Economic and non-economic determinants of Iranian pharmaceutical companies' financial performance: an empirical study.

BACKGROUND: The pharmaceutical industry in Iran is influenced by various parameters such as internal factors caused by the financial information of each economic unit and external factors including major economic and non-economic variables. METHODS: This study is aiming to examine the effect of such variables on the stock return of 34 pharmaceutical companies in the Tehran Securities Exchange market using quarterly data from 1995 to 2016. In this research, an autoregressive model was utilized to examine the way that variables affect the stock market index. In such patterns, there is no need for explicit short-term structural relationships and structural knowledge is extracted from causal relationships. Finally, to analyze the results, impulse-response functions, forecast error variance, and historical decomposition were collected. RESULTS: Results of this research show that positive shock to the variables, namely the currency rate, collection period of quests, and healthcare costs lead to a decrease in the return of pharmaceutical companies. On the other hand, a positive shock to the variables such as GDP, and money volume, leads to an increase in the stock return of pharmaceutical companies. CONCLUSION: Different factors contribute to the stock return of pharmaceutical companies. Among the variables examined in this study, market currency rate, money volume, pharmaceutical sector inflation, bank interest rate, GDP in the healthcare sector, healthcare costs, and collection period of quests have the most effect on describing changes within the stock return of pharmaceutical companies.

Converging or diverging trajectories of mortality under one year of age in the Baltic States: a comparison with the European Union.

BACKGROUND: Information about trends in perinatal and child health inequalities is scarce, especially in the Eastern Europe. We analyzed how mortality under 1 year of age has been changing in the Baltic States and the European Union (EU) over 25 years, and what associations occurred between changes in macroeconomic factors and mortality. METHODS: Data on fetal, neonatal, infant mortality, and macroeconomic factors were extracted from WHO database. Joinpoint regression analysis was performed to analyze time trajectories of mortality over 1990-2014. We also investigated how the changes in health expenditures and Gross Domestic Product (GDP) contributed to the changes in mortality. RESULTS: The reduction of fetal, neonatal and infant mortality in the Baltic countries led to convergence with the EU. In Estonia this process was the fastest, and then the rates tended to diverge. The strongest effect in reduction of neonatal mortality was related to the annual increase in health expenditure and GDP which had occurred in the same year, and a decrease in fetal mortality associated with an increase in health expenditure and GDP in the 4th and 5th year, respectively, following the initial change. CONCLUSIONS: These findings outlined convergences and divergences in mortality under 1 year of age in the Baltic States compared with the patterns of the EU. Our data highlighted a need to define health policy directions aimed at the implementation of effective intervention modalities addressing reduction of risks in prenatal and early life.

Testing for multiple bubbles in the copper price: Periodically collapsing behavior.

This study investigates whether multiple bubbles exist in the copper price on the basis of the Generalized Supremum Augmented Dickey-Fuller (GSADF) approach (Phillips et al., 2013). This technique delivers date-stamping strategies for the emergence as well as collapse of explosive bubble episodes and is best suited for practical application to time series. The results reveal that four explosive bubbles are detected over the period of 1980-2019 when copper price deviates from fundamental value. Besides, this finding is in accordance with the asset pricing model (Gürkaynak, 2008), which generally considers both fundamental and bubble components in the presence of asset prices. Based on the empirical results, the multiple emergence and collapse of multiple price bubbles are attributed to speculation, depreciation of the U.S. dollar, an imbalance between supply and demand, and financial crises. Policymakers should actively recognize bubble episodes and monitor their evolution, which could be conducive to achieving the effective stabilization of the international copper price. To reduce excess price fluctuations and explosive copper bubbles, authorities should impose restrictions on excessive speculative behaviors under extreme market conditions.

