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This article is a transcript of the 58th Joseph Price Oration, delivered by Egon Diczfalusy (MD, PhD) at the 10th Annual Meeting of the American Gynecological and Obstetrical Society, held in Carlsbad, California on September 5-7, 1991. In his speech, Diczfalusy discussed the international community's moral obligation to promoting reproductive health, which hinges primarily on contraceptive prevalence. WHO figures indicate that 85% of the world's births, 95% of the world's infant deaths, and 99% of the world's maternal deaths take place in developing countries. While a women in a developed country has a 1 in 1750 chance of dying from pregnancy-related causes, the risk is 1 in 24 for a woman in Africa. The goals of reproductive health are well-known: reducing the unmet need for family planning, increasing family planning services and methods; lessening maternal, infant, and child mortality and morbidity; and reducing the prevalence of STDs. An investment of $2/capita would eliminate most maternal deaths in the developing world. An additional $2/capita spending increase in developing countries would also immunize all children, eradicate polio, and provide the drugs necessary to cure all cases of diarrheal disease, acute respiratory infection tuberculosis, malaria, schistosomiasis, and STDs. But the most important element with respect to reproductive health is increasing contraceptive prevalence. Over the next decade, yearly world population increments will approach 97 million. 94% of this growth will take place in developing countries. As Diczfalusy explains, the technology and resources to solve these problems exists. At bottom, the obstacle to overcoming the problems is the lack of political will.
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PMID:Contraceptive prevalence, reproductive health, and international morality. 156 58

Subfecundity is caused by disease and nutrition as well as by genetic, environmental, and psychological components. Sexually transmitted diseases (STDs) are caused by 21 different pathogens of which syphilis, gonorrhea, and chlamydia are the most important. Syphilis is caused by the bacterium Treponema pallidum with incidence of 10% in Thailand. 20% in Papua New Guinea, and 40% in Ethiopia. Stillbirths in infected mothers range from 66% to 80%. Gonorrhea is caused by the bacterium Neisseria gonorrhoea and its incidence was 18% in female patients in Ugandan clinic. 20% of women in Africa with cervical gonorrhea develop salpingitis. The risk of pelvic inflammatory disease is several times higher in IUD users. The bacterium Chlamydia trachomatis caused infertility in 15.4% of men in a 1991 study. Herpes simplex virus 2 infects 15-30% of sexually active adults, and the chance of fetal transmission is 40% when maternal lesions are present. Diseases other than STDs include tuberculosis (TB) whose development is aided by conditions such as malnutrition, malaria, leprosy, syphilis, and African sleeping sickness. Genital TB causes a 5-50% rate of menstrual disorders including amenorrhea and a 55-85% rate of sterility in women. Malaria is caused by Plasmodium protozoa, and the feverish state included by it can lead to oligospermia. Severe malarial anemia can lead to fetal and maternal mortality. The protozoa Trypanosoma causes African sleeping sickness that produces azoospermia and impairs the pituitary gland and ovaries. Schistosomiasis (bilharzia) and filariasis have less direct effect on fecundity but they negatively impact nutritional status. Maternal nutrition substantially impacts fetal and infant survival. During the Dutch famine of 1944-45 there was a 50% decrease in births 9 months subsequently. A 10-15% weight loss results in amenorrhea.
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PMID:Endemic disease, nutrition and fertility in developing countries. 163 64

