Therefore, the fractional postcoital test is useful clinically as it is a physiologic indication of sperm transport in cervical mucus. (author's)
Evidence for microbial transfer by spermatozoa.
Ovulatory-phase cervical mucus columns demonstrate that microorganisms migrate in the cervical mucus with moving spermatozoa. Cultures obtained from the distal end of the mucus column after spermatozoal migration was complete yielded the same aerobic and anaerobic microbial isolates that were originally recovered from the seminal fluid. Exogenous aerobic bacteria added to the seminal fluid also appeared at the top of the mucus column. After spermatozoa removal, no bacteria were observed migrating through the mucus. It is concluded that spermatozoa may provide a vehicle for bacteria present in the seminal fluid prior to ejaculation and for those already present in the cervix or vagina. The significance of this finding is discussed, and 1 mechanism for the development of salpingo-oophoritis in the female is proposed. (author's)
Subsequent pregnancies among 161 couples treated for T-mycoplasma genital-tract infection.
Results are presented of a 3-year follow-up study in an infertility clinic which compared pregnancy rates in women whose husbands' T-mycoplasma (Ureaplasma urealyticum) infections were successfully eradicated, as demonstrated by a negative post-therapy culture, with the rates in women whose husbands' infections were not eradicated by treatment. 161 men which T-mycoplasma infection in their seminal fluid were treated, along with their wives, for 4 weeks with doxycycline 100 mg twice daily. The criteria of patient selection were a positive mycoplasma culture and intent to conceive during the observation period. The men's mycoplasma status was reevaluated after therapy; the women's was not evaluated. 129 (80%) of the 161 men treated had negative semen cultures for T-mycoplasma at the conclusion of therapy. A significant association was found between post-therapy pregnancy status and post-therapy mycoplasma status. Among couples eventually having a successful pregnancy, 99% of the men were free of mycoplasma after therapy, compared to only 2/3 among couples not achieving a successful pregnancy. The status of mycoplasma infection after therapy was not associated with age, occupation, order of marriage, presence of children in current marriage, length of marriage, length of time trying to conceive, a history of any of various fertility procedures, or sperm count or quality. Statistically significant differences among distributions of time until pregnancy were related to having undergone a hysterosalpingogram, tuboplasty, dilatation and curettage, and fertility drugs. In each group of patients undergoing 1 of these procedures, the pregnancy rate was lower. Application of the Cox regression technique indicated that the variable most significantly associated with the time until successful pregnancy was mycoplasma status after therapy, followed by hysterosalpingograpy and tuboplasty. Although a thorough understanding of the effect of T-mycoplasma on fertility may be provided only by a double-blind controlled prospective study, the present study established important associations between T-mycoplasma infection and the predictability of pregnancy. The rate of successful pregnancy after therapy was 60% for the groups in which T-mycoplasma was eradicated and 5% for the group in which it was not.
Involuntary childlessness with increasing age.
As more and more women are postponing childbearing until they are over age 30, much interest and concern has been generated by a recent French study of artificially inseminated women conducted by the Federation CECOS. The study suggests that the risk of being infertile at any age is far from small and that the risk increases sharply not only after age 40, but starting as early as 30. The carefully designed CECOS study provides unique data on conception rates following artificial insemination, but it gives a poor basis for estimating levels and trends in infertility for the general population. Artificial insemination with frozen sperm is considerably less effective in achieving conception than natural insemination. With artificial insemination in presumable fecund women, the CECOS study obtained an average of about 0.1 conceptions/woman/month. In contrast, a comparable rate with natural insemination is typically twice as high, and if the frequency of intercourse is increased, rates over 0.4/month can be expected. The principal cause of the lower conception rate with artificial insemination is the damage done to sperm during the freezing process. Freezing causes a large reduction in motility, and it results in structural and biochemical changes in sperm. CECOS researchers note that a major problem with the freezing of semen is the "incontestable drop in fertilizing capacity." Reliable estimates of age specific levels of permanent (involuntary) infertility have not yet been published for any modern contemporary population. Measures of permanent infertility are available for a number of noncontracepting historical populations. A review of this evidence provided the following average levels of infertility: 4.1% between age 20-24; 5.5% between 25-29; 9.4% between 30-34; and 19.7% between 35-39. These percentages may be excessive at this time to the extent that modern medical technology can eliminate some previously untreatable causes of infertility. The CECOS study also reports that the proportion failing to conceive in 12 cycles rose by 13 percentage points -- from 26-39% -- between the late 20s and the early 30s. This finding would have been important if it applied to the general population, but this increase was only about 4%. Although the rise in infertility with increasing age is not negligible, it is sufficiently modest that many women may decide that the benefits of postponing childbearing in order to establish a career outweight the risks of remaining childless.
Global distribution of penicillinase-producing Neisseria gonorrhoeae (PPNG).
Strains of penicillinase-producing Neisseria gonorrhoeae (PPNG) continue to spread throughout the world. Many countries with good surveillance systems have observed a 2-6 fold increase in the number of such cases reported within the last 18-24 months (through May 1981). Many areas of the world currently have a high proportion of patients for whom penicillin therapy is ineffective because of gonococcal strains with plasmid-mediated resistance. It may be difficult to identify alternative regimens for effective treatment, and alternative regimens may result in increased treatment costs to the point where many governments or patients can no longer afford such treatment. Consequently, less effective treatments continue to be used. This further selects for drug resistance and extends the infectious period for patients. Gonorrhea transmission may be expected to continue, and the proportion of infected patients who develop complications may be expected to rise. The number of cases of PPNG infection reported in the US increased from 328 in 1979 to 1099 in 1980 and to 1910 in the 1st 9 months of 1981. This trend apparently resulted from increases in numbers of cases of imported disease (maninly from the Philippines, Thailand, and the Republic of Korea) and from sustained domestic transmission in major metropolitan areas. The effect of such continuing importation can be minimized by more widespread adherence to the use of 2 gm of spectinomycin for initial treatment of uncomplicated, anogenital gonorrhea in patients who acquired the disease in countries with areas of high PPNG prevalence. In some areas of the US, intensified efforts have been successful in controlling the infection even after a period of sustained domestic transmission. Continued efforts to control PPNG in the US must include testing of all gonococcal isolates for penicillinase production, prompt identification of sexual partners of all PPNG patients, screening of all groups considered to be at high risk of PPNG infection; and treatment of all of the following with 2 gm of spectinomycin: all PPNG patients and their sexual partners; patients who acquired gonorrhea in countries with high PPNG prevalence; and all patients for whom penicillin, ampicillin, amoxicillin, or tetracycline are ineffective treatment for gonorrhea. Evaluation of control strategies in the US will continue. Operational research is essential in countries with high PPNG prevalence.
Early embryonic mortality in women.
Measurements of human chorionic gonadotropin (hCG) have been used to assess early embryo loss in women. Urine samples obtained from a control group of sterilized women with normal ovulatory menstrual cycles enabled a concentration limit of 56 IU/l to be determined so that any nontrophoblastic hCG or other cross-reacting compounds could be accounted for. 198 ovulatory cycles were collected from a normal population attempting to conceive. Fecundability was 22-27% for this population. The risk of pregnancy in exposed ovulatory cycles was 59.6%; however, 61.9% of conceptuses will be lost prior to 12 weeks. Most of these losses (91.7%) occur subclinically, without the knowledge of the mother. (author's)
A retrospective analysis of symptomatology, diagnostic procedures, and treatment of all 155 new cases of genital tuberculosis at 47 Swedish gynecology departments in the period 1968-77 was performed. The frequency of genital tuberculosis was 0.002% of all patients admitted for gynecologic disease. Genital tuberculosis occurred more frequently in the postmenopausal period. The most common symptoms were metrorrhagia, pain, and infertility. Chemotherapy alone was used in 40% of the cases. Conservative surgery was attempted in 8%, and 38% had radical surgery. No intrauterine and 4 tubal pregnancies occurred after therapy. We conclude that primary treatment should be conservative, although the chances of having a normal pregnancy are almost nil and the risk of an ectopic pregnancy is great. (author's)
Sperm abnormalities and cigarette smoking.
Sperm samples from a carefully matched group of 43 cigarette smokers and 43 nonsmokers attending an infertility clinic were examined for morphological abnormality. Smokers were found to have a significantly greater percentage of abnormal forms. In light of other work showing increased chromosome damage in blood lymphocytes of cigarette smokers and of the known propensity for mutagens to induce sperm abnormalities in animals, it is suggested that the sperm abnormalities in cigarette smokers may reflect genetic damage to these cells as a consequence of exposure to smoke products. (author's modified)
Epidemiological aspects of gonococcal infections in Dakar [abstract]
In Senegal, particularly in Dakar, gonococcal infections are more frequent among those of the lower socioeconomic groups who are treated at the Institute of Social Hygiene. The progressive increase of cases does not seem to be related to bacterial resistance to the antibiotics commonly used, but, in Dakar, at least, to a deficiency of health education among our population. Patients neglect their infections or obtain only partial treatment because of their poor economic status and the lack of medicines in our dispensaries. Changes in habits due to economic and social progress, as well as migration and urbanization, explain the higher occurrence of gonococcal infections in the last few years among young students from 16-18 years of age. A suitable health education program would have every prospect of success in limiting the spreading of the disease, since in our country the gonococcus has apparently not yet developed resistance to antibiotics. (full text)
Epididymal obstruction in azoospermic males.
12 patients evaluated for infertility and found to be azoospermic on semen analysis underwent testicular biopsy. Those with adequate spermatogenesis underwent exploration and vaso-epididymostomy was done when possible. The operative technique consisted of serial sectioning of the epididymis beginning at the tail and extending as high as necessary to see sperm on a wet smear. A microsurgical 2 layer single tubule epididymovasostomy was performed on demonstration of patency. Of 3 patients with congenital obstruction of the epididymis, 2 had adequate sperm counts postoperatively. A patient with mucovicidosus remained azoospermic postoperatively, as expected. Congenital obstruction of the epididymis appears to be more common in the head and mid-portion of the epididymis, while inflammatory disease appears to occur in the tail of the epididymis. The 3 patients with histories of epididymal obstruction due to infection all had sperm postoperatively and 2 pregnancies subsequently occurred. A patient injured in Vietnam leading to severing of the right vas deferens and left orchiectomy underwent right vasoepididymostomy and had sperm in his ejaculate 1 year later. A patient with epididymal obstruction after attempted vasectomy reversal had a fair sperm count 3 months after vasoepididymostomy. Among 4 patients with primary epididymal obstruction, 3 remained azoospermic after vasoepididymostomy and 1 had a negligible sperm count. Of the 12 patients, 8 were documented to have sperm in their ejuculate after follow-up of 3 months to 3 years. At present, ductal obstruction offers excellent opportunity for repair while congenital abnormalities have yet to be controlled surgically.
The preliminary findings of the Vital Statistics Survey Project, conducted under the auspices of the University of Yaounde in 2 rural districts of Cameroon in 1975-78, are reported. Vital statistics surveys were conducted in 20 villages in the Jakiri district and 3 villages in the Mbandjock district in 1976. Longitudinal surveys were conducted in 1976-77 and again in 1977-78 in Jakiri and in 1976-77 in Mbandjock. Jakiri's population is characterized by high fertility and high mortality. In contrast, Mbandjock shows low fertility and a stagnant or decreasing population trend. Data on factors related to fertility were collected from 3592 women in Jakiri and 251 women in Mbandjock. The crude birth rate in Jakiri was 37.5 livebirths/1000 population in 1976-77 and 27.5/1000 in 1977-78. In Mbandjock, the 1976-77 rates were 20.1, 31, and 12/1000 in the 3 villages surveyed. The average number of living children per woman was 2.67 in Jakiri and 1.55 in Mbandjock. 68.9% of Jakiro women and 79% of Mbandjock women ages 15-50 were currently married; however, the latter district is characterized by widespread marital instability. The average number of pregnancies per women was 3.1 in Jakiri and 2.67 in Mbandjock, with average child wastage ratios of 0.43 and 1.12, respectively. The infant mortality rate in Jakiri was 147/1000 livebirths in 1976-77 and 137/1000 in 1977-78. The rate in Mbandjock declined from 417/1000 livebirths in 1976 to 0 in 1977, a decrease attributed both to an effective measles campaign and the small sample size. The average desired family size was 9 in Jakiri and 6 in Mbandjock. Jakiri demonstrated a total infertility rate of 17%. The corresponding rates in the 3 Mbandjock villages were 48, 46, and 52%. The proportion of infertile women ages 20-29 was 18% in Jakiri and 22, 16, and 24% in the Mbandjock villages. According to the World Health Organization, a 15% infertility rate in this age group is the limit for declaring a serious public health problem. However, since Careroon authorities seem satisfied with the fertility situation in Jakiri, it is suggested that the limit be raised to 18%. Mbandjock, on the other hand, is considered to have a serious infertility problem. 4 recommendations are made to improve the health profile for this part of rural Cameroon: 1) family planning programs should be introduced in areas of population explosion; 2) health education campaigns should be directed against the high rates of communicable diseases and childhood immunization campaigns should be introduced; 3) nutrition education should be integrated into community development programs; and 4) vital statistics collection should be centrally supervised.
The frequency of mumps and of mumps orchitis and the consequences for sexuality and fertility.
Statistical methods are used in an effort to elucidate and treat permanent lesions in adult males following mumps orchitis. The statistical computations were carried out at the State Institute of Human Genetics and Race Biology. Clinical data were made available by a large number of army doctors and by the chiefs of Garrison Hospitals, Hospitals for Communicable Diseases, and Laboratories. Following a review of the literature (epidemiology and statistics of mumps, frequency of orchitis, survey of the morphology and endocrine functions of the testicle, sterility, and hormonal imbalances following mumps orchitis), attention is directed to statistics of mumps in Sweden (character of the cases investigated and epidemiology of mumps, i.e., incidence of childhood mumps in conscripts, incidence of mumps during military service, incidence of mumps in conscripts who previously have had the disease, mumps as a military disease, and influence of mumps on effectiveness); and the problems of mumps orchitis (character of the cases investigated, orchitis and testicular atrophy due to mumps in conscripts, marriage frequency and fertility after mumps orchitis, spermiogenesis, and hormone excretion). It has been known for ages that in adult males orchitis may be a manifestation of mumps. Orchitis occurs as a rule only during and after puberty, and the literature contains only a few case reports before that age. The frequency of orchitis in an epidemic of mumps has been variously estimated by different authors. According to data in the literature, the frequency of orchitis in adult males seems to be between 20-30% of all cases of mumps. The frequency of bilateral orchitis appears to be between 10-20% of the cases of orchitis and between 2-5% of all cases of mumps. The literature contains data indicating that mumps orchitis is not an uncommon cause of sterility in men. Statistical data in the annual reports from the Swedish armed forces were studied. In the 1st series, 698 questionnaires completed in 1944 by conscripts on service, 29.9% reported having had mumps before beginning their term of military service. Among the conscripts in the 2nd series 45.8% reported having had mumps before being called up the 1st time. To study the consequences of mumps orchitis, a large number of records from Swedish troop units for the years 1919-37 were studied. The men from the series of bilateral mumps orchitis averaged just over 1 child; the mean for each control was just over 2 children. This difference in fertility was statistically significant. Normal morphological findings were shown by sperm samples from 2 single and 8 married men who had undergone bilateral mumps orchitis. The same was the case for 6 of the 10 examined controls. The situation was less clear for those persons whose spermiograms suggested impaired fertility, i.e., 26 men of whom 22 had undergone mumps orchitis and 4 controls.
Gulf money in Kerala: coping with the problems of plenty.
The recent phenomenon of emigration from Kerala to the Gulf countries and the increasing inflow of remittances is having a tremendous impact on Kerala's economy. The state planning board reports that the remittances from the Gulf to this tiny state are Rs. 400 crones/year. An annual inflow of this amount cannot help influence the fortunes of the population. Although emigration from Kerala is not new, the current outflow reached massive proportions only in the wake of the intensive construction boom in the West Asian countries, after a huge volume of petro dollars flowed into those countries in the aftermath of the 1973 hike in oil price. In December 1977 a total of 135,000 Keralities were employed in foreign countries, mainly in West Asia. These adventurous migrants, in their quest for a wage, emigrated mainly from 4 areas in the state: Varkala in Trivandrum district; Thiruvalla in Alleppey district; Chavakkad in Trichur district; and almost all parts of Malappuram district. The bulk of the remittances are sent to households and next of kin concentrated in these areas. This unprecedented inflow of remittances has kindled the hopes of politicians and administrators of tapping these resources to solve the problems of economic development of the state. 1 category of emigrants come from poor households, are poorly educated, and are masons, carpenters, or even unskilled laborers. Because of their ignorance and gullibility they are exploited by middlemen who charge them Rs. 12,000 for a no objection certificate (NOC). Moneylenders are also doing a thriving business. Another type of emigrant is from relatively well off households, better educated, and able to obtain better jobs. There are also rich businessmen and contractors among them. It is this category of better educated emigrant who is able to save a substantial part of his income. State administrative circles note that remittances at best can provide only the financial capital. According to T.C. Razajm a businessman in Abu Dhabi since 1965, emigrants will invest in an industry only if they are convinced of the viability of the project, have a say in its management, and if there is reservation of jobs in the enterprise for their competent dependants. Thus far, the money mobilized into industry seems to be only a tiny proportion of the remittances. A major avenue of investment for the emigrants is real estate and, consequently, the prices of land have registered a marked increase. Even the service sector -- taxis and travel agencies -- have received a sizable boost because of the inflow of Gulf money into the state. According to G. Narayana Pillai, culturally and socially the new found wealth will not bring about any substantial social improvement.
Regionalization of infertility services in a rural area.
