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[The Estonian Genome Project in the context of European genome research].

It is the aim of the Estonian Genome Project to establish a database which compiles phenotype and genotype data of a large part of the Estonian population. The Gene Bank will only be used for scientific and public health research. Researchers hope that it will help identify disease genes and prepare the ground for the personalized medicine of the future. Additionally, the project will improve Estonian's international competitiveness in high technology and have a strong educational effect on the population. The legal framework, the Human Genes Research Act, was passed by the Estonian parliament in December 2000. It had been drafted by a group of experts who took into account all available international guidance documents on genetic research. With the pilot project involving three selected regions successfully finished, the main project has now started.

Databases, Nucleic Acid↗

[Demographic forecasts of medical workforce supply in France (2000-2050). What numerus clausus for what future?].

UNLABELLED: In France, medical training and graduation of medical doctors are under the full control of the State. A numerus clausus barrier is established between the first year and the second year of medical schools. The first year is open to all students having successfully completed their secondary schooling (18 years old) but the number of those allowed to start the second year is decided every year by the government. Foreign medical graduates can practise only if they have obtained authorization from the State. Theoretically, the authorities have all means for shaping the size of the medical workforce, either in the short term (e.g. by importing foreign medical graduates to fill up vacant posts) or in the long run (by increasing or decreasing the numerus clausus, or student intake, to cope with shortage or oversupply of doctors). In practice, due to various constraints, the issue is far from simple (resistance to change, divergent lobbying forces and, more importantly, lack of relevant information). METHODS: In this study, the forecasting techniques of demography are used to assess the future trends of supply of medical doctors, on the basis of the formula t2 = t1 + e - l t1 is the medical workforce at the beginning of the period t2 is the medical workforce at the end of the period e is the number of doctors entering the medical workforce (new national graduates or foreign graduates) during the period l is the number of doctors leaving the medical workforce (death, retirement, out migration) during the period. Calculations are performed for each 5-year age group and for the successive 5-year periods. At the end of a 5-year period, one obtains the number of professionally active doctors in each 5-year age group and, by addition, the total number of active physicians in the country. The starting point of the projection work is December 31st 2000 when the French medical profession numbered 200,800 (i.e. 334 physicians per 100,000 population). As concerns the inflow e (physicians entering the profesion), calculations are performed step by step: number of students starting the 2nd year of medical schools: two basic hypotheses are adopted as concerns the future intake decided by the government, 8000 and 6000 (Table A) from the numerus clausus barrier (2nd year of medical training) to the 6th year of medical training from the 6th year to graduation (the residency period) from graduation to registering in the Medical Council (effective start of the career) moreover, it is assumed that from 2000 through 2025, for each 5-year period, 1200 foreign medical graduates are allowed to join the national medical workforce; after 2025, this number will decrease to 300. As concerns the outflow l, a "professional life table" is used to determine the numbers of doctors of each age-group who leave the career by death, retirement, outmigration ... during each 5-year period (Table B). CONTEXT: From 1965 onwards, the number of students entering the medical schools grew steadily. The numerus clausus system, established in 1972, became effective five years later. However, due to resistance to change, the number of students allowed to start the 2nd year of medical schools reached a really low level only at mid-80's. In other words, during the period 1974-1994, France experienced a significant "graduate boom". The young doctors graduated during these two decades were in extremely high numbers and fueled a strong feeling of manpower oversupply. But from mid-90's onwards, the annual number of new graduates decreased (as a result of the low numerus clausus decided from mid-80's). In hospitals, post vacancies became frequent. In ambulatory care, medical practitioners encountered great difficulties to find locum tenens. From 2000 onwards, the term of manpower shortage was openly evoked in public debates. Starting 1999, the authorities increased again the numerus clausus which reached 5100 in October 2003. The mood was in favor of an upward trend. As a matter of fact, the numerous physicians graduated during the 1974-1994 boom period will begin to retire around the year 2010 and the French medical profession would sharply decrease without a vigorous growth of the numerous clausus. As started above, this projection work adopts two basic hypotheses as concerns the numerus clausus: the number of medical students allowed into the 2nd year, will progressively increase in October 2007 either to 6000 or to 8000 and will remain constant later on. RESULTS: With a 8000 student intake, the number of physicians (200,800 in 2000) will increase to 209,300 in 2010 then will slowly decrease to 205,900 in 2030. After, it will grow again and reach 229,500 in 2050. With a 6000 student intake, the number of physicians will also increase to 209,300 in 2010, then will rapidly decrease to 173,700 in 2030. The downward trend will stop in 2035. After, a slow growth will take place and the medical profession will number 173,500 in 2050 (Table C and Fig. 1). In other words, if a numerus clausus of 8000 is decided, the large retirement of the 1974-1994 graduate boomers (during the period 2010-2030) will be nearly offset by the newcomers. At the same time, the aging of the medical workforce will be stopped. Instead, a new younging process of the medical profession will take place again after 2020 (Fig. 2 and Fig. 3). As it was the case during the early 70's, the younging process or pouring in of new graduates in great numbers may possibly fuel a strong perception of oversupply and lead to a sharp decrease of the numerus clausus after 2020 (sec variants Ib, Ic, IIb, IIc in Table A and C). As the numerus clausus has been increased during the first decade of the century, the two opposite moves (upward and downward) will create once again a phenomenon of "graduate boom". The boom will be far more important with a student intake of 8000 (Table F and Fig. 5) than a student intake of 6000 (Table G and Fig. 7). Even with 8000 students, the boom will not appear if the intake (numerus clausus) is not decreased after 2020. Consequently, if the decision is made today to increase sharply the student intake, we should be sure not to have to decrease it strongly in two or three decades. A less important increase decided today will not totally fill the gap when those graduated during the period 1974-1994 will retire and the national number of physicians will diminish. But such a decision will probably avoid the appearance of a feeling of oversupply in the coming decades and its subsequent problems (decreased student intake and, a decade later, a new graduate boom).

