Concerns about immunisation Breast feeding should be promoted Editor—Bedford and Elliman make some important statements about immunisation. 1 Certainly, millions of lives have been saved. Smallpox has been eradicated, and polio should be eradicated soon. But are routine vaccines safe? Four months after the Centers for Disease Control and Prevention in the United States recommended that all babies should receive three doses of the rotavirus vaccine, the use of this vaccine was being indefinitely suspended after reports of over 100 cases of intussusception and two deaths resulting from its use. 2 The manufacturer voluntarily withdrew the vaccine. In July 1999 the US Public Health Serv- ice and the American Academy of Pediatrics asked vaccine manufacturers to eliminate the preservative mercury from vaccines because of concern about its cumulative effects. 3 Babies who receive the 15 recom- mended vaccines in the first six months of their lives have a cumulative mercury expo- sure that exceeds limits set by the Environ- mental Protection Agency. What is the impact when, by the age of 5 years, children have received over two dozen doses of vaccines containing mercury and other toxins? Some scientists say that the massive polio immunisation campaign in Zaire and other African countries in the 1950s accelerated the spread of HIV. 4 The aerosol vaccine was grown in monkey kidney tissue; that same species of monkey carries a simian immune deficiency virus. The places where the vaccine was administered are the epicentre of the AIDS epidemic. Was the vaccine the vector that carried the immune deficiency virus to humans? The answers to this most important question are inconclu- sive and controversial. It costs millions to develop, research, and market a vaccine. Wouldn’t it make more sense to spend that money to protect, promote, and support breast feeding for every baby? There is much evidence that breast feeding reduces the incidence and severity of rotavirus, respiratory syncytial virus, and otitis media, without side effects. 5 There can be conflict when economic and political interests enter the realm of public health. We have seen how important information about safety has been hidden to protect profit; the tobacco industry lawsuits are an illustration. We have seen it when the sons and daughters of the mothers who were given diethylstilbestrol showed up seri- ously ill a generation later, and when infants whose mothers were given thalidomide were born deformed. How long must a clinical trial be to ensure safety? One generation? Two? More? Nikki Lee faculty member Center for Breastfeeding, 8 Jan Sebastian Way, Number 13, Sandwich, MA 02563, USA Competing interests: None declared 1 Bedford H, Elliman D. Concerns about immunisation. BMJ 2000;320:240-3. (22 January.) 2 CDC. Withdrawal of rotavirus vaccine recommendation. JAMA 1999;282:2113-4. 3 Miller JL. Elimination of thimerosal from vaccines set as goal. Am J Health Syst Pharm 1999 Aug 15;56:1589, 1593. 4 Stricker RB, Elswood BF. Polio vaccines and the origin of AIDS: an update. Med Hypotheses 1997;48:193. 5 Grover M, Giouzeppos O, Schnagl RD, May JT. Effect of human milk prostaglandins and lactoferrin and respira- tory syncytial virus and rotavirus. Acta Paediatr 1997;86:315-6. Is vaccination cause célèbre or bête noire? Editor—Bedford and Elliman discuss some of the concerns about immunisation. 1 The Faculty of Homoeopathy speaks for a medically qualified minority. The more numerous medically unqualified homoeo- paths belong to the Society of Homoeopaths, the Institute of Complementary Medicine, or the Homoeopathic Medical Association, totalling some 2000 practitioners. None of these bodies supports vaccination. The Society of Homoeopaths, in a leaflet, encour- aged parents to seek advice about it. Currently the Homoeopathic Medical Association has no policy on vaccination. The Institute of Complementary Medicine, which has a register of “classical homoeopaths,” opposes vaccination. Homoeopaths’ views derive more from leading writers than professional bodies. James Compton Burnett discovered vaccine damage in the 1880s, and Stuart Close denounces all mass treatments as funda- mentally unholistic. Harris Coulter, a histo- rian, blames vaccination for mental illness, crime, and social deviance. A prominent Dutch homoeopath describes “post vaccina- tion syndrome,” and he claims that poten- tised vaccines can cure this syndrome and act prophylactically against many infections. This claim was confirmed by Margery Grace Blackie, the Queen’s former physician. 2 Martin Miles, a London homoeopath, extends Coulter’s views, claiming that vacci- nation causes cancer, meningitis, arthritis, constitutional weaknesses and neurological damage, and increases the level of mucus in the body. A leading homoeopath, George Vithoulkas, thinks that vaccination ignores the susceptibility of individual patients, is fundamentally unhomoeopathic, and leads to the degeneration of whole populations’ health. None of them supports vaccination: the original article and the faculty stand alone. From about 1903 until the 1970s, even the faculty endorsed an approach that regarded bacteria as harmless scavengers and opposed vaccination. 23 The data presented by Bedford and Elliman do not conclusively show that vaccination caused the decline of infectious diseases. Diphtheria, tuberculosis, and pertus- sis were virtually extinct before vaccines were introduced. American and British data show similar patterns. More likely causes are improved water supply, sanitation, adequate food supply, and birth control. Many were declining before the immunisation pro- grammes began. 4 I therefore remain uncon- vinced and agree with Stacey’s assessment that the decline of many infectious diseases is or was as much due to improved sanitation as to anything else—including immunisations. 5 Peter Morrell honorary research associate, history of medicine Department of Sociology, Staffordshire University, Stoke-on-Trent ST4 2DE [email protected]Competing interests: None declared. Advice to authors We prefer to receive all responses electronically, sent either directly to our website or to the editorial office as email or on a disk. Processing your letter will be delayed unless it arrives in an electronic form. We are now posting all direct submissions to our website within 24 hours of receipt and our intention is to post all other electronic submissions there as well. All responses will be eligible for publication in the paper journal. Responses should be under 400 words and relate to articles published in the preceding month. They should include <5 references, in the Vancouver style,including one to the BMJ article to which they relate.We welcome illustrations. Please supply each author’s current appointment and full address, and a phone or fax number or email address for the corresponding author.We ask authors to declare any competing interest. Please send a stamped addressed envelope if you would like to know whether your letter has been accepted or rejected. Letters will be edited and may be shortened. bmj.com [email protected]Letters Website: bmj.com Email: [email protected]108 BMJ VOLUME 321 8 JULY 2000 bmj.com
Transcript
Concerns about immunisation
Breast feeding should be promoted
Editor—Bedford and Elliman make someimportant statements about immunisation.1
Certainly, millions of lives have been saved.Smallpox has been eradicated, and polioshould be eradicated soon. But are routinevaccines safe? Four months after the Centersfor Disease Control and Prevention in theUnited States recommended that all babiesshould receive three doses of the rotavirusvaccine, the use of this vaccine was beingindefinitely suspended after reports of over100 cases of intussusception and two deathsresulting from its use.2 The manufacturervoluntarily withdrew the vaccine.
In July 1999 the US Public Health Serv-ice and the American Academy of Pediatricsasked vaccine manufacturers to eliminatethe preservative mercury from vaccinesbecause of concern about its cumulativeeffects.3 Babies who receive the 15 recom-mended vaccines in the first six months oftheir lives have a cumulative mercury expo-sure that exceeds limits set by the Environ-mental Protection Agency. What is theimpact when, by the age of 5 years, childrenhave received over two dozen doses ofvaccines containing mercury and othertoxins?