The implementation of an infertility program administered by the Family Planning Council of Central Pennsylvania (FPCCP), established using federal guidelines and to serve an essentially rural environment, was examined. Data obtained from 6 individual agencies were analyzed, but the predominant focus was on the 4 agencies remaining within the program. The data were collected during the 1st 24 months of program operation. Due to the long distances involved and the limited personnel and funds available, a system was designed utilizing 3 levels of infertility health care which were established prior to but concordant with federal guidelines. At level 1 every member agency within the FPCCP agreed to serve as an initial access point for clients requesting infertility services. Thus, 33 sites scattered throughout 24 counties of central Pennsylvania were available to respond to client inquiry by providing information, education, and referral both within and outside the system. To maintain quality control the degree of contact at level 1 is purposefully limited. No intensive individual counseling of clients or provision of medical services are provided at level 1. Clients are referred for further information and care to the level 2 center selected for that area. Each level 2 center was expected to provide resources necessary to conduct basic but intensive fertility evaluation and therapy as well as counseling. Regarding level 3, it was determined that the resources needed to supervise and complete a comprehensive infertility program would be most appropriately available at a university medical center, and the Pennsylvania State University College of Medicine operates the only such facility in central Pennsylvania, at the Hershey Medical Center. During the initial 24 months of program operation, 112 infertility "units" were enrolled. An infertility unit was definded either as a couple, or an individual person, presenting for infertility services. Of the 112 units, 76% had never been able to establish pregnancy (primary infertility); 6% had conceived without a subsequent live birth; and 18% were unable to establish a 2nd successful pregnancy following a previous live birth (secondary infertility). The average length of infertility experienced by these units before enrollment was 2.25 years. During the initial 24 months, 50 postcoital tests, 41 semen analysis, 16 endometrial biopsies, 11 hysterosalpingograms, 4 testicular biopsies, and 1 laparoscopy were performed. Only 3 units required referral to the level 3 center. The vast majority of services were provided by the local level 2 agency site. 44% of the units were able to have a diagnosis firmly established during their evaluation. The remainder either became pregant during the evaluation, chose adoption or child free living before a final diagnosis was established, or were lost to follow-up. Fully 1/3 of all units enrolled were able to establish pregnancy either during evaluation, or as direct result of therapy.
Prevention of congenital syphilis.
The importance of congenital syphilis has been noted in Ethiopia, and the Ministry of Health has developed a health service research project, utilizing the existing antenatal care (ANC) system, to prevent this treatable cause of pregnancy wastage and childhood disability. The project will be instituted at 1 pilot site in order to develop study procedures and instruments and to clarify operational aspects of such a program. Subsequently, the project will be modified and expanded to encompass 7 additional sites. Subobjectives of the project are: to evaluate a syphilis screening and treatment program in ANC clinics: to evaluate the effect of such a program on pregnancy outcomes; to develop an appropriate screening test for use in health centers; to identify sociocultural and historical risk factors associated with syphilis among ANC clinic attendees; and to evaluate health education materials developed to support this program. The project will focus on treating infected pregnant women. Methods which can be used to identify pregnant women in need of treatment are: a community at risk approach in which all pregnant women in a particular community are at high risk for syphilis; an individual at risk approach where sociocultural and/or historical items are predictive for a pregnant women having syphilis; and a serological screening approach where a blood test identifies women who have reactive serologic tests for syphilis and therefore are at risk for syphilis. 8 health facilities in urban, semiurban, and rural areas have been selected. These facilities provide ANC for an estimated 15,500 pregnant women each year. A syphilis screening and treatment protocol will be implemented within the study site ANC clinics. In addition to the existing procedures, blood will be obtained by fingerstick from all new clinic attendees. Patient education, counseling, and spouse referral efforts will be incorporated into the established group discussions given by ANC staff as well as those individual counseling sessions provided by the clinician. Treatment given to patients and spouses will be the World Health Organization recommendations for early syphilis. The Central Laboratory and Research Institute will assume the training and quality assurance role for the health center laboratories, syphilis serologic tests. Their maintenance unit will also be responsible for microhematocrit centrifuge maintenance. The program has been explained to kebele, women's, and youth association leaders. They will assist in the education of the community, encourage early ANC attendance of pregnant women, encourage 3rd trimester ANC follow-up, enhance spouse referrals, and assist in the pregnancy outcome cohort studies.
Clomiphene citrate in the management of infertility associated with shortened luteal phases.
Repetitively short luteal phases were found in 8 infertile women. The short luteal phase was defined as 10 days or less from the presumed time of ovulation (as assessed by basal body temperature recording) to the onset of the menses. Clomiphene citrate (Clomid) therapy resulted in pregnancy in 2 patients and lengthened the luteal phase in the other 6. Ultimately, 7 of 8 patients conceived during Clomid therapy. Clomid therapy can lengthen the luteal phase in patients with luteal temperature elevation of 10 days or less. The occurrence of short luteal phases may be associated with infertility. (author's)
Serologic evidence of Ureaplasma urealyticum infection in women with spontaneous pregnancy loss.
Among 71 couples with histories of pregnancy wastage, 84.5% were colonized with Ureaplasma urealyticum and/or Mycoplasma hominis; whereas in couples with successful deliveries the incidence was 25.4%. The distribution of U. urealyticum and M. hominis was comparable in the fertile and infertile populations. Of women with positive cultures, 96% aborted, compared with an expected rate of 19-45%. Serologic studies revealed that, at delivery, 42.9% of infants of mothers with pregnancy losses had 4-fold elevations in titers above the mothers' levels compared with 15% of normal infants. Mothers with pregnancy wastage histories had elevated titers above their infants in 42.9% of cases compared with 10% of normal mothers. Thus, both mothers and fetuses had responded immunologically to the presence of U. urealyticum. When the mean antibody titers in the normal and pregnancy wastage groups were calculated for each ureaplasma serotype, the infants of mothers with pregnancy losses exhitited significantly elevated mean titers to serotypes 6 and 8, while the mothers had elevated mean titers to serotypes 4 and 8. These observations suggest that U. urealyticum causes infection in mothers and fetuses and that certain ureaplasma serotypes may be more pathogenic than others. (author's)
Migrants and innovation in African societies: definition of a research field.
Discussion focuses on the position, role, and importance of migrants in African societies. Specifically, it directs attention to the role of migrants both as innovators and as agents for the spatial diffusion of innovations. In this respect it seeks to identify those factors predisposing migrants to innovate and those that induce both their host community and their home community to be receptive to their innovativeness. The 4 sections of the discussion cover the following: a conceptual framework to explain the migrant's predisposition to innovate and the nature of the innovation carried out; empirical evidence, largely from West Africa, of some innovative activities of migrants; research implications of this phenomenon; and the significance of this type of study for current attempts at economic development in Africa. All forms of migrations need not have innovative implications. A simple change of residence from 1 city to another need not encourage innovativeness. It is not so much the distance factor as the intensity of contrast which predisposes to innovativeness. In Africa such intensity of contrasts is found between the social organizations, the behavior and activity patterns, and the norms and thought habits of various ethnic groups. A 2nd element is deprivation of essentials, as referred to by Barnett who regards essentials as an entirely relative term having significance only for a particular group. Migration often creates a sense of deprivation and stimulates innovative cultural readjustments if a people are to survive. Adjustments, at the very least, must be made to accommodate for the absence of essentials that were relied upon in the old habitat. The 3rd dimension is the home area of the migrants, an area to which they can return whenever they like if their migration has been free and voluntary. In this situation their innovative impact can be considerable. Usually, the fact of their having migrated enhances their social. Return migrants can come to be important local opinion leaders, fostering social change and development in their areas. Possibly 1 of the most important areas of migrants' innovative activities in West Africa is in the spread of new agricultural crops. Institutional innovations due to the activities of migrants also abound in West Africa. Migrants in West Africa also have been known to influence social norms, attitudes, and behavior patterns in some of the areas to which they had migrated. Regarding research implications, it is argued that a more fruitful and insightful understanding of social change comes from the detailed examination of the role of migrants as innovators. An increasing number of studies on migrants in African countries can serve as a means of assessing the vital role of migrants in the development of different parts of a country.
The state of the contraceptive art.
The high failure rates of available contraceptive methods attest to the fact that the present technology is inadequate to meet the needs of many women, and new, safer, and highly effective contraceptive methods must be developed for both the female and the male. Previously, industry was largely responsible for the research and development of many of the currently available contraceptives, but at this time it is less than enthusiastic about carrying out further research because of the time and cost associated with the approval of new drugs. Additionally, because of the medico legal climate that exists today, particularly concerning present contraceptive drugs and devices, pharmaceutical companies are concentrating on developing drugs for the treatent of disease conditions, a less risky area. The US federal government, which currently is the single largest funder in the world of contraceptive and related research, is directing little attention to this particular area. The most obvious obstacles to enhanced federal support is the debate over the federal budget priorities. Other deterring factors include the controversy over abortion which has discouraged efforts to call attention to contraceptive research because of concern that it might result in funding cuts instead of increases. Another factor is the traditional allocation of 40% of National Institute of Health funds to population research and 60% to maternal and child health. An overview of currently available contraceptive methods covers oral contraception (OC), long lasting injectable contraception, IUDs, the condom, vaginal contraceptive sponge, the diagphragm, and fertility awareness techniques. Determining the actual benefits versus the risks of OC has proved difficult. OC has changed considerably since it came into use. The most serious side effects attributed to the OCs involve the cardiovascular system, specifically thromboembolism, stroke, and heart attack. The risk of developing these diseases has declined as the dosage of hormones in the pill has been decreased. Yet, other specific factors can increase the degree of risk. Overall, the OC is still one of the safest and most effective methods of preventing unwanted pregnancy. The Food and Drug Administration (FDA) has denied its approval of Depo-Provera, 1 of several long acting progestins, because of its association with breast tumors in the beagle dog and because of bleeding problems and delays in the return of fertility in human females. All IUDs have potential adverse side effects. The major ones continue to be cramping, bleeding, and infection. The IUD requires only a single act of motivation on the part of the patient, a definite advantage. Condoms of all types continue to be one of the most widely used forms of contraception at this time. The major disadvantage of vaginal chemical contraceptives is that they are coitally related and not aesthetically pleasing. The FDA recently approved for consumer use a polyurethane foam sponge containing a spermicide that is released gradually over a 24-hour period. The diaphragm is effective and has no serious side effects. The failure rate of the various fertility awareness methods is higher than other methods.
On the emigration of the peasantry.
This analysis concentrates on the migration of unskilled labor and particularly on the emigration of country folk, or on what Latin Ameiricans call "campesinos." 1 reason for this concentration is that most migrants are of rural origin, although many may have resided in an urban area during the period immediately preceding emigration. Another reason for this focus on rural migrants is that one can thereby scrutinize several of the specific allegations that are made against emigration. In particular, the claims that migration turns agricultural producers into consumers, lowers the productivity of labor, reduces the supply of food and exports, leaves gaps in the labor force, and produces inflation are examined. The effects of massive emigration on the distribution of income are discussed. The most superficial review of the facts is sufficient to indicate that the pursuit of self interest by peasant migrants is not incompatible with the rapdid growth of per capita income in the country of emigration. In the countries of south and southeastern Europe where emigration has been massive, exceptionally rapid rates of growth have been achieved. Between 1960-70 the growth of gross national product (GNP) per capita in the identified 5 countries varied from 4.3% a year in Yugoslavia to 6.6% in Greece. Similar rates of growth of income per head have been achieved in recent years, i.e., 1968-73, in most of the underdeveloped countries of the Mediterranean basin from which emigration has been substantial. The restrictions on immigration currently being adopted in almost all of the industrialized countries are likely to harm the prospects of several underdeveloped countries and to restrict severely the opportunities for betterment of the poorest people in these countries. The burden of adjustment to reduced emigration will fall disproportionately on the lowest income groups. In some regions, the effects may be calamitous. The disadvantages of mass emigration are unclear and almost certainly exaggerated, while the advantages are obvious. The migrants and those who receive remittances benefit directly. Other member of the migrants' social class benefit indirectly from less competition for jobs and increased bargaining strength. Consequently, the emigration of the peasantry lead to an improvement in the distribution of income at the expense of those who depend on income from property for their livelihood. No evidence exists that emigration reduces a country's rate of growth and in principle it could raise it.
The technique for human embryo transfer.
In a program of human in vitro fertilization (IVF), the results of 204 attempted intracervical embryo transfers, using a variety of catheters in 3 trials over 18 months, have been analyzed for the ease of transfer and pregnancy rate. In nulliparious patients, transfers were more difficult than in multiparous patients; and a closed-end Teflon catheter was found to be more easily passed through the smaller cervical canal than an open-end catheter. The overall pregnancy rate was 17% (March 1980-August 1981) and was not related to catheter type, although when chemical pregnancies were excluded, it was found that transfers using open-end catheters were more successful. The transfer procedure developed finally for routine use incorporates a consideration of these results. (author's)
T-mycoplasma and reproductive failure.
86 infertile couples and 20 couples of proven fertility as well as 30 pregnant women were investigated for the presence of ureaplasma urealyticum (T-mycoplasma) in the cervical secretion and semen. The frequency of T-mycoplasma was greater among infertile patients than the fertile group. Moreover, the rate of pregnancy wastage and the finding of nonspecific inflammatory cytology was more common in patients with positive cultures for T-mycoplasma. (author's)
Gonorrhoea and fertility in Uganda.
The opportunity for collecting data on gonorrhea and fertility in Uganda arose in 2 ways. The General African Census and Sample Census in 1959 provided fertility data which were fairly reliable and the errors of which were known. There were large variations in fertility rates between Districts. All Uganda government and Mission Hospitals and government dispensaries are required to provide monthly and annual returns of disease, allowing connections between gonorrhea and fertility to be studied on a District basis. Additionally, opportunity was taken of studying urethral stricture in men, a late manifestation of gonorrhea which is very common in some areas. Fertility data were taken from the 1959 General and 5% Sample Census. The index selected for use was the general fertility rate (GFR). Annual returns of disease for all government hospitals and dispensaries and all Mission Hospitals was scrutinized, and those for the years 1959 and 1960-61 and the 6-month period January to June 1960 were used. The Annual Medical Reports from all Districts for the 5 years 1956-60 were read. The relevant totals for inpatient acute gonorrhea, urethral stricture, outpatient acute gonorrhea, and dispensary acute gonorrhea were extracted. Only the figures for males were used because the diagnosis of gonorrhea in women is much less certain than in men and because the utilization of medical services by African women varies considerably so that hospital and dispensary figures for them reflect the total amount of disease less accurately than the figures for men. Only inpatient figures for male urethral strictures were used. To calculate an approximate incidence for gonorrhea and stricture, the totals from each District were related to the total number of individuals at risk. For both gonorrhea and stricture the total was assessed at 1/7 of the whole male population. The District rates for gonorrhea and for stricture were plotted against the District Fertility Rate and regression lines were calculated. The gonorrhea rate varied widely between Districts. The correlation coefficient for the gonorrhea/fertility relation was 0.64 and was statistically significant and that between stricture and fertility was 0.59 and was also significant. The findings strongly suggest that in Uganda fertility is largely determined by the frequency of gonorrhea. Although urethral stricture in men does not bear the same causal relation to stertility as gonorrhea, it correlates with the fertility rate fairly well. A closer correlation is unlikely.
Studies on infertility in males.
115 infertile men were examined for circulating spermagglutinating antibodies by the Kibrick spermagglutination test; 33 (28%) were found to have positive agglutination titers--1:32 or more in 13 samples. This high figure may be explained by the high incidence of genital tract infection and of urinary schistosomiasis in our study group. Of the 33 men who demonstrated autoantibodies in their sera, 21 had microscopic agglutination of more than 10%. There was a positive correlation between the serum autoantibody titer and spermagglutination. 8 cases (6.9%) of sperm-immobilizing antibodies were found. (author's)
Controlling city size in Africa.
In Africa many suggestions have been made with regard to manipulating the growth and size of urban centers. On the 1 hand, recommendations have been made for promoting cities as growth points. On the other hand, efforts have been made or proposed to restrict the growth of cities and even to reverse the seemingly inexorable flow from rural to urban areas. An overview of some of these efforts is presented. A recent UN study recommended the creation of a viable urban center with its attendant institutions and infrastructure as quickly as possible in those areas which still lack a major urban center to serve as the building ground for economic growth. This does not appear to have much pertinence for Africa. The only countries which might be considered as in need of a more prestigious primate city are Mauritania, Rwanda, and Lesotho. Many authors have commented upon the excessive concentration upon 1 city in African countries, and it is commonly proposed that efforts be made to develop secondary centers and new poles of growth. Part of the analysis of such proposals involves determining what the actual situation is in African countries. This reveals that concentration on 1 primate city may be considered grossly excessive in only a few countries. In some other countries the main city may seem to be out of proportion to its nearest rival but at least other growth nodes exist and are growing with considerable rapidity. A few scholars have suggested that a country's hierarchy of urban centers should be induced to conform more closely to some idealized geometrical distribution patterns. There are objections to both the suggestion that new poles of growth be deliberately developed as a matter of priority and to the proposal that the siting and size of cities be made to conform to mathematical laws. Considerable concern has been expressed concerning the overly rapid growth of African cities, and this has led to a variety of efforts to stem the influx to them and even, in some cases, to stimulate a flow from them back to the rural areas. Due to the inadequacies and social problems which are so highly visible in most African cities it is no surprise that efforts have been made to restrict growth in many of them. Several of these efforts date back to well before accession to independence. Only in the cases of controlling foreign migrants and of the rigid system in South Africa have the efforts to reduce or reverse the flow to the cities been effective, and even the latter has failed to meet the stated goals of the government. Other measures that have been designed, at least in part, to restrict urban growth include rural labor projects, youth corps and workers brigades, raising urban taxes with the goal of discouraging residence in the cities, and leveling of bidonvilles or shanty towns and restrictions on construction of new dwellings. None of these measures have provided an answer to the problem. If the cities continue to receive a disproportionate share of total investment, they will continue to attract large numbers of migrants, thus heightening the dilemma. (summary in FRE)
Genital and neonatal chlamydial infection in a trachoma endemic area.
85 consecutive male patients with urethritis attending the Medical Research Council outpatient department in Fajara, The Gambia, were investigated for Chlamydia trachomatis infection by intraurethral swab and culture on cylcoheximide-treated McCoy cells. 7 specimens were contaminated, but C. trachomatis was isolated from 12 of the remaining 78 (15.4%)--from 8 of 59 with gonorrhea (13.6%) and 4 of 19 with nongonococcal urethritis (21%). C. trachomatis was also isolated from cervical swabs from 6 of 33 female contacts of men with urethritis (18.2%), 3 of 22 women with gynecological symptoms (13.6%), and 6 of 87 randomly selected antenatal women (6.9%). Eye swabs were taken from 37 infants with ophthalmia neonatorum; C. trachomatis was isolated from 13 (35.1%). (author's)
Pregnancy, childbirth and the newborn: a manual for rural midwives. 2nd ed.
