The Pharmaceutical Journal
Vol 275 No 7367 p350
17 September 2005

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Why not consult patients about prescribing choice? more
Virtues of soap and water are not strained more
Never neglect the whole for the parts more
Hallmark of a politician / The meaning of culture more

Why not consult patients about prescribing choice?

Correspondence in The Lancet for 23 July raises the question of how far the views of the patient should be considered when it comes to prescribing a remedy on which some doubt has been thrown by evaluators.

A case in point has arisen over the use of co-proxamol, a combination of dextropropoxyphene and paracetamol, to relieve mild to moderate pain, particularly in patients suffering from rheumatoid arthritis.

Co-proxamol was established in the 1960s, and some 1.7 million patients in the UK receive about 7.5 million prescriptions for it annually. Despite this, the Committee on Safety of Medicines has called for its phased withdrawal from the market on the grounds that the balance between risk and benefit it demonstrates is unfavourable.

Groups of patients who have come to rely on the benefits, and an impressive number of professional health bodies concerned, have strongly opposed the CSM’s move. Among the objectors is the Royal Pharmaceutical Society. Others are the Royal College of Physicians of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow, the British Pain Society, the British Society for Rheumatology, the Faculty of Pharmaceutical Medicine of the Royal College of Physicians, the Royal College of General Practitioners, the General Practitioners Committee of the British Medical Association and the Royal College for Paediatrics and Child Health.

These bodies are all calling for more evidence of risk before the withdrawal of co-proxamol is decided. One minor suggestion has been put forward — that the number of tablets in the pack might be reduced.

Most patients with rheumatoid arthritis who have been asked for their opinion have deplored the idea that a medicine which they have found effective and free from the disadvantages associated with more powerful analgesics such as dihydrocodeine and other narcotics (notably constipation) should be denied to those who prescribe for them.

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Virtues of soap and water are not strained

An article by scientists from a number of disease-control centres, published in The Lancet for 16 July, describes effects of regular hand washing and bathing with soap on the health of children in Karachi, Pakistan, where communicable disease is a leading cause of morbidity and mortality.

Field workers visited households at least once a week to discuss washing of hands by individuals dealing with cleaning after defaecation, preparing family food and feeding infants. Participants were encouraged to bathe daily with soap and water, using either an unmedicated soap or one containing 1.2 per cent of the antibacterial compound triclocarban.

A survey revealed that encouragement to use soap and to bathe daily significantly reduced the incidence of respiratory infections, diarrhoea and impetigo in families. Children younger than 15 living in households provided with plain soap showed a 50 per cent reduction in coughs and breathing difficulties. Children younger than five developed 50 per cent less pneumonia. The incidence of respiratory illness was similar whether plain or medicated soap was used while antibacterial soap was only slightly more effective than plain soap against impetigo.

Triclocarban has been found to be more effective against some streptococci, but ineffective against gram-negative bacteria and viruses.

It is important that better hand-hygiene should be promoted in the interests of public health, although in some areas of the world, access to suitable water supplies poses grave problems. As Mark Twain commented in 1872, “Soap and education are not as sudden as a massacre, but they are more deadly in the long run.”

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Never neglect the whole for the parts

One perverse characteristic of our age is the habit of breaking current issues, whether scientific, political or ethical, into distinct fragments and turning a blind eye to the effect that altering one aspect will produce on any other. We are a society of specialists, each ignorant or negligent when we encounter yet another specialty. We may be experts in our narrow field of knowledge and experience, but unappreciative regarding its repercussions on things about which we know little or nothing. Hence the enormous value of a wide education, with which our global capitalists have no sympathy.

One important aspect of our short-sightedness is the effect of human industry on our behaviour. In Science for 22 July, Paul Ehrlich and Donald Kennedy call for the establishment of a global discussion of key ethical issues related to the human environment. which they call “a millennium assessment of human behaviour”. Both scientists and laymen should explore their own values relating to environmental sustainability, consider how we treat one another and our life-support systems and bring pressure on politicians to acknowledge the problems we face in the future.

Cultures evolve, and should embody positive goals. We must consider how scarce and unevenly distributed non-renewable resources are used, study the world trade system, reproductive and environmental goals, and economic, racial and gender inequities as they produce degradation. Armed conflict, national and international governance and health issues call for intensive discussion. Previous cultures have collapsed because of maladaption and unwillingness to consider the overall effects of policies. Resource allocation and risk assessment have been at fault.

We have much to learn, write Ehrlich and Kennedy, about behavioural relationships, societal goals and institutional organisation. The different disciplines by which we study these matters have historically been segregated in universities, and interdisciplinary engagement has been lacking. An urgent need is for scholars to allocate time and looming tasks in a world facing increasingly serious problems of survival.

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And I quote…

Hallmark of a politician
"He knows nothing, and he thinks he knows everything. That points clearly to a political career."
—George Bernard Shaw, in ‘Major Barbara’ (1907).

The meaning of culture
"Culture, the acquainting ourselves with the best that has been known and said in the world, and thus with the history of the human spirit."
—Matthew Arnold, in ‘Literature and dogma’ (1873).

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