ISA METTING Publications

 

     1.    Aljunid, S. M. and Zwi, A. B. Differences in public and private health services in a rural district of Malaysia. Med J Malaysia. 1996 Dec; 51(4):426-36.
Abstract: A cross-sectional study, comparing the nature of services in 15 private clinics and 6 public health facilities, was undertaken in a rural district of Malaysia. Semi-structured interviews and observations using check-lists were employed. Public health facilities were run by younger doctors (mean age = 31.1 years), supported mostly by trained staff. The private clinics were run by older doctors (mean age = 41.2 years) who had served the district for much longer (8.9 years vs 1.5 years) but were supported by less well trained staff. The curative services were the main strength of the private clinics but their provision of preventive care was less comprehensive and of inferior quality. Private clinics were inclined to provide more expensive diagnostic services than the public facilities. 'Short hours' private clinics had very restricted opening hours and offered limited range of services.

     2.    Banatvala, N. and Zwi, A. B. Conflict and health. Public health and humanitarian interventions: developing the evidence base. BMJ. 2000 Jul 8; 321(7253):101-5.

     3.    Barnabas, G. A. and Zwi, A. Health policy development in wartime: establishing the Baito health system in Tigray, Ethiopia. Health Policy Plan. 1997 Mar; 12(1):38-49.
Abstract: This paper documents health experiences and the public health activities of the Tigray People's Liberation Front (TPLF). The paper provides background data about Tigray and the emergence of its struggle for a democratic Ethiopia. The origins of the armed struggle are described, as well as the impact of the conflict on local health systems and health status. The health-related activities and public health strategies of the TPLF are described and critiqued in some detail, particular attention is focused on the development of the baito system, the emergent local government structures kindled by the TPLF as a means of promoting local democracy, accountability, and social and economic development. Important issues arise from this brief case- study, such as how emerging health systems operating in wartime can ensure that not only are basic curative services maintained, but preventive and public health services are developed. Documenting the experiences of Tigray helps identify constraints and possibilities for assisting health systems to adapt and cope with ongoing conflict, and raises possibilities that in their aftermath they leave something which can be built upon and further developed. It appears that promoting effective local government may be an important means of promoting primary health care.

     4.    Bennett, S.; Dakpallah, G.; Garner, P.; Gilson, L.; Nittayaramphong, S.; Zurita, B., and Zwi, A. Carrot and stick: state mechanisms to influence private provider behavior. Health Policy Plan. 1994 Mar; 9(1):1-13.
Abstract: The behavior of private sector health care providers will depend critically on the environment within which they operate. A bewildering array of possible regulatory and incentive setting structures exist. Most developing countries have the basic legislation for regulation, but there are frequently difficulties in enforcing such controls. While process aspects of quality of care regulation are often the responsibility of professional organizations, these organizations may have limited incentives to be active in ensuring high quality medical car.e There has been less experience with the use of incentives to encourage appropriate behavior amongst private providers: this appears a promising area for further work. Above all, adequate information is essential both for the enforcement of regulations and the application of incentive mechanisms.

     5.    Brugha, R.; Chandramohan, D., and Zwi, A. Viewpoint: management of malaria--working with the private sector. Trop Med Int Health. 1999 May; 4(5):402-6.
Abstract: Recent reviews have demonstrated that a substantial proportion of cases of malaria are managed in the private sector, and international policy initiatives routinely emphasize the need for malaria control programmes to collaborate with the private sector. However, information on how to develop successful partnerships between the public and private sectors remains limited. This paper reviews the current knowledge about the management of malaria by private providers, considers the potential of different strategies for influencing the quality of care provided, and identifies processes for facilitating public-private sector collaborations. We contend that public sector-led interventions, such as training of private providers or the distribution of prepackaged antimalarials through the private sector, are unlikely to scale up to sustainable national level programmes if they do not take into account a wide range of needs and concerns, represented by private provider organizations and other interest groups, including service users. These groups should be involved at key stages including the design and piloting of interventions, through to the dissemination and implementation of findings. Research priorities are outlined for the development of tools to facilitate public-private partnerships for improving the management of malaria.