Researchers analyzed data on 2627 Australian tourists returning from Kenya, Sri Lanka, Thailand, and the Maldives (November 1988-March 1989 and October 1989-January 1990) to examine tourist behavior regarding prophylaxis measures. 94.1% sought health information. 1st time tourists were more likely to get this information than those who had already made at least 1 visit (98.1% vs. 92%; p.05). Many tourists relied on travel agencies (37.5%) and friends (20.2%) for this information. Experienced tourists were not as likely to depend on travel agencies and friends as were 1st time tourists (p.05), however. 92% of those who sought information took at least 1 precautionary measure. 96.3% of tourists to Kenya carried out a prophylactic measure compared with 79.6% of those to the Maldives (p.05). Tourists tended to obtain immunoglobulin prophylaxis against hepatitis A (75.1-84.8%), yet not obtain vaccinations for typhoid fever (55.7-68.1%), tetanus (43.3-56.7%), and polio (25.9-38.7%). They appeared to be aware of dietary risks (86.1%), but not about sexually transmitted disease risk such as AIDS (41.7%) or taking a medical travel kit (50.5%). After a mass media campaign, these figures increased to 93.1% (not significant), 64.7% (p.01), and 68.2% (p.05). The Maldives was free of malaria, but 31.9% still took malaria prophylaxis. Most travelers to Thailand (88.35) also took malaria prophylaxis, yet 81.8% of them went to malaria-free areas. Tourists to Kenya had better compliance than those to Sri Lanka (94.2% vs. 82.7%, p.05). Moreover only 74.7% of travelers to Kenya took mefloquine, the recommended choice for short-term travelers. Compliance was greater among those who took mefloquine than it was for those taking chloroquine (74.1% vs. 90.3%, p .01). The most important finding was the considerable misinformation about and noncompliance with malaria prophylaxis. For example, the more complex the intake instructions the more likely noncompliance occurs.
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PMID:Compliance of Austrian tourists with prophylactic measures. 164 43

The high prevalence of hepatitis B markers in the Sudan (up to 80% of those surveyed) suggests the potential for a rapid spread of human immunodeficiency virus (HIV) since both viruses are transmitted in similar ways. Although clinical cases of acquired immunodeficiency syndrome (AIDS) have not been reported from Port Sudan, southern Sudan borders on several countries with a high prevalence of HIV infection. Sudan's National AIDS Committee plans a series of surveys to determine the prevalence of HIV infection in high risk groups and the general population in several geographic regions. The 1st such survey was conducted in Port Sudan in 1987 among 593 high-risk individuals (203 prostitutes, 103 lorry drivers, 118 prisoners, and 169 in mixed occupations). The study population included 330 males and 263 females. About half of the participants were married and in the 21-30-year age group. Over 75% had been exposed to hepatitis B and 76% had been treated for malaria, largely through injection. Overall, the incidence of non-sex-related risk factors for HIV infection among Port Sudan subjects was: injection, 48%; scarification, 40%; and tatoos, 38%. 32% reported a prior history of a sexually transmitted disease. 71% of the males had used prostitutes. Surprisingly, no study participants were positive for HIV infection. This finding presumably reflects Port Sudan's geographic isolation from other Central and East African countries with large numbers of HIV-positive individuals. On the other hand, Port Sudan is the site of importation of all goods by sea into the country and many people from other African and Arab countries are associated with the seaport. Thus, once the HIV virus is introduced by infected persons from other areas, the risk factors suggest the potential for rapid transmission.
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PMID:Serosurvey of prevalence of human immunodeficiency virus amongst high risk groups in Port Sudan, Sudan. 225 74

From the moment WHO was established in 1948, the control of venereal diseases was felt to deserve highest priority, together with activities to control malaria and tuberculosis. International action was needed in view of the high morbidity and mortality from venereal diseases, their serious human and social consequences, and the prevalence of congenital syphilis and other sexually transmitted diseases (gonorrhoea, chancroid, venereal lymphogranulomatosis, granuloma inguinale). WHO immediately set up a global programme for the control of STDs and, with the participation of other agencies, especially UNICEF, furnished countries with assistance in the form of personnel, equipment and funds for the operation of programmes to assess the extent and impact of STDs and to plan and implement practical measure of control. The 1950s witnessed a steady and considerable decline in syphilis and gonorrhoea and many health authorities relaxed their control activities and efforts to maintain public awareness of the problem. In contrast to the prevailing optimism, WHO repeatedly stressed the possibility of a renewed upsurge of STDs. In the 1960s and 1970s, there was a sharp rise in STDs, both in the "classic" diseases (the five venereal diseases mentioned above) and also in the "second generation" STDs (chlamydial infection, genital herpes, human papillomavirus and other infections). Through its programme for the control of STDs, WHO put forward suitably designed control strategies, essentially based on information and education for health, screening for STDs, diagnosis and treatment of cases, contact tracing, and the training of health personnel. By the end of the 1970s, the bacterial, but not the viral STDs, had been contained in the industrialized countries. In many of the developing countries, STDs remained a priority public health problem, above all on account of the seriousness of their sequelae. In 1981, a new sexually transmitted disease-the acquired immunodeficiency syndrome (AIDS)-was identified. As of 1982, the WHO Programme on STDs organized meetings to define the extent of the problem, compare experience, promote and coordinate research and propose strategies for prevention. In 1987, WHO established a Global Programme on AIDS. It is clear that the control of STDs is now more than ever a priority. We have strategies for the prevention and control of STDs and the WHO Programme will continue to collaborate closely with countries in strengthening their national control programmes.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:[The campaign against sexually transmissible diseases and endemic treponematoses]. 245 57

