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AIDS in Cuba

SIR,—I wish to comment on the way in which the Ministry ofPublic Health of Cuba (MINSAP) is dealing with AIDS in Cuba.This disease is threatening to spread throughout the world, andthere is a real need for governments and health institutions to act

internationally. Each government must recognise and face its ownmistakes and difficulties in the same way that others exposed tosimilar challenges do.We in Cuba should not continue to minimise the importance of

AIDS. We are duty-bound to recognise AIDS in Cuba as aproblem of considerable potential that has probably already affectedmore people than those isolated in the treatment centre known as"Villa los Cocos". We do not believe that it is just to send AIDS orHIV-seropositive patients against their will to places where,although they receive medical attention, they must remain ininvoluntary seclusion until they die. It is not difficult to imagine thesadness, suffering, and psychological disturbances brought on bythe sudden division of families. Is such isolation really a solution toAIDS in Cuba? Is it justified to take such action on the grounds thatthis is done for the common good? Has this method of AIDS controlbeen tried in any other country?

I believe that several points should be considered by theMINSAP so that AIDS patients are treated more humanely, toavoid unnecessary suffering to the patients and their relatives, andabove all to arrest the spread of AIDS in Cuba. First, a greater effortshould be made to increase the education of the people in terms ofepidemiological aspects of sexual hygiene; the risks of promiscuityshould be underscored to show the importance of this in relation toAIDS. Second, all health personnel should receive more

information about the disease. Third, involuntary confinement forAIDS patients and HIV-seropositive people should be stopped andshould be replaced by a national programme, with ambulatorytreatment. Fourth, all Cubans should be told the number of AIDSand HIV-seropositive patients in the community, the number ofmen, women, and children affected, and the number of deaths dueto AIDS, how the epidemic is progressing, and the general outlook.Cubans should also be made aware of treatments available.

This information should be provided through a systematic,national AIDS information and education programme.The sanatorium at Los Cocos should be closed and the

prohibitory regulations ended. The centre should be replaced withone that provides ambulatory therapy, where not only the AIDSvictims can go for help but also where health personnel may go tostudy, research, and help in this serious problem. Up to now, only avery few health-care professionals, who have been hand picked bythe government, have been allowed to deal with the AIDS epidemic.We truly believe that if these ideas are accepted this would help to

avoid the violation of the rights proclaimed in the UniversalDeclaration of Human Rights. We would also be finding a bettersolution to this health problem, which that has serious repercussionsin other spheres of Cuban society.Committee for National Unity,Havana, Cuba OMAR DEL POZO MARRERO

*** This open letter to the Minister of Public Health in Havana waswritten in April, 1991, and according to information received DrPozo Marrero is detained in prison in Cuba without clear

charges.-ED. L.

Health of the Nation and back painSIR,-Malcolm Dean (July 18, p 166) reports that of the 2000

responses to the first draft of the Health of the Nation document

only 200 did not relate to smoking.My response concerned back disability and other chronic pain

problems which seem to be increasing alarmingly, especially inyounger people. Back pain disabilty has doubled during the pastdecade, having already increased two-fold during the previousdecade. Back pain is the largest single cause of chronic ill health inthe 16-44 age group, and much is preventable with appropriateresources (data from Department of Social Security and Office ofPopulation Census and Surveys).Back pain disability is another "silent epidemic" needing

governmental awareness and a central initiative if it is to be brought

under control. Alas, it is not mentioned as a priority in the whitepaper.

CAMPAIN,9 Bedford Square,London WC1B 3RA, UK CHARLES E. PITHER

Ganglioside therapy and overuse ofcoadjuvants in Italy

SIR,—Mr Raschetti and colleagues (July 4, p 60) report that4·1% of the population in Rome received at least one prescription ofgangliosides in 1989. Defined daily dose (DDD) methodology1allows better estimation of drug use and exposure. Gangliosideshave not been assigned an internationally acknowledged DDD bythe World Health Organisation Collaborating Centre for DrugStatistics Methodology, and we have therefore adopted a

provisional value of 30 mg/day in our databank Farmaguida.2Our analysis of drug use by general practitioners in Emilia

Romagna (a region in northern Italy with about 4 millioninhabitants) revealed that neurotrophics (almost 7 DDD per 1000inhabitants daily) together with cerebroactive drugs (about 6·5DDD per 1000 daily) are the most prescribed subgroups of thenervous system therapeutic group, and that these drugs account forthe largest proportion of National Health Service (NHS)pharmaceutical gross expenditure in this group. Benzodiazepinesand other anxiolytics are not included in the NHS reimbursementlist. Antidepressants and antipsychotics are also directly dispensedin psychiatric units to severely ill psychiatric outpatients andtherefore the volume of exposure of these drugs may beunderestimated.

Among neurotrophics, gangliosides are the most prescribeddrugs (table) and their use in the general population, which wasstable at the value of about 1·6 DDD per 1000 inhabitants dailyfrom 1988 to 1990, rose sharply to 2·3 DDD in 1991 (+44%).Italy’s NHS pharmaceutical gross expenditure for outpatients alsogrew appreciably (from 6·43 to 8·31 £ per 1000 inhabitants daily;+ 29%). Such data indicate that the widespread use of gangliosidesis far from decreasing, despite the fact that the Italian Ministry ofHealth has restricted the indications to the treatment of diabetic

neuropathies and acute spinal cord lesions. The sharpest increase inganglioside DDD consumption in 1991 resulted from the HealthMinistry’s approval of the 50 mg preparation (which has virtuallyreplaced the more economical 20 mg preparation). Theconcomitant restriction of the 100 mg preparation to neurologistsand diabetologists should have led to a reduction in DDD

consumption, but this has been circumvented by generalpractitioners’ prescribing 2 × 50 mg.

In view of the widespread and non-specific use of gangliosides, tocompare gangliosides with the prescription data of the other

MOST REPRESENTATIVE REIMBURSABLE COADJUVANTSUBSTANCES PRESCRIBED IN GENERAL PRACTICE IN ITALY*

*Volume of use (DDD/1000 inhabitants/day) and gross expenditure (f/1000/mhabrtants/day) in 1991 tMostly used in mild depression