Adult↗

Place of residence as a health resort for rheumatic patients.

This paper deals with institutional aspects of health promotion in relation to a research programme comprising five projects currently in operation in various regions of the Federal Republic of Germany. The aim of these projects, which are supported at the federal level, is to provide locally based, interdisciplinary care for rheumatic patients throughout the course of the disease. Different organizational means are applied by the different projects to realize these goals. The project described here started in 1985 in Unna, a small town of some 60,000 inhabitants located in the Ruhr area. It involves intensive efforts in health promotion, the aim being to firmly establish self-help activities in everyday life. The following gives an overview of the project, its objective, structure and programme--especially the "cure seminars" organized on an outpatient basis--and some of the difficulties encountered with regard to practical implementation and the long-term provision of health-oriented care. The last part of the paper deals with the research component of the model.

Arthritis, Rheumatoid↗

The genes of Na,K-ATPase, a selfreview.

The review is devoted to analysis of research carried out in the author's laboratory on structure-function relationships in genes coding for Na,K-ATPases. Also considered are problems related to molecular evolution of ion-transporting ATPases. This brief review is devoted to a fragment of research carried out in my laboratory, the Laboratory of Human Genes Structure and Function at the Shemyakin Institute of Bioorganic Chemistry, USSR Academy of Sciences. The area of the review may be named as structural-evolutionary analysis of functional anatomies of genes. The approach is fairly standard and its essence was formulated long ago: evolution decides 'to be or not to be' based on usefulness or lack of it. The elements of genes that are important for the gene function are retained in the course of evolution, and a comparison of genes having similar functions in different species should, hopefully, reveal different behavior of gene blocks, conservation of functionally significant blocks and variability of less significant or insignificant ones. An approach like this has been widely used in comparing proteins. However, a study of genes gives the investigator yet another tool of structural and evolutionary import: the exon structure may be relevant to the gene's evolutionary history, with exons corresponding to the functional domains (arguments for and against this fascinating hypothesis have been reviewed by Blake (Blake, 1985). However, even if the exon-domain correlation does not hold in the general case, a similarity in the exon-intron pattern of genes from different species is indicative of their common evolutionary origin and is enforcing the logic of variability analysis, provided, of course, that the compared genes have a common predecessor. A few years ago we employed this approach to analyze the functional structure of genes coding for subunits of bacterial DNA-dependent RNA polymerases and constructed functional maps of the enzyme. After that, a similar study of Na,K-ATPase genes to be reviewed here was started. The entire project became possible through collaboration with the lab of Dr. N. N. Modyanov, an eminent specialist in protein chemistry who had already accumulated considerable information on Na,K-ATPase from pig kidneys by that time. I would also like to stress that the work has been started on the initiative of the deceased Director of the Institute, Yu. A. Ovchinnikov. Since this is a self-review, I am asking my colleagues whose work will not be cited here to excuse me.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

Implementation of the project 'Support and Consultation on Euthanasia in The Netherlands' (SCEN).

