Lancet 28 Oct 2006

Here is an important case-control study which goes a long way towards proving that conjugate pneumococcal vaccine could save a great many children’s lives, especially in the developing world (see editorial, p.1469). The investigators looked at the serotypes of pneumococcus involved in 782 cases and 2512 controls. They conclude that the vaccine is highly effective against penicillin-sensitive strains in the USA but less so against penicillin-resistant strains. Strains will change and targets will move, but we now have an effective weapon which needs to be used where it will make the most difference.

1516 The paradox of pneumocococcal vaccine is that it is used most in countries where it makes the least difference: this is even more true of Caesarean section. It is generally accepted that CS rates in most developed countries are far in excess of anything that is medically justified, whereas in the poorest countries, many women and babies die for lack of access to operative birth. The figures in Table 1 of this paper make for bizarre reading: in Chad the CS rate is 0.28%, whereas in Brazil it is 36%; there are gross discrepancies in the rates between the poorest and the richest in every country except Uganda—even in the People’s Republic of Vietnam, the richest get seven times as many.

1524 The search for an ideal, equitable health system goes on. Actually, I’m not sure that it does in many Western countries, and least of all our own, where the Government’s only concern is to shift responsibility away from itself and indeed from all democratic accountability. So full marks to Richard Horton for hitting on Mexico as a model for the world. Here “reform