     6.    Brugha, R. and Zwi, A. Improving the quality of private sector delivery of public health services: challenges and strategies. Health Policy Plan. 1998 Jun; 13(2):107-20.
Abstract: Despite significant successes in controlling a number of communicable diseases in low and middle income countries, important challenges remain, one being that a large proportion of patients with conditions of public health significance, such as tuberculosis, malaria, or sexually transmitted diseases, seek care in the largely unregulated 'for profit' private sector. Private providers (PPs) often offer services which are perceived by users to be more attractive. However, the available evidence suggests that serious deficiencies in technical quality are often present. Evaluations of interventions to promote evidence-based care in high income countries have shown that multi- faceted strategies which increase provider knowledge have had some success in improving service quality. A wider range of factors needs to be considered in low and middle income countries (LMICs), especially factors which contribute to discrepancies between provider knowledge and practice. Studies have shown that PPs, especially, perceive or experience patient and community pressures to provide inappropriate treatments. LMIC governments also lack the capacity to enforce regulatory controls. Context-specific multi-faceted strategies are needed, including the local adaptation and dissemination to providers of relevant evidence, the education of patients and communities to adopt effective treatment-seeking and treatment-taking behaviour, and feasible mechanisms for ensuring and monitoring service quality, which may include a role for self-regulation by provider organizations or provider accreditation. Developing, implementing and evaluating strategies to improve the quality of service provision will depend on the involvement of the key stakeholders, including policy makers and PPs. Focusing on studies from Asia, Africa and Latin America, this paper develops a model for identifying the influences on PPs, mainly private medical practitioners, in their management of conditions of public health significance. Based on this, multi-faceted strategies for improving the quality of treatment provision are suggested. Interventions need to be inexpensive, practical, efficient, effective and sustainable over the medium to long term. Achieving this is a significant challenge.

     7.    ---. Sexually transmitted diseases. Lancet. 1998 Aug 22; 352(9128):649-50.

     8.    Brugha, R. and Zwi, A. B. Sexually transmitted disease control in developing countries: the challenge of involving the private sector. Sex Transm Infect. 1999 Oct; 75(5):283-5.

     9.    Ehrlich, R. I.; Rees, D., and Zwi, A. B. Silicosis in non-mining industry on the Witwatersrand. S Afr Med J. 1988 Jun 18; 73(12):704-8.
Abstract: Silicosis outside the mines in South Africa has received little legislative or public attention. Between 1972 and 1986 217 such cases were seen at the National Centre for Occupational Health clinic, including 46 cases of progressive massive fibrosis. The relatively high proportion of cases of progressive massive fibrosis (21%), of patients less than or equal to 40 years at diagnosis (21% of blacks) and with exposures of less than or equal to 10 years (18%) indicate high silica exposures in industry. Four industries accounted for 83% of the cases-- foundries, ceramics factories, refractories, and ore and stone crushing. Radiologically, readings of a mixture of rounded and irregular opacities were not uncommon (14%). Lymphadenopathy was very uncommon (less than 1%), while pleural thickening other than loss of the costophrenic angle was absent. Prevalences of symptoms, signs and lung function abnormality were high, probably owing to a range of factors other than silicosis. Cases of progressive massive fibrosis had significantly higher prevalences of these clinical abnormalities. When two separate lung function prediction equations were applied to the observed values in these cases, the number that met criteria for 'abnormality' differed. This finding has important implications for compensation. Recommendations include control of silica-using industries and careful occupational history-taking by clinicians.

   10.    Forjuoh, S. N. and Zwi, A. B. Violence against children and adolescents. International perspectives. Pediatr Clin North Am. 1998 Apr; 45(2):415-26.
Abstract: Selected topics of violence against children and adolescents that occur in countries outside of the United States are discussed. Focus is given to middle-income and low-income countries and emphasis is placed on the epidemiology of this pressing public health problem, particularly on conditions that are peculiar to children and adolescents in international settings, such as female genital mutilations, wars, displacements, and land mines. The discussion of child maltreatment is presented in the context of child rearing and discipline in different cultures. Recommendations for action and violence prevention are offered in the light of vast cultural differences.

   11.    Forjuoh, S. N.; Zwi, A. B., and Mock, C. N. Injury control in Africa: getting governments to do more. Trop Med Int Health. 1998 May; 3(5):349-56.
Abstract: Despite increasing recognition of injury as a major public health problem worldwide, it has received limited attention and resources. This lack of attention is most notable in low-income countries. As part of efforts to develop coordinated injury control activities in Africa, a round table session was held at the Third International Conference on Injury Prevention and Control in Melbourne, Australia. The aims of the forum were to provide injury control researchers from Africa the opportunity to come together and reflect on issues of injury control in Africa, to deliberate on strategies of getting African governments to show more interest in injury control, and to solicit more assistance from the international donor community Participants from Ghana, Kenya, South Africa and Zimbabwe presented the magnitude of the injury burden in their respective countries, reflected on current research efforts and highlighted the preventive efforts being undertaken. The forum made many recommendations including several regarding specific actions required of African governments, individual researchers and donor agencies.

   12.    Heise, L. L.; Raikes, A.; Watts, C. H., and Zwi, A. B. Violence against women: a neglected public health issue in less developed countries. Soc Sci Med. 1994 Nov; 39(9):1165-79.
Abstract: Violence against women is a significant public health issue in countries of both the industrialized and less developed world. This paper describes the magnitude and health consequences of domestic violence and rape, with an emphasis on developing countries; it recognizes, however, that there is a dearth of documentation regarding the wide range of activity opposing violence against women which is taking place in less developed countries. It briefly explores the factors that perpetuate violence against women and the strategies that have evolved to respond to the problem. It analyses the constellation of factors that may assist violence to emerge as a legitimate public health concern, and explores opportunities and obstacles to further progress in this field. Particular attention is devoted to the role of research in the policy-making process; research areas which may assist those opposing violence against women in all its forms are tentatively suggested.

