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than the host did, and this notion lead to the use of thesynthetic antifols which are one bulwark of cancer

therapy today.15 The concept of antimetabolites was alsoused to create antimicrobial agents which work byimpairing the nutrient supply of the pathogenicorganism.

ANOREXIA AS A DEFENCE?

The relationship between food intake and resistance todisease presents some other interesting paradoxes. Why isanorexia so regularly associated with infection and fever?It would be reasonable to expect infection to increase

appetite because of the need for fuel to sustain the fever.The appetite increases during other energy drafts, suchas exercise, pregnancy, adolescent growth, glycosuria,and hypermetabolism in thyrotoxicosis. Does anorexiafollow fever because this is a primordial defencemechanism, a means of impairing the invadingorganisms? If it is, we should heed the old axiom tostarve a fever because forced feeding may aid the

pathogen. If anorexia is a defence, we need to knowwhich nutrients are involved because it may be

advantageous to restrict some nutrients and force feedothers.

Patients with malignant tumours often have anorexiaand weight-Ioss.16 Why does this happen even when thecapacity to eat or absorb food is unimpaired and oftenwhen small tumours are far from the digestive tract?Could anorexia be a defence against malignancy? If so,the practice of forced feeding and parenteral nutritionI7could be better for tumours than patients, because itcould break down the defence against the proliferatingtumour.

DIET OF PATIENTS WITH INFECTION OR CANCER

There are many studies of the effects of infection onnutritional status, but less attention has been paid to theconverse which may be of more practical importance.’sThe increasing interest in the role of nutritional supportin the management of patients with cancer is directedmainly towards means of supporting patients so that theycan tolerate noxious treatment. It may be as senseless toforce feed in cancer as to treat pneumonia with aspirin.19A better understanding of appetite regulation mightindicate which nutrient restrictions impair pathogenicagents. We still do not know how feeding is controlled.

In particular, we need to know if the primordialdefence against invaders is mediated through restrictionof energy or, for example of thiamine, deficiency ofwhich is a well-known cause of anorexia.2O We mightthen begin a more useful system of nutritional supportfor people with either infection or cancer.

Requests for reprints should be addressed to G.V.M. Department ofBiochemistry, Vanderbilt University, Nashville, Tennesse 37232,U.S.A.

REFERENCES

1. Kretschmar W. Die bedeutung der p-aminobenzosaure fur den krankenhutssuerlaufund die immunitat bei der malaria in tier und in menschen.Zeitschr Troppenmed Parasitol 1966; 17: 301.

2. McGregor I A, Immunology of malarial infection and its possibleconsequences. Brit Med Bull 1972; 28: 22.

3. Mann G V, Shaffer R D, Anderson, R S, Sandstead H H. Cardiovasculardisease in the Maasai. J Atherosclerosis Res 1964; 4: 289-312.

4. Shaffer R D, Njai D. Water and health—Amboseli Maasai. Conference onTropical Water-related disease. London 1978.

5. Price D L, Mann G V, Roels O A, Merrill J M. Parasitism in Congo Pygmies.Am J Trap med Hyg 1963; 12: 383-87.

6. Mann G V, Roels O A, Price D L, Merrill J M. Cardiovascular disease inAfrican Pygmies. A survey of the health status, serum lipids and diet ofPygmies in the Congo. J Chron Dis 1962; 15: 341-71.

7. Scrimshaw N S, Taylor C E, Gordon J E. Interactions of nutrition andinfection. WHO Monograph Series 57. Geneva: WHO, 1968.

8. Murray J, Murray A, Murray M, Murray C. The biological suppression ofmalaria. Am J Clin Nutr 1978; 31: 1363.

9. Masawe A E J, Swai G. Iron deficiency and infection. Lancet 1975; i: 1241.10. Barry D M J, Reeve A W. Iron and neonatal infections. Ped. Soc. N.Z.

