597

Health in NepalThe work of the Britain-Nepal Medical Trust (BNMT) to providehealth services to the Nepali people is now in its 21st year.According to the trust’s 1989 annual report,! the rebuilding andrepair of damaged hostels, clinics, and hospitals after the earthquakein August, 1988, is almost complete. But another obstacle arose lastApril when the trade and transit treaty between Nepal and Indiaexpired: India has closed its borders with Nepal for the passage ofalmost all goods, although drug supplies have not yet been affected.The resulting fuel shortage has led to transport difficulties, whichhave had a serious effect on Nepal’s economy and development.Furthermore, people in the cities are using more firewood, whichincreases the already excessive deforestation. Training programmesin Kathmandu and Dharan have been cancelled, but work in thehills has been unaffected, since most transport there is fuel

independent. Despite these setbacks the tuberculosis programme,which forms the bulk of BNMT’s work, is continuing successfully,and progress is being made in the drug supply and communityhealth programmes. The female literacy programme was completedin Dhupu and Kharang and was started in other areas, and trainingcourses were run to train literate women to teach fellow villagewomen to read and write. That these courses were almost entirelyplanned and run by Nepali field staff shows that the trust’s aim tohelp people help themselves is being fulfilled.

1. Britain-Nepal Medical Trust. 21st annual report, 1989. Available from the trust atStafford House, 16 East Street, Tonbridge, Kent TN9 1HG, UK.

Alcohol in the workplace

Many employees-perhaps as many as 1 in 10, according to AlcoholConcem-regularly attempt to carry out skilled tasks or makeimportant decisions while under the influence of alcohol or

struggling with a hangover. Moreover, twice as many days are lostthrough alcohol-related absenteeism as through strikes. Drinking,even (or especially) "social" drinking, is clearly a sizeable problemfor employers, and Alcohol Concern has now set up a WorkplaceAdvisory Service for those who want to introduce an alcohol policyand will tailor a programme to an individual company’s needs. Atypical programme might include a presentation for senior

management explaining the value of an alcohol policy; help withplanning and implementing an alcohol policy; educational materialabout alcohol for the workforce; training for those who will run theprogramme; and access to counselling services to which employeeswith an alcohol problem can be referred.

Further information can be had from the Workplace Advisory Service,Alcohol Concern, 305 Gray’s Inn Road, London WC1F 8QF, UK(telephone Ol-833 3471).

Nutrition and drugsDiet and nutritional status can affect the absorption, binding,distribution, metabolism, and excretion of a drug. Dosage schedulesprescribed by manufacturers (who usually have a well-nourishedpatient population in mind) may need to be modified forundernourished patients. This is one of the main conclusions of DrKamala Krishnaswamy in a review of recent studies of nutrition anddrug metabolism in India.l The effects of malnutrition are by nomeans consistent or predictable. Food can either enhance ordiminish drug absorption (Krishnaswamy reports treatment

failures with tetracycline as a result of reduced absorption), drugprotein binding (and hence volume of distribution) can be higher(eg, propranolol) or lower (tetracycline) in malnourished patients,and chronic nutritional deficiencies can both decrease and increase

enzyme activity. Undernourished populations are also more

susceptible to the toxic effects of chemicals and potentialcarcinogens-an argument, if one is needed, for greater concernabout environmental pollution. Drug-induced nutritional disordersmay further complicate and compound the problem. Dr

Krishnaswamy calls for further research, since these importantaspects of drug therapy are neglected.

1. Krishnaswamy K. Nutrition and drug metabolism: a review of recent Indian studies.NFI Bull 1990; 11: 1-4.

Drawing criticism

Newspaper editors recognise the worth of a skilled cartoonist;authors of research articles have long been wedded to the maximthat an illustration is often more valuable than a page of text; anddoodles left on the telephone pad can speak volumes, even whenthey are no more than closely packed "isobars" (for mother-in-law ?). Yet seldom have teachers had the courage to ask students torate lectures in artistic terms. The pluck of Hasekura and

colleagues1 at the Department of Legal Medicine, Shinshu

University School of Medicine, Japan, is therefore all the moreremarkable. Having noted that Japanese medical students

commonly find the medical ethics course dull to the point ofhypnosis, the lecturers issued their pupils with attendance cards andinvited them to illustrate their impressions of the lectures. Moststudents responded frankly and seemed prepared to draw criticismsthat they would have been loath to voice, sometimes incorporatingcharacters from popular television programmes that were

unfamiliar to their mentors. If lengthy explanations that go againstthe spirit of the scheme are to be avoided, other teachers who adoptthis approach will presumably find themselves boosting theaudience ratings for Dallas.

1. Hasekura H, Fukushima H, Hiraide K. Evaluation of lectures on medical ethicsthrough students’ drawings. Med Educ 1990; 24: 42-45.

Hearty memories

If you enjoy the weekly antics of the In England Now columns ofThe Lancet, then you should add Myocardial Medley1 to yourreading list. This new anthology has been compiled with some ofthe manuscripts submitted by family doctors in a competition forhumorous writing about the heart. These anecdotes, based onpersonal experiences, include descriptions of the tools of the trade,recollections of student days and general practice, and poemsadapted from children’s nursery rhymes. Why do doctors wearstethoscopes? The suggestions are that, apart from the usual clinicaluses, the instrument is donned to impress student nurses, to winmore respect from the public and patients, to influence policeofficers (especially when guilty of a driving misdemeanour), or evento trace faults in car engines. And of course no doctor gets it rightevery time. For example, there was Dr D, who misdiagnosed hisown severe chest pain as a heart attack when a wasp sting would havesufficed, and the anaesthetist who banned the wearing of nailvarnish in theatre when he mistook a patients fashionable purplenails for cyanosis. And a healthy heart is yours if you take thefollowing advice:

"Curly Locks, Curly Locks, wilt thou be mine?Thou shalt not eat junk food, nor drink beer nor wine,But do thine aerobics in catsuit of silk,And dine upon muesli, stewed prunes and skimmed milk."

1. Myocardial medley. Gray IR, ed. Oxford: Radcliffe Medical Press, 1990. ISBN1-870905-36-9. £5.95. Pp 121.

Parasitology Research Centre at Imperial CollegeThe Wellcome Trust has awarded C4 million to support a newresearch centre in parasitic diseases at London’s Imperial College ofScience, Technology, and Medicine. Research at the new centrewill concentrate on diseases caused by parasitic worms, particularlywhy these infestations persist in the face of immunological attack.The centre will be directed by Prof R. M. Anderson, FRS.