Canada and international health The major international health problems are overpopulation, malnutrition and infectious diseases. Most population control experts now agree that overpopulation can be controlled only through education, amelioration of the standard of living and improvement of general health. (It is not possible to tell parents to have fewer than three children if one out of two children born does not live past the fifth birthday.') Malnutrition can be checked only by population control and increased productivity - and productivity of workers requires that they be healthy.1 Although degenerative, malignant and cardiovascular diseases, and diseases due to factors in personal lifestyle (e.g., smoking, alcohol abuse and lack of exercise) are the most important health problems in Canada, infectious diseases remain the most important cause of illness and death in tropical countries. Malaria, schistosomiasis, filariasis, trypanosomiasis, onchocerciasis, infection with intestinal parasites, diarrheal diseases, tuberculosis and leprosy are responsible for much of the illness in developing countries. All these diseases can be eradicated, given political stability and financial resources. While smallpox may soon be eradicated, new viral diseases (e.g., Lassa fever and Marburg disease) with high transmissibility and mortality are appearing.1'3 Though Canada is fortunate in its high standard of living, hygiene and medical care, it is no longer protected by the "quarantine period" given by long sea voyages of years ago; today immigrants can travel by plane from the tropics to Canada in hours, well within the incubation period of any infectious disease.4 Nearly half of the immigrants to Canada come from tropical countries and increasing numbers of native-born Canadians work and travel overseas. Many individuals acquire illnesses peculiar to the tropics, which may be life-threatening (e.g., falciparum malaria) or a hazard to the community (e.g., smallpox and Lassa fever). It is most important that physicians know
the fundamentals of geographic medicine, and that they ask patients where they have been in the past.5 The common symptoms of tropical illnesses are fever, diarrhea, skin rash and chronic fatigue. Of these, fever is the most urgent and requires immediate investigation to rule out falciparum malaria. Typhoid fever is the second most important disease to consider in a febrile patient from the tropics. Despite efforts by the World Health Organization (WHO) to eradicate malaria the disease remains endemic in all parts of tropical Africa, the Indian subcontinent, southeast Asia, and parts of South and Central America; it continues to be the most important and life-threatening disease in the tropics.1 The clinical expression of malaria, described by Flegel in this issue (page 409), can be prevented by proper chemoprophylaxis, though in hyperendemic areas clinical attacks of malaria occur despite appropriate therapy. Because many travel agencies minimize the health hazards of travel to the tropics, tourists often become ill with malaria. For most endemic areas weekly administration of chloroquine is the standard prophylaxis. In parts of Africa and Asia, however, a different regimen, such as administration of proguanil daily and pyrimethamine weekly, may be more effective. Malaria may be a cause of fever up to 2 years after return from an endemic area; after 2 years it is a less likely cause. In patients who have a fever in the first 2 months after return from an endemic area falciparum malaria is an important diagnostic consideration because it is a life-threatening form of malaria. It must be treated promptly, especially in nonimmune patients. In this issue of the Journal (page 405) Asch reports 15 cases of malaria seen at the Hospital for Sick Children, Toronto, in 14 of which the patient had emigrated from an endemic area. Complaints of diarrhea are common in travellers to foreign countries. "Travellers' diarrhea" is especially common in Mexico and is caused by a variety of pathogens, most commonly
enterotoxigenic Escherichia coli.6 As a rule, travellers' diarrhea is self-limiting and there is no vaccine or other preventive agent. Elsewhere other pathogens are more important - for example, Giardia lamblia. The key to good health in warm climates is avoidance of unclean food and drink. Profuse diarrhea with dehydration requires hospitalization. Cholera, as is well known, is a cause of profuse diarrhea, and in this issue of the Journal (pages 393, 397 and 401) papers based on a review of the first case of cholera to be diagnosed in Canada outline the pathophysiology of cholera, the laboratory aspects and the principles of treatment. In a recent editorial in the Annals of Internal Medicine Knowles7 asked why