17 Caucasian patients with aquired immunodeficiency syndrome (AIDS) contracted after long stays in Africa are reported. All 17 patients had previously been healthy; AIDS was diagnosed in them in France after July, 1983, except in 2 patients who were admitted to hospital before 1981. AIDS was diagnosed according to the Centers for Disease Control criteria--severe opportunistic infection or Kaposi's sarcoma. After 1983 every patient was given a questionnaire about where he or she had travelled in Africa, his or her profession, previous venereal disease or malaria, and sexual activity. It seems likely that these patients contracted HIV infection in Central Africa. The picture of the disease was similar to that in patients in other AIDS risk groups. Malaria was the only parasitic disease found in 2 of the patients, and there was no evidence of correlation between hepatitis B and AIDS in these patients. No patient was a hemophiliac or an intravenous-drug abuser, and only 1 patient had received a blood transfusion. Injections in Africa do not appear to be involved in the transmission of AIDS; in these patients, injections were carried out with sterile equipment. The study confirms that prostitutes constitute a reservoir of HIV, particularly in Central Africa, and suggest that the virus will continue to spread through heterosexual contacts. Public health programs are urgently needed to limit sexual contacts with people at risk of transmitting AIDS in Africa and to promote the use of condoms.
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PMID:Acquired immunodeficiency syndrome after travelling in Africa: an epidemiological study in seventeen Caucasian patients. 288 Nov 42

AIDS in rural Africa seems to differ in its epidemiology from hepatitis B and appears to be spread predominantly by preexisting patterns of heterosexual activity responsible for high rates of other sexually transmitted diseases. The authors compared the seroepidemiologies of AIDS, hepatitis B, and syphilis at 2 rural hospitals in southwest Uganda. During August 1986, 3% of 357 outpatients, reflecting the age and sex composition of the general population, were anti-HIV positive. Anti-HIV seropositivity, both in the outpatients and among 36 suspected prostitutes and 14 suspected AIDS cases, was confined to individuals aged 20 or over. For men, seropositivity was associated with sexual contact with prostitutes (a risk factor for 61% of young men in the study). In the prostitute group, 25% were anti-HIV positive and 46% were positive on the Treponema pallidum hemagglutination (TPHA) test for syphilis. The risk factors for HIV, but not hepatitis B, were the same as for having a history of sexually transmitted disease (STD). However, there was, surprisingly, an association between a history of STD and seropositivity for hepatitis B virus but not for HIV infection. The geographical and age distributions of seropositivity for HIV and hepatitis B virus were also quite different. Finally, blood transfusions, scarification, and exposure to mosquitoes (as assessed by a history of malaria) were not evident risk factors for either HIV or hepatitis B virus.
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PMID:Risk factors for the spread of AIDS in rural Africa: evidence from a comparative seroepidemiological survey of AIDS, hepatitis B and syphilis in southwestern Uganda. 314 Aug 31