OBJECTIVE: In the project 'Support and Consultation on Euthanasia in The Netherlands' (SCEN), general practitioners (GPs) receive training in formal consultation and in giving expert advice to colleagues who have questions about euthanasia and physician-assisted suicide (EAS). This study describes the way in which this project was implemented in The Netherlands and how it was received by GPs. METHOD: In the period from April 2000 to December 2002, all GPs in the districts in which SCEN had been implemented received a written post-test questionnaire a year and a half after the start of the project. Registration forms were also filled in by the SCEN physicians and the GPs who contacted SCEN. The post-test questionnaire was returned by 60% of the GPs (n = 3614), and registration forms were returned by 86% (n = 3337) of the GPs who contacted SCEN. RESULTS: The gradual nation-wide implementation of SCEN was completed within the 4-year study period. Almost all GPs were familiar with the project (99%) and most GPs knew what they could contact SCEN for. Most GPs felt supported by the presence of SCEN, and most GPs also had a positive attitude towards consultation and SCEN. GPs who had received an explicit request for EAS, or had performed EAS, often consulted SCEN physicians (71 and 85%, respectively). Reasons for contacting SCEN were: independence (60%), expertise (58%), and accessibility/availability of a consultant (45%). Reasons for not contacting SCEN were: enough other possibilities for counselling and consultation (48%) only at the beginning of the decision-making process (36%), and sufficient knowledge about EAS (22%). Most GPs intended to use SCEN in the future (96%). CONCLUSION: The implementation of SCEN has been successful, according to the four steps for successful implementation: awareness, attitude, use and future use. In this respect, linking up with existing networks and good organisation may play an important role. Furthermore, GPs consider it important to have a facility like SCEN which they can contact concerning EAS.

Attitude of Health Personnel↗

Atlas of pesticide concentrations in Dutch surface waters: a pilot study.

A pilot study was conducted to explore the potential for geographically mapping concentrations of individual pesticides in Dutch surface waters and compiling these maps into a National Pesticide Atlas. This atlas could be used for various purposes: 1) To see where specific pesticides are monitored, observed and find out whether these are problematical. 2) To explore the relationship between environmental pesticide levels and land use, using the results as feedback to improve national pesticide admission procedures (post-registration review) 3) To review the quality of the present Dutch pesticide monitoring system. For the study we used measured data for the years 1997 and 1998, preparing maps for six illustrative pesticides. The data are presented on a grid scale of 5x5 km2. Pesticide concentrations are compared with three standards: the EU drinking water standard, the maximum tolerable risk (MTR) level and the admission standard set by the Dutch Pesticide Admission Board (CTB). The results show that all these pesticides can be satisfactorily mapped at the national level and that for most of the compounds investigated a useful relationship can be established between environmental concentration and land use. The maps also serve to show up gaps in the present pesticide monitoring system. The study yielded several new insights, among them that standards were found to be exceeded in areas and at times of the year not anticipated on the basis of land use and pesticide use statistics. As a follow-up to this pilot study a new project has been started to develop an internet version of the pesticide atlas for all measured pesticides in The Netherlands.

Environmental Monitoring↗

Identification of novel homologues of three low molecular weight subunits of the mitochondrial bc1 complex.

Large-scale random cDNA sequencing projects have been started for several organisms and are a valuable tool for the analysis of quantitative and qualitative aspects of gene expression. However, the reliability of the obtained data is limited as most of the clones are only partially analysed on one strand. As a consequence the sequence entries derived from random cDNA sequencing projects usually comprise incomplete open reading frames. They nevertheless define complete and reliable coding sequences, if two prerequisites are fulfilled: (i) the clones encode very small proteins, and (ii) the clones have a high frequency in the cDNA-banks. The present study describes the use of cDNA databases for the identification of homologues of three low-molecular-weight subunits of the mitochondrial bc1 complex, termed the QCR6, QCR9 and QCR10 proteins. These polypeptides are only characterized for a small number of organisms, have a scarcely defined function and exhibit a low degree of structural conservation if compared between different species. Several clones were identified for each polypeptide by searches with TBLASTN using the known sequences as probes. Most of the database entries contain complete open reading frames and sequencing queries could be excluded due to the abundancy of the clones. Multiple sequence alignments are presented for all three polypeptides and consensus sequences are given which may provide a basis for the investigation of the proteins by site-directed mutagenesis.