Impact of the Economic Downturn on Elective Lumbar Spine Surgery in the United States: A National Trend Analysis, 2003 to 2013.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: The impact of the 2008-2009 economic downtown on elective lumbar spine surgery is unknown. Our objective was to investigate the effect of the economic downturn on the overall trends of elective lumbar spine surgery in the United States. METHODS: The Nationwide Inpatient Sample (NIS) was used in conjunction with US Census and macroeconomic data to determine historical trends. The economic downturn was defined as 2008 to 2009. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), were used in order to identify appropriate procedures. Confidence intervals were determined using subgroup analysis techniques. RESULTS: From 2003 to 2012, there was a 19.8% and 26.1% decrease in the number of lumbar discectomies and laminectomies, respectively. Over the same time period, there was a 56.4% increase in the number of lumbar spinal fusions. The trend of elective lumbar spine surgeries per 100 000 persons in the US population remained consistent from 2008 to 2009. The number of procedures decreased by 4.5% from 2010 to 2011, 7.6% from 2011 to 2012, and 3.1% from 2012 to 2013. The R2 value between the number of surgeries and the S&P 500 Index was statistically significant (P ≤ .05). CONCLUSIONS: The economic downturn did not affect elective lumbar fusions, which increased in total from 2003 to 2013. The relationship between the S&P 500 Index and surgical trends suggests that during recessions, individuals may utilize other means, such as insurance, to cover procedural costs and reduce out-of-pocket expenditures, accounting for no impact of the economic downturn on surgical trends. These findings can assist multiple stakeholders in better understanding the interconnectedness of macroeconomics, policy, and elective lumbar spine surgery trends.

Feminist group plans "economic pressure campaign" for access to RU 486.

PIP: A grant for $10 million has boosted the efforts of the Feminist majority Foundation, a Boston activist group committed to bringing RU-486 into the US. The group is planning to research the corporate structure of Hoechst, A.G., the owner of Roussel-Uclaf, and that of its US subsidiary Hoechst Celanese Corporation of Somerville, NJ. Ultimate strategies may include a boycott of Hoechst products in the US, formation of a consortium of small pharmaceutical companies, or of a feminist pharmaceutical firm to research and develop RU-486 or other antiprogestins for the US. The Hoechst Company denies any connection to Roussel-Uclaf. Meanwhile, US researchers have organized in some states to encourage research on the drug, and a bill has been introduced to force the US Food and Drug Administration to lift its ban on importation. An opposition bill to ban importation of RU-486 for any purpose including research has also been introduced by right-to-life forces. New research is underway to test the antineoplastic effects of RU-486 on breast cancer in Canada, and on meningioma in California.^ieng

Epidemiology of cervical cancer by cell type.

A multicenter case-control study of 481 invasive cervical cancer patients and 801 population controls enabled comparison of risk factors for squamous cell tumors (n = 418), adenosquamous cancers (n = 23), and adenocarcinomas (n = 40). The epidemiology of the squamous cell tumors resembled that found in other studies, with the major risk factors being absence of Pap smear screening (relative risk = 3.6 to 4.8 for those not screened within 5 yr), multiple sexual partners (relative risk = 2.9 for over ten partners), and history of genital infections or sores (relative risk = 2.3). Although based on small numbers, adenosquamous tumors appeared to share some of these risk factors, notably number of sexual partners, years since last Pap smear, and level of education. Adenocarcinomas were not similarly affected, although sexual practices were marginally predictive. Obesity increased the risk of adenocarcinoma, but no other similarities to endometrial adenocarcinoma were observed. Smoking was a significant predictor of squamous cell tumors but did not affect adenocarcinomas. Extended use of oral contraceptives was a risk factor for all tumor types, especially adenocarcinoma, and a familial tendency to cervical cancer was also observed for all cell types.

Impact of the Economic Downturn on Elective Cervical Spine Surgery in the United States: A National Trend Analysis, 2003-2013.