This book was written to accompany courses given in China to women and girls with no more than a primary school education and no previous knowledge of medicine or nursing. Included are chapters on the anatomy and physiology of female reproductive organs, on the progress and conduct of pregnancy and childbirth, and on care of the newborn. It is suggested that this manual be used along with audiovisual aids such as charts, models, and diagrams. The authors discuss the following topics: fetal development, labor and delivery, postpartum care, nutrition and diet in pregnancy and lactation, infant feeding, prematurity, vaccination, injections, sterilization of supplies, and the midwife's responsibility to her community. The text is written in simple language and accompanied by line drawings; technical terms are defined the first time they are used.
Alcohol, marijuana damage male's reproductive system.
The consumption of alcohol and marijuana appears to damage the male reproductive system but in different ways. Dr. Wylie C. Hembree III, reporting at a symposium on the endocrinologic effects of drugs of abuse, stated that chronic marijuana users have a high incidence of semen abnormalities. The clinical significance of these adverse effects on germ cell production are still unknown. Hembree indicated that the semen abnormalities are not of sufficient severity to cause infertility, but there is concern that they could alter the integrity of the male reproductive system. Dr. David H. Van Thiel, speaking at the same symposium, maintained that both alcohol and acetaldehyde, its 1st metabolic byproduct, are toxic to the testes. Even when blood alcohol levels are below the legal limit for intoxication, acetaldehyde exerts a toxic effect on the testes. Van Thiel stated that consumption of alcohol produces a prompt and extensive drop in testosterone secretion in men. Van Thiel and Hembree mostly confined their comments to the endocrinologic effects of drugs of abuse in men because research to date has mainly been performed in men. Hembree reported on 16 chronic marijuana smokers who self administered an average of about 15 standardized marijuana cigarettes per day during a 28-day period. Their luteinizing hormone (LH), follicle stimulating hormone (FSH), and testosterone levels were normal. Smokers did not experience any changes in semen volume, but sperm counts declined by an average of 30%, sperm motility fell, and there was a significant decrease in the percentage of morphologically normal sperm produced. All of these adverse effects were reversed during a 4 week nonsmoking follow-up period. Hembree has not seen any gynecomastia, impotence, or infertility in 50 subjects who are heavy marijuana smokers but do not use other drugs. The normal LH, FSH and testosterone levels seen in marijuana smokers indicate that there is no obvious derangement of their hypothalamic/pituitary axis, but a more subtle abnormality may be present. 9 chronic marijuana smokers were tested with clomiphene, an antiestrogen that results in increased gonadotropin secretion if the hypothalamic/pituitary axis is normal. 3 of the 9 subjects failed to respond to clomiphene, and 2 subjects actually experienced suppression of gonadotropin secretion.
Asymptomatic mycoplasma tied to pregnancy wastage.
Dr. Quinn, of the Hospital for Sick Children in Toronto, reported at a meeting of the Society of Obstetricians and Gynecologists of Canada, that asymptomatic mycoplasma infection appears to play a significant role in pregnancy wastage. Genital cultures in 71 couples with a history of pregnancy wastage revealed that 84.5% were colonized with Ureaplasma urealyticum and/or Mycoplasma hominis, compared with 25.4% of couples who had been delivered normally. 96% of the women who were positive for mycoplasma aborted, compared with an expected rate of 19-45%. 62 mycoplasma positive couples who had lost 237 pregnancies were divided into 3 treatment groups. 1 group received doxycycline in conjuction with barrier contraception for at least 1 menstrual cycle until they were mycoplasma negative. The 2nd group received no initial therapy but were given erythromycin during pregnancy. The 3rd group received doxycycline plus erythromycin. A 4th group had no antibiotic therapy. Doxycycline therapy reduced pregnancy wastage significantly, and ethythromycin and combined therapy reduced it still more. In 38 pregnancies treated initially with doxycycline, there were 18 spontaneous abortions. With erythromycin during pregnancy, 4 of 21 aborted; and 2 of the 12 who had both antibiotic regimens aborted. 22 of 24 pregnancies in which the women received no antibiotic therapy ended in abortion. The efficacy of antiobiotic therapy was independent of maternal age and of the number and timing of previous losses. The therapy was as effective in couples who were otherwise normal as in those who had other potential causes of abortion, such as uterine fusion defects, incompetent cervix, fibroids, adhesions, and endometriosis. A recent study found significantly more spontaneous abortion, prematurity, and perinatal morbidity when placentas were infected with U. urealyticum. Recurrence during pregnancy is a risk in about 40% of women. In 43% of cases, maternal antibody titers were elevated at delivery, compared with those of their infants, suggesting that new IgM antibody, which cannot cross the placenta, was manufactured during pregnancy. The high incidence of reinfection argues the use of doxycycline before conception and erythromycin during pregnancy. Since the effects of the antibiotic on the fetus are unknown, erythromycin should only be given during pregnancy if infection has returned.
The bacterial pathogenesis of acute pelvic inflammatory disease.
To study the bacterial pathogenesis of acute pelvic inflammatory disease (PID), peritoneal fluid was obtained by culdocentesis in 133 of 344 women with this disease. In 104 of the specimens, bacteria were identified both in the gram-stained smear and culture. Neisseria gonorrhoeae was isolated from the lower genital tract in over 1/2 of these women, and there were 3 patterns of bacterial recovery from peritoneal fluid: N. gonorrhoeae alone (22%), N. gonorrhoeae and other organisms (32%), and nongonococcal organisms alone (46%). In women without cervical gonorrhea only nongonococcal organisms were identified from peritoneal fluid. In both groups of women, a similar number of nongonococcal organisms were isolated. The results of this study supported those reported prior to availability of antimicrobials and suggest that N. gonorrhoeae initiates most cases of PID. A significant number of these women have superinfection with nongonococcal organisms which may preclude recovery of gonococci. (author's)
Management of gonococcal pelvic inflammatory disease.
Information that has become available since 1974 on the management of pelvic infections unrelated to abortions, the puerperium, or pelvic surgery, with an emphasis on those associated with Neisseria gonorrhoeae are summaried. Attention is directed to both diagnosis (clinical, bacteriologic) and therapy (hospitalized patients, outpatients, indications for hospitalization, and IUDs). Most investigators classify acute pelvic inflammatory disease (PID) as gonococcal or nongonococcal on the basis of the presence or absence of N. gonorrhoeae in cervical specimens. As compared with patients who have nongonococcal pelvic inflammatory disease, patients who have gonococcal disease are often younger, more likely to have elevated temperatures, and more often experience pain in the first 10 days of the menstrual cycle. It is not possible to differentiate gonogoccal from nongonococcal pelvic inflammatory disease without the aid of laboratory tests. N. gonorrhoeae can be isolated from the cervix in 20-80% of acute PID. Much of the variation can be explained by differences in the prevalences of gonorrhea in different populations. In populations with high prevalence of gonorrhea, most cases of acute PID are associated with gonorrheal infection. Where gonorrhea is less common, N. gonorrhoeae is isolated from the cervix in fewer than half of cases of acute PID. Neisseria gonorrhoeae can be demonstrated in the fallopian tube or peritoneal cavity of 8-70% of patients with PID whose cervical cultures yield N. gonorrhoeae. When N. gonorrhoeae is isolated from the lower genital tract of a patient who has acute pelvic inflammatory disease, causal significance is appropriately ascribed to that organism. The use of gram staining of cervical specimens to diagnose uncomplicated gonorrhea in women has been discouraged due to low sensitivity and specificity compared with cultures on selective medium. Comparative evaluation of studies of therapy of acute pelvic inflammatory disease is hampered by differences in criteria for diagnosis of cases, in indications for hospitalization and surgical treatment, in durations of therapy and follow-up, and in criteria for cure. The information available is insufficient to justify recommending a change in the 1974 schedules for therapy of hospitalized patients. Results of 2 studies of treatment of outpatients with PID are summarized in a table. Cunningham et al. reported satisfactory bacteriologic and clinical cure rates for gonococcal PID after use of the currently recommended treatment schedules. McCormack et al. obtained satisfactory results with a 5-day course of spectinomycin HCI administered to a small number of patients. Sweet recommended that hospitalization be considered for all patients with acute PID, as is the practice of many facilities in Sweden. It is now clearly documented that users of IUDs have a 3-9 fold greater risk of developing PID as compared with nonusers. All patients treated for acute PID should be followed closely to monitor their responses to therapy. Controlled therapeutic trials of acute PID should ensure similarity of case definition and identification of "cure."
Increased pregnancy rate with oil-soluble hysterosalpingography dye.
The diagnostic value of hysterosalpingography remains unquestioned. Previous studies have suggested that patients who underwent hysterosalpingography with an oil-soluble contrast medium (OSCM) rather than a water-soluble contrast medium (WSCM) had higher subsequent fertility rates. This study evaluated subsequent fertility rates in 339 patients who underwent hysterosalpingography in which OSCM or WSCM was used. All forms of infertility were included and overall, pregnancy occurred in the WSCM group in 21 of 162 patients (13%), and in the OSCM group in 51 of 177 patients (29%); these rates were significantly different (P<0.001), with the unexplained infertility group and the male factor infertility group showing the most significant difference. Adverse effects of OSCM hysterosalpingography were not corroborated. For this reason, it is suggested that initially the patient undergo hysterosalpingography with WSCM. Once patency has been established, 3 ml of OSCM should be injected as a therapeutic modality to increase subsequent fertility. (author's)
Probabilities of fetal mortality.
The Kauai Pregnancy Study (KPS) was designed to provide information about early pregnancies from 4 weeks' gestation on, which is not ordinarily available for study, that is reports of pregnancy from the women themselves as soon as they suspected they were pregnant. This made it possible to obtain information about more pregnancies and more early fetal losses than is possible through customary reports from physicians, hospitals, and registrars of vital statistics. Due to the follow-up nature of this study, losses which were known to have occurred in the various months of pregnancy could be related to well defined groups of women known to be pregnant during each interval of gestation. This was accomplished by the life table method of analysis. 55% of the fetal deaths in the study, 150 out of total of 273, were registered. Of losses recorded in physicians' records, the percentage registered increased from 43% for those ending 4-7 weeks from the last menstrual period (LMP) to 86% for pregnancies ending after 23 completed weeks. For another 62 fetal deaths (23%), records of a physician or a hospital indicated that a fetal death had occurred or that a pregnancy had been diagnosed with no other explanation of the initial findings. In some instances the expelled conceptus was brought to the physician and pregnancy was confirmed. In others the woman's description of her early loss episode was the basis for the diagnosis. The remaining 61 fetal deaths (22%) were not recorded in physicians' records. These losses occurred to women whose pregnancies were reported to KPS prior to termination and as far as is known were not reported because of an imminent loss. 51 pregnancy reports were judged to have been in error. The customary practice of measuring the period of gestation from the 1st day of the LMP to the beginning of pregnancy was followed. Estimated probilities of fetal death for monthly gestational periods formed a decreasing curve from a high point of 108/1000 during 4-7 weeks of gestation. This was followed by a rate of 70 for women pregnant from 8-11 weeks and 45 for those observed during 12-15 weeks' gestation. Rates continued to decline as pregnancies progressed with a slight upswing for the last interval. Based upon monthly estimated probabilities of fetal loss, 237 of each 1000 pregnancies, about 24%, ended in loss of the conceptus. This excluded the 1st 4 weeks of gestation not covered in studies of this measure of the total fetal death rate was twice as high as the ratio of 117 based on all live births and fetal deaths.
Venereal disease and treponematoses--the epidemiological situation and WHO's control programme.
In recent years the epidemiological pattern of venereal disease and endemic treponematoses has undergone important changes in both developing and developed countries. This discussion outlines the present situation and indicates the role that the World Health Organization (WHO) is playing in efforts to combat these infections. About 15-20 years ago 2 contrasting epidemiological situations confronted health authorities around the world. The developed countries were experiencing the lowest recorded incidence of venereal diseases since World War 2. At the same time in developing countries nonvenereal endemic treponematoses were becoming a major health problem because of their widespread endemicity and their disabling effect on the sufferers, which was causing a serious reduction in manpower resources. By the mid 1950s reports from several countries showed an increase in the incidence of early syphilis and gonorrhea and during the subsequent years the rising trend continued and began to affect most countries of the world. Simultaneously, the prevalence of endemic treponematoses dropped markedly in several developing nations as a result of WHO/UN International Children's Emergency Fund (UNICEF) assisted mass treatment campaigns. There can be little question that the introduction of penicillin for the treatment of venereal diseases and treponematoses made a major contribution to the developments outlined. The marked treponemicidal effect of this drug, its ease of administration, and the low incidence of side effects made it almost ideal for the safe, short-term, ambulatory treatment of both venereal and nonvenereal treponematoses as well as of gonorrhea. The immediate result of intensive antivenereal campaigns in the developed countries at the end of World War 2 as well as of the mass treatment campaigns against endemic treponematoses was excellent. Yet, it led some to believe that these infections could be completely eliminated by treatment alone. Subsequent experience has shown this opinion to be unjustified, because the transmission of venereal diseases and treponematoses is closely dependent upon the socioeconomic structure of the society concerned. It is clear at this time that a new approach is required in the field of endemic treponematoses. The era of mass treatment is most likely nearing its end. The endemic treponematoses will remain a longterm public health problem until the hygiene and socioeconomic conditions of the populations concerned are improved so as to eliminate low level transmission of the disease. In regard to the increase of early syphilis and gonorrhea reported from most countries since 1955-57, it should be noted that national statistics are unreliable. Underreporting is general and the statistics are variously estimated to represent between 10% and 50% of the true number of cases.
The role of the medical auxiliary is outlined and a case is made for a specially trained cadre of medical auxiliaries for venereal disease work in busy urban clinics in developing countries. Evidence exists that all forms of venereal disease are very common in urban and rural areas of several developing nations. Very high rates of gonococcal strains less sensitive to penicillin and other antibiotics have been reported in Uganda, Kenya, Bombay, Ethiopia, and Thailand. The situation in these countries and possibly elsewhere in Africa and The Far East is much worse than in Europe. The fear of the spread of venereal syphilis after mass campaigns against the endemic treponematoses and the consequent loss of cross immunity from yaws is already becoming a reality in some developing countries. In many developing nations venereal diseases are often seen late in the natural history of the condition when complications have set in and the medical auxiliary is called on to treat not merely an irritating symptom but a serious complication or an emergency. Peripheral units in most developing countries are now considered to be the ideal units, offering an integrated service comprising all basic health care. Such health centers are also appropriate for urban communities. These health centers are staffed with trained medical auxiliaries, preferably indigenous to the area concerned. Many countries are unable to provide in every unit the full team of auxiliaries required to run all the basic health services. Dispensaries may be operated by a less well-trained cadre of medical auxiliaries supervised from the Health Center or District Hospital. Where the full range of basic health services are offered there is considerable opportunity for team work. In big cities the medical care in most developing countries is provided by Government Hospitals, Urban Health Centers operated by the City Councils, and private practitioners. Venereal disease clinics form part of the outpatient departments in big hospitals and Urban Health Centers. The overall scarcity of fully qualified professional workers means that tasks which are the strict prerogative of doctors and specialists in the developed countries must be delegated to auxiliaries. If equipped with better knowledge and skills their contribution to venereal disease control can be improved. Where sexually transmitted diseases are most common and the daily number of patients very great, as in urban areas, medical auxiliaries should undergo extra training.
Chemical hazards to human reproduction.
In this report the results of studies in exposed humans, methods for testing chemicals in laboratory animals, and the predictive value of animal tests are presented. Environmental factors are significantly associated with reproductive impairment in segments of the US population; these factors include nutrition, diet, stress, infections, access to and quality of medical care, radiation, and chemicals. Studies have shown that cigarettes and alcoholic beverages have important adverse effects in heavy users and may have substantial effects in moderate users. Also certain therapeutic drugs such as thalidomide and diethylstilbestrol have had important adverse effects. Some key findings of this study are: 1) the relationship between chemical exposure and human reproductive impairment requires further research; 2) toxic chemicals can exert effects at many different stages in male and female reproduction; 3) estimates of the proportion of reproductive attempts that fail or are impaired range approximately from 30-80%; 4) the practicality of conducting studies on human populations depends on the ability to identify an exposed group and to document its exposure; the problems encountered in human studies involve the selection of appropriate control groups, elimination of bias, and identification of confounding factors; 5) a preliminary study of data on 21 chemical agents shows a reasonably close concordance between effects reported in humans and in 1 or more experimental animal species; 6) very little has been published on dose-response relationships for agents that affect reproduction in humans; 7) apart from labeling prescription drugs, regulatory agencies have placed little emphasis on reproductive hazards in their recent actions; and 8) the present state of scientific knowledge of chemical hazards to reproduction is similar to that of chemical carcinogens in the late 1960s. Some policy implications of these studies are: 1) the importance of reproductive impairments as a public health problem, 2) the role played by chemicals in reproductive impairment, 3) the reliability of existing methods for identifying chemical hazards to reproduction, 4) the lack of accepted procedures for risk assessment, 5) the scientific basis for regulatory actions, and 6) the differential regulation of exposure to men and women. The appendix is a compilation of human and animal evidence for adverse reproductive effects of chemicals and chemical processes.
The authors investigated the relationship of route of delivery and of antepartum Chlamydia trachomatis cervical infection to selected forms of puerperal infectious morbidity, including intrapartum fever, or early (<48 hours) postpartum fever not attributable to infections of sites outside the uterus and late (48 hours-6 weeks) postpartum endometritis. Infectious morbidity occurred in 27 (44%) of 62 women who underwent cesarean section and in 33 (10%) of 329 who underwent vaginal delivery (P<0.001). Postsection infectious morbidity was not correlated with C. trachomatis infection and was largely limited to early postpartum fever. Among women who underwent vaginal delivery, infectious morbidity occurred in 10 (34%) of 29 women with and in 23 (8%) of 300 without C. trachomatis infection (P<0.001), and chlamydial infection was associated only with intrapartum fever and late postpartum endometritis. Separate matched case-control analyses confirmed that cesarean section was associated with an increased risk of ealry postpartum fever; whereas among women who underwent vaginal delivery, antepartum C. trachomatis infection was associated with an increased risk of development of intrapartum fever or late postpartum endometritis (P=0.002). (author's)
Hsia-Fang: the economics and politics of rustication in China.