Annual Conf. Abstr. 1975.11. Weinberg E D. Infection and iron metabolism. Am J Clin Nutr 1977; 30:

1485.12. Nurse G T. Iron, the thalassæmias, and malaria. Lancet 1979; ii: 938.13. Gräsbeck R. Intrinsic factor and other vitamin B12 transport proteins. Prog

Hematol 1969; 6: 233.14. Farber S. Temporary remissions in acute leukemia in children produced by

folic acid antagonist... aminopterin. N Engl J Med 1948; 238: 787.15. Scott R B. Cancer chemotherapy. Br Med J 1970; ii: 259-65.16. Theologides A. Weight loss in cancer patients. Cancer J Clin 1977; 27: No 4,

205.17. Welmore D W, McDougall W S, Peterson J P. Newer products and formulas

for alimentation. Am J Clin Nutr 1977; 30: 1498.18. Chandra, R K. Nutrition as a critical determinant in susceptibility to

infection. World Rev. Nutr Diet 1976; 25: 166.19. Blackburn G L. Nutritional assessment and support during infection. Am J

Clin Nutr 1977; 30: 1493.20. Platt BS. Thiamine deficiency. Fed Proc 1958; 178-20: Suppl. 3, 8-12.

Infant FeedingCode of Marketing Practice

THE possibility of an international code of marketingfor infant-feeding products moved a step closer duringthe 33rd World Health Assembly in Geneva last month.Delegates approved a resolution endorsing the statementand recommendations of last October’s W.H.O./UNI-CEF meetingl.2 on infant and young-child feeding. Theresolution requested the Director General of W.H.O. tointensify his activities for implementing the recommen-dations, including efforts to promote breast-feeding,work on the development of weaning foods based onlocal products, assisting in better health education,training, and information on infant feeding, and thepreparation of an international code.The code will be governed by three principles: produc-

tion, storage, distribution, and advertising of infant-feeding products should be subject to national legisla-tion ; information on infant feeding should be providedby the health-care system; and products should meet in-ternational standards of quality. According to W.H.O.,the process for the further elaboration of a code will in-clude two consultation meetings before October. Thefirst consultation will be with scientific experts, U.N.

specialised agencies, non-Governmental organisations,and the infant-food industry. The second meeting will bewith a representative sample of Governments. Fromthere a semi-final version of the code will be submittedto the W.H.O. executive board in January and then tonext year’s assembly for final ratification. At presentthere are two options for its final implementation: eitheras an international regulation, which would be bindingon member states unless they signified rejection of itwithin a stated time; or as a recommendation, whichwould be less authoritative. During the debate on the

1. Anonymous. W.H.O./UNICEF meeting. Lancet 1979; ii: 841-43.2. Editorial. The campaign against malnutrition. Lancet 1979; ii: 833.

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resolution most delegations from developing countriesfavoured the idea of a regulation, with some countriessuggesting that either the milk powder or feeding bottlesshould be available only on prescription. The industria-lised milk-exporting countries were more in favour of a"flexible approach" or "general guidelines" that wouldnot necessarily be binding.

Both Britain and the U.S. suggested that the industrycould introduce voluntary controls over its marketing toensure there was no interference with the lactation pro-cess. The likelihood of voluntary controls being success-ful was thrown into question by the publication duringthe Assembly of a report by the International Baby FoodAction Network. The report set out over 200 alleged vio-lations of the October recommendations by 19 com-panies in 33 countries between January and April of thisyear.

Round the World

From our Correspondents

JamaicaLOCAL THIRD WORLD BLUES

THE Caribbean Islands are as beautiful as ever they were,the vegetation as lush, the flowers as splendid, and the seas thatmarvellous deep blue. But the economic situation is different.The ’70s have been described by a prominent West Indianeconomist as a "decade of disaster" for the whole region. Inso saying, the Governor of the Central Bank of Barbados,which is among the few that are flourishing, picked an appro-priate time, place, and occasion for his remarks-an awardceremony at the University of the West Indies in Mona,Jamaica. It was at a time when Jamaica’s trade defict in thefirst eight months of 1979 was announced as having risen to$180.3 million. Most of the increase was due to the cost ofmineral fuels and manufactured goods, though food imports insome months had declined. Dr Blackman noted that in the pre-vious decades the University had been brillantly led in the fieldof political economy, as a recent Nobel award testifies. Whathad gone wrong?He placed much of the blame on the academics in econom-

ics, politics, and sociology, whose views had so much in-fluenced local politicians. He did not mince his words. "In allfrankness I must say that much of the self-inflicted disastershad its intellectual roots in the social science faculties of this

university." He identified "comroon-or-garden bad scholar-ship, ideological aberration" and "a deep cultural inferioritycomplex" as the main sins of the attacked academics, which,together with the adaptation of alien models and modes ofthought, had produced such damaging effects. He had bluntcriticism for those academics who plunged into the politicalarena with half-baked economic and sociological theories,which led to the economic disasters he had witnessed.