   13.    Iliffe, S. and Zwi, A. Beyond 'clinical'?: four-dimensional medical education. J R Soc Med. 1994 Sep; 87(9):531-5.
Abstract: Medical education is in crisis. Undergraduates experience an excessive burden of information, develop attitudes to learning that are based on passive acquisition of knowledge than on curiosity and exploration, and suffer from progressive disenchantment with medicine. There is also a serious problem of providing adequate clinical experience for medical students at existing teaching sites, largely because of reduction in bed numbers, increased patient throughput and clinical specialization. This problem was identified over a decade ago in London but has not been solved by the merger of medical schools. A recent survey in one London teaching hospital showed underemployment of students and limited patient contact. A review of clinical clerkships in an Australian medical school revealed that one-third of teachers were perceived as unconcerned, discouraging, derogatory or hostile, and only one-half were rated as effective educators. One consequence has been the development of a wide-ranging debate on changing medical education. Traditionalists have diminishing room for manoeuvre in defence of existing educational practices, as cautious bodies like the General Medical Council (GMC) opt for fundamental reform.

   14.    Irwig, L.; Zwarenstein, M.; Zwi, A., and Chalmers, I. A flow diagram to facilitate selection of interventions and research for health care. Bull World Health Organ. 1998; 76(1):17-24.
Abstract: Decisions about health care should be informed by systematic review of valid research evidence on the effects of interventions on health outcomes that matter. If systematic review suggests it is likely that a health care intervention does more good than harm in some settings, questions must be addressed about the local applicability of the intervention, its cost-effectiveness, and feasibility of implementation. If systematic review suggests that it is unlikely that an intervention does more good than harm in any setting, its use should be discouraged, while existing interventions are improved or alternative interventions developed. If it is uncertain whether an intervention does more good than harm, further analysis of existing data or new controlled trials are required. The article contains a flow diagram, which provides a structure for making such decisions.

   15.    Lanjouw, S.; Macrae, J., and Zwi, A. B. Rehabilitating health services in Cambodia: the challenge of coordination in chronic political emergencies. Health Policy Plan. 1999 Sep; 14(3):229-42.
Abstract: The end of the Cold War brought with it opportunities to resolve a number of conflicts around the world, including those in Angola, Cambodia, El Salvador and Mozambique. International political efforts to negotiate peace in these countries were accompanied by significant aid programmes ostensibly designed to redress the worst effects of conflict and to contribute to the consolidation of peace. Such periods of political transition, and associated aid inflows, constitute an opportunity to improve health services in countries whose health indicators have been among the worst in the world and where access to basic health services is significantly diminished by war. This paper analyzes the particular constraints to effective coordination of health sector aid in situations of 'post'-conflict transition. These include: the uncertain legitimacy and competence of state structures; donor choice of implementing channels; and actions by national and international political actors which served to undermine coordination mechanisms in order to further their respective agendas. These obstacles hindered efforts by health professionals to establish an effective coordination regime, for example, through NGO mapping and the establishment of aid coordinating committees at national and provincial levels. These technical measures were unable to address the basic constitutional question of who had the authority to determine the distribution of scarce resources during a period of transition in political authority. The peculiar difficulties of establishing effective coordination mechanisms are important to address if the long- term effectiveness of rehabilitation aid is to be enhanced.

   16.    Macrae, J.; Zwi, A. B., and Gilson, L. A triple burden for health sector reform: 'post'-conflict rehabilitation in Uganda. Soc Sci Med. 1996 Apr; 42(7):1095-108.
Abstract: While conflict continues to threaten health development in many countries, relative peace has been secured in others. The transition from war to peace carries important political and economic opportunities for the reappraisal of social policy in general, and of health policy in particular. The health systems of countries recovering from prolonged periods of conflict often carry a double burden: the inheritance of an inappropriate and unaffordable health system developed in the pre-conflict era, and the particular, long-term effects of conflict on health and health services. This paper reports on the particular policies designed to rehabilitate the Ugandan health system, and argues that they exacerbated, rather than alleviated, the health crisis inherited in 1986. In this way they posed a third burden. By analyzing the context and process of policy formulation in the immediate post-conflict period, it explores the rationale which lay behind the adoption of these policies and identifies potential strategies for strengthening policy development in these unstable, resource-poor and health-deprived situations.