For almost 20 years China has been implementing a policy of sending urban dwellers to the countryside in a mass movement of reverse migration. From 1961 through 1963 some 20 million were sent, and from 1969 through 1973 more than 8 million urban youths had been "plunged into the battle to build a socialist countryside." The movement, which assumes different interrelated forms, has a variety of objectives. The following are included among the political aims: ideological rectification and remolding; ethnic and military strategies; and shifting allegiance away from the family unit. Among the primary economic objectives is that of relieving actual and preventing potential urban unemployment. More or less spontaneous migration of rural labor to towns was significant during the 1st 5-year plan (1953-57) and phenomenal during the 1st year (1958) of the Great Leap Forward. In 1958 alone urban population increased by 15.6 million, of which about 10 million are thought to have resulted from migration from the countryside. Total industrial employment in 1958 rose by 16.6 million, according to official Chinese sources, but a large part of this increase consisted of jobs in workshop type, labor intensive rural industry. Yet, modern urban industrial enterprises markedly increased their labor intake in response to pressures for higher output. Even assuming that the 10 million migrants were absorbed in urban industrial employment, the economic value of such employment is questionable. There must have been considerable overstaffing (labor hoarding) and consequent underemployment. Between 1950-57 many instructions were issued in order to control the "blind outflow" of rural labor to the cities. The network of administrative controls over labor mobility came to include local authority permisision to leave the farm, permission from city authorities to stay, and the imposition in 1961 of a ban lasting 3 years on recruitment of rural labor for urban industry. The intent of all these measures was to make labor allocation as much as possible an administrative function of the planning authorities. Currently, the most important form of rustication is the transfer of unemployable urban youths with middle school education, a transfer in most cases intended to be permanent. In mid 1974 the strategy of inserting urban educated young people into the countryside began to show a definite pattern. The whole process is marked by considerable compulsion, primarily moral and partly internalized through a long drawn out process of ecucation. The 1st step is to lower the young people's level of expectation. This is followed by enormous and organized peer group pressure on school leavers to move to the country. The general impression is that there must be considerable dissatisfaction and frustration among the rusticated youths, some of whom are not so young any more.
Residence background, migration, and fertility.
This paper attempts to clarify confusion concerning residence background and migration, and to demonstrate that each of these factors exerts an independent effect on fertility. Basic premises underlying the direction of the effect of these variables on fertility are examined. Data from the 1967 Survey of Economic Opportunity indicate that migration and residence background do have independent effects. It is concluded that present generalizations as to the direction of their influence should be submitted to closer scrutiny with additional data in the future. In addition, an index of rural exposure is developed to test the proposition that fertility varies directly with degree of rural experience. The data only partially support this hypothesis. Moreover, rural-to-urban migrants are found to have only slightly higher fertility than the receiving urban-origin population. (author's)
Fertility in cultural perspective: Egypt, Jordan, Morocco, Tunisia, and Yemen.
The main hypothesis of this report postulates that incorporating cultural beliefs and traditional institutions within a family planning program will improve acceptability of contraceptive methods. Also, it provides the basis for programs that are culturally specific and not general in nature. Interviews were conducted by phone or through personal meetings and a questionnaire was developed to guide discussion. Questionnaires were mailed to 28 researchers in the US and abroad. Tunisia and Egypt seem to have overcome public sensitivity to family planning and are involved in various projects, but Morocco and Jordan are still struggling with acceptance of the idea. Yemen does not have either the government commitment requirement or the institutional capabilties, but the private sector is involved in family planning counseling and contraceptive sales. The complex attitude towards sex in the Near East and the importance placed upon virginity, marriage, and procreation is discussed. Near Eastern women are in general ignorant of reproductive physiology, not knowing when conception occurs or how the sex of the child is determined; this ignorance makes the practice of rhythm or barrier methods difficult. It is suggested that indigenous transmitters of information should be used to convey knowledge about family planning, including the "hammam" lady, the singer at the weddings, or elders of the village. Sermons at the mosque are another source to transmit information about the need for spacing children. The person who transmits information on contraception on a face to face basis should be an older married woman who has already had children; it would be acceptable also for a man to transmit information to a woman but not for a young man to an older man. It was also found that: 1) any contraceptive that disturbs the regularity of amount of bleeding upsets the cultural norms regarding menstruation, and 2) newlyweds should not approach any form of family planning until at least 1 child was born. In the Near East breastfeeding and other traditional methods such as sperm blocks, suppositories, creams, and foams are still popular; modern methods are popular in urban areas. It is recommended that: 1) an increased use of condom, withdrawal, and diaphragm be advocated; 2) women be taught about ovulation so that they can predict their fertile periods; 3) the argument for family planning be presented by using the healthy baby and healthy mother approach; 4) research on traditional weaning patterns in Yemen be done; and 5) research on the attitudes of men and other family members be conducted. In general it is recommended that a total family planning strategy be developed for these countries with family planning awareness campaigns followed by method-specific programs.
Health. Congressional presentation, fiscal year 1984 [exerpt]
Progress toward increasing life expectancy has been made in recent years, but the health of the majority of people in most developing countries remains poor by any measure. In many nations life expectancy does not exceed 50 years. More than 1/3 of infants die before the age of 5 and hundreds of millions of adults suffer from chronic, debilitating diseases. Poor health conditions lead to higher mortality, less working time, and lower productivity among both children and adults. Economic growth and human capital development are closely related. Sustained growth cannot be realized without at least a minimally trained, healthy populace. Improved health is critical to improving productivity in general, and agricultural output in particular. The US Agency for International Development (USAID) is committed to supporting measures to improve health directly in developing countries and recognizes that programs in population, education, and income generation all have indirect effects on health. Poor health in the developing world is caused by a series of interrelated factors: undernutrition; numerous, closely spaced births that debilitate mothers and result in underweight infants with poor chances of survival; unhealthy environments that encourage the spread of disease; ignorance of the causes of disease and of simple means of preventing or curing common illnesses; and uneven distribution of effective health services. Infectious diseases are a major contributing factor to death and to impaired agricultural productivity in developing countries and therefore constitute a serious obstacle to development. 200 million people are afflicted with malaria and 300 million are believed to be suffering from schistosomiasis. Disease control activities represent approximately 20% of USAID's total health assistance requests in fiscal year 1984. USAIDs program to combat infectious disease includes: vaccination against communicable childhood diseases; disease control programs; promotion and support for oral rehydration therapy; basic biomedical research; and applied research programs. Improvements in domestic water supply and basic sanitation can help substantially to improve health, particularly in conjunction with primary health care. USAID's request for water supply and sanitation programs in fiscal year 1984 constitutes about 7% of total health funds, largely for continuation of ongoing programs. USAID's health staff comprises approximately 100 direct hire professionals in Washington and in overseas missions. The Washington based staff serves as the principal source of technical support for the field missions.
Future directions of population education in the Pacific Region.
The main objectives of the Regional Consultative Seminar on the Future Directions of Population Education in the Pacific, held in Nuku'alofa, Tonga during November 1982, were to provide opportunities for sharing of country experiences in population education and to assess further needs and requirements for future programming in population education at the national and regional levels in the formal and nonformal sectors. The general report section of these conference proceedings presents a background and review of developments and experiences and examines problems and needs in population education, trends and future directions of population education, and the role of regional cooperation in population education. Country reports are included for Cook Islands, the Federated States of Micronesia, Fiji, Kiribati, Marshall Islands, Palau, Solomon Islands, Tonga, Vanuatu, and Western Samoa. The following were among the conference recommendations: at the national level conduct awareness seminars and meetings for different levels of people and use the radio and other mass media; at the regional level continue regional advisory services to create awareness for policy and decision makers and participate in national seminars; stress quality of life as a goal of population education; conceptualize population education according to what is acceptable and workable in societal context; continue regional advisory services to explain the nature, concepts, and goals of population education; in relation to out-of-school population education and family planning, stress the improvement of maternal/child health by spacing, rather than having fewer children; point out family size development cultural issues; form high level committee of policy, decision makers and involve them in all levels of planning; organize national seminars to foster understanding and commitment; organize regional seminars for heads of country programs and other key officials in order to create and sustain interest and commitment of population education; encourage inclusion of multisectoral groups in the preparation of development plans, and not only economists; integrate population education into development goals, population policy, and educational aims; provide orientation and training for all levels of personnel involved in population education, both in school and out of school; and assess the effectiveness of training programs.
Haiti: a favorable context for family planning in one of the world's least developed countries.
Publication of the results of the 1977 Haiti Fertility Survey confirm the accuracy of previous Haitian Institute of Statistics estimates of fertility levels and trends for the 1970s and suggest that despite great obstacles to development and current low levels of living, the Haiti National Family Planning Program is off to a good start in a cultural context favorable to fertility regulation. The survey was conducted between July and December 1977 and covered 3211 women aged 15-49 years of age, of whom 2176 were ever in a union. A total of 1843 women were in union at the time of the survey. The findings showed marked differences in fertility levels in urban and rural areas, among educated and illiterate women, and among those married compared with those in commonlaw or visiting unions. Over 40% of women in union and fecund said that they wanted no more children. The rate of ever use of contraception was 37% and the rate of current contraceptive use was 25% of exposed women. 82% of the women knew of at least 1 efficient contraceptive method only 4 years after the National Family Planning Program began providing services primarily in urban areas. The Division of Family Hygiene (DHF), responsible for the National Maternal and Child Health and Family Planning Program, has begun numerous innovative approaches to the delivery of contraceptives and basic primary health care during the last 4 years. Progress in recent years makes the 1977 findings on contraceptive use probably already outdated. Initiatives to improve service delivery include a household distribution of contraceptives project, a community development program, commercial retail sales of contraceptives, and extensive use of existing government and nongovernment institutions to provide services. Voluntary sterilization is also becoming increasingly available through DHF efforts. In addition the organization of an extensive rural health delivery system is likely to greatly extend maternal and child health (MCH) and family planning services to the rural poor in the years ahead. An important factor in fertility trends in addition to union patterns and contraceptive use which the Survey did not examine directly is outmigration. Recent estimates suggest that around 14% of native born Haitians left their country between 1950-80. The total fertility rate for the 3 year period prior to the survey was 5.5 children for Haiti as a whole. In recent years there appears to be a slight tendency toward fertility decline in rural areas and a marked decline in Port-au-Prince. Further verification of the data is necessary before it will be possibl e to identify a fertility decline in Haiti.
It was hypothesized that internal migrants to urban destinations in Third World countries attain in the course of their work careers labor force status and occupational distributions comparable to those of nonmigrants, at the destinations. The data pertain to the capital cities of Colombia, Egypt, and Thailand. The 3 countries differ culturally, in their degree of urbanization, and in the extents to which they have acquired nonextractive economies. The data were collected in a comparative migration project conducted under the auspices of the Carolina Population Center. Interviews were obtained in the capital city and in selected rural villages of each country in close consultation with research counterparts and in a uniform manner. In each capital city a sample of approximately 1000 households was selected using a multistage cluster sampling procedure. The primary interviews in each household were randomly selected from among the occupants between 18-55 years of age. Both current and retrospective information on a variety of migration related topics was obtained in the interview for all primary respondents. Migration to the capital cities of Colombia, Egypt, and Thailand was not a source of economic disadvantage. Although migrants experienced some problems in gaining entry to the active labor force, their participation rates eventually converged upon nonmigrant rates. Upon reaching their current employment status, migrant unemployment and underemployment rates were generally lower than were those of nonmigrants. These outcomes were due in part to the fact that migrants originate largely from other urban places and, where there has been previous work experience, from nonagricultural sectors. Most had some direct or indirect experience with capital city conditions. The success of migrants in the respective labor forces was fairly uniform in all of the capital cities. There was much less evidence of convergence in the occupational distributions of male nonmigrants and migrants than was found for male labor force status distributions. The failure of migrants to acquire similar distributions was due largely to their greater tendency to concentrate in the highest white collar occupations, notably the professions. The data fail to provide as strong a support for the hypothesis as was expected, but do point to a fair amount of cross country consistency in migrant labor force experience. If rates of unemployment and underemployment are measures of potential social costs, there is little evidence that migrants are burdens on the cities of destination. In view of the problable selectivity of migration, a case can be made for its making a positive contribution.
Focus in this book is about rural populations. The primary emphasis in upon health and health services. The relationship between rural hopelessness and health is complex. Although ill health adds to hopelessness, its removal does not mean that there is hope. The problem and the priority must be the total rural hopelessness complex and not simply ill health. It is difficult to understand why members of the health services have tried to separate "health concerns" from other parts of the complex. Studies demonstrate that many of the "causes" of common health problems derive from parts of society itself and that a strict health sectoral approach is ineffective with other actions taken outside the field of health possibly having greater health effects than strictly health interventions. If the restricted approach is not considered valid, than the reaction to its rejection is even more strange. As the health services fail in their bid for additional resources to further their priorities, the health professions turn their backs on the problem and direct their energies toward developing additional methods for helping the privileged persons who can both afford and appriciate them. Some views, which could be said to be widely held, also are biased as they ignore some events that have been occurring during the past 25 years. Individual groups and some states have tried to approach the problem from a different direction. Some have tried to extend services, including health, outwards towards the villages. Some countries have tried to face the total problems in an interlocking series of political, economic, and social measures. Some persons have tried to build upwards and outwards with the villages, using health benefits as trigger mechanisms or consequential benefits of change. Health workers and health service techniques have often played an important role in these efforts. To learn what really happened in these endeavors and why efforts were successul in 1 place and failures elsewhere, the World Health Organization asked a group of individuals who participated in some of these attempts at change to write down what happened. Thus, this book is a selection of examples from many different countries. It includes contributions from observers, from national participants, from local groups, and from persons who participated.
The national health system in Cuba.
Focus in this discussion of Cuba's national health system is on the following: the original situation in regard to health; the current Cuban experience in the field of health; the approach taken; financing; progress; and the present position. In Cuba the existence of a national health system is a relatively recent phenomenon, a consequence of the changes that occurred in the country after the Revolution in 1959. From the beginning of this new era health and education have been accorded high priority by the government. Health is regarded as a fundamental human right and health services are free for everyone. A permanent objective is to achieve an equal distribution of services as soon as possible. From the outset it was considered necessary to integrate all the formerly separate components into a single organization able to give direction, set standards, and control all health activities. As a consequence of the appliclation of this principle, all institutions in the medical field, including those formerly in the private sector, as well as the industrial and commercial undertakings concerned with drugs, were incorporated into this single health organization. This long process was completed in 1970. The health budget for 1968 was almost 10 times that for 1958. The health services cover practically the entire population. Utilization of services approaches 100%. The number of hospital beds increased from 28,500 in 1958 to 41,000 in 1973. The increase in beds in the most needy of all the provinces has been 100.5%, compared with only 1.8% in Havana, the capital province. The planned 56 new rural hospitals have already been completed and staffed. In the capitals of the 7 provinces there are general hospitals with 400-1000 beds; there are 6 in Havana as well as maternity and children's hospitals. In each 1 of the 43 regions there is a general hospital with 150-450 beds. Except for neurology, which is mostly available at provincial level, and some other specialties requiring a low doctor/population ratio, all the specialties function at the level of the region. The medical profession has been transformed and the curative doctor of former times has been replaced by a professional with a wide comprehensive concept of medicine. In 1973 there were on average 8.5 antenatal visits per pregnant woman, and child health visits, which began in 1967, are now at the level of 4.5 per infant per year. Mortality from infectious diseases has been markedly reduced in the revolutionary period. Education has been given the same priority as health, and in 1959 the eradication of illiteracy was begun. Although many of the fundamental elements of the national health system have now been established, there is room for improvement.
The Ayurvedic system of medicine in India.
The government of India established a committee to study indigenous systems of medicine, and the committee's report was published in 1948. The inquiry was concerned with the history of Ayurveda, or Hindu medicine (including Sidha), and of the Unani Tibbi indigenous systems of medicine and their place in India today. Ayurveda is reputed to have been practiced for over 3000 years, its history being divided into 4 periods: The Vedic period; the original research and classical periods; a period of compilation of Ayurvedic methods and periods of Rasa Tantras and Sidhas -- chemist physicians; and a period of stagnation and eventually recompilation. Ayurveda was at its height during the 2nd and 3rd periods. Discussion of Ayurveda, covers the following: the science and philosophy of Ayurvedic medicine (the ancient method of study, basic elements, and the disease process); the practice of Ayurvedic medicine (preventive measures, personal and social hygiene, rejuvanating measures, and the practice of yoga) and curative measures (internal medicine and therapeutics, application of medicinal preparations externally, surgical measures, and treatment by psychosomatic measures); and the role of Ayurveda in modern medicine (review of the training curriculum, earlier efforts at integration, and proposals for integrating medical education and practice). The system of ancient Indian medicine -- Ayurveda -- was developed against the rich background of social, cultural, and philosophical principles prevailing in India between the period 600 B.C. to A.D. 700. According to the principles of Ayurveda, the human being is a miniature imitation of the universe, and whatever properties are contained in the universe are also found in the human body and whatever are in the human body are found in the universe. Illness occurs if there is any derangement in the body humors. The internal administration of drugs plays an important part in treatment. The drugs are used primarily to eliminate causative factors. Ayurveda also prescribes a large number of medicines for external use in the form of pastes, medicated oils for massage, medicated baths, gargles, and powers. Ayurveda describes in great detail various surgical conditions and their management. The Ayurvedic physician is required to individualize therapy with regard to drug components and ingredients, dosage, diet, and rest, according to the psychosomatic condition of the individual patient and the predominance of vitiated humors in the disease process. At this time in India there are about 50,000 institutionally qualified registered practitioners and about 150,000 noninstitutionally qualified registered practitioners of Indian medicine, including the Ayurvedic, Unami, and Sidha systems of medicine. It is estimated that there are another 200,000 traditional Ayurvedic practitioners practicing in the rural areas who are neither qualified from any institute nor registered with any state council. Nearly 100 Ayurvedic colleges have been established in India, and most Ayurvedic physicians trained at the colleges have a good basic knowledge of Ayurvedic medicine and an adequate practical knowledge of modern medical sciences.
