Subcommittee on Health Issuesof the House of ... program in Angola faces huge problems" [Can Med Assoc ... director of maternal and child health of the World ...
information to ensure that the safest blood products are provided to our members. Information obtained since November 1992 has convinced the CHS to push for a full, independent public investigation into Canada's blood delivery system. Accordingly, the CHS is cooperating fully with the Subcommittee on Health Issues of the House of Commons' Standing Committee on Health and Welfare, which is holding weekly hearings on this matter. The CHS would welcome the support of the CMA in the pursuit of our goals. Our members say that at the very least we need an investigation to make sure this situation doesn't happen again. David Page President Canadian Hemophilia Society Montreal, Que.
Aid to developing countries
More to the point is the inescapable fact that governmental apathy, ineptitude, corruption and theft are responsible for much of the sorry state of affairs in both countries. Until this problem is addressed satisfactorily a great deal of well-intentioned aid from the West will be wasted, much of it ending up in the hands of adroit entrepreneurs. In an attempt to deal with rampant theft and corruption at the local level and to overcome the hopeless resignation of the staff, a very limited form of local health insurance or cost sharing has been instituted at the hospital in Tororo. This will improve health care a little, but the basic problem of inefficient distribution of aid from outside will remain. Any effort to improve the situation in Tororo is largely due to the efforts of the Canadian International Development Agency and funding from the Community Practice Programme at Memorial University of Newfoundland, St. John's. Although this is a useful beginning, unless the donors of aid start to demand accountability from the national governments, the delivery of health care in much of Africa and probably all other developing countries will continue just as Timmermans describes.
r. Frank Timmermans' account of his work in Africa ("Canadian aid program in Angola faces huge problems" [Can Med Assoc J 1993; 148: 1007, 1010-1011]) is heartrending and one that Western governments and charitable Kenneth M. Leighton, MB, FRCPC aid agencies would do well to Vancouver, BC heed. Haphazard handouts and advice from health care experts do not help the sick inhabitants of
D
developing countries. After spending 6 months in 1992 in the government hospital at Tororo, Uganda, I can echo much of what Timmermans says. The hospital in Tororo has water and electricity, but without drugs, surgical supplies, satisfactory sterilization and almost everything else that makes the provision of some sort of basic medical care possible, the conditions are similar to that in the Angola hospital. JUNE 1, 1993
Epidural analgesia during labour T n he article "Ontario's birthing-centre concept may have impact on hospitals, MDs" (Can Med Assoc J 1993; 148: 1004-1006), by Cameron Johnston, attributes the following comment to Dr. Marsden Wagner, director of maternal and child
health of the World Health Organization and a speaker at a conference held in London, Ont., last fall: "Fewer than 600 women worldwide have participated in trials involving epidural anesthesia, despite the thousands of times this procedure has been performed in delivery rooms." The tone of this statement might lead one to believe that the provision of epidural analgesia for pain relief during labour is a relatively innovative therapy. A search of the Oxford Database of Perinatal Trials with use of the terms "epidural anaesthesia" for topic, "as an intervention" for occurrence and "during labour" for time, revealed that 207 891 women had been enrolled in randomized controlled trials that met the inclusion criteria. These trials were conducted to determine the efficacy of local anesthetic mixtures, adjuvants and techniques of administration. Some were conducted to determine specific biochemical markers of labour, neonatal outcome and patient satisfaction with the method of pain relief. Because serious side effects of epidural analgesia are relatively uncommon, both retrospective and cohort studies are appropriate to determine safety. Ong and associates' studied a cohort of 9400 patients in Winnipeg who had received epidural analgesia for labour. Scott and Hibbard2 conducted a retrospective study of 505 000 patients who had received epidural anesthesia in Britain between 1982 and 1986, 400 000 for pain relief in labour. Because of these and other studies the risks of epidural analgesia are relatively well understood and documented. To suggest that the use of epidural analgesia has not been evaluated does a disservice to those who provide this method of pain relief during labour. Perhaps Wagner's comment was taken out of context. If not, other statistics CAN MED ASSOC J 1993; 148 (1 1)
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As for Halpern's suggestion or conclusions from his lecture that one regard the rest of Wagmust be viewed with scepticism. ner's lecture with scepticism, that FRCPC MD, Scott Halpern, is merely the opinion of one physDirector of obstetric anesthesia ician who clearly has a vested Women's College Hospital interest in seeing to it that midToronto, Ont. wives and alternative childbirth caregivers are given as little room References as possible to practise in Ontario 1. Ong BY, Cohen MM, Esmail A et al: or elsewhere in Canada. I suspect Paresthesia and motor dysfunction that Halpern's real concern is not after labor and delivery. Anesth Analg so much the accuracy of Wagner's 1987; 66: 18-22 2. Scott DB, Hibbard BM: Serious non- statements as the threat to his fatal complications associated with ex- profession posed by midwives tradural block in obstetric practice. Br J who function in birthing centres Anaesth 1990; 64: 537-541 and don't rely on epidural analgesia. [The author responds.]
ther lent credence nor allowed to diminish the journal. Removing statements that are "libellous, unduly abusive or downright stupid" is not censorship: it is editorship. Any other course would undermine the integrity and value of CMAJ to its readership. Islam G. Mohamed Class of 1995 University of Alberta Edmonton, Alta.
true. As a medical reporter my job is to report what was said and to keep my opinions to myself as much as possible. Therefore, I cannot presume to put words into Wagner's mouth, but he could have meant to say that fewer than 600 patients had ever taken part in planned, prospective, randomly controlled clinical trials. Dr. Halpern cites retrospective studies, I believe.
Although editors are not legally required to "censor" (if that is the correct term) personal remarks made about others in letters to journals, to do so in CMAJ would Cameron Johnston save the Canadian medical profesLondon, Ont. sion further embarrassment. There is certainly nothing humorous in remarks that have nothing to do with the issues, as exemplified by Dr. Iain D. MackShould we censor ie's letter (Can Med Assoc J 1992; 147: 991), and it is regrettable letters? that editors should have to conT was disappointed by the soft sider censorship in the first place. stand Dr. Bruce P. Squires MD, FRCPC took in his Editor's Page on Ray G.L. Holland, Ont. Colbome, Port the admissibility of letters to CMAJ (Can Med Assoc J 1992; 147: 1627). A publication that serves the CMA, a professional medical association, should reflect the dignity and sensitivity of the The bigger slice profession. The Letters section of the pie? should be reserved for thoughtful contemplation of articles or med- I n the third paragraph of this letter to the editor, by Dr. ical issues, for constructive opinBrian W. Gregory (Can Med colof in a forum ions aired J 1993; 148: 707), the page Assoc leagues. given for the article by numbers should writers Although "all Gellman should Dr. D. Derek thembe free to make fools of We apol"1682-1686." have been secselves in the correspondence error this confusion for any should ogize tion" the editor-in-chief Ed. caused. have may neiare remarks ensure that petty
CAN MED ASSOC J 1993; 148 (1 1)
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According to my notes and a tape recording of his talk, Dr. Wagner did indeed state that fewer than 600 women worldwide have taken part in controlled clinical trials to evaluate the effectiveness of epidural analgesia during childbirth. Furthermore, his statement was not taken out of context. Wagner made this comment in a forum of family physicians, eminently qualified obstetriciangynecologists and midwives. Since none of these professionals questioned his comment I saw no reason to believe that it might not be
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[correction]