OBJECTIVE: To analyze overall trends of elective cervical spine surgery in the United States from 2003 to 2013 with the goal of determining whether the economic downturn had an impact. METHODS: Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification were used to identify elective cervical spine surgery procedures in the Nationwide Inpatient Sample from 2003 to 2013. National Health Expenditure, gross domestic product, and S&P 500 Index were used as measures of economic performance. The economic downturn was defined as 2008-2009. Confidence intervals were determined using subgroup analysis techniques. Linear regressions were completed to determine the association between surgery trends and economic conditions. RESULTS: From 2003 to 2013, posterior cervical fusions saw a 102.7% increase. During the same time frame, there was a 7.4% and 14.7% decrease in the number of anterior cervical diskectomy and fusions (ACDFs) and posterior decompressions, respectively. The trend of elective cervical spine surgeries per 100,000 persons in the U.S. population may have been affected by the economic downturn from 2008 to 2009 (-0.03% growth). The percentage of procedures paid for by private insurance decreased from 2003 to 2013 for all ACDFs, posterior cervical fusions, and posterior decompressions. The linear regression coefficients (ß) and R2 values between the number of surgeries and each of the macroeconomic factors analyzed were not statistically significant. CONCLUSIONS: The overall elective cervical spine surgery trend was not likely impacted by the economic downturn. Posterior cervical fusions grew significantly from 2003 to 2013, whereas ACDFs and posterior decompressions decreased.

Macro influencers of electronic health records adoption.

While adoption rates for electronic health records (EHRs) have improved, the reasons for significant geographical differences in EHR adoption within the USA have remained unclear. To understand the reasons for these variations across states, we have compiled from secondary sources a profile of different states within the USA, based on macroeconomic and macro health-environment factors. Regression analyses were performed using these indicator factors on EHR adoption. The results showed that internet usage and literacy are significantly associated with certain measures of EHR adoption. Income level was not significantly associated with EHR adoption. Per capita patient days (a proxy for healthcare need intensity within a state) is negatively correlated with EHR adoption rate. Health insurance coverage is positively correlated with EHR adoption rate. Older physicians (>60 years) tend to adopt EHR systems less than their younger counterparts. These findings have policy implications on formulating regionally focused incentive programs.

AIDS: costs of care in the developed and the developing world.

PIP: The costs of care for AIDS patients in developed and developing countries, expressed in patient-years and in patient lifetimes, as well as by total national costs are analyzed here. In industrialized countries, known as WHO Pattern I countries, the costs of AIDS care is generally proportional to GNP, and has been declining as caregivers learn how to manage the disease. Much of the decline is due to less intensive hospital care and more ambulatory care. Although the U.S. has the highest number of AIDS cases, the countries with the highest rate of disease are Canada (59.2/million), Australia (48.1) and New Zealand (22.4). In the U.S. 92% of patients are male, and 87% are 20-49 years old. In Pattern II countries, the sex ratio is less than 2.0. Cost information is very sparse, especially for children. Some representative lifetime costs for Pattern I countries are $19,000-147,000 in the U.S., $21,000 in France, $40,200 in Germany, $13,400-46,000 in U.K., and $15,800 in Australia. Costs per person-year are generally comparable, depending on whether hospitalization is more or less common in given countries. In the developing world, expenditures are much lower, because of the limited budget for health care available. Although costs tend to be in line with a country's GNP, costs are expected to become more standardized in the future as clinical experience with AIDS treatment increases and costing methodology becomes more uniform. Estimates of AIDS treatment costs for the U.S. in the near future range widely, but range from 1% to 3.3% of the total personal health-care expenditures of the nation. An estimate for Australia predicts $58.5 million by 1991, including hospital expenses only. None of the available costs estimates even deal with the costs of managing HIV-infected persons who have not developed AIDS. Needs in cost estimation methodology are discussed.^ieng

Antiretroviral treatment in Africa.

PIP: Demand for treatment with antiretroviral (ARV) drugs increased in Africa in the wake of the July 1996 AIDS Conference in Vancouver, during which combination ARV treatment including protease inhibitors was shown to dramatically improve the quality and length of life for people with AIDS. However, 1 year after the Vancouver Conference, ARV drugs remain scarce in Africa. Most people treated with antivirals in Africa try to acquire their drugs by ordering them through friends outside Africa or by travelling to Europe or the US. ARV treatment is becoming more complicated and treatment strategies change rapidly. The imbalance between the high price of ARV treatment and the scarcity of resources, competing health care needs, and the continent's weak health care systems all impede the introduction of large-scale ARV treatment in Africa. Nonetheless, if neither governments, organizations, nor industry provide ARV, HIV-infected people, their families, and physicians may try to obtain them through informal channels. Poor quality ARV may then be procured, sold at extremely high prices, and inadequately administered. Indications for ARV treatment, indications of ARV as preventive therapy, and requirements to introduce ARV are discussed.^ieng

Psychological distress, drug and alcohol use as correlates of condom use in HIV-serodiscordant heterosexual couples.