Ethiopia is a country of 45 million people in northeast Africa. With a stagnant, agriculture-based economy and a per capita gross national product of $110 in 1984, it is one of the world's poorest nations. 70% of the children are mildly to severely malnourished, and 25.7% of children born alive die before the age of 5. Life expectancy is 41 years. The population is growing at the rate of 2.9%/year, but only 2% of the people use birth control. After the 1974 revolution, the socialist government nationalized land and created 20,000 peasant associations and kebeles (urban dwellers' associations), which are the units of local government. The government has set ambitious goals for development in all sectors, including health, but famine, near famine, forced resettlement programs, and civil war have prevented any real progress from being made. The government's approach to health care is based on an emphasis on primary health care and expansion of rural health services, but the Ministry of Health is allocated only 3.5% of the national budget. Ethiopia has 3 medical schools -- at Addis Ababa, Gondar, and the Jimma Institute of Health Sciences. Physicians are government employees but also engage in private practice. A major problem is that a large proportion of medical graduates emigrate. Ethiopia has 87 hospitals with 11,296 beds, which comes to 1 bed per 3734 people. There are 1949 health stations and 141 health centers, but many have no physician, and attrition among health workers is high due to lack of ministerial support. Health care is often dispensed legally or illegally by pharmacists. Overall, there is 1 physician for 57,876 people, but in the southwest and west central Ethiopia 1 physician serves between 200,000 and 300,000 people. In rural areas, where 90% of the population lives, 85% live at least 3 days by foot from a rural health unit. Immunization of 1-year olds against tuberculosis, diphtheria-pertussis-tetanus, poliomyelitis, and measles is 11, 6, 6, and 12% respectively. Infectious diseases dominate the medical scene in Ethiopia. In 1984, tuberculosis accounted for 11.2% of hospital admissions and 12.2% of deaths. The leading cause of childhood mortality in 1984 was diarrhea (45%). Malaria, trypanosomiasis, schistosomiasis, leishmaniasis, and meningococcal meningitis are endemic. Intestinal parasitism is rampant, and the nationwide prevalence of leprosy is 3/1000. Venereal diseases were the 9th most common cause of hospital outpatient visits in 1984, but AIDS is rare. The leading noninfectious diseases are rheumatic and syphilitic heart disease, hypertension, diabetes mellitus, hepatoma, and elephantiasis. Ethiopia has the highest number of cases of nonfilarial elephantiasis -- an estimated 350,000 cases -- in the world. Aside from a large influx of money, the most necessary changes to improve the health system are lowering the salaries of doctors and nurses, reorienting physician training toward primary health care, increasing the quality of existing health services, more efficient management, and better coordination between the Ministry of Health and the voluntary organizations.
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PMID:Health and medical care in Ethiopia. 271 Jan 85

Reported causes of death (1899-1911) and of admission to hospital (1884-1910) of Indian migrants to Natal are analysed, and an attempt is made to relate them to the circumstances and way of life of the community. The most frequently reported causes of death were pneumonia, enteritis and pulmonary tuberculosis; the commonest reason for admission was venereal disease. Fluctuations in reported mortality and morbidity from year to year were most marked for malaria, with a formidable epidemic in 1905-1906. Typhoid fever and diphtheria were uncommon, as were diabetes and the sequelae of arteriosclerosis.
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PMID:Nostalgia and alligator bite--morbidity and mortality among Indian migrants to Natal, 1884-1911. 636 94

International travels are increasingly frequent. Beside malaria prophylaxis, the general practitioner will review several vaccinations.e Tetanus and poliomyelitis vaccines should be administered once every ten years. It will often be useful to give a protection against hepatitis A, and less often, against typhoid fever. The yellow fever vaccine, which may be required or recommended to visit several African and South American countries, is injected only by officially recognised centres. For some travels, vaccination against hepatitis B, meningococcal meningitis or, rarely, against rabies may be considered. The vaccine against cholera will never be administered, due to its lack of efficacy and high frequency of side effects. Travellers diarrhoea will be discussed, and a "pocket" treatment prescribed. Finally, general information will be provided, including those on STD.
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PMID:[Vaccinations and useful advice for travelers]. 793 82


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