   17.    McKee, M.; Zwi, A.; Koupilova, I.; Sethi, D., and Leon, D. Health policy-making in central and eastern Europe: lessons from the inaction on injuries? Health Policy Plan. 2000 Sep; 15(3):263-9.
Abstract: The burden of disease due to injuries has elicited virtually no public health response in the countries of central and eastern Europe, even though injuries have long been a much greater problem in the east of Europe than in the west, with children especially affected. This paper seeks to identify factors that have inhibited policy development on this topic and to draw lessons for health policy development in this region more generally. Several factors emerge. Deaths from injuries have had low visibility. Data have not been assembled in a way that would facilitate identification of the burden of disease that they constitute. Those organizations responsible for public health, whether within government or at local level, were typically very weak with little capacity either to identify the nature and scale of threats to the health of their populations or to develop strategies to address them. There was uncertainty about ownership, with fragmentation of responsibility but no tradition of intersectoral working. Non- governmental organizations, which have placed injuries on the health policy agenda in the west, are weak or non-existent. International donors, who could have had a role, have focused on issues such as health care reform. This analysis provides a potential framework for examining policy responses, or lack thereof, to other health challenges in this region. It highlights the need for a better understanding of the potential for using available data, which, in turn, requires a major strengthening of capacity. However, in many countries, there is a need for new ways of working, involving a broadening of the sense of ownership, with clearly designated responsibilities but designed in ways that encourage rather than inhibit intersectoral action. There is also a need to develop non-governmental organizations that have sufficient capacity to undertake their own analyses and to place issues on the agenda.

   18.    Odero, W.; Garner, P., and Zwi, A. Road traffic injuries in developing countries: a comprehensive review of epidemiological studies. Trop Med Int Health. 1997 May; 2(5):445-60.
Abstract: Motor vehicle accidents are the leading cause of death in adolescents and young adults worldwide. Nearly three-quarters of road deaths occur in developing countries and men comprise a mean 80% of casualties. This review summarizes studies on the epidemiology of motor vehicle accidents in developing countries and examines the evidence for association with alcohol.

   19.    Odero, W. and Zwi, A. B. Drinking and driving in an urban setting in Kenya. East Afr Med J. 1997 Nov; 74(11):675-9.
Abstract: A roadside alcohol prevalence survey of drivers randomly selected from the general traffic was conducted in Eldoret, Kenya. Blood alcohol concentration (BAC) data obtained by a breath test in 90% of the sample (n = 479) was analysed by demographic and travel characteristics. 19.9% had a positive breath test (BAC > or = 5 mg%), 8.4% had BACs greater than 50 mg%, and 4% exceeded 80 mg%. A greater proportion of males (20%) had been drinking compared to females (12.5%): all drivers with high BACs (> or = 50 mg%) were males. The likelihood of having consumed alcohol was greater in motorists aged 25 years and above (20.4%) than in younger drivers aged 16-24 years (15.4%), their mean BACs were also more elevated (57 mg% versus 31 mg%). In comparison to operators of public service vehicles (PSV), people driving personal cars were more than twice as likely to have been drinking: with 21.9% being BAC positive against 10.8% (OR = 2.3; 95% CI, 1.0 to 6.3, p = 0.05). Educated individuals with skilled careers tended to indulge in drink- driving to a greater extent than professional drivers (operators of public transport, taxi and heavy goods vehicles), with BAC prevalence rates of 23.7% and 15.5%, respectively. Other circumstances influencing the probability of drink-driving were number of vehicle occupants, distance to destination, road location, time of the night and whether it was a weekend or weekday. These findings are discussed in relation to the potential for promotion of relevant deterrent measures, including the establishment of an appropriate BAC legal limit for drivers in Kenya.

   20.    ---. An evaluation of sensitivity and specificity of blood alcohol concentrations obtained by a breathalyser survey in a casualty department in Kenya. Accid Anal Prev. 1999 Jul; 31(4):341-5.
Abstract: Whereas breathalysers have been shown to provide blood alcohol concentration (BAC) measurements comparable to those obtained by gas chromatography, such evidence has not been reported in low and middle income countries where measures for preventing alcohol-related injuries are virtually non-existent. Before promoting any method of blood alcohol evaluation, as a routine procedure for monitoring the association of alcohol with different types of injuries in Kenya, we sought to assess the reliability and validity of blood alcohol results obtained by a breathalyser, using gas chromatography analysis values as the reference, in a sample of 179 trauma-affected adults presenting to casualty departments. No differences in proportions of subjects with high levels of blood alcohol (equal to or greater than 50 mg%) were detected by breath and blood test procedures (58.7 vs 60.3%). Breathalyser readings yielded high levels of sensitivity and specificity (97.2 and 100%, respectively) with optimal positive and negative predictive values (100 and 95.9%, respectively) at higher BACs (> or = 50 mg%). The study thus reaffirms that breathalyser tests are of value in detecting high blood alcohol levels and can be used to rapidly identify intoxicated subjects. The procedure is easy to perform and can be used for monitoring the association between blood alcohol level and driving in low-income developing countries.

