634
Doctors and torture SIR,-Your note on the medical aspects of torture (Aug 25, p 498) that the Pinochet regime in Chile did not attract particular
states
hostility from Western governments. Most torture victims are the poor and underprivileged and those who speak for them. Pinochet took power following US sponsored destabilisation of the Allende government (which had promised land reform and other measures for the poor). Prominent amongst his victims of torture and arbitrary execution were trade unionists and progressive workers of all kinds, besides those doctors (a minority) who had associated themselves with social reform because of the prospect of health gains for the impoverished majority. Western politicians and businessmen make common cause with Third World military and economic elites who deploy such abuses to defend deep-rooted social inequities. Multinational economies have an unacknowledged investment in Third World workforces which are leaderless, fragmented, and cowed, and thus docile and cheap. Governments serving Western geopolitical interests provoke at most mere routine denunciations when they torture their citizens. The 1988 assembly of the UN Commission on Human Rights confirmed that in El Salvador and Guatemala torture, disappearances, and extrajudicial execution were in effect institutionalised-yet in the 1980s the USA gave$4000 million in military aid to fortify those regimes and to kill off Nicaragua’s fledgling attempt at a fairer society. During the same decade half a million children perished in Mozambique and Angola as a result of destabilisation wrought by South Africa, according to UNICEF estimates. Yet pragmatic attitudes to the South African government, still perceived as a geopolitical ally, have survived even this torture of whole nations, and the flow of dividends from the apartheid economy into British business and finance houses continues as ever. Official positions on unbridled tyrannies such as those of Marcos in the Philippines, Mobutu in Zaire, and, until last month, Hussein in Iraq have been shaped by similar considerations. Torture and other human rights violations in the Third World will decline only when the dominant institutions of the West seriously want this. What can doctors do, beyond treating the consequences of torture and censuring direct medical participation in it? Torture is a particular instance of a general relationship-namely, that social factors are major determinants of ill-health and suffering. Doctors have a duty to be advocates for the abused and poor who populate their clinics and surgeries.
D. A. SUMMERFIELD
registries in Germany
SIR,-Annette Tuffsreport (Aug 11, p 365) on German cancer registries points out clearly some of the difficulties in this area of research. It should be mentioned, however, that the oldest cancer registry in the world, in the Federal State of Hamburg, is, contrary to the comment, based upon a special cancer registry law. Your correspondent is correct that the population of the Saarland covers about one million people, but there are another 60, not 35, million in West Germany. Department of Clinical Social Medicine, University of Heidelberg, Medical Clinic, D-6900 Heidelberg, West
Germany
WOLFGANG SCHEUERMANN E. NÜSSEL
Applications to Canadian medical schools SIR,-Your Round the World correspondent (Aug 11, p 364) paints gloomy picture of the morale of the medical profession in Ontario. I will not quibble over all the reasons adduced for this, but I am puzzled by the claim that "Applications to medical schools have dropped sharply and last year were the lowest for seventeen years". The Association of Canadian Medical Colleges’ annual study of applicants for admission to medical school provides unduplicated
a
Year 1971 1972
1973 1974 1975 1976 1977 1987 1979 1980
No* 4602 5900 7272 7593 7423 7042 7156 6891 6987 6769
Ratet 244 311 376 379 357 330 326 307 307 294
Year 1981 1982 1983 1984 1985 1986 1987 1988 1989
No 7071 6912 7417 7887 7828 7908 7724 7392 7160
Rate 302 293 314 334 336 350 352 350 351
* Foreign applicants excluded. t per 100 000 population aged 20-24. Whatever evidence there may be of physician discontent in Ontario and Canada today, it cannot be found in levels of interest in medicine as a career, as reflected in applications for admission to study medicine. Perhaps your correspondent is confusing the situation in the USA with that of Canada? Or perhaps it is the declining number of medical graduates to which your correspondent refers? The drop in output of Canadian medical schools is a result of cutbacks in places for the study of medicine introduced after pressure from provincial governments to stem a predicted surplus. The high demand for medical school places coupled with the reduction of first-year places has maintained a ratio of less than one in four applicants being successful in gaining admission. In this a measure of lack of interest in a career in medicine? Office of Research and Information Services, Association of Canadian Medical 151 Slater, Suite 1006, Ottawa, Canada K1 P 5N1