there is so little interest in tropical medicine, international health and population studies in America. He counted fewer than 10 independent departments of tropical medicine and international health in the 107 medical schools in the United States. He also noted that 70% of medical schools give less than 16 hours of teaching in tropical medicine to medical students. The Canadian record is worse. We have not a single independent department of tropical medicine in any of our medical schools. I suspect few Canadian medical schools devote more than a few hours to this subject. Furthermore, individuals responsible for teaching in this area have had no experience and little or no professional involvement in the field. The result is that the medical students are disinterested and uninformed in tropical medicine. Medical and other health educators have taken a narrow view of what is relevant in medicine. If only medical problems indigenous to North America and northern Europe are taught in the medical schools, the students will learn a disease spectrum limited to 20 to 30% of the world.8 There are five major problems in international health in Canada? (a) lack of adequate information on the scope of the problem; (b) lack of knowledge of the health professionals; (c) lack of interest and teaching in medical schools;
CMA JOURNAL/SEPTEMBER 4, 1976/VOL. 115 377
(d) lack of an adequate career structure for persons interested in tropical medicine and international health; and (e) lack of adequate diagnostic, treatment and follow-up facilities in tropical diseases. The solution suggested is the establishment of regional centres for tropical disease and international health in the large Canadian cities. (Sweden has five such centres, which care mainly for Swedes returning from the tropics.) These centres should be supported by the local university and established in the university hospitals. They would be the regional diagnostic and treatment centres and serve as depots for rarely used drugs such as sodium suramin and emetine. At these centres a core of highly trained staff would teach international health and geographic medicine to undergraduate and graduate students, and medical students and residents could do electives in these centres to acquire in-depth training not given in medical schools. The larger centres would give annual postgraduate courses in tropical medicine and parasitology to doctors and other health professionals who intend to work overseas. The centres should seek affiliation with others overseas to conduct research and gain understanding and expertise in the treatment of endemic diseases. It is essential that these centres be supported by the deans of medicine and the chairmen of the major clinical and basic sciences departments, for without their support such centres cannot be established.8" Initial funding should be by the federal and provincial governments, the Canadian International Development Agency and the International Development Research Centre. The architect and first director-general of WHO was a Canadian, Brock Chisholm. This organization has always shown interest in tropical diseases, principally by convening meetings of the expert advisory committees and by publishing technical reports. It has now decided to focus its attention on the conquest of the major tropical diseases (malaria, schistosomiasis, filariasis, onchocerciasis, trypanosomiasis, leishmaniasis and leprosy) by applying modern research tools in molecular biology and immunology. It is establishing a research and training centre in Africa (Ndola, Zambia) and later hopes to have similar centres in South America and Asia. Canada has been asked to participate. In the words of Knowles: We need a resurgence of interest in public health and tropical medicine, for we share with the developing countries the fact that the next major advances in health will be based on the elements of nutrition, family planning, control of infec-
tious disease and a massive change in individual and national lifestyles.7 S.K.K. SEAH, MD, PH D, FRCP[CI Montreal General Hospital 1650 Cedar Ave. Montreal, PQ
References 1. BRUCE-CHWATF U: Endemic diseases, demography and socioeconomic development of tropical Africa. Can I Public Health 66:
31, 1975 2. SMITH CE: Changing patterns of disease in the tropics. Br Med Bull 28: 3, 1972 3. MONATH TP: Lassa fever and Marburg virus disease. WHO Chron 28: 212, 1974
4. ZUIDEMA PJ: Tropical diseases in Europe. I R Coil Physicians Lond 10: 67, 1975 5. SEAH SKK, FLEGEL KM: African trypanosomiasis in Canada. Can Med Assoc 1106: 902, 1972 6. MERSON MH, Mosuus GK, SACK DA, Ct al: Travellers' diarrhea in Mexico. A prospective study. N Engi I Med 294: 1299, 1976 7. KNOWLES JH: American medicine and world health 1976 (E). Ann Intern Med 84: 483, 1976 8. WARREN KS: Summary. Proceedings of the Macy conference on teaching tropical medicine, New Orleans, Louisiana 11-12 June 1973. Am I Trop Med Hyg 23: 832, 1974 9. SEAN SKK: Tropical medicine in Canada problems and prospects. Can I Public Health 65: .69, 1974