   21.    Ogden, J.; Rangan, S.; Uplekar, M.; Porter, J.; Brugha, R.; Zwi, A., and Nyheim, D. Shifting the paradigm in tuberculosis control: illustrations from India. Int J Tuberc Lung Dis. 1999 Oct; 3(10):855-61.
Abstract: Drawing on literature from India and key contributions from social science, this paper asks and attempts to answer the question 'who is to blame for treatment failures in TB'? Some key lessons emerge: effective tuberculosis control cannot be achieved so long as the disease is considered in isolation from the social processes that maintain it, create the conditions facilitating its spread and act as barriers to care. Insights into the economic and social burdens incurred with a diagnosis of TB are essential to understand why many patients, especially the most disadvantaged, are unable to comply with treatment regimens. TB and health care interventions need to be appropriate to the health service contexts in which they are applied, and sensitive to the competing demands, needs and priorities of people's lives. The paper argues for the need to reorient TB control programmes towards enabling patients to obtain care. The problem of access emerges as central to people's ability to obtain and maintain appropriate therapy. Examples and characteristics of successful non-governmental projects, from which policy makers, programmers and practitioners could learn, are outlined and contrasted with more rigid directly observed treatment approaches. We conclude that treatment failures are not patient failures, and that TB control programmes need to address the social dimensions of TB, and adhere to the principles of good TB care, with the same commitment that is devoted to ensuring patients follow treatment guidelines. We suggest a paradigm shift away from a focus on diseased patients towards enabling health in the community.

   22.    Palmer, C. A.; Lush, L., and Zwi, A. B. The emerging international policy agenda for reproductive health services in conflict settings. Soc Sci Med. 1999 Dec; 49(12):1689-703.
Abstract: Over the past 20 years, shifts in the nature of conflict and the sheer numbers of civilians affected have given rise to increasing concern about providing appropriate health services in unstable settings. Concurrently, international health policy attention has focused on sexual and reproductive health issues and finding effective methods of addressing them. This article reviews the background to the promotion and development of reproductive health services for conflict-affected populations. It employs qualitative methods to analyse the development of policy at international level. First we examine the extent to which reproductive health is on the policy agendas of organisations active in humanitarian contexts. We then discuss why and how this has come about, and whether the issue has sufficient support to ensure effective implementation. Our findings demonstrate that reproductive health is clearly on the agenda for agencies working in these settings, as measured by a range of established criteria including the amount of new resources being attracted to this area and the number of meetings and publications devoted to this issue. There are, however, barriers to the full and effective implementation of reproductive health services. These barriers include the hesitation of some field-workers to prioritise reproductive health and the number and diversity of the organisations involved in implementation. The reasons for these barriers are discussed in order to highlight areas for action before effective reproductive health service provision to these populations can be ensured.

   23.    Palmer, C. A. and Zwi, A. B. Women, health and humanitarian aid in conflict. Disasters. 1998 Sep; 22(3):236-49.
Abstract: The burden of political conflict on civilian populations has increased significantly over the last few decades. Increasingly, the provision of resources and services to these populations is coming under scrutiny; we highlight here the limited attention to gender in their provision. Women and men have different exposures to situations that affect health and access to health-care and have differential power to influence decisions regarding the provision of health services. We argue that the role of women in planning is central to the provision of effective, efficient and sensitive health-care to conflict-affected populations.

   24.    Rifkin, S. and Zwi, A. Preventing crime and violence. A population approach is needed. BMJ. 1995 May 6; 310(6988):1198.

   25.    Sethi, D.; Watts, S.; Watson, J.; McCarthy, C., and Zwi, A. Experience of 'screening' for domestic violence in women's services. J Public Health Med. 2001 Dec; 23(4):349-50.

   26.    Sethi, D. and Zwi, A. Challenge of drowning prevention in low and middle income countries. Inj Prev. 1998 Jun; 4(2):162.

   27.    Soderlund, N. and Zwi, A. B. Traffic-related mortality in industrialized and less developed countries. Bull World Health Organ. 1995; 73(2):175-82.
Abstract: Road traffic-related mortality has traditionally been regarded as a problem primarily of industrialized countries. There is, however, growing evidence of a strong negative relationship between economic development and exposure-adjusted traffic-related death rates. Cross- sectional data on road traffic-related deaths in 1990 were obtained from 83 countries. The relationship between such mortality and a number of independent variables was examined at the individual country level by means of multiple regression techniques. These were also used to elucidate factors associated with variations in age, sex, and case- fatality patterns of road traffic mortality. Countries were grouped according to region and socioeconomic features, and the mortality data were summarized by these groups. The gross national product per capita was positively correlated with traffic-related mortality/100,000 population/year (P = 0.01), but negatively correlated with traffic deaths/1000 registered vehicles (P < 0.0001). Increasing population density was associated with a proportionately greater number of traffic- related deaths in the young and the elderly (P = 0.036). Increasing GNP per capita and increased proportional spending on health care were associated with decreasing case-fatality rates among traffic-accident victims (P = 0.02 and 0.017, respectively). Middle-income countries appear to have, on average, the largest road-traffic mortality burden. After adjusting for motor vehicle numbers, however, the poorest countries show the highest road traffic-related mortality rates. Many industrialized countries would appear to have introduced interventions that reduce the incidence of road traffic injury, and improve the survival of those injured. A major public health challenge is to utilize this experience to avoid the predicted increase in traffic- related mortality in less developed countries.

