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American Journal of Public Health. 2005 Jul; 95(7):1173-1180.The availability of limited funds from international agencies for the purchase of antiretroviral (ARV) treatment in developing countries presents challenges, especially in prioritizing who should receive therapy. Public input and the protection of human rights are crucial in making treatment programs equitable and accountable. By examining historical precedents of resource allocation, we aim to provoke and inform debate about current ARV programs. Through a critical review of the published literature, we evaluate 4 precedents for key lessons: the discovery of insulin for diabetes in 1922, the release of penicillin for civilian use in 1943, the development of chronic hemodialysis programs in 1961, and current allocation of liver transplants. We then describe current rationing mechanisms for ARVs. (author's)
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY. 1988 Jan; 158(1):80-3.The Maternal and Child Health Unit of the World Health Organization undertook a series of prospective studies in the early 1980s in Burma, China, Thailand, and Viet Nam to determine how much variation in the incidence of hypertensive disorders of pregnancy there was and how much of it reflected differences in baseline blood pressures. Pregnant women in 3 urban and 2 rural centers in Burma, a part of the city of Shanghai, 1 urban and 1 rural center in Thailand, and 1 urban and 2 rural centers in Viet Nam were enrolled. Each mother was given a card recording weight, signs of edema, proteinuria, and blood pressure with diastolic pressure based on the 4th Korotkoff sound. Gestation was calculated from the 1st day of the last menstrual period, and all the women were primigravidas. There was wide variation in the distribution of highest diastolic pressure before the onset of labor. The proportion of mothers whose diastolic pressure was greater than 89 mm mercury at any time during pregnancy varied from 33% in China to 26% in Thailand, 7% in Burma, and 5% in Viet Nam. There as very little variation in the numbers of mothers with proteinuria. China had the lowest rate of eclampsia but the highest prevalence of hypertensive disorders, presumably because preeclampsia was treated. Hypertensive disorders were diagnosed among 31% of Chinese women, 5% of Burmese women, and 1% of women in Viet Nam and Thailand. Blood pressure measurements were analyzed for each country by week of gestation, and the mean diastolic pressure in the 2nd trimester was constant across all 4 populations; the difference between the lowest and highest was only 3.5 mm mercury. Thereafter the differences increased, with the greatest increases in China and Thailand and very little increase in Burma and Viet Nam. The differences thus appear to be racial, but whether they are genetically or environmentally caused remains to be determined.
Geneva, Switzerland, World Health Organization [WHO], Division of Family Health, Maternal Health and Safe Motherhood Programme, 1992. iii, 46 p. (WHO/MCH/MSM/92.3)WHO's Maternal Health and Safe Motherhood Programme has guidelines for health workers to detect early signs and symptoms of preeclampsia and to provide early treatment of mild preeclampsia to prevent severe preeclampsia. Health workers must take accurate blood pressure measurements, test for protein in urine, and identify substantial edema. This manual helps them determine when blood pressure equipment does not work accurately and know how to fix it. The manual covers all parts of the sphygmomanometer (blood pressure machine): the cuff, rubber bladder, the aneroid sphygmomanometer, stethoscope, and pump and control valve. Health workers should know that certain conditions elevate blood pressure in normal patients. They can alleviate them to obtain accurate blood pressure measurements. These conditions are fear, cold, full urinary bladder, exercise, tight clothes around the arm, obesity, standing up, and lying on the back. Health workers should place either the left or right arm on a table or on another object thereby allowing the muscles to relax. The upper arm needs to be at the same level of the heart. It is important that all levels of health workers be adequately trained in taking blood pressures correctly. Training should not occur in busy and noisy clinics. The trainer should use a double stethoscope to determine whether the trainees correctly identify the Korotkoff sounds. Health workers must feel pregnant women how to collect a midstream urine sample, free of vaginal secretions and discharges, so the health workers can test for protein in the urine. Its presence indicates kidney failure. Diagnosis of mild preeclampsia includes a blood pressure at least 140/90 mmHg or an increase of 30 mmHg systolic or 15 mmHg diastolic and at least 300 g/l protein in urine. In addition to these signs, sudden onset of edema of face and/or hands, severe headaches, great reduction of urine output, epigastric pain, visual disturbances, and reduced fetal movement are reliable signs of severe preeclampsia.