Some scientists say that the massivepolio immunisation campaign in Zaire andother African countries in the 1950saccelerated the spread of HIV.4 The aerosolvaccine was grown in monkey kidney tissue;that same species of monkey carries a simianimmune deficiency virus. The places wherethe vaccine was administered are theepicentre of the AIDS epidemic. Was thevaccine the vector that carried the immunedeficiency virus to humans? The answers tothis most important question are inconclu-sive and controversial.
It costs millions to develop, research, andmarket a vaccine. Wouldn’t it make moresense to spend that money to protect,promote, and support breast feeding forevery baby? There is much evidence thatbreast feeding reduces the incidence andseverity of rotavirus, respiratory syncytialvirus, and otitis media, without side effects.5
There can be conflict when economicand political interests enter the realm ofpublic health. We have seen how importantinformation about safety has been hidden toprotect profit; the tobacco industry lawsuitsare an illustration. We have seen it when thesons and daughters of the mothers who
were given diethylstilbestrol showed up seri-ously ill a generation later, and when infantswhose mothers were given thalidomide wereborn deformed. How long must a clinicaltrial be to ensure safety? One generation?Two? More?Nikki Lee faculty memberCenter for Breastfeeding, 8 Jan Sebastian Way,Number 13, Sandwich, MA 02563, USA
Competing interests: None declared
1 Bedford H, Elliman D. Concerns about immunisation. BMJ2000;320:240-3. (22 January.)
2 CDC. Withdrawal of rotavirus vaccine recommendation.JAMA 1999;282:2113-4.
3 Miller JL. Elimination of thimerosal from vaccines set asgoal. Am J Health Syst Pharm 1999 Aug 15;56:1589, 1593.
4 Stricker RB, Elswood BF. Polio vaccines and the origin ofAIDS: an update. Med Hypotheses 1997;48:193.
5 Grover M, Giouzeppos O, Schnagl RD, May JT. Effect ofhuman milk prostaglandins and lactoferrin and respira-tory syncytial virus and rotavirus. Acta Paediatr1997;86:315-6.
Is vaccination cause célèbre or bête noire?
Editor—Bedford and Elliman discuss someof the concerns about immunisation.1 TheFaculty of Homoeopathy speaks for amedically qualified minority. The morenumerous medically unqualified homoeo-paths belong to the Society of Homoeopaths,the Institute of Complementary Medicine, orthe Homoeopathic Medical Association,totalling some 2000 practitioners. None ofthese bodies supports vaccination. TheSociety of Homoeopaths, in a leaflet, encour-aged parents to seek advice about it.Currently the Homoeopathic MedicalAssociation has no policy on vaccination. TheInstitute of Complementary Medicine, whichhas a register of “classical homoeopaths,”opposes vaccination.
Homoeopaths’ views derive more fromleading writers than professional bodies.James Compton Burnett discovered vaccinedamage in the 1880s, and Stuart Closedenounces all mass treatments as funda-mentally unholistic. Harris Coulter, a histo-rian, blames vaccination for mental illness,crime, and social deviance. A prominentDutch homoeopath describes “post vaccina-tion syndrome,” and he claims that poten-tised vaccines can cure this syndrome andact prophylactically against many infections.This claim was confirmed by Margery GraceBlackie, the Queen’s former physician.2
Martin Miles, a London homoeopath,extends Coulter’s views, claiming that vacci-nation causes cancer, meningitis, arthritis,constitutional weaknesses and neurologicaldamage, and increases the level of mucus in
the body. A leading homoeopath, GeorgeVithoulkas, thinks that vaccination ignoresthe susceptibility of individual patients, isfundamentally unhomoeopathic, and leadsto the degeneration of whole populations’health. None of them supports vaccination:the original article and the faculty standalone. From about 1903 until the 1970s,even the faculty endorsed an approach thatregarded bacteria as harmless scavengersand opposed vaccination.2 3
The data presented by Bedford andElliman do not conclusively show thatvaccination caused the decline of infectiousdiseases. Diphtheria, tuberculosis, and pertus-sis were virtually extinct before vaccines wereintroduced. American and British data showsimilar patterns. More likely causes areimproved water supply, sanitation, adequatefood supply, and birth control. Many weredeclining before the immunisation pro-grammes began.4 I therefore remain uncon-vinced and agree with Stacey’s assessmentthat the decline of many infectious diseases isor was as much due to improved sanitation asto anything else—including immunisations.5
Peter Morrell honorary research associate, history ofmedicineDepartment of Sociology, Staffordshire University,Stoke-on-Trent ST4 [email protected]
Competing interests: None declared.
Advice to authorsWe prefer to receive all responses electronically,sent either directly to our website or to theeditorial office as email or on a disk. Processingyour letter will be delayed unless it arrives in anelectronic form.
We are now posting all direct submissions toour website within 24 hours of receipt and ourintention is to post all other electronicsubmissions there as well. All responses will beeligible for publication in the paper journal.
Responses should be under 400 words andrelate to articles published in the precedingmonth. They should include <5 references, in theVancouver style, including one to the BMJ articleto which they relate. We welcome illustrations.
Please supply each author’s currentappointment and full address, and a phone orfax number or email address for thecorresponding author. We ask authors to declareany competing interest. Please send a stampedaddressed envelope if you would like to knowwhether your letter has been accepted or rejected.
1 Bedford H, Elliman D. Concerns about immunisation. BMJ2000;320:240-3. (22 January.)
2 Winston J. The faces of homeopathy: a history of the first 200years. Wellington, New Zealand: Great Auk Publishing,1999.
3 Miles M. Homeopathy and human evolution. London: WinterPress, 1992.
4 Leavitt J, Numbers R. Sickness and health in America. Madi-son, WI: University of Wisconsin, 1978.
5 Stacey M. The sociology of health and healing. London:Unwin, 1988.
Facts are not enough
Editor—Bedford and Elliman provide auseful summary of the main evidencesupporting the safety and effectiveness ofvaccines.1 They suggest that their evidencebased refutations of erroneous beliefscommonly expressed by immunisationdefaulters are useful in dispelling their con-cerns. This assumes that those who expressthese beliefs are simply mistaken and whenexposed to counter-arguments will realisethis.
Although we believe that it will always beimportant for scientists and health profes-sionals to refute misleading information,there is little empirical support for the hopethat decision making about vaccination isbased on “facts” alone. In their research oncognitive processes in vaccination decisionmaking, Meszaros et al showed that whenparents opposed to the vaccine for diphthe-ria, tuberculosis, and pertussis were pre-sented with factual information about risksand benefits they became more committedto their antipathetic position. This responsewas moderated by underlying values aboutdeath and chronic disability.2
Our own research on antivaccinationpress reportage has shown that manifestclaims about vaccines being dangerous andineffective tend to be located under a canopyof more general discourses about cover upand conspiracy, manipulation by venalprivate enterprise interests, governmentswith totalitarian agendas, and the back tonature idyll.3 We argue that what generatesthe appeal of antivaccination claims isunderlying reference to these wider issues.We are now undertaking qualitative researchwith parents and immunisation providers inan attempt to explore the nature of theappeal of both anti-immunisation rhetoricand reassurances by providers. Althoughthis work is incomplete, we have beenimpressed by how frequently parents infocus group discussions are adamant thatthey want to be given the “facts” but demon-strate minimal retention of these whenexposed to television items containingpro-immunisation and anti-immunisationclaims. What is retained and discussed andprompts strong responses from participantsare images of children who have allegedlybeen damaged by vaccines. In other words,the facts have little potency when competingwith the very emotive news stories found inthe media.