   28.    Sondorp, E.; Kaiser, T., and Zwi, A. Beyond emergency care: challenges to health planning in complex emergencies. Trop Med Int Health. 2001 Dec; 6(12):965-70.

   29.    Sondorp, E. and Zwi, A. B. Complex political emergencies. BMJ. 2002 Feb 9; 324(7333):310-1.

   30.    Tollman, S. M. and Zwi, A. B. Health system reform and the role of field sites based upon demographic and health surveillance. Bull World Health Organ. 2000; 78(1):125-34.
Abstract: Field sites for demographic and health surveillance have made well- recognized contributions to the evaluation of new or untested interventions, largely through efficacy trials involving new technologies or the delivery of selected services, e.g. vaccines, oral rehydration therapy and alternative contraceptive methods. Their role in health system reform, whether national or international, has, however, proved considerably more limited. The present article explores the characteristics and defining features of such field sites in low- income and middle-income countries and argues that many currently active sites have a largely untapped potential for contributing substantially to national and subnational health development. Since the populations covered by these sites often correspond with the boundaries of districts or subdistricts, the strategic use of information generated by demographic surveillance can inform the decentralization efforts of national and provincial health authorities. Among the areas of particular importance are the following: making population-based information available and providing an information resource; evaluating programmes and interventions; and developing applications to policy and practice. The question is posed as to whether their potential contribution to health system reform justifies arguing for adaptations to these field sites and expanded investment in them.

   31.    Waterston, T. and Zwi, A. Health professionals and South Africa: supporting change in the health sector. BMJ. 1993 Jul 10; 307(6896):110-2.
Abstract: Now that political change is on the way in South Africa, what should be the position of doctors who are invited to visit the country? Does the "academic boycott" still have relevance? Waterston and Zwi review the case for and against an academic boycott policy, using evidence collected during the recent visit by Physicians for Human Rights (UK) and the Johannes Wier Foundation. The health system in South Africa is still inequitable, and despite progress towards desegregation in hospitals there is little momentum towards universal provision of primary health care, especially in the rapidly growing townships around big cities. The authors consider that pressure on the government should be maintained by outside organisations but that support directed towards appropriate health care should be encouraged, particularly in public health and primary health care.

   32.    Watts, C.; Zwi, A.; Wilson, D.; Mashababe, S., and Foster, G. Capture-recapture as a tool for programme evaluation. BMJ. 1994 Mar 26; 308(6932):858.

   33.    Watts, C. H.; Zwi, A. B., and Foster, G. Using capture-recapture in promoting public health. Health Policy Plan. 1995 Jun; 10(2):198-203.

   34.    Zwi, A. A comparison of the mortality rates of various population groups in South Africa. S Afr Med J. 1979 Sep 8; 56(11):424.

   35.    ---. War and public health. BMJ. 1999 May 8; 318(7193):1295.

   36.    Zwi, A.; Fonn, S., and Steinberg, M. Occupational health and safety in South Africa: the perspectives of capital, state and unions. Soc Sci Med. 1988; 27(7):691-702.
Abstract: South Africa is one of the most technologically advanced countries of Africa. The main sectors are mining, agriculture and industry. Many work environments are dangerous. Since the early development of the mines in South Africa, occupational health and safety (OHS) has received the attention of the state, the employers, and the workers. Although there have been some advances in legislation, conditions are often still poor and enforcement of legislation is lacking. The paper outlines the history of concern with OHS issues, and draws attention to the Erasmus Commission of Enquiry (1976) into Occupational Health. The paper attempts to provide an overview of the different activities and perspectives of these interest groups: the state is concerned with minimising conflict and disruption of productivity, while ensuring that conditions do not deteriorate too badly; the employers are concerned to maximise profits and to undertake improvements in OHS only insofar as these are profitable and in the interest of stable industrial relations; and the union movement has sought to make work safer. These perspectives are different and conflicting. The only interest group with an unambiguous commitment to improving OHS is the union movement in South Africa. However, many difficulties and problems mitigate against the movement achieving its OHS objectives, including the limited number of workers which have been organised into unions and the many pressing issues which require the movement's immediate attention.