A health services development project in Iran.
A health services development project was created in Iran in 1971 with the general objective of determining and testing better ways to solve multiple health problems through both an effective and efficient health delivery system. 5 stages to the project were described: specification of project objectives and design (July 1971-July 1972); situational analysis beginning with field activities (July 1972-November 1972); formulation of proposals for plans for further health services development (November 1972-April 1973); preparatory step (July 1973-March 1974), including feasibility studies, small field trials, detailed planning, experimental small scale action in the field, and forming new types of working groups; and implementation (from April 1974 onwards), including evaluation. The project is planned and conducted as a joint action oriented research activity. The province of West Azerbaijan, a typical province in regard to health conditions, was selected as the field area for the project. It is one example of several projects in Iran aiming at similar goals. The estimated crude birthrate in this province is 42-45/1000 population and the estimated crude mortality rate is 10-14/1000. Census results indicate a crude annual population growth of 3.2% in rural areas. The problem of high fertility and population growth is common to both urban and rural populations. The geographical distribution of the existing health services is such that the basic units form a network, with a major health center in the capital, health centers (where they are developed) in the districts, and units of lower level in the local urban and rural settings. These units are parts of different organizations and agencies and their management and supervision are organized through separate channels. The most obvious characteristics of the picture given by situational analysis was that only a small proportion of health problems was being dealt with by health service activities, particularly in the rural areas. 3 types of health needs were identified: mass and emergency problems, with organized mass campaigns considered to be the most appropriate intervention and the formation of mobile units as an efficient operational program; the problems of risk groups in the population, with an organized community approach and a family approach deemed necessary; and illness randomly distributed in the community, and an individual approach required in this instance, i.e., the treatment of episodes of illnesses. The delivery system as a whole must be considered as functioning at something less than an optimal level. It was proposed that the main stimulus for initiating and propagating the development of the delivery system in the West Azerbaijan Project should come from within the existing services, and specifically from action with the population. Primary health care functions at the village level were introduced by the use of new types of primary health workers whose role is described. During the 1st year of operations the primary health workers were integrated into the health system.
"Simplified medicine" in the Venezuelan health services.
The origins, conceptual basis, organizational and administative features, progress, and present situation of Venezuela's Simplified Medicine Program is summarized. The program was developed in recognition of the need to provide services to meet the elementary general health needs of remote and dispersed populations. In Venezuela the modern public health movement began with the creation in 1936 of the Ministry of Health and Social Security. During the ensuing period of 1936-63, there were several events that deserve review, for they led gradually to the implementation of the Program. While the idea of a single National Health Service was growing, there was a movement for merging efforts, both central and peripheral in order to achieve some integration, through the development of agencies known as Health Regions or Cooperative Health Service. This step was of crucial importance to the Program. The Program, being a normal component of the health services, can be implementing only where there is an organized regional health services able to provide the necessary technical and administrative support. The Program has had to wait until that requirement has been met and thus has not been extended to all states of the country. The Program is built on certain fundamental conceptual elements, including the following: comprehensiveness of health care delivery; continuity; supervision and referral. The existence of an adequate structure for support, supervision, and referral is not sufficient for the kind of Program described unless there is careful training of the key element, i.e., the auxiliary. Usually 10, and never more than 12 candidates, attend a 4 month training course held in district health centers. The manual is the "bible" of the course, to guide in the teaching/learning process. Great care is given to practical teaching, and ethical aspects are stressed at every opportunity. The Program has been gradually absorbed as a regular activity of the Venezuelan health services. The types of activity performed by the dispensaries incorporated in to the Program are: health promotion; health protection; health restoration; and miscellaneous. The dispensaries are mostly located in simple constructions specially built by the state or by local communities. The insistence of supervision, a key Program element, cannot be overemphasized. Supervision of the auxiliary's work is carried out in several ways. At the end of 1973 the Program was operating in 12 of the 23 major political entities of Venezuela. By March 1974, 82 training courses had been completed by 836 trainees. 1 of the administrative problems is the high turnover rate of auxiliaries. In the basic proposals for the new integrated National Health Service of Venezuela, it is clearly stated that "simplified medicine," supported by the whole health system, will cover the primary health needs of the rural populations.
In this book 10 groups of people describe the dramatic changes in the delivery of health care that occurred in their areas or countries. Their starting points were different, as were their methods and the end results, but all are successes. This chapter examines some of the goals, the methods, and the results to determine if their were some general principles that could be used to help other countries and communities to improve their health. In all of the examples described the new system of primary health care was either linked with the indigenous system or attempted to play a role having some of the same qualities that existing systems had. Each country or area also started with the formation, reinforcement, or recognition of a local community organization. This appeared to have 5 relevant functions: it laid down the priorities; it organized community action for problems that could not be resolved by individuals; it controlled the primary health care service by selecting, appointing, or legitimizing the primary health worker; it assisted in financing services; and it linked health actions with wider community goals. Another common element is the use of a primary health care worker who does not fit the expected description of a doctor or nurse. Frequently, this person is a villager selected by the community and trained locally for a period that could be as short as 3-4 months initially, an unpaid volunteer, or a person possibly partially or totally supported by the village people in cash or kind, and with responsibilities for aspects of promotional, preventive, or curative health. The relationship of the primary health worker to the remainder of the health services warrants a separate study. In no example presented is there a separation of the promotional, preventive, and curative health actions at the primary health care level. Arguments for a linkage between financing and service are not so clear. The need for primary health care to be self sufficient has been expressed many times. The examples presented fall into 3 overlapping types: national change (China, Cuba, Tanzania); extensions of the existing system (Iran, Niger, and Venezuela); and local community development (Guatemala, India, and Indonesia). The countries that started the process of national change by a political process have a clear advantage in speed and coherence, but the forces that influence such a change are beyond the scope of this discussion. It is concluded that in most countries health development as a part of rural development is possible if one goes about it in acceptable ways. These ways include the quick evolution of a village based development organization and a primary health care system designed for that country and accompanied by a parallel national effort to build such a peripheral expession into the national scene.
Birth-control decisions: hidden factors in contraceptive choices.
The whole subject of contraception is characterized by multiformity and change, depending on the time and place. Culture and psychology, no less than safety and comfort, clearly affect an individual's contraceptive choice. In the 19th century, the most prevalent contraceptive method was the earliest--coitus interruptus. The vaginal douche was probably second in popularity. Neither of these methods was totally reliable. The 3rd method most frequently used was probably the condom. No contraceptive device better exemplifies the fashions, fluctuations, and revivals inherent in the field of birth control. For much of the 20th century condoms were America's foremost method of birth control. This was all changed by oral contraceptives (OCs) in the 1960s. The decline in condom sales was reversed when a British study found a relationship between OC use and the formation of blood clots. Little by little the adverse side effects of OCs and IUDs gained notoriety. Open display of condoms in retail stores, which began about a decade ago, really took hold in the late 1970s. Of all contraceptives, condoms by far offer the best protection against venereal disease. Currently, condoms are more widely used than ever. They are the method of choice for approximately 20% of American couples. Worldwide, condoms are the most commonly used contraceptive. Subsequent fear of OCs played a major part in turning women back to the diaphragm, introduced in the 1920s and ranging in effectiveness from 80-98%. The number of OC users is now back up to at least 10 million and growing. There are several reasons for the recent upturn, aside from a success rate of more than 99%. Today, only combination OCs, containing both estrogen and progestin and demonstrably safer than sequentials, are approved for use in the US. There are more than 40 different brands, with varying combinations of these hormones. Recent studies show that there may be some positive health gains from OCs. Another nonbarrier contraceptive that has had varying public acceptance is the IUD. In the early 1970s some types of IUDs were found to cause serious infections, sterility, and even death. Since the Dalkon Shield was removed from the market in 1974, improved IUDs have been developed. By 1976 nearly 1 out of 5 American married couples had chosen sterilization as their contraceptive method. At present, the ratio of male to female sterilization is about even. Improved techniques are making sterilization easier to reverse for both sexes. In the US, age, ethnicity, income, religion, education, and region all matter in explaining an individual's contraceptive choices. Some important findings in terms of these characteristics are presented for the year between 1965-76.
Budd-Chiari syndrome associated with oral contraceptive steroids. Review of treatment of 47 cases.
Oral contraceptives (OCs) have been implicated as the cause of a number of instances of hepatic vein thrombosis (Budd-Chiari syndrome). Survival appears to be related to early diagnosis and treatment, but there does not appear to be a consensus as to the most appropriate management of these patients. Portosystemic shunting has frequently been advocated, although the results have been quite variable. Some patients appear to do well with conservative measures only. In the effort to obtain a clearer understanding of the effects of different medical and surgical therapies in this disorder, we analyzed the treatment of 47 cases associated with OCs, 29 of which were found in the literature and 18 additional cases identified through a questionnaire survey mailed to members of the American Association for the Study of Liver Diseases (AASLD). Surgery had been performed in 27 of these 47 patients (57%); 17 patients had been treated medically (36%); 2 individuals had received unspecified treatment, and 1 patient died before any treatment could be initiated. In the surgical group, 13 patients underwent portosystemic shunt surgery with 6 surviving up to 5 years. 2 patients survived more than 15 months following orthotopic liver transplant and 1 patient is well after partial hepatectomy. Of 10 who underwent exploratory laparotomy (3 with the intent to perform a shunt), 7 died postoperatively. Mean survival for the surgically treated group was 19.4 months (10 days-7 years). Of those patients treated medically with a combination of diuretics, anticoagulants, antiplatelet agents, fibrinolytic agents, and peritoneovenous shunts to control ascites, 11 (65%) have survived from 3 months-6 years (mean survival 29.0 months). We conclude that a satisfactory response may accompany either medical or surgical management of patients with Budd-Chiari syndrome associated with OCs. Patients with severe occlusive disease may benefit from most surgical decompression of the hepatic veins. However, for those with mild to moderate disease, the proper role for operative intervention remains to be defined. (author's modified)
Breast cancer, lactation, and genetics.
A review of mortality rates from breast cancer in several nations indicates that most Caucasian populations have higher rates than do most non-Caucasians. The only environmental factor shown to affect breast cancer rates consistently is parity, and its mechanisms of actuation are unknown. The higher risks of breast cancer among relatives of patients are reviewed, and a multifactorial genetic control is assumed in which all the effects of genetic and environmental factors may be in part additive. While genetic effects are evident in both breast cancer and lactation, it is not clear whether they depend on 2 distinct sets of genetic factors or on a single set. Assuming that the higher frequencies of breast cancer in Caucasian populations are in some way associated with abnormal genetic factors in hypolactation, the hypothesis is suggested that their rate of elimination by natural selection might have become relaxed or diminished in remote prehistoric times only in Caucasian populations through their widespread development of domestic animal milk as an artificial infant food. Relaxed selection of genetic factors for hypolactation might have caused them to accumulate among Caucasian populations in sufficient frequencies to produce appreciably higher rates of breast cancer in these populations today, even when breastfeeding is the rule. (author's)
Oral contraceptives and cancer [letter]
The publication of the important paper by Professor Vessey and his colleagues (October 22, p.930) has caught us at a time when we are transferring our activities to a new computer, and we shall be unable to undertake any new analyses for several months. I have available, however, a relatively unsophisticated analysis which is based on the data we had accumulated up to December 1981. The assessment of cervical cancer is notoriously difficult because there are so many complicated and subtle confounding variables. We are unable to take account of all these at the moment. We can, however, gain some indication of the likely effects of the frequency of cervical smearing and hysterectomy rates in the 2 comparison groups. In our study populations, cervical smears have been done up to 40% more often in the ever-users than in the controls. Thus, the neoplasia detection rate in controls is likely to be lower than that in the ever-users. Secondly, we know that the hysterectomy rate is higher in the controls than amongst the ever-users. Thus, the population at risk (i.e., the denominator) is spuriously inflated in the control group to a greater extent than it is in the ever-user group. The effect of both these confounding variables is likely to be to reduce the apparent difference between the 2 groups--that is, to reduce the relative and absolute risks associated with oral contraceptive (OC) use. The excess risk of invasive cervical cancer derived from the table is about 1 in 14,000 ever-users of OCs/year, and as suggested, this is likely to be an overestimate. It therefore seems possible that the paper from Vessey et al. has presented an exaggerated view of the magnitude of the problem. (full text)
Oral contraceptives and cancer [letter]
Whilst taking seriously the findings in Professor Vessey and colleagues' paper I should like to make certain points. Firstly, the absence of any cases of invasive neoplasm in users of the IUD probably "occurred by chance" (expected number being 3-4). Secondly, although no significant findings were obtained when different brands of pill were compared, I note, in a throwaway line, "a high proportion of the oral contraceptive use in our study relates to products containing 50 mcg estrogen or more." In our youth counseling clinic, with clients under 21 years, we have not once in the past 5 years used a pill containing more than 30 mcg estrogen. I believe that this is generally true throughout Britain. Many more trials are needed, looking particularly at current practice, before firm conclusions can be drawn. (full text)
Oral contraceptives and cancer [letter]
Professor Vessey and his colleagues' important study revealed a 75% increase in all forms of cervical neoplasia in women with prolonged pill use as compared with those using an IUD. Unfortunately, but of necessity, they have been unable to compare the risk of cervical cancer developing among women using oral contraceptives with the risk in the general population, so no control population was available who neither took the pill nor used an IUD. Further in-depth studies that take into account all factors concerned are now needed. Vessey and coworkers comment significantly that "women using a diaphragm would be unsatisfactory as a comparison group in view of the relatively low incidence of cervical neoplasia among them." In view of the results shown by the Oxford team it seems appropriate to stress again the protection afforded against cervical cancer by both types of barrier contraception (diaphragm and sheath). Surely, this lends important support for a move to encourage greater use of these methods. 13 of the 16 cases of invasive cancer described in Vessey's paper (table 5) were picked up by cervical cytology with tests done according to the previous DHSS recommendations on age and frequency of screening. However, as a cytopathologist, I am disturbed by the long interval between the reporting of the most recent abnormal smear and the biopsy in some of these patients. In 3 cases there appear to have been intervals of 4, 7, and 8 months. Were the delays due to a failure of the doctors requesting the test to appreciate the significance of the report and/or subsequent hospital admission? Fortunately, all these cases proved, on biopsy, to have early invasive disease and were successfully treated. (full text)
Oral contraceptives and cancer [letter]
So many young women under 25 in Britain are taking "microgynon 30' or 'Ovranette' for effective and comfortable contraception that it is very important to be clear about whether there is an excess risk of breast cancer attributable to its longterm use or not. In the American study of Professor Pike and his colleagues (October 22, p.923), the risk seemed to be concentrated among pill combinations relatively high in estrogen as well as progestogen, of a type rarely used in Britain since 1969. The equivalent of our microgynon 30/ovranette appears to be 'Lo-ovral' if the 0.3 mg of norgestrel is present as the racemic mixture. The contribution of 'lo-ovral' to the total excess of breast cancer in the study seems to be slight, 0.5 month of average use by the cases as against none by the controls. We cannot tell from the paper whether this was prolonged use by a few or brief use by a larger number of the women contracting breast cancer, and it is difficult to estimate reasonably the relative risk for this combination if none of the controls used it. Is there a way in which Pike et al. can confirm that lo-ovral is a serious threat to the under-25s? It does not seem right to condemn an otherwise useful preparation on the basis of a hypothetical "progestogenic potency" value alone, especially when the method of indicating this potency is so controversial and may have little to do with the effects of progestogens on breast tissue. Pike et al. mention in their introduction that combinations with both components at a high level would be more likely to cause the effect. (full text)
Oral contraceptives and cancer [letter]
The classification of oral contraceptives (OCs) by Professor Pike and his colleagues according to "progestogen potency" must be challenged. It has been known since 1960 that the activity of progestogens in the delay of menses test is potentiated by estrogen, though the precise dose relationship remains uncertain, yet in their classification Pike et al. take no account of the amount and type of estrogen in the various combination of OCs referred to in their table 1. There can be little doubt that it is the progestational activity of the mixture, not of the progestogen alone, that matters for physiological or pathological purposes. In any case, the potencies assigned to the various progestogen components in table 1 must themselves be questioned. According to the table, norethisterone is rated as having half the progestogen potency of norethisterone acetate, when combined with ethinyl estradiol 50 mcg, but I have found that norethisterone has twice the potency of norethisterone acetate in this combination when compared in the delay of menses test. Furthermore, table 1 shows ethynodiol diacetate as having 7.5 times the progestogen potency of norethisterone acetate while, for combinations with ethinyl estradiol 50 mcg, I have found the potencies of the combinations to be equal in the delay of menses test. No reliance, I would suggest, can be placed on the ordering, in accordance with the figures given in the column headed progestogen potency; of the combinations shown in table 1. These arguments apply equally to the table of OCs in the UK distributed by the Committee on Safety of Medicines, which contains, in addition, obvious errors (such as Eugynon 50 being given a progestogen potency of 0.5 while Eugynon 30, with the same progestogen dosage is rated as 15; and Loestrin 30, containing 1.5 mg norethisterone acetate, being rated as 9 while in other norethisterone acetate containing combinations the rating is 2/mg). My competence in epidemiology does not allow me to criticize the general contention by Pike et al. that longterm use of OCs by young women may increase the risk of breast cancer, but I would seriously question the validity of the basis on which rests their claim that so-called "progestogen potency" of combined OCs influences this risk. (full text)
Oral contraceptives and cancer [letter]
Professor Pike and his colleagues have shown that women who take highly progestogenic oral contraceptives (OCs) for a long time before they have reached the age of 25 are at increased risk of breast cancer in later life. The use of OCs with "low" progestogenic activity appears to increase the breast-cancer risk little or not at all. Professor Vessey and colleagues, in the same issue of The Lancet, demonstrate that longterm OC use may increase the risk of cervical neoplasia. Studies by Kaufman et al. and by Weiss et al. have shown that OCs protect against cancer of the endometrium. Similarly Rosenberg et al. demonstrated that OCs provide longlasting and significant protection against cancer of the ovary. The Centers for Disease Control, Atlanta, has confirmed both these beneficial effects. It is often hard for a clinician to interpret epidemiological evidence and to present a fair and informative assessment to his patient. It is even harder for a woman who seeks contraceptive advice to evaluate such contrasting risks and benefits and to make an informed decision. From her doctor she needs not only a reasoned exposition but also sympathetic guidelines to help her overcome irrational fears which may have been engendered by media reporting. What we all need is an informed epidemiological assessment of the total effects of "the pill" on neoplasia. (full text)
Vaginal mechanical contraceptive devices.