Any attempt at refuting or deflating thepersuasive power of vaccination argumentsmust address the potential gut level appealat which anti-immunisation rhetoric tendsto operate. What we have learnt aboutimmunisation science will be of no public
value ultimately if we ignore key lessonsfrom health communication science.Julie-Anne Leask research officerSimon Chapman associate professorPenelope Hawe senior lecturerDepartment of Public Health and CommunityMedicine, University of Sydney, Sydney NSW,Australia
Competing interests: Dr Leask and Professor Chap-man have been reimbursed for attending aconference and have received funds for researchfrom CSL Vaccines.
1 Bedford H, Elliman D. Concerns about immunisation. BMJ2000;320:240-3. (22 January.)
2 Meszaros JR, Asch DA, Baron J, Hershey JC, KunreutherH, Schwartz-Buzaglo J. Cognitive processes and thedecisions of some parents to forego pertussis vaccinationfor their children. J Clin Epidemiol 1996;49:697-703.
3 Leask J-A, Chapman S. ‘An attempt to swindle nature’:press anti-immunisation reportage, 1993-1997. Aust N Z JPublic Health 1998;22:17-26.
Authors’ reply
Editor—We welcome the interest taken inour article as we believe immunisation to bevery important. Lee concedes that vaccineshave been an important health initiative butquestions their safety. She rightly points outthat rotavirus vaccine was withdrawn afterbeing in use in the United States for lessthan a year. This is in fact an excellent exam-ple of how closely the safety of vaccines ismonitored. As soon as there was serious sus-picion of a problem, the vaccine wassuspended from use and an extensive inves-tigation conducted. When the results of thiswere announced, the vaccine was perma-nently withdrawn.1
Lee also cites other examples of the pos-sible side effects of vaccines. There is no evi-dence that anyone has come to harm fromthe mercury in vaccines, but it seems reason-able to eliminate any potential risk, howeversmall. For this reason, many governmentshave urged vaccine manufacturers to elimi-nate mercury from vaccines as soon as ispracticable. There is no convincing scientificevidence that polio vaccines in Africa hadanything to do with the origin or spread ofAIDS.
Morrell points out that many homoeo-paths advise their clients to avoid conven-tional vaccines. We were trying to make thepoint that the common assumption thathomoeopathy and orthodox immunisationare incompatible is a myth, a view by whichwe stand. We do not claim that the onlyexplanation for the fall in the incidence ofmany diseases is the introduction of vaccina-tion. There is, however, overwhelmingevidence of the efficacy of vaccines, bothfrom trials conducted before their wide-spread introduction and from experience ofgroups who remain unimmunised whenmost of the population has acceptedvaccine. Outbreaks of disease among com-munities that reject immunisation havecaused not only disease but also death, mostrecently in an epidemic of measles in theNetherlands.2
Leask et al make a fair point, which weaccept. There are many interrelated factorsthat determine whether or not children areimmunised. Parents’ attitudes to the safety
and efficacy of vaccines and the severity ofdisease are among the most importantdeterminants of vaccine uptake.3 We need tolook no further for evidence of this than therecent decline in uptake of measles, mumps,and rubella vaccine in the United Kingdom,which has followed much publicised claimsthat the vaccine is linked with autism.Although we recognise that knowledgealone does not change behaviour, there aremany myths circulating about immunisationand infectious diseases, and without accurateinformation it is not possible to make a fullyinformed decision. The other aspects men-tioned by Leask et al are more intangibleand may reflect the empathy between parentand professional.4 Even that relationship willbe influenced in turn by an individual’swider perceptions of governments andindustry.Helen Bedford senior research fellowDepartment of Epidemiology and Public Health,Institute of Child Health, London WC1N 1EH
David Elliman consultant in community child healthSt George’s Hospital, London SW17 0QT
Competing interests: Dr Bedford and Dr Ellimanhave both been sponsored to attend and speak ateducational meetings and have conducted researchfunded by manufacturers of vaccines.
1 Centers for Disease Control and Prevention. Withdrawalof rotavirus vaccine. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4843a5.htm (accessed 18 Febru-ary 2000).
2 Communicable Disease Surveillance Centre. Outbreaks ofmeasles in communities with low vaccine coverage.Commun Dis Rep CDR Weekly 2000;10:29,32.
3 Peckham C, Bedford H, Senturia Y, Ades A. National immu-nisation study: factors influencing immunisation uptake in child-hood. Horsham: Action Research, 1989.
4 Harrington PM, Woodman C, Shannon WF. Low immuni-sation uptake: is the process the problem? J Epidemiol Com-munity Health 2000;54:394-400.
Hyperbaric oxygen in carbonmonoxide poisoning
Authors of study clarify points that theymade
Editor—We would like to clarify some ofthe statements that Weaver made about ourdouble blind randomised trial of hyperbariccompared with normobaric oxygen treat-ment of carbon monoxide poisoning.1 2
Weaver expresses concern that concomitantdepression and use of psychoactive drugsmight have influenced the results, given thelarge percentage of suicide attempts in ourcohort of patients. Depression and the use ofdrugs may indeed have resulted in a higherincidence of poor outcome overall, but thiswould not have biased the comparisonbetween normobaric and hyperbaricgroups: patients were specifically stratifiedfor attempted suicide before randomisationto treatment.
Weaver seems to be concerned aboutthe delay in receiving hyperbaric oxygentreatment. Although the geometric meantreatment delay was 7.1 hours, we per-formed subgroup analysis of patientstreated within four hours (all patients, andseverely poisoned patients alone). We alsoanalysed outcome in four groups according
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to time to treatment ( < 3, 3-60, 6-12, > 12hours) and found no difference in outcomebetween hyperbaric and normobaric oxygengroups. Further multivariable analysis didnot identify delay in treatment as a predictorof poor outcome. Thus there was noevidence that delay to treatment might haveexplained the lack of benefit of hyperbaricoxygen.
Weaver also questions our use of clusterrandomisation. With this we allocated morethan one person simultaneously to the sametreatment on 22 occasions (two on 12 occa-sions, three on five occasions, and four onfive occasions). Overall, 14 clusters (40patients) were allocated to hyperbaricoxygen and eight clusters (19 patients) tonormobaric oxygen. Continuous outcomevariables were analysed by the mixed proce-dures in SAS, which allows a repeated meas-ures analysis of variance, with the variablecluster being treated as a random repeatedmeasurement, thus adjusting for within clus-ter variation.3
We also repeated the analysis excludingall patients who were allocated as part of acluster and further repeated it adjusting forthe three variables (exposure time, time tocarboxyhaemoglobin measurement, andtime to treatment) that uniquely defined thecluster. These analyses suggest that ourresults were not biased by cluster randomi-sation.