   37.    Zwi, A.; Marks, S., and Andersson, N. Health, apartheid and the Frontline States. Soc Sci Med. 1988; 27(7):661-5.

   38.    Zwi, A. and Ugalde, A. Towards an epidemiology of political violence in the Third World. Soc Sci Med. 1989; 28(7):633-42.
Abstract: Political violence is distressingly widespread in many parts of the world. This paper reviews the forms and effects of political violence and devotes particular attention to experiences from Central America and Southern Africa. The forms of violence vary from those which are extensive such as civil unrest and war, to those which are intensive, such as assassinations, disappearances and torture. The effects of violence on health may be direct, such as deaths, disabilities, psychological stress and the destruction of health services, or indirect such as the erosion of innovative health policies in favour of increased military expenditure. Health workers have a role to play in opposing political violence, providing care for those affected by violence, and documenting and analysing its impact on health. Research needs include documenting the impact of different forms of violence on health, and analysing the social and political factors which promote and support political violence. It is hoped that increasing recognition of political violence and man-made violence as being of major public health concern will play a part in promoting a more peaceful world.

   39.    Zwi, A. B. Commentary: life in the real world is more complicated. BMJ. 1995 Oct 14; 311(7011):1001-2.

   40.    ---. Injury control in developing countries: context more than content is crucial. Inj Prev. 1996 Jun; 2(2):91-2.

   41.    ---. Isocyanates and health--a review. S Afr Med J. 1985 Feb 9; 67(6):209-11.
Abstract: Isocyanates are chemical compounds used increasingly frequently in industry for the production of a wide range of goods. They can produce severe asthmatic responses in the sensitive. Health hazards, diagnosis, first-aid measures, prevention and legislation are discussed. Patients presenting with apparently work-related asthma should be questioned about exposure to these substances, and workers should be informed of the dangers of such exposure. Legislation should be passed setting limits for exposure to isocyanates and ensuring compensation for those workers whose health is affected by exposure to these compounds.

   42.    ---. Militarism, militarization, health and the Third World. Med War. 1991 Oct-1991 Dec 31; 7(4):262-8.
Abstract: This paper examines the relationship between militarism, militarization, health and development. It draws attention to the fact that world military expenditure has continued to soar since the Second World War. Wars increasingly exact a heavy civilian toll. Third World countries are consuming, producing, and exporting more armaments than ever before. The rate of growth of military expenditure in developing countries has been far greater than their rate of growth in gross national product or in foreign economic aid. Countries under military control tend to be more repressive and to have suffered more years at war than those under civilian rule. Widespread availability of arms makes the settlement of disputes through violence more likely. Internal wars and violence are stimulated by a range of factors including inequalities in political and economic power, uneven development, and lack of popular participation in policy decisions by the majority of the population. The support of the industrialized countries for armament sales should be monitored, challenged and made politically unpalatable. Local development and regional cooperation should be stimulated. Health workers, as witnesses to the destruction to public health caused by war and violence, should play a part in advocating a reduction in the arms trade and the promotion of development in Third World countries.

   43.    ---. The political abuse of medicine and the challenge of opposing it. Soc Sci Med. 1987; 25(6):649-57.
Abstract: A fundamental aim of medicine is to protect and promote health. The practice of medicine has, however, been used to promote political aims which may be detrimental to health. The article attempts to isolate the ways in which political abuses may interfere with good medical practice: by allowing health policies to be influenced by undemocratic political considerations; by using health services to reward or punish political supporters or opponents; by direct medical involvement in political acts which contradict accepted medical ethics; and by the support which conventional medical practises give to perpetuating inequalities in health and social services. Each of these is examined with the use of a number of examples. The ways in which medical personnel have opposed the political abuse of medicine is explored by a brief review of the opposition of Chilean doctors to torture, the involvement of South African doctors in opposing the abuse of health services in perpetuating apartheid, and the growing medical movement in opposition to nuclear war. Some comments concerning the monitoring of a multitude of medical disciplines which are open to political abuse are made. The purpose of the paper is primarily to stimulate debate around this important issue and it does not attempt to provide a comprehensive review of the political abuse of medicine.

   44.    ---. Reassessing priorities: identifying the determinants of HIV transmission. Soc Sci Med. 1993 Mar; 36(5):iii-viii.

   45.    Zwi, A. B.; Brugha, R., and Smith, E. Private health care in developing countries. BMJ. 2001 Sep 1; 323(7311):463-4.

   46.    Zwi, A. B. and Cabral, A. J. Identifying "high risk situations" for preventing AIDS. BMJ. 1991 Dec 14; 303(6816):1527-9.

   47.    Zwi, A. B. and Ehrlich, R. I. Occupational history-taking in the RSA. S Afr Med J. 1986 Nov 8; 70(10):601-5.
Abstract: Medical practitioners need to elicit a comprehensive occupational history from their patients, since this may play an integral part in establishing the diagnosis, may indicate the most appropriate form of management, and will ensure that claims for Workmen's Compensation are initiated when appropriate. This history can also assist in identifying undetected workplace hazards and in formulating and testing hypotheses concerning the relationship of work to health. The particular problems encountered in taking an occupational history effectively in the RSA are discussed.

