134 Health care in cities SIR-May I raise two points about your May 28 editorial on health and health care in cities? First, we need to be cautious on the judgment that city people are healthier than country people. That is true on average, and so far as statistics go. It may not be true for the poor, especially the large numbers of people living in marginal areas, whose very existence in the cities is often not legally recognised and therefore whose health is incompletely reported. The street children of some South American cities are only one example of how such lives can be nasty, brutish, and short. Without proper survey of specific deprived urban communities we would be unwise to assume that the story told by the averages is complete. Second, I am wary of your conclusion that "The problems ... do not require new solutions, merely judicious application of already proven measures". At the technical level that may be true, but I am not at all sure it is true managerially or system wide. For example, making a community health worker programme effective is different and more difficult in the urban setting than in rural areas, especially within range of a major acute hospital. Moreover, although there are shining successes with individual projects, I am not aware of any large city in the poorer countries of the world that has managed to move from good projects to a total system that works well for the poor. In most of the wealthier countries, the same might be said. If I am right about that, it may be too complacent to say that we know it all. Robert J Maxwell The King’s Fund, London W2 4HS, UK What do commercial ginseng preparations contain? SiR-During the past three decades, consumption of ginseng has greatly increased in western countries. In Sweden more than 5% of the adult population is estimated to consume ginseng, and the situation seems to be similar in many other European countries. In general, commercial ginseng preparations are not well defined and they are known to contain a large number of substances. The most characteristic compounds in the ginseng roots are the ginsenosides, and most biological effects have been ascribed to these compounds. Ginsenosides, being glycosylated steroids, are very difficult to analyse and quantify in small amounts. We have now developed an accurate method for measurement of the two aglycones of ginsenosides-20S-protopanaxadiol and 20S- protopanaxatriol.’ In addition, we could also quantify oleanolic acid, which is a compound structurally similar to the two aglycones. We found that the aglycones could be released measureably without production of artifacts by the use of a new oxidative cleavage procedure This new method allows accurate analysis of the composition of different ginseng preparations. We have now examined 50 commercial ginseng products sold in eleven countries. The material was bought in pharmacies or reputable stores for natural remedies. Each preparation was analysed blind and in triplicate. In 44 of these preparations the concentration of ginsenosides varied from 1-9% to 9-0% (weight/weight). Surprisingly, 6 of the commercial products sold in Sweden, the UK, and the USA did not contain any specific ginsenosides, as shown by complete absence of 20S-protopanaxadiol and 20S- protopanaxatriol (table). One of the preparations contained Product name Claimed source Country Ginsenosides Oleanolic (company, lot no) and amount* (%, wt/wt) acid (%, wt/wt) Brasiliansk ginseng Pfaffia paniculata Sweden <0.01 <0.01 (Viterna Brasilian) 250 mg Ren Rysk Rot Eleutherococcus sent Sweden <0.01 <0.01 (Svensk Ortmed Inst, 100 mg 92E01) Up your gas Glnsengt Sweden <0.01 <0.01 (National Health Products, USA, 32811) Siberian ginseng 500 mg ginsenosides UK <0.01 <0.01 (Pharmadass, UK) from 2500 mg standardised Siberian ginseng Sibenan ginseng 400 mg Siberian USA <0.01 S (Nature’s Herbs, USA) ginseng root Manchunan ginseng 500 mg USA <0’01 <0.01 (Herbal Harvest, USA, Manchurian ginseng 31860) S=small amounts. *per capsule or tablet. tcombined with other ingredients; substantial ephedrine detected but not declared. Table: Ginsenosides content in some commercial preparations small amounts of oleanolic acid, indicating the presence of some herbal material. In connection with a doping test in 1993, a young Swedish athlete tested positive for ephedrine. As a result he was accused of doping. He had taken the ginseng preparation "Up your gas", which contains no ginsenosides (table). We could, however, show that this product contains large amounts of ephedrine. It is evident that there are commercial ginseng preparations that do not contain any true ginsenosides. At least one preparation may lead to a positive doping test. We conclude that quality control is urgently needed for commercial ginseng preparations and other natural remedies with suspected or assumed biological activity. J Cui, M Garle, P Eneroth, I Bj&ouml;rkhem Clinical Research Centre and Department of Medical Laboratory Science and Technology, Karolinska Institute, Huddinge Hospital, 141 86 Huddinge, Sweden 1 Cui J, Garle M, Bj&ouml;rkhem I, Eneroth P. Analysis of ginsenosides by chromatography and mass spectrometry: release of 20S-protopanaxadiol and 20S-protopanaxatriol for quantitation. Anal Biochem 1993; 210: 411-17. 2 Cui J, Bystr&ouml;m S, Eneroth P, Bj&ouml;rkhem I. Alkaline cleavage of ginsenosides and methyl glucosides: evidence for an oxygen dependent clevage of the glycosidic bond. J Org Chem (in press). Use of injectable depot medroxyprogesterone acetate in lactating Indian women SiR-Depo-Provera (injectable depot medroxyprogesterone acetate, DMPA) has lately been approved by the Indian drugs control authority for use as a contraceptive for private marketing. The Upjohn company (manufacturer of Depo- Provera), the Drugs Controller of India, and the World Health Organization regard this drug as safe for use in breastfeeding women. Safety has so far only been assessed on the grounds of transfer of the drug in breast milk, changes in milk composition and volume, and the resultant effect on the infant. A study in New Zealand has shown that DMPA users had significantly lower bone density in the lumbar spine (mean difference 7-5%, 95% CI 19-131%, p=0002) and femoral neck (6-6%, 0-8-12-3%, p=0007) than in control premenopausal women.’ The amount by which bone density