Weaver refers to Thom et al’s findings ofno relapses in their patients given hyper-baric oxygen, but it is important to note thatall five relapses in our study occurred inpatients given hyperbaric oxygen (P = 0.03).C D Scheinkestel deputy [email protected]
D V Tuxen directorDepartment of Intensive Care and HyperbaricMedicine, Alfred Hospital, Melbourne, Australia
M Bailey statistical consultantDepartment of Epidemiology and PreventiveMedicine, Monash University, Melbourne
P S Myles head of researchDepartment of Anaesthesia and Pain Management,Alfred Hospital, Melbourne
K Jones psychologistSchool of Psychology, La Trobe University,Melbourne, Australia
D J Cooper head of trauma intensive care unitAlfred Hospital, Melbourne
I L Millar head of hyperbaric medicineAlfred Hospital, Melbourne
2 Scheinkestel CD, Bailey M, Myles PS, Jones K, Cooper DJ,Millar IL, et al. Hyperbaric or normobaric oxygen for acutecarbon monoxide poisoning: a randomised controlledclinical trial. Med J Aust 1999;170:203-10.
3 Littell RC, Milliken GA, Stroup WW, Wolfinger RD. SAS(computer program). Version 6.12. Cary, NC: SAS Institute,1996.
100% oxygen is best option
Editor—Weaver presents a well balancededitorial on the controversy surroundingthe treatment of carbon monoxide poison-ing with hyperbaric oxygen.1 This is refresh-ing, as a previous editorial in the BMJ wasnot so objective.2
Weaver mentions four prospective ran-domised studies of normobaric versus
hyperbaric oxygen. The latest of these is themost convincing, being prospective, ran-domised, and double blind, with shamhyperbaric treatments.3 Weaver is critical ofthe use of continuous high oxygen concen-trations for three days in the control groupbecause this was not representative of usualpractice. Previous studies have been flawedby a failure to optimise treatment in the nor-mobaric group, and Scheinkestel et al’sstudy clearly shows that such cheap,available, safe treatment is also effective. Theclaim that optimal normobaric oxygentreatment is not in routine use for thiscondition is cause for considerable concern.
Weaver also criticises Scheinkestel et alfor not applying hyperbaric oxygen earlierin their study. This criticism comes despitethe lack of evidence from controlledprospective comparative studies that earliertreatment is any more beneficial and despitethe fact that subgroup analysis of treatmentwithin four hours showed no benefit fromhyperbaric oxygen. Scheinkestel et al’s studyis representative of most clinical practicebecause of late presentation and the needfor stabilisation and transport to a remotehyperbaric facility.
Scheinkestel et al’s study has shown thathyperbaric oxygen results in a worseoutcome than does normobaric treatment.Even if it is wrong, the degree of any benefitis unlikely to be clinically importantcompared with the risk of such treatment.Hyperbaric oxygen and the associatedtransportation are associated with appreci-able hazards to both the attendant and thepatient, which are often understated. I there-fore suggest that the multicentre study thatWeaver proposes would now be unethical.
In carbon monoxide poisoning 100%oxygen should be given immediately andcontinued for several days. Resourcesshould be concentrated on promulgatingthis message together with preventingcarbon monoxide poisoning and detecting itearly rather than on providing more hyper-baric oxygen facilities. The NHS and health-care agencies in the United States shouldreview their funding strategy for the use ofhyperbaric oxygen in acute carbon monox-ide poisoning, because the only benefitwould seem to be towards the profitability ofindependent hyperbaric facilities.S Q M Tighe consultant anaesthetistCountess of Chester Hospital NHS Trust, ChesterCH2 [email protected]
2 Kindwall EP. Hyperbaric oxygen. BMJ 1993;307:515-6.3 Scheinkestel CD, Bailey M, Myles PS, Jones K, Cooper DJ,
Millar IL, et al. Hyperbaric or normobaric oxygen for acutecarbon monoxide poisoning: a randomised controlledclinical trial. Med J Aust 1999;170:203-10.
Author’s reply
Editor—Scheinkestel et al clarify the issuesregarding concomitant depression, delay tohyperbaric oxygen, and cluster randomisa-tion in their clinical trial.1 I agree thatattempted suicide probably did not bias theoutcome between the two arms.2 The data
provided strengthen the inferences fromtheir trial.
Thom et al found no delayed neuro-psychological sequelae in their patientsgiven hyperbaric oxygen,3 whereasScheinkestel et al found relapses only inpatients given this treatment. Clearly the evi-dence regarding the effectiveness of hyper-baric oxygen in carbon monoxide poisoningremains conflicting.
In the United States the commonesttreatment for acute carbon monoxidepoisoning is inhalation of oxygen by highflow, non-rebreathing face mask (70-80%fractional inspired oxygen), or 100% oxygenif the patient needs intubation, for 4-6 hours.I am unaware of anyone who treats acutepoisoning with 100% oxygen for 2-3 days,apart from Scheinkestel et al in their trial.No trial has shown that inhalation ofnormobaric oxygen improves outcome incarbon monoxide poisoning or the optimalduration of this treatment.
Since the neuropsychological and disabil-ity rate in Scheinkestel et al’s control groupwas relatively high and similar to that seen byothers,3–7 it is unclear if giving 100%normobaric oxygen for three days has anyadvantage over giving 70-100% oxygen foronly a few hours. Since optimal oxygen treat-ment is poorly defined, I disagree with Tighethat three days of treatment is indicated foracute carbon monoxide poisoning.
Tighe takes exception to the delay tohyperbaric oxygen treatment, andScheinkestel et al have provided illustrativeadditional information. I agree with Tighethat transportation to a hyperbaric oxygenchamber can present problems. I disagreewith him that a multicentre prospective ran-domised controlled trial of hyperbaricoxygen would be unethical. On the basis ofexisting trials,1 3 4 7 such a trial would be ethi-cal because present evidence is conflicting.Because the evidence is conflicting I see noreason why hyperbaric oxygen treatment foracute carbon monoxide poisoning shouldbe abandoned.
The NHS and the Health Care Financ-ing Administration in the United Statesmight review their funding strategies forhyperbaric oxygen treatment in acutecarbon monoxide poisoning, but the cost ofhospital admission for three days (to provide100% normobaric oxygen) is also consider-able and needs to be considered. Regardlessof the treatment of carbon monoxidepoisoning, increased societal awareness andprevention of carbon monoxide poisoningremain critically important.Lindell K Weaver medical director,hyperbaric medicineLDS Hospital, Eighth Avenue and C Street, SaltLake City, UT 84143, USA
1 Scheinkestel CD, Bailey M, Myles PS, Jones K, Cooper DJ,Millar IL, et al. Hyperbaric or normobaric oxygen for acutecarbon monoxide poisoning: a randomized controlledclinical trial [see comments]. Med J Aust 1999;170:203-10.
2 Hopkins RO, Weaver LK, Churchill S. Attempted suicidein carbon monoxide (CO) poisoning does not influencelong-term neuro-psychological (npt) outcome: programand abstracts. Undersea Hyperb Med 1999;26(suppl):51.
3 Thom SR, Taber RL, Mendiguren II, Clark JM, Hardy KR,Fisher AB. Delayed neuropsychologic sequelae aftercarbon monoxide poisoning: prevention by treatment with
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hyperbaric oxygen. Ann Emerg Med 1995;25:474-80.4 Raphael JC, Elkharrat D, Jars-Guincestre MC. Trial of nor-
mobaric and hyperbaric oxygen for acute carbon monox-ide intoxication. Lancet 1989;ii:414-9.
5 Smith JS, Brandon S. Morbidity from acute carbonmonoxide poisoning at three-year follow-up. BMJ1973;i:318-21.
6 Weaver LK, Hopkins RO, Howe S, Larson-Lohr V,Churchill, S. Outcome at 6 and 12 months following acuteCO poisoning. Undersea Hyperb Med 1996;23(suppl):9-10.
