Editor’s Choice

Public health and personal ethics

There has always been an element of conflict between measures necessary in the interests of public health and the need to preserve personal autonomy. The recent epidemic of measles in the UK is a direct consequence of 25% of parents exercising their right not to immunise their children with the controversial MMR (measles, mumps, and rubella) vaccine. The mooted link with autism not having been confirmed, we are now playing catch up to re-establish herd immunity. Perhaps the most famous case of coercion in the public interest is that of ‘typhoid Mary’. Mary Mallon (1869–1938) was the first person in the USA to be identified as a healthy carrier of typhoid fever. Unfortunately, she was a cook, who infected 47 people, 3 of whom died. As she refused to stop working as a cook, she was forcibly quarantined and died while thus confined.

As a trainee working in both the gynaecology outpatient clinic and the family planning clinic, I regularly prescribed metronidazole for women diagnosed to have Trichomonas vaginalis infection and included in the prescription a similar course for their sexual partner. However, metronidazole carries a small risk of significant adverse effects, including seizures, and my growing appreciation of the medico-legal risk of prescribing for someone I had not seen or examined made me discontinue this policy in favour of recommending that the partner seek treatment from their family practitioner.

Infection with Chlamydia trachomatis is undoubtedly an increasing threat to fertility in women worldwide because it can damage the fallopian tubes. Transmission is common because the men (and sometimes the women) often have few symptoms. But how to expedite treatment of someone who does not feel unwell and may be reluctant to see a doctor? Patient delivered partner therapy (PDPT) is accepted in Sweden and some parts of the USA, but currently conflicts with the recommendations of the UK General Medical Council guidelines on good prescribing and with the UK Medicines Act. On page 357, Louise Melvin et al. report their survey of women being treated for Chlamydia and men attending genitourinary medicine, family planning, or fracture clinics, regarding the acceptability of PDPT (or patient delivered partner medication, PDPM, as they call it) compared with use of a postal test kit followed by individualised therapy. The majority of women chose PDPT, although according to them their partners expressed no particular preference. However, the men approached directly and preferred to be referred for evaluation treatment. The findings are summarised in a Mini Commentary by Editor Austin Ugwumadu on page 363, and the ethics evaluated in a Mini Commentary by Deputy Editor in Chief Michael Marsh on page 364. The public health, personal and ethical issues are drawn together in a Commentary by Sharon Cameron on page 345, a member of our Editorial Board and a leader in the provision of community-wide health services for women in the UK.

Global inequality in women’s health

It has been widely appreciated for many years that one of the most cost-effective ways of improving public health is to educate women and improve their access to health care. This has knock-on benefits for the whole family, including male partners as well as children. However, perhaps because global politics remains largely dominated by men, research into women’s health, and particularly the toll exacted by pregnancy, continues to be relatively underfunded. While the underfunding of service is widely acknowledged, the extent to which there is a deficit in research has perhaps been less well appreciated. On page 347, Nicholas Fisk (an obstetrician) and Rifat Atun (a professor of international health management) detail their analysis of government and charitable funding for maternal and perinatal research worldwide. Shockingly, they found that research investment ranged from less than 1% to no more than 4% of the total of medical research expenditure around the globe. So concerned were we about these findings that Editor John Thorp commissioned Mini Commentaries by Althabe and Belizán of the Institute for Clinical Effectiveness in Argentina on page 355 and by James Roberts of the Magee Women’s Research Institute in Pittsburgh, USA, on page 356.