Cholera in Canada The word cholera evokes the image of community devastation, fumigating pots and quarantine establishments. For the majority of Canadian physicians it represents a tropical disease of no concern in North America. However, one cannot consider cholera as only an intellectual exercise or a disease of the East. With modern transport facilities, many travellers from North America visit areas where cholera is endemic, and emigration from these countries is high. When an infection is not recognized, an epidemic may ensue. The mortality in untreated severe cases is over 50%, while with early diagnosis and immediate treatment, mortality can be reduced to less than 1%. In 1974 we treated a patient with cholera in Kingston, Ont. and we have reviewed, in a series of three papers in this issue of the Journal, the problems presented by this case. The first paper (page 393) sets the stage by reporting the case and reviewing the pathophysiology of cholera. The second paper (page 397) reviews the diagnostic steps undertaken by the hospital and by provincial bacteriologists and describes the epidemiologic aspects of cholera and
measures taken within the hospital. The third paper (page 401) is a synopsis of the clinical aspects and principles of treatment of cholera. These three papers and the experience they represent do more than describe the diagnosis, treatment and infection control related to thi'i interesting case of cholera: they illustrate the value of teamwork that is available in Canada to deal with unusual circumstances. The team consisted of clinicians, hospital microbiologists, regional bacteriologists, the local medical officer of health, provincial epidemiologists and federal health and welfare officers. Each member played an essential role. Thus was one "exotic" disease in Canada identified and prevented from spreading. I.T. BECK, MD, PH D, FRCP[C], FACP R. BOURDAGES, MD, FRCP[C] Department of medicine Queen's University
R.G. LEWIS, PH D, DIP BACT Department of microbiology and immunology Queen's University Kingston, ON AJ. RHODES, MD, FRCP (ENN), FRCP[C] Department of microbiology University of Toronto Toronto. ON
Diabetic hearts and biguanides - a reply In a recent editorial1 Professor Pierre Biron presented some provocative comments on a study reported by the University Group Diabetes Program (UGDP) on the effects of phenformin therapy on vascular complications in patients with adult-onset diabetes mellitus.2 The UGDP compared the clinical course of 204 such patients treated within 12 months of diagnosis by diet and a long-acting preparation of phenformin (100 mg/d) with that of a
378 CMA JOURNAL/SEPTEMBER 4, 1976/VOL. 115
similar group of patients treated with diet and either insulin or placebo tablets for periods of 5½ to 9 years, up to October 1971 when phenformin therapy was discontinued. Up to that time 27 (13.2%) of the patients treated with phenformin had died of cardiovascular disease (myocardial infarction, 5; sudden death, 6; extracardiac vascular disease, 8; and other forms of heart disease, 8). As the mortality in patients treated with phenformin was far greater
the fundamentals of geographic medicine, and that they ask patients where they have been in the past.5 The common symptoms of tropical illnesses are fever, diarrhea, skin rash and chronic fatigue. Of these, fever is the most urgent and requires immediate investigation to rule out falciparum malaria. Typhoid fever is the second most important disease to consider in a febrile patient from the tropics. Despite efforts by the World Health Organization (WHO) to eradicate malaria the disease remains endemic in all parts of tropical Africa, the Indian subcontinent, southeast Asia, and parts of South and Central America; it continues to be the most important and life-threatening disease in the tropics.1 The clinical expression of malaria, described by Flegel in this issue (page 409), can be prevented by proper chemoprophylaxis, though in hyperendemic areas clinical attacks of malaria occur despite appropriate therapy. Because many travel agencies minimize the health hazards of travel to the tropics, tourists often become ill with malaria. For most endemic areas weekly administration of chloroquine is the standard prophylaxis. In parts of Africa and Asia, however, a different regimen, such as administration of proguanil daily and pyrimethamine weekly, may be more effective. Malaria may be a cause of fever up to 2 years after return from an endemic area; after 2 years it is a less likely cause. In patients who have a fever in the first 2 months after return from an endemic area falciparum malaria is an important diagnostic consideration because it is a life-threatening form of malaria. It must be treated promptly, especially in nonimmune patients. In this issue of the Journal (page 405) Asch reports 15 cases of malaria seen at the Hospital for Sick Children, Toronto, in 14 of which the patient had emigrated from an endemic area. Complaints of diarrhea are common in travellers to foreign countries. "Travellers' diarrhea" is especially common in Mexico and is caused by a variety of pathogens, most commonly