7 Ducasse JL, Celsis P, Marc-Vergnes JP. Non-comatosepatients with acute carbon monoxide poisoning: hyper-baric or normobaric oxygenation? Undersea Hyperb Med1995;22:9-15.
Investigations of doctors byGeneral Medical Council
Procedure for consent still leaves much tobe desired
Editor—As a patient advocate whoattended the entire hearing of the caseagainst gynaecologist Ian Fergusson, I wasdisappointed at the complacency inherentin the panel’s assertion that “fortunately” theconsent procedure has “been improved” inthe eight years since the incident.1
Some hospitals have undoubtedly madegreat strides. Patients consistently report,however, that the procedure adopted inmany hospitals leading to their signature ona totally unacceptable consent form stillleaves a lot to be desired. They still do nothave an opportunity to identify in writingany procedure to which they object, andthey are still expected to sign that everythinghas been explained, despite the absence ofsupporting written evidence.
Though the General Medical Councilhas produced excellent guidelines,2 theirapplication is a matter of local whim. A simi-lar situation applies to guidelines on consentto anaesthesia.3 Consent to anaesthesia andsurgery is a matter of basic human rights. Itshould not be a matter of individual hospitalpolicy.
Unless new regulations enforceable inall trusts are evolved by patient representa-tives working in partnership with the profes-sion and the government, we are likely to seemore such cases, in which there are no win-ners, only losers. Public trust and confidencein medical practice will continue to sufferunnecessarily, to the detriment of patientsand doctors alike.Roger M Goss director (and lay member, BMJeditorial board)Patient Concern, PO Box 23732, London SW5 [email protected]
1 Dyer D. Gynaecologist cleared in hysterectomy case. BMJ2000;320:535. (26 February.)
2 General Medical Council. Seeking patients’ consent: the ethicalconsiderations. London: GMC, 1998.
3 Association of Anaesthetists of Great Britain and Ireland.Information and consent for anaesthesia. London: AAGBI,1999.
Expert witnesses who are out of stepshould be named and shamed
Editor—Like, I suspect, many other sur-geons, I was delighted to learn that the Gen-eral Medical Council found Ian Fergussonnot guilty of serious professional miscon-duct.1 I appreciate that the council mustinvestigate a surgeon who has several
complaints against him relating to hissurgery. I have difficulty, though, with theconcept of investigation related to a singlecase in what I suspect is an otherwise blame-less career of a doctor who has done muchgood during his professional life.
The issue that causes me much greaterconcern, however, is that for the GMC tohold this hearing at least one gynaecologistmust have expressed to it, both in writingand in evidence, that Mr Fergusson’s actionswere indeed those of a man who shouldreceive the strongest condemnation that ourprofession has to offer. Clearly, that gynae-cologist is himself or herself seriously incor-rect in holding this view. The charge ofserious professional misconduct is so gravethat that gynaecologist must have been inabsolutely no doubt that Mr Fergusson hadbehaved in so extreme a manner. Yet thatgynaecologist was wrong.
What, therefore, is to become of thegynaecologist whose advice to the councilwas so erroneous? In court, if an expert wit-ness expresses an opinion that is so far offthe mark there is an increasing tendency forsuch opinions to be recorded in law reports.Such naming and shaming may have theeffect of limiting future instructions for thatexpert. I would like to be reassured that theGMC will follow such an approach.G J Jarvis consultant obstetrician and gynaecologistBUPA Hospital, Leeds LS8 1NT
1 Dyer D. Gynaecologist cleared in hysterectomy case. BMJ2000;320:535. (26 February.)
Risk assessment of leftventricular systolic dysfunctionin primary care
Drug treatment might be contaminatingfactor
Editor—The burden on echocardiographyservices could indeed be reduced if natriu-retic peptide concentrations plus electrocar-diography were used as screening tools forleft ventricular systolic dysfunction.1 Nielsenet al’s paper confirms the high negative pre-dictive value of these tests. Concomitantdrug treatment could, however, be a crucialcontaminating factor.
The use of natriuretic peptides todiagnose left ventricular dysfunction inpatients who are already taking cardiacdrugs deserves particular attention. Diuret-ics, digoxin, and angiotensin convertingenzyme inhibitors reduce natriuretic pep-tide concentrations.2 Especially important isthe fact that frusemide (furosemide) reducesthese concentrations3 but will have virtuallyno effect on an echocardiogram; it will notalter left ventricular dysfunction. Obviously,therefore, frusemide could severely distortthe relation between natriuretic peptidesand the echo finding of left ventricularsystolic dysfunction.
The predictive value of natriureticpeptides could conceivably be considerablyaffected by the presence of frusemide and
other cardiac drugs. This could explain whythe sensitivity of natriuretic peptides is lowin Nielsen et al’s study. No study has yetaddressed the usefulness of natriuretic pep-tides in identifying left ventricular dysfunc-tion before diuretics have been prescribed,which is obviously the real clinical question.When general practitioners want to know ifleft ventricular dysfunction is the cause ofbreathlessness in a patient they want to beable to take a blood sample to measure thenatriuretic peptide concentration there andthen (and before prescribing a diuretic).They can then prescribe a diuretic as afailsafe mechanism pending the result of thetest. The opposite may occur with â blockersas recent data suggest that they increasebrain natriuretic peptide while having abeneficial effect on left ventricular dilata-tion.4
Cardiac drugs could therefore be amajor contaminating factor in the use ofnatriuretic peptides to diagnose left ven-tricular dysfunction. An interesting questionnow arises from Nielsen et al’s work: werethere any differences in the predictive valueof atrial natriuretic peptide concentration,clinical features, findings on electrocardiog-raphy, and heart rate and blood pressurebetween those patients taking cardiac drugsand those patients not taking any treatmentin this study?Robert Kelly research fellowAllan D Struthers professor of clinical pharmacologyDepartment of Clinical Pharmacology, NinewellsHospital, Dundee DD1 9SY
2 Murdoch DR, McDonagh TA, Byrne J, Blue L, Farmer R,Morton JJ, et al. Titration of vasodilator therapy in chronicheart failure according to plasma brain natriuretic peptideconcentration. Am Heart J 1999;138:1126-32.
3 Northridge DB, Newby DE, Rooney E, Norrie J, Dargie HJ.Comparison of the short-term effects of candoxatril, anorally active neutral endopeptidase inhibitor, and fruse-mide in the treatment of patients with chronic heartfailure. Am Heart J 1999;138:1149-57.
4 RESOLVD Investigators. Effects of metoprolol CR inpatients with ischemic and dilated cardiomyopathy.Circulation 2000;101:378-84.
Authors’ reply
Editor—Kelly and Struthers make a pointthat applies in many branches of medicaldiagnosis—namely, that drug treatment mayinfluence not only subjective symptoms butalso biological disease markers. If a drugbreaks into a complicated system of feed-back regulations, as is the case withnatriuretic peptides, the net effect is unpre-dictable and must be assessed empirically.The question whether cardiac medicationinfluences the predictive power of natriu-retic peptides in subjects with minorsymptoms is therefore an important one.