   48.    Zwi, A. B.; Forjuoh, S.; Murugusampillay, S.; Odero, W., and Watts, C. Injuries in developing countries: policy response needed now. Trans R Soc Trop Med Hyg. 1996 Nov-1996 Dec 31; 90(6):593-5.

   49.    Zwi, A. B.; Garfield, R., and Sondorp, E. Health and peace: an opportunity to join forces. Lancet. 2001 Oct 6; 358(9288):1183-4.

   50.    Zwi, A. B.; Reid, G.; Landau, S. P.; Kielkowski, D.; Sitas, P., and Becklake, M. R. Mesothelioma in South Africa, 1976-84: incidence and case characteristics. Int J Epidemiol. 1989 Jun; 18(2):320-9.
Abstract: Malignant mesothelioma is a rare tumour known to be associated with prior exposure to asbestos. Previous studies have described the occupational and clinical features of cases of mesothelioma in the Republic of South Africa (RSA) but none has set out to determine incidence of this disease. To estimate incidence, a case register was compiled for 1976-84 by contacting all medical practitioners and institutions likely to have seen cases of mesothelioma in this period; demographic, diagnostic and exposure details were sought. Cases were accepted if they provided evidence of histological diagnosis of mesothelioma. Fifty-two per cent of 1347 cases identified were in whites, 31% in blacks, 16% in coloureds and 1% in Asians. Seventy-three per cent of cases occurred in males. The majority of whites were aged 51-70 years, while the majority in other race groups were aged 41-60 years. The ratio of only pleural to only peritoneal mesothelioma was 11:1, although there were marked differences by race. Eighty-five per cent of males with exposure information available had prior exposure to asbestos, mostly occupational. A similar proportion of women had contact with asbestos but mostly through other types of exposure. Standardized incidence rates per million population aged 15 years and over were calculated for sex-race subgroups and were highest in white males (32.9 per million per year, 95% Cl 22.7-46.4), coloured males (24.8 per million per year, 95% Cl 16.2-36.9) and coloured females (13.9 per million per year, 95% Cl 7.7-23.5). These incidence rates are amongst the highest ever reported for a national population. Age- specific standardized incidence rates were highest in white males (over 100 per million per year in men over 55 years). Reasons for the differing rates by population group are likely to include differential access to health services. More rigorous control of asbestos exposure in the RSA is recommended.

   51.    Zwi, A. B. and Rifkin, S. Violence involving children. BMJ. 1995 Nov 25; 311(7017):1384.

   52.    Zwi, A. B. and Ugalde, A. Military expenditure and foreign aid: should they be linked? BMJ. 1992 May 30; 304(6839):1421-2.

   53.    Zwi, A. B.; Zwarenstein, M.; Tollman, S., and Sanders, D. The introverted medical school--time to rethink medical education. S Afr Med J. 1994 Jul; 84(7):424-6.
Abstract: Curricular reform in the education of medical students is highlighted within the context of changing patterns of provision of health care. A number of industrialised countries' medical schools have accepted that they have a 'social contract' to respond to the health needs of the populations they serve. Such a contract, and the commitment to populations which it would necessitate, is also relevant in the South African context.

   54.    Zwi, K. J.; Zwi, A. B.; Smettanikov, E.; Soderlund, N., and Logan, S. Patterns of injury in children and adolescents presenting to a South African township health centre. Inj Prev. 1995 Mar; 1(1):26-30.
Abstract: OBJECTIVES: To describe the patterns and causes of childhood injury presenting to a South African township health centre in 1991. DESIGN: Retrospective review of clinic held case notes. SETTING: Typical South- African urban township within Greater Johannesburg. SUBJECTS: 695 subjects aged 0-19 years presenting as a direct result of injury. RESULTS: Overall rates of presentation for injury were 6297/100,000/year (95% confidence interval 5463 to 7131); 35% of injuries were caused by violence, 14% by traffic, and 51% by other unintentional causes (such as falls and sport injuries). Males had higher rates of presentation than females for violent (p < 0.001) and unintentional injuries (p < 0.01), but rates were similar for traffic injuries. The highest rates were for injuries caused by violence in 15- 19 year-old males and were 9319/100,000/year. CONCLUSIONS: Rates are lower than in more developed countries. However, they appear to represent the more severe end of the spectrum of injury severity. The rates are similar for those below age 10 years and higher for those above age 10 years compared with severe injury rates in other studies. These data are likely to underestimate true rates. The risk of injuries caused by violence increase with age and these injuries are more serious than those due to other causes. Males are at higher risk for all types of injury except traffic injury.