OBJECTIVE: To investigate the relationship between psychological distress, alcohol, drug and condom use in HIV-serodiscordant heterosexual couples. METHODS: Structured interviews were conducted to collect demographic information, detailed data on psychological distress, drug and alcohol use and sexual behavior. RESULTS: Analyses were based on 106 pairs of sexually active discordant couples. Significant differences among heterosexual condom users and non-users varied according to gender and HIV serostatus. Affect domains of interpersonal sensitivity and hostility were significant, as were the variables of regular drug or alcohol use and combining sex with drugs or alcohol. Employment was strongly associated with condom use in HIV-negative women whose regular sexual partners were HIV-positive men. CONCLUSION: The risk of vaginal sex without condoms in HIV-serodiscordant heterosexual couples may be reduced by specific psychological counseling and attention to drug and alcohol use as risk factors. Further research on the effect of employment of HIV-negative women is required.

PIP: The authors investigated the relationship of psychological distress and drug and alcohol use to reported condom use in 106 sexually active HIV-serodiscordant heterosexual couples. Significant differences were found among heterosexual condom users and non-users which varied according to gender and HIV serostatus. Affect domains of interpersonal sensitivity and hostility were significant, as were the variables of regular drug or alcohol use and combining sex with drugs or alcohol. Further, employment was strongly associated with condom use HIV-negative women whose regular sex partners were HIV-positive men. The authors therefore conclude that the risk of vaginal sex without condoms in HIV-serodiscordant heterosexual couples may be reduced by specific psychological counseling and attention to drug and alcohol use as risk factors. Further research is, however, called for on the effect of employment on HIV-negative women.

Risk factors for HIV among prostitutes in Chiangmai, Thailand.

The discovery of a 44% (44 out of 100) prevalence rate of HIV infection among female prostitutes working in brothels in Chiangmai in Thailand in June 1989, prompted this follow-up study in August to confirm the high prevalence rate and to look for risk factors for infection. We studied 238 female prostitutes working in 14 brothels and confirmed this high prevalence rate. Eighty-seven (36.5%) out of 238 prostitutes were found to be HIV-positive by enzyme-linked immunosorbent assay with IFA or Western blot confirmation. Logistic regressions found a significant association between HIV infection and frequency of sexual intercourse greater than 3 times per day [odds ratio (OR) = 2.82, 95% confidence interval (CI) = 1.47-5.41], sexual service charge less than 150 Baht (OR = 9.1, 95% CI = 2.9-33.3), and post sexual cleansing with water alone (OR = 3.85, 95% CI = 1.90-7.80). Of 56 women found seronegative in the June survey, 35 were re-tested in the August study. Seven (20%) of them were seropositive, giving an HIV seroconversion incidence rate of 10% per month. The findings of this study prompted intensive health education programmes among prostitutes, their customers, and owners of brothels.

Decreased incidence of sexually transmitted diseases among trucking company workers in Kenya: results of a behavioural risk-reduction programme.