In our study we applied the tests on abroad spectrum of suspected heart patientsfrom general practice. We did not considertreatment in the analysis because diuretictreatment is based on subjective andarbitrary decisions, because a subdivision ofthe small cohort would increase the risk ofmaking type II errors, and because we onlyhad limited space for publication.
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Despite these limitations, and promptedby the query by Kelly and Struthers, we havemade a renewed analysis of those 25patients treated with either loop diuretics oran angiotensin converting enzyme inhibitorin combination with another diuretic,comparing them with 95 patients withoutthis treatment (table). Missing values andpacemaker patients were excluded. Totalsare thus different from those of the originaltable 3. The prevalences of left ventricularsystolic dysfunction were 30% and 7%respectively.
This difference in prevalence of systolicdysfunction makes it hard to compare testbehaviour in the two groups. It appears fromthe table, however, that electrocardiographicanomaly gives full sensitivity (scoring nofalse negatives), whereas the predictor heartrate > diastolic blood pressure has anunchanged performance. As Kelly and Stru-thers may have expected, the natriureticpeptide improves its discriminative power inthe untreated patient group, especially if thecut-off point is lowered. The lower cut-offpoint, however, weakens the predictive posi-tive value of the test.
In conclusion, there seem to be fewerfalse negatives among the untreated patientsby several criteria. The table thereforesuggests that when testing is restricted tountreated patients one can more safely ruleout left ventricular systolic dysfunction bynormal electrocardiographic results and anormal natriuretic peptide concentration.The table also suggests that echocardio-graphy should always be considered if a loopdiuretic is required to control symptoms.Since this subanalysis is based on a smallpatient sample, we plan to undertake a morecareful analysis in a larger cohort, wherepotential confounders other than drugtreatment will also be considered.Olav Wendelboe Nielsen research [email protected] Department Y, CopenhagenUniversity Hospital, 2400 Bispebjerg, Denmark
Jørgen Hilden lecturerDepartment of Biostatistics, CopenhagenUniversity, 2200 Panum Institute, Denmark
Jens Svanegaard chief physicianDepartment of Cardiovascular Medicine, HaderslevHospital, Denmark
Jørgen Fischer Hansen chief consultantCardiovascular Department Y, CopenhagenUniversity Hospital, 2400 Bispebjerg
Ethnic minorities have specificneeds with regard tocardiovascular riskEditor—The identification of patients athigh risk of coronary heart disease is vitalfor preventive clinical care.1 2 Robson et alstate that a reduction of absolute cardiovas-cular risk in the tenth of the population withcoronary risk >30% is likely to be cost ben-eficial.3 South Asians and Afro-Caribbeansin the United Kingdom are at increased riskof coronary heart disease and stroke, respec-tively, compared with people of Europeanethnicity. Most of the United Kingdompopulations studied for assessment ofcardiovascular risk have not, however, beenstratified by ethnic group, and little researchhas been conducted into factors affectinguptake of preventive care in such patients.
We recently performed a pilot study ofassessment of cardiovascular risk factors insouth Asian and Afro-Caribbean patientsaged 16-79 attending one south Londonpractice.4 We found that half had at least tworisk factors for cardiovascular disease.Women were less likely than men to besmokers (relative risk 0.4; 95% confidenceinterval 0.2 to 0.8) but more likely to takelittle or no exercise (1.7; 1.1 to 2.5). Focusgroups suggested that barriers to effectivehealth promotion included lack of aware-ness of risk, language difficulties, andcultural and lifestyle differences.
Motivational state and lack of perceivedor actual risk may also cause delays in seek-ing medical help even after risk factors havebeen identified. Another London basedstudy found that hypertensive patients ofAfro-Caribbean ethnicity were less likely touse antihypertensive drugs than werepatients of European ethnicity.5 Generalpractitioners and primary care groupsdetermining local policies for coronarydisease prevention need to be aware of thespecific needs of ethnic minority groups.Mariam Molokhia clinical research fellowEpidemiology Unit, London School of Hygieneand Tropical Medicine, London WC1E [email protected]
Pippa Oakeshott senior lecturerDepartment of General Practice, St George’sHospital Medical School, London SW17 0RE
1 Wood D, Durrington P, Poulter N, McInnes GT, Rees A,Wray R. Joint British recommendations on prevention ofcoronary heart disease in clinical practice. Heart1998;80:1-29S.
2 Ramsay LE, Williams B, Johnston GD, MacGregor L,Potter JF, Poulter NR, et al. Guidelines for management ofhypertension: report of the third working party of theBritish Hypertension Society. J Hum Hypertens1999;13:569-92.
4 Molokhia M, Oakeshott P. A pilot study of cardiovascularrisk assessment in Afro-Caribbean patients attending aninner city general practice. Fam Pract 2000;17:60-2.
5 Morgan M. The significance of ethnicity for health promo-tion: patients’ use of antihypertensive drugs in innerLondon. Int J Epidemiol 1995;24(suppl 1):S79-84.
Writing a book—a personalexperienceEditor—Albert’s article on how to becomea book author struck a chord with me, as Ihave been through the experience hedescribes.1 I was talked into writing atextbook after meeting a publisher at a party,and did so largely without thinking aboutwhy I was doing it. My social life sufferedhugely while I spent three years trying towrite the book as well as do my day job.
Would I do it again? I’m not sure. It cer-tainly gained valuable points for my resumé,and it probably helped my careerimmensely. Financially, it was a disaster.Although I made some money out of thebook, students these days can rarely afford tobuy textbooks, so despite having hadexcellent reviews it has not sold well and willprobably soon be out of print. Working outhow much I have earned in royaltiescompared with how much time I spent onthe book, my hourly rate was probably nomore than about 50p.
The one piece of advice I would add toAlbert’s eminently sensible suggestionswould be to join the Society of Authors at anearly stage. The society provides wonderfulsupport for authors, including vettingpublishing contracts. It can be found atwww.writers.org.uk/society.Adam Jacobs directorDianthus Medical, Mitcham, Surrey CR4 [email protected]
1 Albert T. How to become a book author [career focus].BMJ 2000;320:(classified section 18 Mar):2-3.
Career development in publichealthDoctors should lead public healthdepartments
Editor—McPherson’s letter exemplifies theproblem inherent in the demedicalisation ofpublic health medicine.1 Of course the qual-ity of the training available to non-medicalpublic health workers needs to be improved.So do career and pay structures to recruitand retain those highly skilled individualsfrom a variety of specialties who make upthe public health team, particularly publichealth infection control nurses, who are inextremely short supply.
A broad range of skills is requiredto make public health teams function
Risk assessment of left ventricular dysfunction in patients according to treatment with diuretics (loopdiuretic or angiotensin converting enzyme inhibitor plus other diuretic)
Type of test
Untreated (n=95) Treated (n=25)Pooledoddsratio
Left ventricular systolic dysfunction Left ventricular systolic dysfunction
Yes No Odds ratio Yes No Odds ratio
Abnormal ECG (as in paper):
Yes 7 39 ∞ 6 9 6 16
No 0 49 1 9
N-terminal atrial natriuretic peptide (nmol/l):
>0.8 2 5 6 4 4 7 9
0.5-0.8 4 24 0 7
<0.5 1 53 11 2 7 1 5
Heart rate > diastolic blood pressure:
Yes 4 12 8 4 2 11 9
No 3 75 3 16
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112 BMJ VOLUME 321 8 JULY 2000 bmj.com
properly in the real world. Differentmembers of the team bring different knowl-edge and skills, and these are not readilyinterchangeable.