But such troubles in the Third World are not confined toone area. They are to be seen in many countries where therehas been politically and sociologically inspired destruction ofproductive agriculture and industry with great damage to localeconomies. Dr Blackman’s remarks were made in a region longabounding in attacks on capitalism and imperialism, as well asin revolutionary rhetoric and sloganism, as substitutes for hardthinking. Indeed, many believe that what some Third Worldcountries need is repeated doses of capitalistic entrepreneur-ism. Why import expensive vegetables and fruit from Europeand the U.S. when they can be produced locally?The basic problems of these islands are overpopulation, high

unemployment, and low, and indeed diminishing, productivity.The pilloried University faculty is not the only place in whichDr Blackman’s words should strike home.

Transkei

DEPARTURE OF BRITISH

THE Transkei is multiracial now-and medically multina-tional. The Indians are at Holy Cross, Philippinos at Butter-worth, a Nepalese doctor has joined the staff at St Lucy’s, Ger-mans at Sulinkama, a few Hollanders around, a South Africanor two. Last -week a young American pathologist toured thecountry assessing the laboratories and making modest andpractical suggestions for improvements. And the British? TheBritish are going home, fearful that, if they do not find a nichesoon, it may be too late to insert themselves into the increas-

ingly rigid structure of the N.H.S. From reports I have heardit is the same in other parts of Africa. -

In my chauvinist way, I find this a pity. Very many of whatare now the district general hospitals of developing countrieswere founded by the British. The need which inspired them isstill there; in fact it has probably grown as more people cometo trust their local hospitals. But many of the British mustnow, for the sake of their families and future, put career beforeconcern. Much goodwill is thereby being lost, for doctors areprivileged in that they live in closer contact with the local com-munity than any other expatriates (now that teachers, nurses,administrators, and agricultural officers are all indigenous gra-duates). Gratitude for their help is often very touchingly andsincerely expressed.

British doctors do, of course, travel, but they are, increas-ingly, high-level consultants flying from one technologicaltower block to another, sales representatives of the British wayof medicine. Overseas graduates still flock to Britain to signon for courses and sit the postgraduate examinations. Theywill probably continue to do so for surgery, but for medicinedisillusionment may be creeping in. The Nepalese doctor putit very simply. "I come to England, I work hard, I take the ex-amination, I am a specialist. The next day I may shut thebook. I will never use it again." Most of his compatriots nowgo to India.

Could we be guilty of the same failure to appreciate localneeds as has bedevilled British industry? It would be sad if aBritish-trained doctor became as rare here as a British-madecar.

United States

COMPLAINTS AGAINST DOCTORS

IN New York State, the Office of Professional Medical Con-duct, which is seriously understaffed on the legal side, investi-gates complaints and brings them before the Board of Profes-sional Medical Conduct, which is a branch of the State HealthDepartment. If this group of four physicians and one non-phy-sician votes the complaints valid, it turns the matter over tothe State Attorney General for action--or inaction, it oftenseems to be. The Attorney General can seek suspension orrevocation of a licence to practise. It seems that, nationwide,in 1978 some 216 medical licences were revoked and 302 phys-icians were suspended from practice. Corresponding figuresfrom New York are not available, but in four years some 4425complaints have resulted in 3196 cases being completed. Thisinvocation of the State Attorney General is naturally not thelast stage in the disciplinary process, for the State Commis-sioner of Health now has his say and if necessary then passesthe matter to the actual licensing authority, the State Boardof Regents. It is thus not surprising that disciplinary action isslow and that a physician finally found grossly at fault cancontinue practising for years. This situation is causing com-plaints by politicians in the State; but it is not clear how thingscan be improved and the process speeded up. No other Stateseems to have an answer either.