Consumers and physicians are considering mechanical contraceptives as alternatives now, for in recent years there has been an increasing number of reports of adverse reactions and risks associated with IUD and oral contraceptive (OC) use. Yet, the contraceptive devices designed to mechanically cover the cervix have been the least studied and evaluated method of birth control. The currently available vaginal mechanical contraceptive devices are described and their efficacy and advantages and disadvantages are compared. Vaginal sponges are made from various types of synthetic and natural polymers. There is a wide variation in the reported rates of efficacy of vaginal sponges, and it is difficult to obtain accurate figures on rates of efficacy. The International Fertility Research Program (IFRP) has reported a failure rate with the sponge of approximately 7 or 8 pregnancies/100 woman years, or a 6 month pregnancy rate (according to life table analysis) of 3.8 +or- 1.3/100 women. The sponge does not interrupt sexual spontaneity. The spermicide is immediately available after each coital act, and 1 sponge lasts for many coital acts. The sponge is easy to use, and no medical supervision is required for fitting, as the sponges come in only 1 size. Women have cited discomfort to themselves or their partners as the main reason for discontinuing the use of vaginal sponges. The cervical cap is a thimble shaped rubber or plastic device that is placed over the cervix to provide a barrier against sperm. The cap is often used in combination with a spermicidal agent, and it must be left in place at least 12 hours after intercourse to prevent remaining viable spermatozoa from entering the uterus. Failure rates for cervical caps compare favorably with those for diaphragms (3-16%, and 1.9-19.6% respectively). Cervical caps can be left in place longer than other barrier methods, and there is no absolute need to use chemical spermicides. Disadvantages of the cervical cap are the limited number of sizes available and the fact that 40-60% of women cannot be fitted, including those with a long cervix, a flat cervix and vault, or vaginal prolapse. The diaphragm is a shallow rubber cup strengthened by a rim containing a spring. The use of a spermicidal agent increases the efficacy of a diaphragm. The device should be inserted a maximum of 6 hours before intercourse, and a new application of spermicide is required for each repeated coital act. The diaphragm should not be removed until 6-8 hours after the last coitus. Failure rates are in the range of 1.9-2.0 pregnancies/100 woman years. The diaphragm is safe, effective, temporary, natural, easy to use, and inexpensive. Disadvantages are that the diaphragm interferes with sexual spontaneity, is messy and inconvenient, and some women cannot be fitted because of anatomic abnormalities.
[Effects of "compound prescription progestogen no. 1" on induction of sister chromatid exchanges]
This paper presents the effects of "compound prescription progestogen No. 1" on the induction of sister chromatid exchanges (SCEs) in human lymphocytes in vitro with or without the addition of exogenous activation system S-9 mix. The results of this study showed that progestogen No. 1 15 mcg and 150 mcg/ml medium did not affect the frequency of SCEs with or without exogenous activation system S-9 mix, compared with the normal controls. When cultured lymphocytes were treated with progestogen No. 1, the mean values of SCEs/cell were 5.79 +or- 2.45-7.92 +or- 2.96, ranging from 1-15 SCEs/cell, and those of the controls were 6.56 +or- 3.89-6.68 +or- 3.18, ranging from 2-14 SCEs/cell. The differences between them were not statistically significant (P>0.05). When the concentration of progestogen No. 1 was as high as 300 mcg/ml medium, the mean values were 9.76 +or- 3.30-10.36 +or- 2.42, ranging from 5-18 SCEs/cell, which were obviously higher than those of the controls. The differences between them were statistically significant (P<0.05). When cyclophosphamide was present (0.5 and 20 mcg/ml medium), the SCEs mean values were 12.27 +or- 4.19-26.36 +or- 7.01, ranging from 5-40 SCEs/cell. They were higher than in the treated (5.79 +or- 2.45-10.36 +or- 2.42) and the controls (5.56 +or- 3.89-6.68 +or- 3.18). The differences between them were all statistically significant (P<0.05). Progestogen No. 1 cannot be transformed to mutagen/carcinogen, even if exogenous activation system S-9 mix was added, which showed that using progestogen as a longacting OC, No. 1 is comparatively safe. (author's modified) (summary in ENG)
The plasma FSH, LH, PRL, T, E2, and F levels were compared in normal men (group 1), azoospermic men with different etiologies including gossypol treatment (group 2), men with uncertain diagnoses (group 3), and men with Klinefelter's syndrome (group 4) in order to determine whether differences in hormonal changes and their extent could be discerned in affected subjects. Results show that the average FSH and LH levels in azoospermic men as a whole group (n=50) were significantly higher than those in normal men (P<0.001). There was no significant difference in PRL, T, E2, and F levels from the control group (P<0.05). It was interesting to note the extent to which hormone changes were observed in different groups of affected subjects. Normal FSH levels were found in groups 2 and 3 in 50% of the patients while FSH levels in the rest of the patients were markedly higher (P<0.001). The changes in serum LH levels were parallel with FSH levels in groups 3 and 4; in group 2, both LH and T/LH ratio remained unchanged but T, E2, and F levels were elevated while PRL decreased significantly. Patients in groups 3 and 4 have shown a very low T and T/LH ratio when compared with the control group and group 2 (P<0.001). It was concluded that the contraceptive dose of gossypol did not cause obvious damage in Leydig cell function in terms of T production. High FSH levels indicated the severe damage in germinal epithelium of the testis. In order to minimize side effects and to avoid irreversibility in spermatogenesis, the minimal effective dose of gossypol must be used as a contraceptive. Some objective reference parameters were recommended to monitor the contraceptive dosage of gossypol. (author's modified) (summary in ENG)
There is considerable excitement in Britain at this time due to the publication of 2 reports suggesting that the use of some kinds of oral contraceptives (OCs) by much younger women may increase the risk of cancer of the breast and of the cervix. The obvious danger is that people may panic. In reality, the studies now reported are incomplete and, for the time being, inconclusive. The reason is simply that too little time has passed since OCs have been widely used for the results of prospective epidemiological surveys to be decisive. Only several years from now will it be possible for physicians to offer their patients a complete assessment of the risks of OC use. Already there is a need for a modest change and what physicians tell their patients. Patients should be told that some evidence exists that OCs will increase the risk of contracting some kind of cancer, but there is no way as yet of telling how great the extra risk may be, although it is probably quite small. The study carried out by Pike et al. at the University of Southern California School of Medicine at Los Angeles is technically a case control study in which the cases of breast cancer occurring among younger women (younger than 33 years or, in the latter phases of the study, 37) were matched with apparently normal women of the same age living in the same neighborhood. The study objective was to determine whether the histories of the 2 groups of women differed from each other in ways that might significantly account for the difference of cancer incidence between them. The conclusion is that the 2 groups differed significantly in their past use of OCs. The group of women in whom breast cancer had developed differed from the control group in their greater past use of OCs, whence the inference that OCs increase the risk that breast cancer will develop at a relatively early age. What makes the study persuasive is that there is a positive correlation between the use of OCs and the later development of breast cancer only for those combination contraceptives based on both estrogen and progestogen in which the 2nd ingredient is relatively potent. A 2nd reason for taking Pike et al.'s results seriously is that there appears to be a positive correlation between the duration of OC use and the risk of subsequent breast cancer as well as between first use of these OCs before the age of 25. Yet, very little in the way of statistical significance can be attached to estimates of relative risk based on such a small sample. The parallel study now reported by M.P. Vessey is more easily interpreted in that it consists of a comparison of the incidence of cervical cancer in more than 6000 women using OCs as contraceptives and another 3000 or so relying on IUDs. This study has the advantage of providing its own built in control group, but the age distribution covers a wider range than in the Los Angeles study. The absolute risk is small, perhaps a doubling of the natural rate of something like 0.1%.
The Oxfam Medical Programme in Zimbabwe.
2 distinct phases have occurred in the Oxfam Medical Program in Zimbabwe, developed to improve health care for the majority rural population: taking stock of the situation at the end of hostilities in the struggle for independence and reestablishing health services; and consolidation once reconstruction was begun in earnest and the new government had more information and greater control. The 1st team of 6 doctors and 2 nurses was recruited for 6 months. Following consultations with the Zimbabwean Association of Church Hospitals, Oxfam and the government identified 6 mission hospitals, in particularly isolated locations, to which team members were allocated. The main characteristic of phase 1 was relief work to revive rural health services. Some of the doctors were immersed immediately in demanding hospital work while others spent time outside the hospital in relief work to aid the refugees returning from neighboring countries or leaving the "protected" villages. Outreach clinics were restablished after representatives of branch and district committees determined that this was what people wanted, and some of the Oxfam team collaborated with Ministry of Health vaccination teams. Team members became involved in training health personnel. 1 important task undertaken by the 1st team was a nutrition study to document the extent of undernutrition in Zimbabwe. The findings indicated that overall children's nutritional status was poor, with a high degree of severe undernourishment. During the 2nd phase, a team of 6 doctors and 3 nurses were recruited for 2 years (September 1980-82). Much of the team's time was devoted to improving administration, information, and drug distribution within the mission hospitals. Appropriate therapeutic practices were established in most hospital situations. The team worked with Zimbabweans and have become well integrated into the hospital structure. They have also established contacts with central and local government organizations at district, and sometimes provincial, level. Members of the Oxfam team were enthusiastically involved in the national children's supplementary feeding program (CSFP). The nutritional status of children improved by equally important was the educative role the program played in showing how local foods could combat undernutrition. Aside from hospital and outreach work, data collection, and research, the team was involved in training other health personnel. There is little question that the Oxfam Medical Program was successful in meeting the objectives that were set. The team approach has greatly increased the usefulness of the individual Oxfam doctors and nurses.
Oral contraceptives and cancer [letter]
The October 22 issue of The Lancet carried 2 papers and an editorial on oral contraceptives (OCs) and neoplasia. The media have had a field day with these papers, and through it all runs a strand of sentiment which regards the pill as inherently potentially dangerous. The implication is that if we look at a big enough population for long enough we are bound to find ill-effects. Your editorial suggests that the effects of pill taking among young women in the 1960s might now become apparent as an increased prevalence of breast cancer, despite many papers to the contrary. Blot reported in a survey of the American figures up to 1975 that, for women under the age of 44, there was a clear decline in the prevalence of breast cancer. He ascribes this to earlier childbirth but this could equally be due to the influence of the contraceptive pill. Should we not be taking a more positive attitude to the contraceptive pill? Do 2 papers in The Lancet justify portentous advice on breakfast television that sends young women rushing to their general practitioners (who probably do not read the journal anyway). The risks these women run on the way to the doctor's surgery probably outweigh the risks from the pill over 20 years of use. And what about all the advantages of the pill? Is there, indeed, a safer drug on the market? You do not assess the problems rationally when you pronounce that "not all effects are detrimental," which must be the understatement of the year. I do not ask that you "remain silent" but that only you clearly distinguish marginal risks from enormous benefits when widespread media publicity is assured. (full text)
Oral contraceptives and cancer [letter]
The publicity given to the report of Professor Pike and his colleagues (October 22, p.926) has caused understandable anxiety among women who have taken combination pills containing the so-called "high potency" progestogens before the age of 25. It is difficult to reassure this group of women but it is important that physicians do reassure those who started the pill at an older age. The same type of oral contraceptive (OC), when taken by older women with an established but occult breast cancer of a hormone-sensitive type, may well inhibit the tumor growth. Evidence of this comes from reports that women taking OCs in whom breast cancer subsequently develops shows less advanced disease at presentation and a lower likelihood of recurrence in the 1st 5 years after mastectomy. Significant tumor regression has been observed in 9 of 42 women with metastatic breast cancer treated by 'Lyndiol'. This relatively high dose combination pill (now replaced by a lower dose combination) contains lynestrenol, 1 of the high potency progestogens as defined by Pike. A similar rate of regression was observed whether 1 or 6 pills were given daily. The recommendation by the Committee on Safety of Medicines that women be transferred to agents with a lower progestogenic potency may be justified for a few agents that have been associated with heart attacks or strokes. For most pills, however, there is no obvious justification for such a recommendation in women over the age of 25. Indeed the above evidence suggests that if they have occult breast cancer of a hormone-sensitive type, the progress of the disease may be slowed up by agents presently in wide use. (full text)
Race, nutrition, and infant mortality in South Africa [letter]
In the August 20, 1983 account of R.J. Fincham's contribution to an international conference on ethnic health issues, it was reported that the South African Department of Health and Welfare had undertaken nutritional surveys in the Eastern Cape in response to a 1979 newspaper report that "One out of every 4 black babies born in Grahamstown last year died before the age of 12 months." The true situation was not stated. This figure was drawn from only 396 registered black births in Grahamstown. The city has a black population of 40,000 and the birthrate of black people in South Africa is 40/1000. The true number of black births for this city would thus be about 1600, giving an infant mortality rate of about 62/1000 which is only 1/4 of the rate given in the account. Due to the fact that Grahamstown Hospital serves a population much larger than that of Grahamstown, the number of deaths would have included some infants from outside the city area. The Department undertook the surveys because local authority clinic reports on malnutrition and potential undernutrition failed to correspond to newspaper reports. The Department has for many years been subsidizing local authority clinics to prevent kwashiorkor. The account mentions the high incidence of undernutrition in "resettlement" areas. There is only 1 resettlement area in the Eastern Cape, and this is the only case where this Department renders a direct health service. Other services are all local authority ones subsidized by the Department. The incidence for undernutrition in this resettlement area is negligible, based on the Boston 3rd percentile. Referring to this community a newspaper reported in 1980 that undernutrition was very common and based its findings on the Department's own patient clinic cards. It turned out that the reporter based his results on the 3rd decile instead of the 3rd centile. The objectives of the survey were: to provide information about the nutritional status of specific population groups who were at risk of malnutrition; to provide an insight into factors which influenced nutritional status; to give some indication of the proportion of these populations making use of local authority clinics; to provide a foundation on which the Department could base further health strategies; and to provide feedback, surveillance, and coordination with various bodies.
Philippines: decentralized approach shows results.
In the Philippines several steps have been taken to meet the challenge of increasing population growth. Commencing with the Republic Act 6365, known as the Population Act (1971) program directives focus on achieving and maintaining population levels most conducive to the national welfare. In 1978 a Special Committee was constituted by the President to review the population program. Pursuant to the Committee's findings certain changes were adopted. The thrust is now towards longterm planning to ensure a more significant and perceptible demographic impact of development programs and policies. Increasing attention is paid to regional development and spatial distribution in the country. The 1978-82 Development Plan states more clearly the interaction between population and development. The National Economic and Development Authority, the central policy and planning agency of the government, takes charge of formulation and coordinating the broader aspects of population policy and integrating population with socioeconomic plans and policies. At present the National Economic and Development Authority (NEDA) is implementing a project known as the Population/Development Planning and Research (PDPR) project with financial support from the UN Fund for Population Activities (UNFPA). This project promotes and facilitates the integration of the population dimension in the planning process. It does this by maintaining linkages and instituting collaborative mechanisms with the different NEDA regional offices and sectoral ministries. It also trains government planners in ways of integrating population concerns into the development plan. PDPR promotes the use of population and development research for planning purposes and policy formation. The Philippine Development Plan, 1978-82, recognized that an improvement in the level of 1 sector reinforces the performance of the other sectors. Since the establishment of the National Population Program 12 years ago, population and family planning have been successfully integrated with various development sectors, notably, labor, health, and education. Through the policies of integration, multiagency participation, and partnership of the public and private sectors, the Commission on Population uses existing development programs of government and private organizations as vehicles for family planning information and services and shares the responsibility of implementing all facets of the population program with various participating agencies in the government and private sector.
On the role of urban-to-rural remittances in rural development.
The postulations presented concerning the role of urban to rural remittances in agricultural devleopment stem from a new theoretical approach to rural to urban migration. At the core of this approach lies the utility maximizing family in its specific agricultural context. The easing of the surplus and risk constraints becomes a crucial conditions for carrying out desired technical change. It is rural to urban migration of a family member (i.e., a son or daughter) that, by bypassing the credit and insurance markets who are biased against small farmers, facilitiates the change. This migration succeeds in accomplishing by means of its dual role in the accumulation of surplus (acting as an intermediate investment) and through diversification of income sources in the control over the level of risk. From the perspective of the question at hand, the implication of the new theoretical approach is manifold. First, it is clear that urban to rural remittances cannot capture the total effect that rural to urban migration bears on rural development. Secondly, urban to rural remittances cannot be assumed to account for the total accumulation of surplus consequent upon migration. In principle, a farm produced surplus and an urban produced surplus account in different situations with differing weights, for the total accumulation of surplus consequent upon migration. Urban to rural remittances cannot account for the impact of rural to urban migration on agricultural development or for its total surplus accumulation effect, yet it is important to attempt to quanitify these remittances. 2 serious problems are inherent in the usage and interpretation of existing evidence. The 1st problem stems from the intertemporal changes in the magnitude of the urban to rural remittances flow, and the second arises from the prevalence of a counter flow. There is no reason why remittances (and migration at large) should not be manipulated to become a vehicle of rural propensity even if they were not conducive to agricultural development in the past. This may require some minimal institutional intervention. Sufficient evidence exists to suggest that rural to urban migration and urban to rural remittances can and have been used to transform agricultural modes of production. What a constructive approach should do is try to analyze why in other cases urban ro rural remittances have been less instrumental to agricultural development.
The analysis of "over-urbanization."