But McPherson trivialises what medicaltraining is. A medical degree is much morethan studying the illness of individuals. Mostcourses are designed to enable prospectivedoctors to do their jobs, which means theywill deal compassionately with sick and wellpeople, understand and treat illness as asocial and individual phenomenon, andwork with others in teams. The breadth ofthe scientific and social compass of medicaltraining mirrors the range of additionalskills needed if we are to be effective improv-ers of the public’s health. Doctors who workin public health build on this foundationand develop sufficient competence in mostof the skills needed in any public healthteam either to lead specific areas of work orto understand what others will contribute.No other discipline in the team can do this,but this kind of understanding is essentialfor its proper leadership. This is why webelieve that doctors should lead publichealth departments.Sarah Taylor chairmanCharles Saunders chairman, negotiating teamBMA Committee for Public Health Medicine andCommunity Health, British Medical Association,London WC1H 9JR
1 McPherson K. Removing barriers to career developmentin public health. BMJ 2000;320:448. (12 February.)
Career choice in public health should beless restricted
Editor—McPherson supports careers inpublic health without a glass ceiling andpromises availability of excellence in train-ing in public health for those without amedical degree.1 Why is formal training inpublic health necessary for a career in pub-lic health? The tools that a director of publichealth needs in order to manage the healthof the population are, in principle, no differ-ent from those required by a director ofsocial services, a senior civil servant, or thechief executive of a public body.
The restrictive career choice in publichealth has, like all restrictive practices,distorted and skewed public health in thecountry. Practitioners in public health medi-cine would find it difficult—looking at deathrates from heart disease and cancer—to jus-tify the monopoly of their specialty inimproving the health of the population. Thedismal picture may not be their fault, but itdoes require alternative solutions. TheUnited Kingdom compares unfavourablywith other European countries, where thereis less emphasis on the medically orientedpractice of public health.
Removing the glass ceiling will attractcandidates of the highest calibre, includingdoctors. An unfettered pay structure outsidethe NHS pay scale will reward achievement.As McPherson states, the excellently medi-cally trained public health doctors havenothing to fear from competition.
Change is painful. The BMA has a dutyto protect the interests of its members. It
should not do so from a narrow perspective.Saving Lives: Our Healthier Nation presentsan opportunity to improve dramatically thehealth of the population.2 We should seizethis opportunity with both hands.Surinder Bakhshi consultant in communicabledisease controlBirmingham Health Authority, BirminghamB16 9RG
1 McPherson K. Removing barriers to career developmentin public health. BMJ 2000;320:448. (12 February.)
2 Secretary of State for Health. Saving lives: our healthiernation. London: Stationery Office, 1999. (Cm 4386.)
Allocating prescribing budgets
Limitations of formula should have beenstated more clearly
Editor—Rice et al present what theydescribe as a “needs based” formula for allo-cating prescribing budgets.1 This seems animprovement on the ASTRO-PU (age, sex,and temporary resident originated prescrib-ing unit), which it replaces, but in view of itscrucial impact on the resources available togeneral practitioners and their patients itslimitations should be stated more clearly.
Despite its title, the formula does notassess need directly but relies on data fromthe national census to generate proxy meas-ures. The association between these meas-ures and prescribing costs “explains”observed variation in these costs only in thenarrow statistical sense of the word. Bainsand Parry,2 and Majeed3 point out furtherimportant limitations.
These criticisms are of more thanacademic importance. The formula is“needs based” only in a vague and generalsense, but despite its manifold weaknessesthere is a danger that NHS organisations willuse it as if it were an adequate basis forbudget setting and monitoring prescribingperformance. The patients whose access totreatment will be thus determined andrationed will not be proxies.
Primary care groups have the difficulttask of salvaging something from this mine-field. If we wish to explain variations in pre-scribing in the full sense of the word and ifwe are serious about the pursuit of equityand quality, we have a great deal of work todo. Several actions spring to mind.
Firstly, computerisation gives us themeans to collect detailed morbidity data atpractice level. This will allow us to test theformula for allocating prescribing budgetsagainst real measures of need and, ifnecessary, make allowances in practicebased budgets.
Secondly, by combining prescribing andmorbidity data, and auditing standards ofcare, we can ensure that measures of qualityare built into our incentive schemes. We willalso gain considerably in our understandingof the many causes of variations in prescrib-ing costs.
Thirdly, we might consider foregoing theright to keep savings from our practice pre-scribing budgets. In a cash starved NHS,large handouts for cheap prescribing should
be seen as the occasion for red faces ratheran opportunity for red carpets.C A Ryle clinical governance lead, East HantsPrimary Care GroupCompton, Chichester, West Sussex PO18 9NT
1 Rice N, Dixon P, Lloyd DCEF, Roberts D. Derivation of aneeds based capitation formula for allocating prescribingbudgets to health authorities and primary care groups inEngland: regression analysis. BMJ 2000;320:284-8. (29January.)
2 Bains DL, Parry DJ. Analysis of the ability of the new needsadjustment formula to improve the setting of weightedcapitation prescribing budgets in English general practice.BMJ 2000;320:288-90. (29 January.)
3 Majeed M. New formula for GP prescribing budgets. BMJ200;320:266. (29 January.)
All prescribers in primary care groupsneed to collaborate
Editor—Equity is a central concern ofprimary care groups, which are responsiblefor allocating prescribing budgets to prac-tices. Unfortunately, existing weighted capi-tation formulas can produce anomalies atpractice level. Primary care groups facehaving to make subjective adjustments thatare neither transparent nor acceptable. Thepromise of a new, intuitively plausibleformula,1 especially one that is at last basedon registered practice populations, willtherefore, as Majeed warns,2 be attractive toprimary care groups.
However, primary care groups shouldnot use Rice et al’s formula, for at least threereasons. Firstly, it uses the fatally flawedmethod of trying to predict the needs ofpractice populations from attributed dataderived geographically: the ecological fallacy.
Secondly, applying existing formulas atpractice level has long been controversial.3
Rice et al do not propose their formula forcalculating practice prescribing budgets.
Thirdly, the inherent weaknesses ofusing existing census data are readily admit-ted by health economists.4 Why thencontinue to conjure formulas from poordata of doubtful relevance?
Using registered practice populationsinstead of attributed census counts is abreakthrough, but it is not sufficient on itsown. Clinical research into measures ofhealthcare need should be funded andpromoted by primary care groups. Indeed,information on the back of prescriptionforms has already been used by Lloydet al for a low income index of deprivation.5
This is immeasurably more plausible thanusing old census data on the percentage ofdependants in no carer households.
Years of health economics and statisticshave produced practice budgets that are likerainbows. They have shape and colour but donot touch the ground. What we know aboutbest, on the ground in general practice, is pre-scribing for individual patients. I prefer abottom up approach to budget setting, drivenby collaboration among all the prescribers inthe primary care group. As clinical prescrib-ing data are increasingly computerised, auditcan become more extensive and the quality ofcare be assessed in greater detail, includingcost effectiveness. We should aim to setprescribing budgets for our practices on sum-mated data about individual patients and
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113BMJ VOLUME 321 8 JULY 2000 bmj.com
their care. Meanwhile, cost growth compari-sons among practices will alert the primarycare group to unequal use of the budget.