OBJECTIVE: To establish a cohort of high-risk individuals suitable for HIV-prevention trials, and to measure changes in sexual behaviour and sexually transmitted disease (STD) incidence after a behavioural intervention. DESIGN: Prospective cohort study in trucking company depots in Mombasa, Kenya. PARTICIPANTS: A total of 556 male HIV-seronegative employees of trucking companies. INTERVENTIONS: HIV serological testing, individual counselling, condom promotion, STD diagnosis and management. MAIN OUTCOME MEASURES: Sexual risk behaviour and symptomatic STD incidence. RESULTS: Using time-trend modelling, significant declines in self-reported high-risk sexual behaviour were demonstrated during a 1-year follow-up. The percentage of men reporting any extramarital sex during the 3-month period prior to a follow-up visit decreased from 49% durig the first quarter of follow-up to 36% during the last quarter (P < 0.001). The decline in reported female sex worker contact was from 12% to 6% (P = 0.001). Approximately 30% of men reported consistent condom use during extramarital sex and this percentage remained unchanged during the study period. The incidence of STD declined from 34 per 100 person years (PY) during the first quarter to 10 per 100 PY during the last quarter (P = 0.001). Significant reductions in gonorrhoea (15 to five cases per 100 PY, P = 0.04), non-gonococcal urethritis (10 to two cases per 100 PY, P = 0.05), and genital ulcer disease (nine to two cases per 100 PY, P = 0.02) were observed. CONCLUSIONS: Among truck company workers who participated in a cohort study in Mombasa, Kenya, there was a significant decrease in sex with high-risk partners, but no change in condom use. The change in heterosexual risk behaviour was accompanied by a significant decrease in incidence of gonorrhoea, non-gonococcal urethritis, and genital ulcer disease.

PIP: 556 male HIV-seronegative male employees of trucking companies in Mombasa, Kenya, were exposed to HIV serological testing, individual counseling, condom promotion, and sexually transmitted disease (STD) diagnosis and management, and returned for at least one follow-up visit in a prospective study to measure changes in sexual behavior and STD incidence after the intervention. There was a significant decrease in sex with high-risk partners over the 1-year period of follow-up, but no change in condom use among study participants; 30% of men reported consistent condom use during extramarital sex throughout the study period. The change in heterosexual risk behavior was accompanied by a significant decrease in the incidence of gonorrhea, nongonococcal urethritis, and genital ulcer disease. The percentage of men reporting extramarital sex decreased from 49% to 36%, while contact with female prostitutes declined from 12% to 6%.

Improving sexually transmitted disease management in the private sector: the Jamaica experience.

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60% of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4-month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluated with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre- versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3%; P > 0.05); diagnostics/screening (57.2-71.0%; P= 0.042); treatment (68.3-74.5%; P> 0.05); and knowledge (66.4-83.2%; P= 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8% (P= 0.001), and providing effective treatment for gonorrhea rose from 57.8 to 81.1 % (P= 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4%. CONCLUSION: The introduction of continuing medical education for improved STD care targeting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services, continuing education programs that target the private sector can be successful and should be included as a standard activity to improve care and provide a public/private link to STD/HIV control.

PIP: The Jamaican Ministry of Health has estimated that over 60% of all sexually transmitted diseases (STDs) are managed within the private sector, where 800 (66%) of the country's 1200 registered physicians practice. To improve the quality of STD case management provided by these practitioners, the Medical Association of Jamaica organized a series of 6 half-day seminars repeated at 3-4 month intervals in three geographic locations between December 1993 and July 1995. Topics addressed included urethritis, genital ulcer disease, HIV/AIDS, vaginal discharge, pelvic inflammatory disease, and STDs in children and adolescents. A total of 628 private practitioners attended at least one seminar and almost half the physicians attended two or more. Comparisons of scores on a written pretest completed before the seminar and those from a post-test conducted by telephone after the seminar revealed significant improvements in all four general STD management categories: counseling/education, diagnostics/screening, treatment, and knowledge. The proportion of practitioners who obtained syphilis serologies during pregnancy rose from 38.3% to 83.8% and those providing effective treatment for gonorrhea increased from 57.8% to 81.1%. Overall, 96% of practitioners were providing some level of risk-reduction counseling at the time of the post-test and 74% were prescribing correct treatment regimens. Ongoing education and motivation by the national STD control program or the Medical Association are recommended to improve STD case management even further.

Panel discussion on vaccine development to meet U.S. and international needs. Strategies for reducing the disincentives to HIV vaccine development: description of a successful public-private sector international collaboration.