In this analysis of "overurbanization," the term "overurbanization" is defined, and causes of overurbanization are identified as are consequences. 2 indices are being related to one another in defining overurbanization: the percentage of population living in urban areas and the distribution of the total labor force in the country as between agricultural and nonagricultural occupations. The first is a spatial index without being an occupational one, and the second is the opposite. As modern urbanization is associated with industrialization, it generally may be agreed that there is justification for such a comparison. The main cause of overurbanization, according to current analysis, is the pressure of population on land in the rural areas in developing countries. Economic pressure or "push" in the countryside increasingly pushes out people to the cities in search of employment and livelihood. The rural urban migration that results in overurbanization is primarily a consequence of this "push" from the countryside, rather than the demand for labor by developing economic activity in the towns and cities, or what is termed their "pull." Consequently, these migrants can only obtain employment in activities with very low productivity or swell the ranks of the unemployed. The causal relationship underlying rural urban migration is complicated and cannot be totally explained by the rural push factor. The phenomenon of a rural "push" resulting in urban growth is questionable. Attention now turns to the absence of dynamism in the urban centers which is supposed to be the consequence of overurbanization. The argument is that because this urban growth is abnormal, in the sense that it is not based on sufficient industrial development, the urban centers are not likely to be such dynamic centers of social and cultural change as, for example, they had been in Europe and other developed area. This assumes that urbanization based on industrial development was primarily responsible for the social and cultural changes associated with urbanism. The definition of overurbanization that has emerged in this discussion is both unsatisfactory and vague and that the analysis of causes and consequences of urbanization developed so far is tenuous and oversimplified. The subject must be investigated further.
A total of 211 men with 237 female sexual partners and a total of 155 women with 156 male consorts were examined for genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae. The index patients had either single chlamydial or gonococcal infections or dual infections with both microorganisms. Analysis of recovery rates for groups of sexual consorts indicated that gonorrhea was contracted more frequently than chlamydial infection. Thus, when index patients had dual infections, 45% and 28% of their female and male consorts, respectively, had chlamydial infection, but 64% and 77%, respectively, had gonorrhea. When index patients had single infections with C. trachomatis or N. gonorrhoeae, chlamydial infections were observed in consorts of 45% (women) and 28% (men), but gonococcal infections were observed in 80% (women) and 81% (men). Moreover, a significantly larger proportion of consorts of patients with chlamydial infection eluded infection than did partners of patients with gonorrhea. Women who used an IUD had chlamydial and gonococcal infections more often than those who used other forms of contraception or no contraception at all. (author's modified)
Malaria in African infants and children in southern Nigeria.
2 series of investigations into the incidence and degree of malarial infection in 551 African parturient women in Lagos, an urban and semi urban area of Southern Nigeria and their newborn infants were carried out during 1948-50. The routine technique of the investigation consisted of taking blood slides from the peripheral circulation of the mother and her newborn within 6-24 hours of delivery. A blood slide was made from a deep layer of a piece of the maternal placenta excised near the center. The weight of all newborn infants was recorded, and whenever possible the progress of the infants was followed up throughout the neonatal period. The weight of all newborn infants was recorded, and whenever possible the progress of the infants was followed up throughout the neonatal period. The mean incidence of malarial parasitaemia (mainly due to Plasmodium falciparum) in the sample of 323 Africa parturient women was found to be 33%, somewhat higher than the usual parasite rate of the adult indigenous population. The incidence of malarial infection of the placenta was 23.8%. There were no cases of congenital malaria in 332 babies born of these mothers. The mean weight at birth of 237 babies born of mothers whose placentae were noninfected was 145 mg higher than that of 73 babies born of mothers whose placentae were found to be infected. The difference was statistically significant. There was no apparent correlation between neonatal mortality and infection of the placenta. Periodic investigation of a sample of 138 African infants, followed up from the age of about 1 month through the 1st year of life and through part of the 2nd year, showed that the mean parasite rate, due principally to P. falciparum, increased from 2.2% during the 1st quarter year to 20% in the 2nd quarter, to 60-70% during the 3rd and 4th quarters, and to over 80%, thereafter. The infection rate, when calculated in relation to the known length of exposure to infection, shows that an equally long exposure leads to different frequencies of infection in the various age groups of the sample of infants investigated, and that in the age group 1-3 months the parasite rate was significantly lower than might have been expected. Periodic follow-up of the mean weight curves of infection and noninfected infants indicated that the curves of both groups showed a considerable flattening out at about 5 months of age and later and that the flattening out is more pronounced in the infected group than in the noninfected. Records of 3540 autopsies performed upon children in Lagos during the years 1933-50 revealed that acute malaria can be incriminated as the cause of death in 9% of infants, in 14% of children aged 1-4 years, in 9% of children aged 5-7 years, in 4% of older children, and in 2% of adolescents. The number of deaths due to direct effects of malaria in the Nigerian population under 15 years of age amount to 35,000/annum.
Some aspects of sexually transmitted disease in Swaziland.
A survey was conducted in Swaziland between July 6 and September 28, 1973 to obtain information about sexually transmitted diseases. The survey sample was limited to the outpatient department of the government hospital at Mbabane. Patients included were those who reported at the outpatient department with an STD during the 3 month period of the survey and those of their contacts who could be pursuaded to attend and were found to be infected. Of 240 patients seen during the course of the survey, 124 were suffering from presumed gonorrhea, 67 had genital sores, and 23 reported with both. A further 26 had positive Venereal Disease Research Laboratory (VDRL) reactions and were assumed to have syphilis with or without some other STD. Of the 26 patients whose VDRL test was positive, 3 had lesions usually associated with primary syphlis and 3 had condylomate lata. The rest were cases of presumed latent syphilis presenting with another infection. With 1 exception cases of urethral discharge in men appeared to be due to gonorrhea. No cases of nonspecific urethritis were seen and the explanation of this is obscure. About 29% of the women and 4% of the men were infested with T. vaginalis. It was not possible to determine the prevalence of venereal diseases, but the evidence collected supported the local impression that these conditions were increasing. The need for a vigorous program of contact tracing is clear from the small proportion of female patients attending the clinic. Only 24% of those with a sexually transmitted disease and only 20% of those with a positive VDRL test were females, whereas in a survey undertaken by staff of the local public health unit in 1967, 54% of those with a positive Wassermann reaction were female. The large number of casual partners admitted by men in the 4 weeks before infection implies that this is a major source of infection. Recommendatons made for improving the situation include: offering education in the schools; developing a universal system for tracing contact for the whole country; and making a vigorous attempt to screen all pregnant women by means of the VDRL test.
Adult Schistosoma hematobium and S. mansoni were recovered at autospy. The number of eggs of both species present in the tissues and passed in the excreta was related to the number of female worms (worm pairs) recovered. Only 26% of the S. hematobium infections were active at the time of necropsy. 47% of S. hematobium females were in the mesenteric circulation and 52% were in the genitourinary organs. S. hematobium worm pairs were sedentary, laying eggs in single sites for prolonged periods. In addition, the worm pairs seemed to be clustered in active genitourinary lesions. S. hematobium eggs calcified and accumulated in the tissues, and a geometric mean of 600,000 eggs/worm pair was found. Large numbers of eggs remained in inactive cases. There was a significant increase in eggs/female worm in older persons. The relative contribution of egg accumulation (increasing the numerator) and worm death (decreasing the denominator) to this phenomenon are not known. In contrast, S. mansoni eggs were not retained in the tissues to the degree exhibited by S. hematobium. There was an apparent equilibrium between egg deposition and egg excretion or destruction. A geometric mean of 15,900 eggs/worm pair was present, and did not change with age. The total number of eggs/female worm and the relative proportion of eggs in the lungs, liver, and intestines were similar to those seen in Brazilian cases of S. mansoni infection. The number of eggs/female worm found in feces was lower than that noted in Brazil. S. hematobium infections were much heavier in cases also infected with S. mansoni than in those with pure S. hematobium infection. No pure S. mansoni infections were seen. S. mansoni infection appeared unaffected by S. hematobium infection, except for calcification and accumulation of S. mansoni eggs in the genitourinary system. (author's)
Oral contraceptives and cancer [letter]
Editors of medical journals are heard more often than most condeming the alarmist way that the media cover some medical stories, yet, as both a medical editor and a contributor to a popular current affairs television program, I believe that The Lancet did a poor job in presenting those 2 papers linking oral contraceptives (OCs) with breast and cervical cancer. The fault lay in the omissions and the smugness of the accompanying editorial and press release. Both pointed out that discussion in the past may have been inhibited "by the fear that unpleasant news about the pill might lead to a wave of unwanted pregnancies." The press release then continued: "Whether such a wave ensues on this occasion will depend greatly on the way these findings are presented in the newspapers and on radio and television." This statement of the obvious combined with the reminder of previous fiascos when "pill scare stories" have broken can be condensed to "Steady chaps, you're playing with fire." More useful would have been a few words suggesting how the story might be dealt with, but most useful of all would have been more solid information. Certain questions were bound to come up: how much importance should be placed on these reports; which were the brands that were incriminated as causing breast cancer; how many women in Britain were taking those pills; and what advice should be offered to women? The 1st question is discussed in necessarily qualified statements in both the papers and the editiorial but none of the other questions is adequately answered. The Lancet must have had these papers in its possession for weeks if not months and should, in both the editorial and the press release, have provided answers to the inevitable questions. Perhaps the Editor thought he would be stepping on governmental toes by giving solid advice about what should be said to women or that he risked offending journalists by spoonfeeding them. Neither should worry in my mind, have stopped him. The problems of the journalists trying to work out what to say to his or her audience or readers are not so different from the problems of an individual doctor confronted with an anxious woman. General practitioners must have had a hell of a day on that Friday trying to give their patients some sensible and correct advice. I hope that some of those doctors will write and tell you of their problems and that they will blame you and not the media, which, as far as I can judge, dealt with the story in a responsible way. (full text)
551 children ages 3 months-3 years were followed up at home for 12 months after treatment of diarrhea in a rural treatment center of the International Center for Diarrheal Disease Research, Bangladesh. During follow-up, the children were found to have a significantly higher mortality than generally observed in the community. The 1st 3 months after discharge appeared to be crucial, some 70% of the deaths occurring in that period. Severly malnourished children (nutritional state below 56% of the American National Center for Heatlh Statistics (NCHS) standard for weight of age ratio) had a risk of death 14 times that of their well-nourished counterparts (nutrition state 66% or more of the NCHS standard). The highest mortality occurred in 2 year olds, 1 in 3 of the severely malnourished children dying compared with 1 in 10 of the moderately malnourished. This pattern was not seen in children under age 2. Immediate priority should be given to providing nutritional rehabilitation for malnourished children who contract diarrhea. (author's modified)
There is definite evidence that oral rehydration as the immediate response of the family to diarrhea decreases the severity of the illness and even reduces the death rate. Dr. Michael Watkinson correctly points out that to wait for a physician's prescription for an oral rehydration powder causes delay at the very time when early intervention could be the most beneficial and that buying proprietary rehydration mixtures over the counter is costly. He emphasizes the usefulness of a special plastic measuring spoon to enable parents to make up a scientifically authenticated sugar salt solution, but there is no need to wait for either a prescription or a plastic spoon. At the 1st signs of diarrhea any clear fluid acceptable to the child should be given at frequent intervals even if there is also some vomiting. Carrot, rice, or chicken soup are traditional in some communities and herbal teas or fruit juices in others. Barley water and arrowroot have their advocates, and the concept behind some of these remedies is being reinforced by the recent findings that another starch based mixture, rice powder with electrolytes, is effective for rehydration. More severe diarrhea with some signs of dehydration or acidosis does better with a more complete formula like oral rehydration salts. In the UK the most available and effective home remedy is a sugar and salt mixture measured with the most available tool, the teaspoon. It is difficult to overhydrate orally, but a rough guide to quantity is to give a larger child 200 ml (a glassful) of the fluid for every diarrheal stool passed and half that amount for a small child. Conversations with local pharmacists suggest that many of them would welcome some kind of leaflet containing these instructions with clear indications of when professional advice should be sought. The need to extend communication about oral hydration at home in all countries is urgent.
Propranolol concentrations in plasma after insertion into the vagina.
6 healthy women participated in a study of the concentrations of propranolol achieved in plasma after insertion of the drug into the vagina. In 4 of the women, the concentrations were also determined after administration by mouth. The area under the concentration curve for propranolol administered per vaginam was significantly greater than that after oral administration. There were small significant reductions in systolic blood pressure, pulse rate, and forced expiratory volume in 1 second after vaginal administration but these did not cause any symptomatic side effects. The tolerability of the vagina to drugs and the safety of this form of treatment remain to be determined. Further studies of the contraceptive effects of propranolol should be conducted with the dextro isomer of the drug. (author's modified)
Population and development in Latin America and the Caribbean.
The data sheet compiled by the Population Reference Bureau and reprinted here provides a picture of many of the principal population characteristics of Latin America and the Caribbean. The reduced rate of average population increase, to 2.3% annually, compares favorably with the peak level that reached nearly 3% in 1960. Mortality rates have continued to decline in the intervening period, and fertility has decreased even more, resulting in a notable drop in overall rates of population growth for the region as a whole. Yet, total population has jumped from about 208 million in 1960 to an estimated 390 million in 1983. Statistics for the 2 regions obscure important differences in the patterns of growth among countries. Among Spanish speaking countries, the ones in "Temperate South America" represent a distinct type. Argentina, Chile, and Uruguay are all growing at less than 1.6% annually. These 3 countries have completed the demographic transition. 2 more Spanish speaking political units in the Caribbean, Cuba and Puerto Rico, also fall into this category. Most of the English speaking islands in the Caribbean, plus Martinique and Guadaloupe, have also passed through demographic transition. The growth pattern of nearly all the countries in this category has baeen influenced by outmigration. A 2nd population category in Latin America and the Caribbean is composed of countries that had high rates of growth in 1960 but have reduced growth significantly in the past 2 decades as a result of modernizing influences and family planning programs. This category includes several of Latin America's most populous countries, i.e., Brazil, Mexico, Colombia, and Venezuela, plus several smaller countries like Panama, Costa Rica, and Paraguay. A number of Caribbean countries also fall into this category. This 2nd group is the one to watch for assessing the future relationship of population to development. A 3rd category of countries in the region includes several nations that are growing at over 3% annually. The principal reason for their high growth levels in a sustained high rate of fertility. The prospects for many of these countries are not promising. Changes in the pattern of births and deaths have occurred mainly as a result of modernizing influences and the adoption of family planning. Of the two, modernization seems to be more important. Several countries encourage family planning as a means of reducing population growth rates. A number of countries with public family programs justify them as a human right or as a means of improving the health of mothers and children and not as a way to reduce growth rates. Argentina and Uruguay continue their strong pronatalist policies, and Chile and Bolivia have moved from policies favoring family planning to a reverse position. Other population data presented covers internal and international migration, urbanization, and population growth and development.
Household distribution of contraceptives in Zaire [tables]
Traditional methods of fertility control for child spacing are common in sub-Saharan Africa, but there has been little access to modern contraceptives. In 1980, the Programme d'Education Familiale (PRODEF) was launched in Bas Zaire, Republic of Zaire, to determine whether couples of reproductive age would accept modern contraceptives if they were made readily available. This service/research project is being carried out in an urban area of 130,000 and in a neighboring rural zone of 25,000. A major component of the program is the household distribution of pills, condoms, foam, and vaginal tablets, which have been made available to the population in 3 rounds of home visiting. The results suggest that household distribution is an acceptable approach to the delivery of family planning (FP) services in this area. Approximately 1/2 of the estimated target population (women ages 15-49) were reached during Round 1 of home visiting. 1/3 were ineligible to receive the free supply of contraceptives, either because of a current pregnancy or the absence of the husband in the decision making process. Among those who were eligible, 52% (urban) and 40% (rural) accepted a contraceptive method. Although there was some shift in method preference over the 3 rounds, the urban women generally preferred the pill or vaginal tablets; rural women contraceptive foam, condoms, and (in the final round) the pill. Preference for vaginal methods reflects the large percentage of acceptors who are lactating. Among urban acceptors in Round 1, 83% reported having tried the method and 51% were still using it by Round 2 (6 months later). For acceptors in Round 1 who were not using it at Round 2, their reasons were pregnancy, and fear of side effects, lack of awareness of where resupply was available, and others. Lessons learned from the Bas Zaire experience include the following: 1) the household distribution of contraceptives is acceptable in the population, provided that certain cultural norms are respected; 2) the task of promoting FP is facilitated by the integrated approach (offering child health services as well), but at least in the urban context it is not essential to do so. 3) emphasis in FP services should be placed on child spacing, not family limitation; 4) the distribution of contraceptives by home visitors with no previous training in health is acceptable to community officals and members of the target population; 5) household distribution is an effective means of creating awareness and providing an opportunity for experimentation with modern contraceptives to a large number of people over a limited period; and 6) spermicidals may be more popular in this population than would be expected from experiences in other regions of the developing world. (author's modified)
Report on the Workshop of Rural Women's Involvement in Primary Health Care, 8-10 July 1980.
The Voluntary Health Services Society (VHSS) undertook the task of arranging a workshop focusing on the involvement of rural women in primary health care. Workshop sessions, which shared experiences in small groups, directed attention to problem identification, analysis of problems, the role of women health workers, a review of the field trip, and workshop evaluation. Each session was followed by a question and answer or review session. The activities of the 1st group, made up of 3 nurses, 2 health workers, 1 community nurse and tutor, 1 teacher of nurses, and 1 field worker, included imparting education on the following: primary health care and maternal health care; nutrition; family planning and birth control; cooking method; nurse and midwife training; preparation of home medicine for common illness and minor ailment; first aid; distribution of essential drugs and vitamins; sterilization program; distribution of contraception; day care centers; immunization and vaccination; and distribution of seed and material support for income generating projects. The activities of group 2, which included 6 health workers, 2 community nurses, and 1 family welfare visitor, were mainly in the field of nutrition, cleanliness, care of pregnant mothers and children, and family planning and birth control. 3 health workers, 3 supervisors, 1 nutrition workers, 1 lady health visitor, and 1 counselor constituted group 3. Their activities included: imparting education on health, nutrition, hygiene, and cleanliness; antenatal and postnatal care; extending clinical facilities to the diseased; care of pregnant mothers and children; family planning motivation; heatlh care and nutrition program through village level coopertives; advice and demonstration of proper cooking method; and sterilization and delivelry services. The following were among the activities of the 4th group, made up of a community health supervisor, family planning workers, a home visitor, a nurse, a unit head, a supervisor, a lady health visitor, and a field supervisor: antenatal and postantal care; midwife training; nutrition program; economic assistance program; adult functional literacy program; latrine program; vaccine and immunization program; family planning birth control program; women's club; night school; and prevention and treatment of contagious diseases. The problem areas identified by each group are outlined.