Animals↗

DIABCARE Quality Network in Europe--a model for quality management in chronic diseases.

The DIABCARE Q-Net project developed a complete and integrated information technology system to monitor diabetes care, according to the gold standards of the St Vincent Declaration Action Program. This is the first Telematic platform for standardized documentation on medical quality and evaluation across Europe, which will serve as a model for other chronic diseases. Quality development starts from the comparison of diabetes services, based on the key data on diabetes care in the basic information sheet. This is a 141 field form, which is to be completed once a year for each patient under the care of the diabetes team. The system performs an analysis of the local data and compares the data with peer teams by means of telecommunication of anonymous data. These data are collected regionally. At the next level these regional data are compared on a national basis across Europe using dedicated communication lines. National data can be compared transnationally by the use of the Internet and the DIABCARE benchmarking servers. These different lines are used according to the necessary security standards. Medical data are transferred via dedicated lines, aggregated data via the Internet. The architecture follows the open-platform concept in order to allow for heterogeneous technical environments. Already at the start of the project, the necessity for expanding the quality approach to telemedicine methodology was identified and included. For each level, specific programs are available to improve the performance of diabetes care delivery: DIABCARE data as client and DIABCARE server as regional and DIABCARE 'international server' as transnational server. Functioning pilots were established across all levels. The clients have been linked to the servers on a routine basis. According to the open architecture design, the various countries decided on different systems at the entry point: full system--Portugal; fax systems--Italy, Bavaria; implementation into doctor's office systems--Norway; paper forms and chip cards--France. This system can improve the local, regional and national diabetes care. Initiatives in several countries proved the feasibility of the system. The most extensive use, from Portugal, will be reported later in this paper. The exploitation of the DIABCARE Q-Net system will be performed with the DIABCARE International European Economic Interest Grouping as a co-ordinator and several commercial companies as contractors to market the products inside the system. The key project participants are: DIABCARE Office EURO, DIABCARE Portugal, DIABCARE France, DIABCARE Bavaria, DIABCARE UK, DIABCARE Netherlands, DIABCARE Norway, DIABCARE Italy, DIABCARE Sweden, DIABCARE Austria, DIABCARE Spain, GSF Research Centre for Health and Environment, FAST Research Institute for Applied Software Technology, Tromsø University Hospital, Stavanger Technical College, Technical University of Ilmenau, World Health Organisation (WHO), Regional Office for Europe.

Benchmarking↗

Caries reduction by milk fluoridation in Bulgaria.

The aim of the present study has been to investigate the caries-reducing effect of a community-based milk fluoridation project. In those Kindergartens where fluoridated milk had been delivered on a regular basis, the estimated consumption corresponded to a daily intake of 200 mL milk containing 1 mg F- (5 ppm F-) for periods of 180-200 days per year. A total of 204 six-year-old children, randomly selected, was examined at baseline and three and a half years after the start of the project. A statistically significant reduction in the prevalence of dental caries was obtained for those children who had received fluoridated milk on a regular basis. In six-year-old children, the reduction in the dmft figure was 40% and in the DMFT figure, 90%. Despite the deficiencies in the design of this study (dictated by local circumstances), the results confirm the findings of other studies on the caries-reducing effect of fluoridated milk. The results also confirm that the earlier in the child's life the consumption of fluoridated milk starts, the better the effect.

Age Factors↗

Sensible human projects: haptic modeling and surgical simulation based on measurements of practical patients with MR elastography--measurement of elastic modulus.

To provide realistic surgical simulation, 3D visualization and haptic feedback are important. In the existing surgical simulators, the fidelity of the deformation and haptic feedback is limited because they are based on the subjective evaluation of the expert-user and not on an objective model-based evaluation. To obtain accurate elastic modulus of whole human tissues, we have started a new project called the Sensible Human Project (SHP). This paper deals with establishing the measurement of elastic modulus by the magnetic resonance elastography (MRE) technique, as a first step of the SHP Project.

Computer Simulation↗

Multidisciplinary guidelines in Dutch mental health care: plans, bottlenecks and possible solutions.