Colleges,
E. RYTEN
Insight
Department of Psychiatry, Atkinson Morley’s Hospital, London SW20 0NE, UK
Cancer
of applicants, who may apply to many universities. The results are used to study trends in demand for medical education. In recent years there has been a drop in the absolute number of applicants. However, when the data are compared taking into account demographic change (the declining size of the age cohorts applicants come from), application rates to medical school were higher in the past four years than in the previous ten. Only in 1973/74 and 1974/75 was there a higher demand for medical education in Canada. (For some yet to be investigated sociological reasons(s), these seem to have been the years of peak interest in medicine as a career in the USA and the UK also.) The figures are:
counts
SIR,-I have been accused of writing your editorial (Aug 18, p 408) was based on an article of mine in the British Journal of Psychiatry1 dealing with the term "insight" as applied by psychiatrists and reviewing its use and implications. Not guilty: if I was, would I have had the vanity to quote myself so extensively and would I have misunderstood myself so wantonly? Your criticisms are fine-indeed, "David’s triad" sounds rather good-but it is the tone of the editorial that is objectionable. You state that an assessment of insight is not necessary for treatment decisions. Since treatment compliance, an aspect of insight, is part of the equation, few "working psychiatrists" will agree. The example you provided of visual illusions in delirium tremens is instructive. Many patients, when confronted by pink cobras swimming in front of their eyes, would conclude that they were "seeing things". For others, seeing is believing. For yet others the experience remains real long after the vision has faded and the events have been explained, patients claiming that they really did see snakes crawling along the bedroom wall. You remind us that psychiatry has elements of both the humanities and the sciences-a view the much maligned Jaspers espoused so clearly some eighty years ago. It must also combine the practical and the academic, the empirical and the theoretical. Informed discussion on insight does this, whereas no amount of resentful prattling will.
that
Institute of Psychiatry, London SE5 8AF, UK 1 David AS.
Insight
and
ANTHONY DAVID psychosis Br J Psychiatry
1990; 156: 798-808.
Doctors and torture SIR,-Your note on the medical aspects of torture (Aug 25, p 498) that the Pinochet regime in Chile did not attract particular
states
hostility from Western governments. Most torture victims are the poor and underprivileged and those who speak for them. Pinochet took power following US sponsored destabilisation of the Allende government (which had promised land reform and other measures for the poor). Prominent amongst his victims of torture and arbitrary execution were trade unionists and progressive workers of all kinds, besides those doctors (a minority) who had associated themselves with social reform because of the prospect of health gains for the impoverished majority. Western politicians and businessmen make common cause with Third World military and economic elites who deploy such abuses to defend deep-rooted social inequities. Multinational economies have an unacknowledged investment in Third World workforces which are leaderless, fragmented, and cowed, and thus docile and cheap. Governments serving Western geopolitical interests provoke at most mere routine denunciations when they torture their citizens. The 1988 assembly of the UN Commission on Human Rights confirmed that in El Salvador and Guatemala torture, disappearances, and extrajudicial execution were in effect institutionalised-yet in the 1980s the USA gave$4000 million in military aid to fortify those regimes and to kill off Nicaragua’s fledgling attempt at a fairer society. During the same decade half a million children perished in Mozambique and Angola as a result of destabilisation wrought by South Africa, according to UNICEF estimates. Yet pragmatic attitudes to the South African government, still perceived as a geopolitical ally, have survived even this torture of whole nations, and the flow of dividends from the apartheid economy into British business and finance houses continues as ever. Official positions on unbridled tyrannies such as those of Marcos in the Philippines, Mobutu in Zaire, and, until last month, Hussein in Iraq have been shaped by similar considerations. Torture and other human rights violations in the Third World will decline only when the dominant institutions of the West seriously want this. What can doctors do, beyond treating the consequences of torture and censuring direct medical participation in it? Torture is a particular instance of a general relationship-namely, that social factors are major determinants of ill-health and suffering. Doctors have a duty to be advocates for the abused and poor who populate their clinics and surgeries.