PIP: A representative of Finishing Enterprises, the world's largest manufacturer of intrauterine contraceptive devices (IUDs), discusses how to alter the balance of incentives-disincentives to expedite the development of HIV vaccines for international evaluation. Three main disincentives exist for private manufacturers in the United States to develop a new HIV vaccine to be used in developing countries, outside the profitable North American and western European markets: 1) low profit margin because of limited money, time, and resources. Medium and large-sized corporations are more concerned with a high return on their investment owing to stockholder pressure than with the human benefit of that investment. 2) Lengthy regulatory approval process. The current regulatory process in the US is tedious, time-consuming, and costly. 3) Liability risk. The United States is the most litigious society in the world. Suits filed against US corporations involved in drug manufacture incur legal defence costs, which make an already low profit margin HIV vaccine even lower. Finishing Enterprises' IUD program aimed at providing the safest and most effective IUD at an affordable price in a socially responsible way. The Population Council developed the Copper T and retained the patent rights. They and other international health authorities, such as the World Health Organization, conducted or monitored international clinical trials to determine safety and efficacy. Private foundations and public donor agencies funded these activities. When donor agencies committed to volume purchases for their commodity programs, Finishing Enterprises could commit to volume pricing. Whenever high-margin private sector sales occur, Population Council receives a royalty payment. Thus, the disincentives were overcome: 1) Low profit margin was less an issue for a small, private company created specifically to manufacture IUDs and guaranteed volume orders. 2) Lengthy regulatory approval processes were avoided by various international clinical trials, generating international interest in the product. 3) Liability risk was minimized by the variety of safety tests the product underwent.^ieng

Period and cohort trends for mortality and cigarette consumption in England and Wales, 1946 to 1980, with emphasis on sex ratios.

In an earlier paper (Burch P. R. J. J Chron Dis 1981; 34: 87-103) changes in sex- and age-specific mortality from all causes of death in England and Wales were studied in relation to changes in sex- and age-specific cigarette consumption. The absence of a consistent correlation between the two variables, and the general characteristics of the data, suggested that studies of sex ratios might provide a better test of the hypothesis that the association between smoking and mortality has a causal basis. In this paper temporal changes in the sex ratio of cumulative cigarette consumption by cohort, and of smoking rates by age, are considered in relation to changes in the sex ratio of mortality. Again, no consistent correlations emerge and it is evident that factors other than smoking have played a dominant part in determining recent changes in the sex ratio of mortality in all age groups from 35-39 to 80-84 years. Among these "other factors" are birth cohort effects that can be attributed, in part, to birth cohort changes in the sex ratio of mortality from bronchitis and emphysema. The present results, together with other evidence (vide supra; and Burch P. R. J. J Chron Dis 1984; 37: 148-156), show that great care needs to be exercised when attempts are made to deduce causation from epidemiologic surveys.

Drug supply in Nigeria.

The health situation in Nigeria is typical of tropical Africa. It is characterised by high childhood and maternal mortality and a relatively short life expectancy. Mortality in childhood in due mainly to diseases like malaria, measles, poliomyelitis, tetanus, diarrhoea and acute respiratory tract infections. Diseases like filariasis, schistosomiasis and leprosy which are now readily controlled by drugs cause considerable morbidity in later life. Although the technology and tools (particularly vaccines and drugs) for the control of most of these diseases are now available, it has not been possible to make optimal use of them in Nigeria and other tropical African countries because of unfavourable social and economic conditions. The non-availability of drugs most needed for healthcare and disease control has been found to be due not only to insufficient funds but also to the use of the limited funds on expensive drugs that have little bearing on the disease pattern. The Essential Drug Programme initiated by the World Health Organisation, now adopted by Nigeria and about 100 other countries mostly in the Third World, aims to correct this unsatisfactory drug supply situation by ensuring that the available funds are used to provide those drugs needed by the large majority of the people and are made available at all times at prices that most people can afford. The Bamako Initiative in the African Region of the World Health Organization is also designed to ensure regular availability of drugs particularly to primary healthcare facilities. Seed drugs are provided to the health institutions either by the National Government or through external aid. These are sold to patients at a small profit margin. The proceeds are then used to replenish stocks and the small profit used to improve services in the health centre. The introduction of these programmes in Nigeria has improved drug availability considerably in the past couple of years and should soon start yielding further dividend in the form of measurable improvement in the health situation.