PURPOSE: This article describes the Dutch 'Multidisciplinary Guidelines in Mental Health Care' project and its first products (multidisciplinary guidelines on depressive and anxiety disorders). CONTEXT OF CASE: In the early 1990s, disciplines in Dutch mental health care formulated their first monodisciplinary guidelines, which disagreed on essential features. In 1998, the Dutch government invited representatives of the five core disciplines in mental health care (psychiatrists, general practitioners, psychotherapists (clinical), psychologists and psychiatric nurses) to start a joint project aimed at the development of new integrated multidisciplinary guidelines. DATA SOURCES: The vision document, presented in 2000 by the five core disciplines, describes the directions for the development of new guidelines. The guidelines on depressive and anxiety disorders will appear in 2004. CASE DESCRIPTION: The first draft guidelines were presented in May 2003, in line with the vision document (2000). However, it is still not certain whether they will be authorised by all professional groups. Some disciplines do not recognise themselves in these guidelines. It is argued that these problems can be attributed at least in part to the evidence-based method that was used in drafting the guidelines. Interventions are compared on the basis of their 'level of evidence', the consequence of which is that cognitive behavioural therapy and drug treatment are almost always seen as the only appropriate interventions. Other interventions are excluded because of their lower level of evidence. CONCLUSIONS AND DISCUSSION: The conclusion is that guidelines cannot be based on empirical evidence alone. It is argued that the collective sense of professions involved should also be integrated into the guideline, for example in relation to goal differentiation. It is finally argued that multidisciplinary guidelines must also offer a hierarchy between those goals, i.e. a vision of the appropriate type of care and the order in which the various care components should be administered.

Journal Article↗

The cognitive development of pre-school children treated for chronic renal failure.

Chronic renal failure in young children is associated with impaired cognitive development, but recent studies present a more optimistic perspective. An important question is whether the earlier initiation of renal replacement therapy (RRT) might prevent the reported developmental retardation. The cognitive development of 31 patients (age < 5 years with a serum creatinine clearance of < 20% of normal) undergoing different treatment modalities was monitored by repeated measurements during a prospective 3-year study. Fifteen patients received conservative treatment and 16 patients were on dialysis treatment at the start of the project. We were able to evaluate the effect of the onset of RRT on 12 patients who were transferred from conservative treatment to dialysis. At the beginning of the study, the cognitive development of the total group was significantly delayed (mean developmental index = 78.5, SD = 19.5) compared with a normal population. Patients undergoing conservative treatment scored significantly higher (P < 0.01) than those on dialysis. The effect of starting dialysis treatment appeared to be positive, but only a significant short-term improvement was observed. Follow-up evaluation of 7 patients on conservative treatment and of 9 dialysis patients over a 2-year period did not show any significant change in a positive or negative direction. The present study revealed that pre-school dialysis patients are at risk with respect to their cognitive development. This is particularly true for the group with concomitant disorders. Less severe disease in the group on conservative treatment may be assumed to be a positive contributing factor to the more normal performance of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomarkers↗

Effects of dietary seal oil on fat metabolism.

In the 1970s, Bang and Dyerberg demonstrated that a high intake of n-3 acids in Greenland protected against ischemic heart disease. This started the interest in fish oil as a preventive component in cardiac disease. The fatty acid composition in Greenlandic diet is quite different from the one in the Danish diet, being lower in saturated fatty acids and polyunsaturated fatty acids (PUFAs) and higher in monounsatured fatty acids (MUFAs). During the last decade, evidence has suggested that the MUFA (18:1) is not a neutral dietary component but has a positive effect of its own. This paper reports on a current project undertaken to study the effect of marine MUFAs and PUFAs on atherosclerosis-related parameters and to evaluate their possible synergistic effect in the prevention of atherosclerosis. The project has recently started, so at the moment results cannot be presented. The study will be carried out as an intervention study on 50 healthy volunteers. Capsules of Greenlandic halibut oil (rich in MUFAs) and "Biomarin" (rich in n-3 PUFAs) will be tested against seal oil.

Adult↗

The role of computerized ECG interpretation in clinical trials.