enterotoxigenic Escherichia coli.6 As a rule, travellers' diarrhea is self-limiting and there is no vaccine or other preventive agent. Elsewhere other pathogens are more important - for example, Giardia lamblia. The key to good health in warm climates is avoidance of unclean food and drink. Profuse diarrhea with dehydration requires hospitalization. Cholera, as is well known, is a cause of profuse diarrhea, and in this issue of the Journal (pages 393, 397 and 401) papers based on a review of the first case of cholera to be diagnosed in Canada outline the pathophysiology of cholera, the laboratory aspects and the principles of treatment. In a recent editorial in the Annals of Internal Medicine Knowles7 asked why there is so little interest in tropical medicine, international health and population studies in America. He counted fewer than 10 independent departments of tropical medicine and international health in the 107 medical schools in the United States. He also noted that 70% of medical schools give less than 16 hours of teaching in tropical medicine to medical students. The Canadian record is worse. We have not a single independent department of tropical medicine in any of our medical schools. I suspect few Canadian medical schools devote more than a few hours to this subject. Furthermore, individuals responsible for teaching in this area have had no experience and little or no professional involvement in the field. The result is that the medical students are disinterested and uninformed in tropical medicine. Medical and other health educators have taken a narrow view of what is relevant in medicine. If only medical problems indigenous to North America and northern Europe are taught in the medical schools, the students will learn a disease spectrum limited to 20 to 30% of the world.8 There are five major problems in international health in Canada? (a) lack of adequate information on the scope of the problem; (b) lack of knowledge of the health professionals; (c) lack of interest and teaching in medical schools;
CMA JOURNAL/SEPTEMBER 4, 1976/VOL. 115 377
(d) lack of an adequate career structure for persons interested in tropical medicine and international health; and (e) lack of adequate diagnostic, treatment and follow-up facilities in tropical diseases. The solution suggested is the establishment of regional centres for tropical disease and international health in the large Canadian cities. (Sweden has five such centres, which care mainly for Swedes returning from the tropics.) These centres should be supported by the local university and established in the university hospitals. They would be the regional diagnostic and treatment centres and serve as depots for rarely used drugs such as sodium suramin and emetine. At these centres a core of highly trained staff would teach international health and geographic medicine to undergraduate and graduate students, and medical students and residents could do electives in these centres to acquire in-depth training not given in medical schools. The larger centres would give annual postgraduate courses in tropical medicine and parasitology to doctors and other health professionals who intend to work overseas. The centres should seek affiliation with others overseas to conduct research and gain understanding and expertise in the treatment of endemic diseases. It is essential that these centres be supported by the deans of medicine and the chairmen of the major clinical and basic sciences departments, for without their support such centres cannot be established.8" Initial funding should be by the federal and provincial governments, the Canadian International Development Agency and the International Development Research Centre. The architect and first director-general of WHO was a Canadian, Brock Chisholm. This organization has always shown interest in tropical diseases, principally by convening meetings of the expert advisory committees and by publishing technical reports. It has now decided to focus its attention on the conquest of the major tropical diseases (malaria, schistosomiasis, filariasis, onchocerciasis, trypanosomiasis, leishmaniasis and leprosy) by applying modern research tools in molecular biology and immunology. It is establishing a research and training centre in Africa (Ndola, Zambia) and later hopes to have similar centres in South America and Asia. Canada has been asked to participate. In the words of Knowles: We need a resurgence of interest in public health and tropical medicine, for we share with the developing countries the fact that the next major advances in health will be based on the elements of nutrition, family planning, control of infec-