D. A. SUMMERFIELD
registries in Germany
SIR,-Annette Tuffsreport (Aug 11, p 365) on German cancer registries points out clearly some of the difficulties in this area of research. It should be mentioned, however, that the oldest cancer registry in the world, in the Federal State of Hamburg, is, contrary to the comment, based upon a special cancer registry law. Your correspondent is correct that the population of the Saarland covers about one million people, but there are another 60, not 35, million in West Germany. Department of Clinical Social Medicine, University of Heidelberg, Medical Clinic, D-6900 Heidelberg, West
Germany
WOLFGANG SCHEUERMANN E. NÜSSEL
Applications to Canadian medical schools SIR,-Your Round the World correspondent (Aug 11, p 364) paints gloomy picture of the morale of the medical profession in Ontario. I will not quibble over all the reasons adduced for this, but I am puzzled by the claim that "Applications to medical schools have dropped sharply and last year were the lowest for seventeen years". The Association of Canadian Medical Colleges’ annual study of applicants for admission to medical school provides unduplicated
a
Year 1971 1972
1973 1974 1975 1976 1977 1987 1979 1980
No* 4602 5900 7272 7593 7423 7042 7156 6891 6987 6769
Ratet 244 311 376 379 357 330 326 307 307 294
Year 1981 1982 1983 1984 1985 1986 1987 1988 1989
No 7071 6912 7417 7887 7828 7908 7724 7392 7160
Rate 302 293 314 334 336 350 352 350 351
* Foreign applicants excluded. t per 100 000 population aged 20-24. Whatever evidence there may be of physician discontent in Ontario and Canada today, it cannot be found in levels of interest in medicine as a career, as reflected in applications for admission to study medicine. Perhaps your correspondent is confusing the situation in the USA with that of Canada? Or perhaps it is the declining number of medical graduates to which your correspondent refers? The drop in output of Canadian medical schools is a result of cutbacks in places for the study of medicine introduced after pressure from provincial governments to stem a predicted surplus. The high demand for medical school places coupled with the reduction of first-year places has maintained a ratio of less than one in four applicants being successful in gaining admission. In this a measure of lack of interest in a career in medicine? Office of Research and Information Services, Association of Canadian Medical 151 Slater, Suite 1006, Ottawa, Canada K1 P 5N1
Colleges,
E. RYTEN
Insight
Department of Psychiatry, Atkinson Morley’s Hospital, London SW20 0NE, UK
Cancer
of applicants, who may apply to many universities. The results are used to study trends in demand for medical education. In recent years there has been a drop in the absolute number of applicants. However, when the data are compared taking into account demographic change (the declining size of the age cohorts applicants come from), application rates to medical school were higher in the past four years than in the previous ten. Only in 1973/74 and 1974/75 was there a higher demand for medical education in Canada. (For some yet to be investigated sociological reasons(s), these seem to have been the years of peak interest in medicine as a career in the USA and the UK also.) The figures are:
counts
SIR,-I have been accused of writing your editorial (Aug 18, p 408) was based on an article of mine in the British Journal of Psychiatry1 dealing with the term "insight" as applied by psychiatrists and reviewing its use and implications. Not guilty: if I was, would I have had the vanity to quote myself so extensively and would I have misunderstood myself so wantonly? Your criticisms are fine-indeed, "David’s triad" sounds rather good-but it is the tone of the editorial that is objectionable. You state that an assessment of insight is not necessary for treatment decisions. Since treatment compliance, an aspect of insight, is part of the equation, few "working psychiatrists" will agree. The example you provided of visual illusions in delirium tremens is instructive. Many patients, when confronted by pink cobras swimming in front of their eyes, would conclude that they were "seeing things". For others, seeing is believing. For yet others the experience remains real long after the vision has faded and the events have been explained, patients claiming that they really did see snakes crawling along the bedroom wall. You remind us that psychiatry has elements of both the humanities and the sciences-a view the much maligned Jaspers espoused so clearly some eighty years ago. It must also combine the practical and the academic, the empirical and the theoretical. Informed discussion on insight does this, whereas no amount of resentful prattling will.
that
Institute of Psychiatry, London SE5 8AF, UK 1 David AS.
Insight
and
ANTHONY DAVID psychosis Br J Psychiatry
1990; 156: 798-808.
