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To the Editor: The major cause of diarrhea in poor settlements in Pakistan is strongly believed to be the contamination of drinking water,¹ and water treatment, food hygiene, and handwashing are the standard intervention practices.^2-3 I believe that there is no equipoise in this regard, and because of this no need to have a "placebo" control with standard habits and practices as was done in the study on handwashing and childhood diarrhea by Dr Luby and colleagues.² In their study, field workers neither encouraged nor discouraged handwashing in the control group, allowing habits and practices that were promoting diarrhea in the community to continue. I believe that it would have been more ethical to have a control group that received handwashing promotional messages, and 2 intervention groups that received handwashing promotional messages and either plain or antibacterial soap.

Syed Abdul Mujeeb, MBBS, MPhil
smujeeb@super.net.pk
AIDS Surveillance Center
Jinnah Postgraduate Medical Center
Karachi, Pakistan

1. Luby S, Agboatwalla M, Raza A, et al. A low-cost intervention for cleaner drinking water in Karachi, Pakistan. Int J Infect Dis. 2001;5:144-150. FULL TEXT | PUBMED 2. Luby SP, Agboatwalla M, Painter J, et al. Effect of intensive hand washing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. JAMA. 2004;291:2547-2554. FREE FULL TEXT 3. Curtis V, Cairncross S. Effect of washing hands with soap on diarrhea risk in the community: a systematic review. Lancet Infect Dis. 2003;3:275-281. FULL TEXT | ISI | PUBMED

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2004;292:1682.

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