tious disease and a massive change in individual and national lifestyles.7 S.K.K. SEAH, MD, PH D, FRCP[CI Montreal General Hospital 1650 Cedar Ave. Montreal, PQ
References 1. BRUCE-CHWATF U: Endemic diseases, demography and socioeconomic development of tropical Africa. Can I Public Health 66:
31, 1975 2. SMITH CE: Changing patterns of disease in the tropics. Br Med Bull 28: 3, 1972 3. MONATH TP: Lassa fever and Marburg virus disease. WHO Chron 28: 212, 1974
4. ZUIDEMA PJ: Tropical diseases in Europe. I R Coil Physicians Lond 10: 67, 1975 5. SEAH SKK, FLEGEL KM: African trypanosomiasis in Canada. Can Med Assoc 1106: 902, 1972 6. MERSON MH, Mosuus GK, SACK DA, Ct al: Travellers' diarrhea in Mexico. A prospective study. N Engi I Med 294: 1299, 1976 7. KNOWLES JH: American medicine and world health 1976 (E). Ann Intern Med 84: 483, 1976 8. WARREN KS: Summary. Proceedings of the Macy conference on teaching tropical medicine, New Orleans, Louisiana 11-12 June 1973. Am I Trop Med Hyg 23: 832, 1974 9. SEAN SKK: Tropical medicine in Canada problems and prospects. Can I Public Health 65: .69, 1974
Cholera in Canada The word cholera evokes the image of community devastation, fumigating pots and quarantine establishments. For the majority of Canadian physicians it represents a tropical disease of no concern in North America. However, one cannot consider cholera as only an intellectual exercise or a disease of the East. With modern transport facilities, many travellers from North America visit areas where cholera is endemic, and emigration from these countries is high. When an infection is not recognized, an epidemic may ensue. The mortality in untreated severe cases is over 50%, while with early diagnosis and immediate treatment, mortality can be reduced to less than 1%. In 1974 we treated a patient with cholera in Kingston, Ont. and we have reviewed, in a series of three papers in this issue of the Journal, the problems presented by this case. The first paper (page 393) sets the stage by reporting the case and reviewing the pathophysiology of cholera. The second paper (page 397) reviews the diagnostic steps undertaken by the hospital and by provincial bacteriologists and describes the epidemiologic aspects of cholera and
measures taken within the hospital. The third paper (page 401) is a synopsis of the clinical aspects and principles of treatment of cholera. These three papers and the experience they represent do more than describe the diagnosis, treatment and infection control related to thi'i interesting case of cholera: they illustrate the value of teamwork that is available in Canada to deal with unusual circumstances. The team consisted of clinicians, hospital microbiologists, regional bacteriologists, the local medical officer of health, provincial epidemiologists and federal health and welfare officers. Each member played an essential role. Thus was one "exotic" disease in Canada identified and prevented from spreading. I.T. BECK, MD, PH D, FRCP[C], FACP R. BOURDAGES, MD, FRCP[C] Department of medicine Queen's University
R.G. LEWIS, PH D, DIP BACT Department of microbiology and immunology Queen's University Kingston, ON AJ. RHODES, MD, FRCP (ENN), FRCP[C] Department of microbiology University of Toronto Toronto. ON
Diabetic hearts and biguanides - a reply In a recent editorial1 Professor Pierre Biron presented some provocative comments on a study reported by the University Group Diabetes Program (UGDP) on the effects of phenformin therapy on vascular complications in patients with adult-onset diabetes mellitus.2 The UGDP compared the clinical course of 204 such patients treated within 12 months of diagnosis by diet and a long-acting preparation of phenformin (100 mg/d) with that of a
378 CMA JOURNAL/SEPTEMBER 4, 1976/VOL. 115
similar group of patients treated with diet and either insulin or placebo tablets for periods of 5½ to 9 years, up to October 1971 when phenformin therapy was discontinued. Up to that time 27 (13.2%) of the patients treated with phenformin had died of cardiovascular disease (myocardial infarction, 5; sudden death, 6; extracardiac vascular disease, 8; and other forms of heart disease, 8). As the mortality in patients treated with phenformin was far greater