It would be a mistake to think of inequalities as occurring only between countries. State boundaries often do not reflect substantial variations in health and access to health care even within single countries, especially those with populations as large as China. On page 401, Zhu et al. give us a fascinating insight into differential maternal mortality within a single city, Shanghai (albeit one that has a population larger than many countries). The problem of the ‘rural poor’ has probably been with us since the invention of agriculture some 10 000 or more years ago. Cultivated land can support about a hundred times more people per square kilometre than can hunter-gathering, and so it seems likely that communities that took up agriculture swamped their hunter-gatherer neighbours by sheer force of numbers. Unfortunately, reliance on a limited number of crops impoverishes the diet, with a consequent detrimental effect on health and life expectancy. This is reflected in maternal mortality; Zhu et al. report it to be twice as high in rural China as in urban areas. They have addressed the interesting question of whether migration to an urban centre removes that differential by improving access to medical facilities. They found that while the maternal mortality rate in indigenous Shanghai residents declined dramatically from 22.47 per 100 000 live births in 1996 to only 1.64 per 100 000 live births in 2005 (a remarkably low figure that puts the maternal mortality rate in many European countries to shame), the maternal mortality rate for women who migrated into the city from the country remained stubbornly high, falling only modestly from 54.68 per 100 000 live births to 48.46 per 100 000. It appears that part of the problem is that access to medical care is still restricted for migrants. Because China has long had a communist government, it is often assumed by outsiders that medical care for all will be provided by the state. In fact, the medical system in China relies primarily on private care funded by insurance, employers (e.g. the armed services provide many hospitals for their large numbers of employees), or the individuals themselves. Benefits for low-paid labourers generally include only industrial injuries, critical care, and an old-age allowance. Thus, China has a large ‘underclass’ with poor access to medical care, and it is perhaps a strange irony that the other very large country with a similar problem, the USA (where it is estimated that as many as 48 million people have no medical insurance cover and rely on visits to the emergency room when they become critically ill), is at the other end of the political spectrum. Countries with the lowest maternal mortality rates tend to be those with an economy, which is a mixture of capitalism and socialism. However, even in these countries, dealing with the disparity in health between immigrant and indigenous populations remains a challenge.

You are what your mother eats

The influence of the intrauterine environment on fetal development and long-term development into adulthood is now widely appreciated. In this month’s issue, we have three papers that address this theme. Maternal alcohol intake continues to be controversial, with official organisations such as the Department of Health in the UK persisting in recommending a zero consumption of alcohol during pregnancy; reports continue to appear that have failed to demonstrate any effect of alcohol at low levels (no more than two to three units per week). On page 390, we present further data, this time from Australia, which again emphasises the importance of dose. O’Leary et al. report that consuming less than 70 g of alcohol per week (and no more than two standard drinks on any one occasion) was not associated with an increased incidence of preterm birth or small-for-gestational-age infants. As I have mentioned in a previous Editor’s Choice, the real issue seems to be whether we recommend complete abstinence to assist those who find difficulty in rationing themselves to only a few units per week or simply state the facts and allow women to make their own choices (another example of the tension between public health and individual autonomy). Meanwhile, on page 416, Smedts et al. report that a high intake of vitamin E through the diet or supplements during pregnancy is associated with a 1.7- to nine-fold increase in the incidence of congenital heart disease in the offspring. Coupled with the failure of vitamins C and E supplements to reduce the incidence of pre-eclampsia, and the increasing evidence that iron supplementation of nonanaemic women can adversely affect pregnancy outcomes, this reinforces the recommendation I have given to women throughout my career, which is that the safest option is a healthy balanced diet without artificial supplements. In my view, our objective should be to make this available and acceptable to all pregnant women, dietary fads notwithstanding. What constitutes a healthy balanced diet? On page 408, Vujkovic et al. point out that nutrients from natural food sources are generally consumed as meals and not as isolated components. It seems likely that we are best adapted to the complex interaction that results rather than consuming the nutrients one by one. They looked in detail at the diet of 50 women in the Netherlands whose babies had spina bifida compared with 81 controls. The controls were significantly more likely to be slimmer, better educated, supplementing their diet with folate, drinking alcohol (one or occasionally two glasses of wine per week), and eating a Mediterranean type diet (characterised by a high intake of fruit, vegetables, vegetable oils, legumes, fish, alcohol, cereal products, and a low intake of potatoes and sweets). Such a diet has also been associated with improved general health in the population (in particular reducing mortality from cardiovascular disease), and luckily, it is one that I particularly enjoy.

And finally

We hope you enjoyed last month’s excellent special issue on ‘Emerging technologies in obstetrics and gynaecology’. Our special issue for January 2010 will concern ‘The gynaecological and reproductive health problems of puberty and adolescence’ and is being edited by editors Adam Balen and Pierre Martin-Hirsch. They have recruited several guest editors to help, particularly with encouraging submission of papers on the problems facing pubertal girls in the developing world. Genital mutilation and early onset of sexual activity with the attendant risks of sexually transmitted diseases and pregnancy before full development of the skeleton are major public health issues that we would like to cover, as well as medical problems such as dysmenorrhoea, delayed menarche, and other developmental abnormalities (see http://www.rcog.org.uk/index.asp?PageID=2566 for more details). As in previous years, we look forward to an excellent crop of submissions before the deadline of 31 May.