The Lipid Research Clinics project consisted of the Prevalence Study and the Coronary Primary Prevention Study. The first study characterized the levels of blood lipids in the population studied, and related these to the presence of coronary artery disease as detected by medical history, symptom analysis, resting ECG and treadmill exercise ECG tests. The prevention trial tested whether a reduction of elevated serum cholesterol would reduce the incidence of coronary events (Table I). Both projects collected resting 12-lead ECGs and treadmill exercise test data on the participants. Instrumentation and methodology were standardized. Rest and exercise electrocardiographic data were recorded on analog magnetic tape. Tapes were sent to the ECG Center where they were digitized, analyzed and also reproduced for visual analysis according to the Minnesota Code of Blackburn. There were two reasons for using both visual coding and computer analyses in these projects. It was thought that computer methodology would enhance the accuracy of the electrocardiographic data, but on the other hand its accuracy had not been adequately documented and its output statements were not in the language of the Minnesota Code, which is traditionally accepted by epidemiologists. The other and more pressing reason for using the Minnesota Code is that the computer programming had not been completed at the start of the project, and visual coding was required in order to provide the ECG data necessary for the randomization of the Prevention Trial participants.

Clinical Trials as Topic↗

Study of the role of breast self-examination in the reduction of mortality from breast cancer. The Russian Federation/World Health Organization Study.

The protocol of a study, sponsored by the World Health Organization, of the role of breast self-examination (BSE) in reduction of mortality from breast cancer is presented. The major objective of the study is to determine the effect of a BSE programme on mortality from breast cancer. A population of of over 193,000 women aged 40 to 64 has been defined in Moscow and St Petersburg and randomised to study and control groups. In Moscow the education programme is based on a two-way communication principle allowing efficient person-to-person education in groups of up to 20 individuals and feedback information through specially designed personal calendars. In St Petersburg, class and individual instruction is carried out. After a 1-year feasibility study the project is planned to last for 15 years. It consists of an aggressive education programme, during and following which, all newly diagnosed breast cancers will be registered and treated, and followed up for 3 to 15 years. A key issue of the study is compliance of the population with BSE. The frequency and competence of BSE practice has been defined in subsamples of 400 randomly selected women by means of surveys at 6 months, 1, 2 and 3 years after the start of the project. The study is expected to result in the accrual of more than 1470 new breast cancer cases and 778 deaths from breast cancer. The power of the study is expected to permit detection of a 30% reduction in cumulative breast cancer mortality, assuming that 50-70% of the women in the study group practise BSE.

Adult↗

[Combined outpatient alcoholism therapy and occupational rehabilitation on welfare recipients--results of a pilot study].

This study tested the feasibility of outpatient abstinence treatment among alcohol dependent subjects on welfare. Patients had a long history of alcohol dependence and prolonged unemployment. Over a period of six months a total of 250 patients were approached by the social welfare office and asked to participate in the program. The program involved detoxification and a three month combined alcohol treatment and personal job training. Of the 250 persons approached 96 patients (about 40 %) appeared for the initial examination, 19 patients (13 %) finished detoxification and a total of 5 patients completed the program. The majority of a group of patients considered to be highly therapy resistant did not complete the program. Still it was important to demonstrate that a subgroup of patients did successfully complete this program. We consider this pilot project a successful starting point for further development of treatment approaches targeted more specifically at this group of patients.

Adult↗

The effect of a national control of diarrheal diseases program on mortality: the case of Egypt.

The National Control of Diarrheal Diseases Project (NCDDP) of Egypt began in 1981, became fully operational nation-wide by 1984, and concluded in 1991. The project was designed as a campaign to lower mortality from diarrheal disease in children under five by at least 25% within five years. The principal strategy employed was to improve case-management of diarrhea through rehydration and better feeding: through assured production and distribution of oral rehydration salts, education of families through mass media and health workers through training programs, and creation of rehydration corners throughout the established primary health care and hospital network. A detailed plan for evaluation and research was designed at the start of the project. By its own terms, the NCDDP appears to have succeeded in improving case management; by several local and national mortality surveys, overall infant and childhood mortality fell by at least one-third with the majority proportion in diarrheal deaths. The declines coincided with the peak of NCDDP activities and results in improved case-management. The detailed analyses of this monograph seek to demonstrate that: (a) the mortality decline and the diarrheal mortality decline in particular were actual events; (b) that case-management improved with plausible sufficiency to account for most of the diarrheal mortality reduction; and (c) that changes in other proximate determinants to lowered mortality, such as host resistance or diarrheal incidence, do not plausibly account for the magnitude of the reductions seen. Data are also presented on general socio-economic changes in the decade of the Project. We conclude that improvements in primary care delivery and the use of mass media would have been facilitating factors to NCDDP efforts, while the overall deterioration of economic status would have tended to reduce the benefits. The monograph details the strengths and weaknesses of the available data, and also makes recommendations for sustained efforts in the control of diarrheal diseases.

Causality↗