Perhaps the doctors and nurses chargedwith promoting equity in the “New NHS”are best placed to assess whether practiceprescribing budget calculations are “intui-tively plausible,” at least until rainbows touchthe ground.Tony Thick vice chairNewcastle North Primary Care Group, Newcastleupon Tyne NE1 8BG
1 Rice N, Dixon P, Lloyd DCEF, Roberts D. Derivation of aneeds based capitation formula for allocating prescribingbudgets to health authorities and primary care groups inEngland: regression analysis. BMJ 2000;320:284-8. (29January.)
2 Majeed A. New formula for GP prescribing budgets. BMJ2000;320:266. (29 January.)
3 Sheldon TA, Smith P, Borowitz M, Martin S, Carr-Hill R.Attempts at deriving a formula for setting generalpractitioner fundholding budgets. BMJ 1994;309:1059-64.
4 Sheldon TA, Smith GD, Bevan G. Weighting in the dark:resource allocation in the new NHS. BMJ 1993;306:835-9.
5 Lloyd DCEF, Harris CM, Clucas DW. Low income schemeindex: a new deprivation scale based on prescribing ingeneral practice. BMJ 1995;310:165-9.
Lord, protect me from myfriends
Public needs to be educated
Editor—I am appalled by Farrell’s attitudein his Soundings column.1 I questionwhether a doctor who prescribes antibioticsfor flu for the purpose of “sportingone-upmanship” and “tactical gratification,”in spite of “academically impeccable advice”given by his partner, and for paediatric otitismedia to “keep the parents happy” shouldbe prescribing at all, let alone be allowed toair his views in a serious medical journal.
This sort of attitude is undoing all thework done by those of us trying to educatethe public about the difference between viraland bacterial infections and the role of anti-biotics in order to stem the growing tide ofbacterial resistance. His patients will no doubtturn up to their local accident and emergencydepartment expecting to be treated with anti-biotics for minor ailments and may wellbecome agitated or aggressive if refused.
Many times I have heard the line, “Butmy GP gives me antibiotics when I get this,”and have had to stand my ground in the faceof significant verbal abuse in some cases. Inthis respect, Farrell had succeeded with his“screw them before they screw you” attitudebecause the correct practice of the hospitalis seen by the patient as doing nothing andbeing uncaring, thus antagonising thealready strained relationship between gen-eral practitioners and hospital doctors whenin truth we should be working together forthe benefit of our patients. My sympathygoes to Farrell’s partner, who no doubt getstarred with the same brush in discussions atthe local accident and emergency depart-ment, and I would end with a prayer for himand the rest of us—Lord, protect us fromdoctors like Farrell.Ian Frankel accident and emergency staff gradeWatford General Hospital, Watford WD1 8HB
1 Farrell L. Lord, protect me from my friends. BMJ2000;320:523. (19 February.)
Also my experience
Editor—Farrell’s piece1 accurately describesmy practice over 32 years with largely thesame partners.
The description is accurate almost downto the last period.Colin Mackenzie retired family doctor11 Westwood Road, Santa Cruz, CA 95060-1444,[email protected]
1 Farrell L. Lord, protect me from my friends. BMJ2000;320:523. (19 February.)
Author’s reply
Editor—I remember my time in casualtyvery well, and I could sure sing a few bars ofFrankel’s frustrated song, but “medicalhumour helps us bear the unbearable.”1 It’snot healthy to be excessively sensitive; theGreat Irish Famine was all the fault of theEnglish, but that was a long time ago and I’vekinda gotten over it by now.
There is a certain realpolitik to consider.Casualty attenders are usually one-offs; inprimary care repeat attenders are common,and some unwritten axioms apply. A sickchild seen for the second time should beconsidered for antibiotics, one seen for thethird time perhaps requires admission—andsee how many of them did not receiveantibiotics.
But I do regret taking too lightly what isundoubtedly a serious subject. “Antibioticsare like the F-words; used sparingly they arehave no effect except to indicate that theuser is a foul-mouthed git.’’2
Mea culpa, we general practitioners areimperfect creatures, yet: “Our weakness isour greatest strength; we understand humanfrailty because we ourselves are human andweak”3; a sinner’s prayers are often the best.
The term screw, I emphasise, was purelymetaphorical.Liam Farrell general practitionerCrossmaglen Health Centre, Crossmaglen, CountyArmagh BT25 9HD
1 Farrell L. No laughing matter. BMJ 1995;310:1415.2 Farrell L. No cure for the ‘flu. Lancet 1998;351:920.3 Farrell L. Star Trekking. Br J Gen Pract 2000;50:86.
Sexual health throughleadership and “sanuk” inThailandEditor—In their letters Bellis and Ashton,and van den Akker, comment on the role ofthe media in supporting the cultural changenecessary to promote responsible sexualbehaviour.1 2 Education and service provi-sion as advocated by Yamey are of limitedvalue,3 with much of the target group beingresistant to, or outside the reach of, formaleducation and public health services. TheAsian Centre for Population and Commu-nity Development in Thailand, under the
leadership of Mechai Viravadya (a Thaisenator), provides a practical example ofsuccess in this area.
The Thai attitude to sex is typicallyAsian, discreet and modest (not to beconfused with Western mythology regardingconcubinage and the small but notorioustourist oriented sex industry). The centrehas been remarkably successful in promot-ing use of condoms by appealing to the Thaisense of “sanuk” or fun. While primarilyseeking to address overpopulation, depriva-tion, and child mortality in rural districts, thecentre has also succeeded in other ways:from being an AIDS hotspot, Thailand isnow in the World Health Organization’s“decrease or no growth” category.4
The centre is a charity, and among itsfundraising efforts is a chain of Cabbagesand Condoms restaurants (“our food isguaranteed not to cause pregnancy”). Sosuccessful has the centre been that “Mechai”has become a slang word for condom. Thecentre runs an international training andeducation programme for healthcare work-ers, from which many developed countriescould learn a lot.
If we follow the centre’s example wemust look beyond the attitudes and behav-iour of young people and recognise the dif-ficulties caused by the ambiguous attitudes(if not frank hypocrisy) of older people—often reflected in the most puritanical view-points contrasted with rather more liberalbehaviour. If we admit (as young peoplealready know) that sex is normal and fun, weshould also recognise that it must bepursued responsibly and with respect forothers, just like any other enjoyable but riskyactivity. This should be the focus of our edu-cation and public health activities and themessage that the media is encouraged toendorse.
Perhaps one of our health policy makerscould follow the example of MechaiViravadya: we will recognise progress whena minister is prepared to appear ontelevision juggling inflated condoms and weget a free packet of “Evettes” along with ourafterdinner mints. Perhaps the issue will bewhether or not we have a sufficiently welldeveloped sense of sanuk to deal with thisseriously.Stephen McAndrew managing directorHealthcare Risk Resources International, LondonEC3M [email protected]
1 Bellis MA, Ashton JR. The sexual health of boys and men.BMJ 2000;320:643. (4 March.)
2 Van den Akker O. The sexual health of boys and men. BMJ2000;320:643. (4 March.)
3 Yamey G. Sexual and reproductive health: what about boysand men? BMJ 1999;319:1315-6. (20 November.)
4 United Nations. United Nations human development report.Thailand: UN, 1997.
Correspondence submitted electronicallyis available on our website
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