Focus in this discussion of the worldwide situation and problems of undocumented migration is on the situations in North America and the Caribbean region, Europe, the Middle East, South America, Asia and the Pacific, and Sub-Saharan Africa. Consequences and effects are reviewed as is migration for the development of professional and technical personnel. In an effort to provide an idea of the volume of flows in various parts of the world, recent authoritative estimates and statements were taken as a basis for indications regarding approximate numbers of undocumented migrants in a given continent, region, or country. Most figures quoted are no more than resonable assumptions or estimates. Conservatively, it can be said that there are between 4-5 million migrants in an irregular situation in North America, mainly in the US. For Latin America, estimates vary from 2-3 million. In Europe, by adding up reported bona fide estimates of the principal host countries, a figure approaching the million and a half mark is obtained. In the Middle East, the indications are that the number of migrants in an irregular situation is substantial (between 350,000-500,000), but no exact figure for the whole region has been advanced. No serious estimation can be made for Asia and Africa as there are too few valid indications. It might safely be assumed that these 2 continents have more than 1 million undocumented migrants between them, but this is a "guess" estimate. On the economic side, the effects are not totally negative. It is true that where there are a very large number of immigrants in an irregular situation, such as in the US, these migrants may be depriving nationals of jobs. Yet, it must be recalled that migrant labor in most of the industrialized countries has been employed largely in the so called dirty or heavy jobs, those which nationals are no longer willing to do. It is argued that the employment of a large number of undocumented immigrants holds down wages and is detrimental to ensuring better employment conditions. The availability of illegal migrant labor has led, in some instances, to the proliferation of firms and small businesses. In relation to social and cultural aspects, the effects of undocumented migration are, by and large, negative. Immigrants in an irregular situation usually must accept working conditions which are way below the normal standards of the host country. They are outside of the social security system and do not take full advantage of the country's welfare, medical, and educational facilities. In regard to the migration of qualified personnel for development, there is clear evidence of widespread interest in governmental and intergovernmental circles regarding the planning and implementation of specific programs of this nature.
[Usefulness of the Neo-Prognosticon test]
Pregnancy tests with the Neo-Prognosticon kit Organon were done in 113 cases and it was found that the test was accurate in 90% of early pregnancy cases. In menstruation disorders caused by other pathological factors in the genital tract, negative results were obtained in all cases. In the diagnosis of extrauterine pregnancy, the results were false negative in only 1 of 16 cases. The other results agreed with the clinical condition of the observed patients. (author's modified) (summaries in ENG, RUS)
[Correlation between nutrition and fertility]
Human nutrition has an important influence on fertility. Insufficient nutrition leads to longterm lactational amenorrhea, but also to low birthweight, delayed menarche, high morbidity, and consequently high mortality rates. The hormone prolactin is 1 of the most important factors influencing lactational amenorrhea. Ovulation and menstruation during lactation are absent as long as prolactin concentrations are high. Duration, intensity, and frequency of breastfeeding play important roles. Milk quantity and quality change depending on duration and severity of malnutrition. (author's modified) (summary in ENG)
Fertility control at the community level: a review of research and programs.
Community effects on fertility have been studied from 3 major perspectives. In the functionalist perspective, children confer benefits on particular social groups, and the institutional and community basis for ensuring these functions is therefore of interest. Form the impirical perspective, work has been devoted to attempting to identify community effects through survey analysis, spending little time on theoretical arguments. In the diffusionist perspective, the focus has been on the characteristics of communities as social networks that facilitate the spread of fertility control. Across perspectives, 3 classes of community factors appear most important for fertility control: access within the community to fertility regulation; social pressures to control fertility; and community incentives related to childbearing. Family planning programs which involved these community components are reviewed. The impact on fertility control of community-based contraceptive distribution programs appears clearest; the impact of community pressures seems strong but is somewhat less established, and the impact of structured community incentives is more doubtful. (author's)
A new view of Mexican migration to the United States.
This thesis analyzes Mexican migration to the US. The plan of this study is to review most of the data used to measure the importance of this migration flow and provide new information, both empirical and theoretical, to show that both the data and its interpretation have been, in most cases, not entirely correct. Chapter 1 sketches briefly the basic questions which arise in light of previous empirical evidence and interpretation. Chapter 2 provides a general overview of international migratory flows into the US with specific reference to the structure of the US labor market, and Mexican illegal migrants. Chapter 3 contains an analysis of the quantitative evidence, and provides new data and analysis on remittances and its economic importance at a regional level for both countries. It also provides an estimate of probable range within which could be placed the number of Mexican undocumented migrants. Chapter 4 examines the nature of emigration from rural Mexico, the general characteristics of the migrants, and the importance of this flow to some rural communities. It also offers a theoretical explanation of the possibility of coexistence of 2 entirely different migration patterns coming from the rural villages. Here a description of the role of the Mexican migrants in the US labor market is undertaken along with a study of urban migration, and finally some conclusions regarding the complementarity of the labor markets in both countries are presented. Chapter 5 describes further evidence of the existence of 2 patterns of migration coming from the same rural areas, and census data is used to verify the compatibility of this data with the theoretical propositions advanced in Chapter 4. We conclude that the new advanced evidence here shows different migratory patterns coexisting within the same villages and that this is perfectly rational and closely related to land tenure. It is also clear that the regional distribution of Mexican migrants in the US is becoming increasingly urban and that the relative importance of Mexican undocumented migration in relation to the total of undocumented migrants must be reevaluated. Remittances are less important than what was formerly considered, and it is very likely that the same has happened with the estimates of Mexican undocumented migration. The US labor market contains within its segments a "limbo" labor market composed of undocumented migrats of all nationalities which operates fluidly although clandestinely; this requires urgent study. (author's modified)
A combination of 1.0 mg dl-norgestrel and 0.1 mg ethinyl estradiol was administered orally at 18 hours after detection of luteinizing hormone and again at 30 hours in 5 healthy volunteers with normal menstrual cycles. The effects on ovarian function were studied by comparing the daily serum levels of progesterone (P), 17alpha-hydroxyprogesterone, and estradiol (E2) measured in a control (placebo) cycle with those in 2 consecutive treatment cycles. Treatment did not alter the steroid levels in 1 subject. P was suppressed in 1 or both treatment cycles of 4 subjects. E2 was suppressed in both treatment cycles of 1 subject and produced widely fluctuating patterns in another. The hormonal patterns in the 2 consecutive treatment cycles of the same individual were similar in all but 1 instance, where only the P level in the 2nd treatment cycle was diminished. These results showed that this treatment can elicit steroidogenic responses of varying degrees and duration. The contraceptive action may lie in the altered P and/or E2 level at certain points in the menstrual cycle. (author's modified)
An user acceptability study of vaginal spermicides in combination with barrier methods or an IUCD.
98 women were entered into an open study of Staycept jelly (octoxynol 1% w/w) and Staycept pessaries (vaginal suppositories, nonoxynol-9 6% w/w) in combination with other vaginal methods of contraception. Medical problems during use of either pessary or jelly were few and were restricted to genital irritation or increased vaginal discharge. This seemed more common with the pessaries than the jelly, but this could have been related to the types of women included in the study. There were no unplanned pregnancies. (author's modified)
Ultrasonic measurement of ovarian follicles during chronic LRH agonist treatment for contraception.
Ultrasonic examinations of ovarian follicles were performed in 7 healthy women on continuous luteinizing hormone-releasing hormone (LRH) agonist treatment for contraception. 4 women had 1-4 uterine bleedings during the 4-month study period and the remaining 3 women developed amenorrhea. The follicle diameter varied during LRH agonist treatment up to or above the preovulatory size of the normal menstrual cycle in the menstruating group of women. No ovulation occurred as judged by the low progesterone levels in serum. Slightly raised progesterone concentrations (mean 7.6 nmol/1) were observed during 4 treatment cycles with persistent follicles indicating luteinization of unruptured follicles. No or only small ovarian follicles (8-10 mm) were visualized by ultrasound in the amenorrheic group of women. This study further establishes previous reports that chronic LRH agonist treatment effectively inhibits normal ovulation in regularly menstruating women. (author's)
Reduced plasminogen activator content of the endometrium in oral contraceptive users.
Human endometrium was found to contain 2 different plasminogen activators, urokinase and tissue activator. Urokinase was released in higher amounts from endometrial tissue explants obtained in the midcycle phase than from those obtained in the luteal phase. Plasminogen activator activity of the culture medium followed the same pattern. Treatment of the postmenopausal patients with ethinyl estradiol resulted in the liberation of urokinase and tissue activator from endometrial explants in concentrations similar to those found in the normal midcycle phase. In contrast, treatment with oral contraceptives (OCs), containing ethinyl estradiol and a progestagen, resulted in lowered release of both activators, even lower than was found during the normal luteal phase. Also, the amounts of extractable urokinase from endometrial tissue samples were singificantly lower in OC users than nonusers. Estradiol seems to have a stimulatory effect on the release of plasminogen activators from the endometrium; whereas, gestagens depress the content and release of activators. The low content of plasminogen activators in the endometrium explains the reduced menstrual bleedings found in OC users. (author's)
[Anemias in pregnancy following hormonal contraception]
In order to establish the incidence of anemia in pregnancy following hormonal contraception, hemoglobin was determined in the intravenous blood of 3602 pregnant women in a prospective pilot study. The authors investigated the influence of type of preparation, duration of ingestion, and time of conception as well as the influence of age and parity on the whole group. In a total of 10,800 blood tests, a decrease in Hb-values of 6.2 mmol/l (10 g/100 ml) or less was found in 4.7% of all cases. Age and parity had no significance. The same can be said for the influence of hormonal contraceptives and the duration of ingestion concerning the frequency of anemia in ensuing pregnancies. However, the rate of anemia was markedly increased when conception occurred under hormonal contraceptives (women forgetting to take the pill) or immediately after the pill had been discontinued. A decrease in level of folic acid which might be due to the estrogen component of the ovulation inhibitor is discussed. If a women wishes to have a baby after discontinuation of hormonal contraceptives, a postconcpetional interval of about 3 months is recommended. This is especially advisable when using preparations with a high estrogen content. If conception takes place within this interval, a possible decrease in the level of folic acid and corresponding prophylaxis should be considered. (author's modified) (summaries in ENG, RUS)
[Hormonal contraception and fibrinolysis]
In order to judge the influence of oral contraceptives (OCs) on fibrinolysis, we examined 93 women during the stage of adaptation (group 1), 126 women under longterm administration (group 2), 95 women with venous complaints (group 3), and 51 patients who had thromboses (group 4). During the stage of adaptation and during longterm ingestion, the fibrinolysis-stimulating estrogen part of the hormonal contraceptive is blocked by inhibitors of fibrinolysis if there are high doses or certain types of gestagens present. If the proportion of the 2 hormonal constituents is well-balanced, a positive effect on fibrinolysis can be found. If this is not the case in patients with venous complaints and in patients who suffered a thrombosis while taking OCs, administration of the pill should be avoided. (author's modified) (summary in ENG)
Metabolic effects of two triphasic formulations containing ethinyl estradiol and dl-norgestrel.
The metabolic effects of 2 triphasic oral contraceptives (OCs) containing dl-norgestrel (dlN) and ethinyl estradiol (EE) were studied in young women. The marked difference in the 2 preparations was progestogen content, allowing the study of the metabolic effects of high and low progestogen in OCs. The results suggest that high progestogen increases serum sodium, potassium, blood urea nitrogen, creatinine, total protein, albumen, and lactic dehydrogenase. An increase in aspartate transaminase and a decrease in alkaline phosphatase were probably estrogen-related. High progestogen significantly reduced the fasting blood glucose levels (P<.001). Both preparations significantly increased the levels of cholesterol and triglycerides in women who had not taken OCs for 3 or more months, and with the low progestogen preparation, these increases are dissimilar to the effects reported in the triphasic preparations containing levonorgestrel. (author's modified)
[Wplyw hormonow na stan podloza sluzowkowo-kostnego u kobiet]
The authors describe the local and systemic causes of prosthetic stomatopathies following a survey of the pertinent literature. From among the known forms of this disease developing as a result of systemic disease, the authors isolated stomatopathy caused by hormonal disturbances. It is emphasized that local pathological conditions are exacerbated, particularly in such hormonal disturbances as puberty, pregnancy, menopause, and use of oral contraceptives. It is thought that these flareups are caused mainly by the periodic falls in serum estrogen level. Literature shows that good results have been achieved in stomatopathy treatment by using estrogen preparations administered systemically or locally. In each case of hormonal treatment, cooperation with specialists in endocrinology is obligatory. (author's modified) (summaries in ENG, RUS)
[Influence of spermicides on physiological and pathogenic organisms of the genital tract]
In vitro studies concerning the influence of commercially available spermicides on lactobacillus acidophilus as well as on pathogenic organisms of the genital tract revealed that the perparations had only weak antimicrobial effects on Doderlein's bacteria and pathogenic fungi. However, all 4 preparations tested revealed a good inhibitory effect on Neisseria gonorrhoeae, treponema pallidum, and trichomonas vaginalis. Irreversible damage to gonococci and trichomonas was subject to considerable variation, probably due to the different chemical composition of the commercially available spermicides in Austria. (author's modified) (summary in ENG)
[The course of pregnancy after failure of intrauterine contraception]
The analysis of intrauterine contraception studied in 2548 women during 65,925 cycles over the preiod 1974-79 revealed a total of 227 failures; i.e., in 8.9% of users and 1 pregnancy/290.4 cycles. Of this number, there were 6 extrauterine pregnancies and 11 spontaneous deliveries in women with IUDs. In 2 cases, preterm labor was recorded, and there was no incidence of fetal malformation. Failure of contraception is being evaluated with respect to age, parity, and the number of cycles followed up after IUD insertion. Influences affecting IUD frequency and its failure, as well as its potential adverse effects are discussed. (author's modified) (summaries in ENG, SCC)
A new look at antifertility vaccines.
This article reviews new advances in biochemistry, biotechnology, and immunology relevant to antifertility vaccine development and evaluates the current status and future prospects of contraceptive vaccines and other immunologic approaches to fertility regulation. Contraceptive vaccine candidates include human chorionic gonadotropin, human luteinizing hormone and luteinizing hormone releasing hormone, and reproductive steroid hormones. Sperm enzymes are attractive for a contraceptive vaccine; among the sperm antigens studied are antibodies to hyaluronidase, acrosin, and lactate dehydrogenase-C4. Several laboratories have developed monoclonal antibodies to a variety of sperm antigens and are using them to identify and characterize new sperm proteins and their roles in fertility. Considerable progress has been made toward biochemical characterization of unique glycoproteins constituting the zona pellucida. Zona pellucida antigens are good candidates because antizona antibodies may block both fertilization and implantation, and low amounts of antibody would be sufficient because of the small number of mature eggs with zona present at any time. Studies are underway to identify human embryonic antigens through examination of the protein profile of human teratocarcinoma cell lines at various stages of differentiation and through analysis of antibodies in human pregnancy and infertility sera. Placental and extraembryonic membranes produce several tissue-specific antigens that have been considered for antifertility vaccines, but concern that they could produce late or incomplete abortion has prevented their serioud consideration. Because of possibly serious systemic side effects, presence of the blood-testis barrier, and large number of sperm produced daily, it is unlikely that sperm vaccines can be safely administered to men. Nautural protective mechanisms will probably render some immunocontraceptive approaches ineffective. The possibility of serious pathogenic side effects of contraceptive vaccines demands vaccines demands a cautious approach to their development.
Propranolol as a novel, effective spermicide: preliminary findings.
198 sexually active, parous, nonlactating, women volunteers ranging in age from 15-42 years who wished to discontinue IUD use participated in an 11-month study of the spermicidal efficacy of propranolol at a clinic in Santiago, Chile. Each evening the women inserted a commercially available 80 mg tablet of DL-(racemic)-propranolol into the vagina. No other method of contraception was used. The women were examined after 1 month of treatment and at 3 month intervals thereafter. Further tests were performed on 30 of the women. There were no noticeable effects on menstruation and no systemic adverse reactions. Discontinuation for local itching or discomfort occurred mainly in the 1st 3 months of treatment. 127 women-years of exposure were documented. Calculated life table pregnancy rate at 1 year was 3.4/100 women and the Pearl index was 3.9/100 women years. 5 women who became pregnant were not among those undergoing postcoital tests. All terminated their pregnancies by abortion. Postcoital testing did not show any motile spermatozoa in the endocervical samples. The results suggest that propranolol is an effective vaginal contraceptive whose failure rate compares favorably with that of other contraceptive methods. Further study of propranolol and similar compounds should be undertaken.
Hysteroscopic tubal occlusion with formed-in-place silicone plugs: a clinical review.
415 patients have undergone hysteroscopic tubal occlusion under local anesthesia with formed-in-place silicone plugs since January 1981 as an office procedure in Phoenix, Arizona. The method involves flowing catalyzed liquid silicone into the oviduct through a silicone rubber obturator tip positioned at the tubal ostium. The resulting plug is larger at both ends than is the isthmus and thus remains in place to effect tubal occlusion. A pelvic flat-plate X-ray obtained immediately after the procedure and a repeat pelvic X-ray 3 months later were used for evaluation. Patients were grouped into 4 categories: 1) 328 who had a successful procedure and satisfactory X-rays; to date, 3200 woman-months of sterilization and no pregnancies have been recorded; 2) 6 with satisfactory initial procedure and X-rays but 3-month X-rays revealing plug abnormalities including migration of a plug into the peritoneal cavity or a unilateral discontinuous plug; 3) 6 who had a successful procedure but unsatisfactory immediate X-ray because of extravasation of silicone into the peritubal myometrium or shortened plug lacking distal bulbous swelling; and 4) 75 who had an unsuccessful initial procedure for a variety or reasons, of which tubal spasm and obscured visualization were the most common. After repeat attempts, 90% of the initial study group ultimately had a successful procedure; there have been no serious sequelae. A 2-year follow-up X-ray is becoming important to detect a small incidence of intact plug migration into the peritoneal cavity.