Drug use and the role of patients and prescribers.

In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.

PIP: In the effort to improve rational drug use in local or national settings, especially in developing countries, the behavior of prescribers and users is the subject of the least research. The effectiveness of drugs depends on a complex set of factors involved in the situation of prescription and acquisition. One aspect that needs examination is the information given to prescribers by drug advertisers and detailers, a deficiency being addressed by an international network of prescribers. In many countries, the largest outlet for drugs is the private sector pharmacies, where drugs are often dispensed without prescription. A simple inexpensive way of researching prescription behavior is to use fictitious tracers to follow case management of given conditions, such as infant diarrhea. There are many factors involved in prescribing; the process must be studied with an epidemiologic approach, i.e., by description, analysis, intervention and evaluation. Standard treatment schedules, essential drugs lists, targeted intervention with treatment guidelines should be audited by local therapeutic committees. Drug information should also be scientifically evaluated by the same analytical principles. The experimental method of group randomization is suggested as a feasible choice for developing countries. In this technique groups of physicians are observed or interviewed, and quantitative outcome data are collected. Behavior of individual users is best studied by combining anthropological and biomedical approaches, from the case-study perspective. An example of a problem amenable to this approach is the possible use of shorter courses of antibiotic treatment to lessen the risk of development of resistant organisms.

The influence of gender on determinants of urban childhood mortality in Bangladesh.

To assess sociodemographic characteristics predicting childhood mortality in urban Bangladesh, we conducted a case-control study of subjects selected from 51 low and middle class areas of urban Dhaka between 14 October 1984 and 13 October 1985. Cases were the 38 children who died aged under six years during the study interval; six surviving controls aged under six years were selected for each case. Factors associated with childhood deaths included being under one year of age (OR (odds ratio) = 11.80; p less than 0.0001), and several direct and indirect indicators of poor economic status: ie head of household earning a daily wage rather than a salary (OR = 2.63; p less than 0.01); residence in a single-room dwelling (OR = 2.63; p less than 0.05); or residence in a structure of inferior construction (OR = 2.58; p less than 0.05). There were important gender-specific differences in the risk factors. Having one or more male siblings was associated with an increased risk of death for male children (OR = 2.78; p less than 0.05), while having at least one female sibling was suggestively associated with the risk of death for female children (OR = 2.47; p less than 0.10). Family dependence on daily wages rather than on a salary was associated with male deaths (OR = 6.24; p less than 0.001) but not with female deaths (OR = 1.38). Other indices of poverty (poor construction of house and single-room dwellings) were also associated with an increased risk of male but not female deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Trends in occupational mortality among middle-aged men in Sweden 1961-1990.

BACKGROUND: Many European countries have in recent decades reported growing socioeconomic differentials in mortality. While these trends have usually paralleled high unemployment and increasing income disparities, Sweden had low unemployment and narrowing income differences. This study describes trends, 1961-1990, in total and cardiovascular mortality among men, 45-69 years of age, in major occupational classes in Sweden. METHODS: From census data four cohorts were created from those enumerated in 1960, 1970, 1980 and 1985. Through record linkage with the Swedish cause of death registry the mortality in each cohort was followed for 5-10 years. Age-standardized mortality trends 1961-1990 were calculated for occupational groups, categorized according to sector of the economy. RESULTS: The increase in mortality among middle-aged men in Sweden 1965-1980 was mainly a result of increasing cardiovascular mortality among industrial workers and farmers. In the 1980s the trend for these groups changed into a last decrease in mortality similar to that for non-manual occupations for the whole period. Consequently the rate ratio for industrial workers in comparison with men having a professional/managerial type of occupation increased from 0.98 to 1.43. The slowest decrease is now found among unqualified occupations in services and transportation. CONCLUSIONS: While Sweden, during the period studied, had narrowing income differentials and low unemployment this result points to the importance of working conditions in understanding trends and distribution of male adult mortality.