1599
S:R,—Malcolm Dean (London Perspective, Nov 30, p 1383) makes valuable comments on the UK Government’s inaction on tobacco. One factor omitted is of increasing political importancenamely, inflation. The weighting of tobacco in the retail prices index (RPI) is 31/1000,’ so a 31 % rise in the price of tobacco will add 1% to the rate of inflation; the 15-9% rise last yearl contributed 0-5% to the inflation rate. Tobacco consumption is sensitive to price-as governments are to inflation. Until tobacco products are removed from the RPI we are unlikely to see significant tax-driven price rises. We are aiming to make tobacco a product consumed by a decreasing minority and its presence in the RPI is an anachronism.
they receive from these doctors; but there is no audit of coroner’s necropsies. As a haematologist, I cannot understand why postmortem examinations done for the coroner are not all undertaken by histopathologists with training in both general and forensic pathology. This 19th century practice should surely be brought up
Department of Public Health Medicine, Sheffield Health Authority, Sheffield S11 8EU, UK
SiR,—Dr Moulton and Mr Pennycook (Nov 23, p 1336) note that in Scotland certification of sudden death without necropsy is more likely than it is in England and Wales. I am no epidemiologist, but their observation might explain why the mortality rate from ruptured aortic aneurysm (ICD 441.3) (a cause of death probably likely to mimic a death from coronary heart disease [CHD]) in Scotland is half that in England. Moreover, I believe that the necropsy rate in England and Wales is two and a half times that in Scotland. I just wonder whether, to reach Government targets of decreasing the incidence of CHD in Scotland by the year 2000, it might be cheapest to employ more pathologists.
KEITH NEAL
1. Johnson R. Fall in meat and cheese prices helps to cut RPI. Financial Times 1991; Aug 17: 4.
SIR,-Apart from the huge amounts of money spent by the industry on promotion and the enormous leverage that industry has on the government because of the revenue (over c22 billion) that tobacco sales bring, it is interesting to note the subsidies handed out by the European Community. In 1971 the EC paid 330 million to tobacco growers in Italy, Germany, France, and Belgium (written reply to a House of Commons question in July this year). By 1990, with the membership of Greece, Spain, and Portugal, this had risen to c957 million, of which 14 % is paid by the UK. Of the European tobacco crop about 10% is exported to developing countries. Apparently we are unable to stop these subsidies since the Treaty of Rome includes tobacco under the Common Agricultural Policy.
tobacco
D. EUSTACE S. MONEY
St Thomas’s Hospital, London SE1 7EH, UK
Doctors and manslaughter SIR,-Mrs Brahams’ report (Nov 9, p 1198) reminds me of a mistake I made when I was a final-year medical student in Brussels in 1986. Under a junior doctor’s guidance, I injected methotrexate into a patient’s spine in Belgium’s leading cancer institute. It was late in the day, with no methotrexate on the hospital wards, so I had hurried to the pharmacy, got the vials in a box, and thrown away the wrappings while walking back. Under a modicum of supervision I prepared the syringes, did the lumbar puncture, and injected the substance. About an hour later a more experienced junior doctor noted that the empty vials were for intravenous, not intrathecal use. The vials were not so labelled, though the medication box I retrieved from the rubbish bin was. The junior doctors were inclined to forget the incident without even putting a note in the chart, but as a compulsive legal-minded American I documented both the episode and my hours spent on the telephone consulting with senior physicians. They knew no way to palliate the error and avoid arachnoiditis, transverse myelitis, or worse. I was told that the patient experienced unusual back pain with paraesthesia a week later, but eventually recovered from the iatrogenic insult. Medical errors do occur. It is difficult to decide at what point their gross or reckless nature constitutes a criminal offence. 3033 Bateman St, Berkeley, California 94705, USA
LANCE MONTAUK
Investigating death SIR,-In her comments on the 6th Annual Bar Conference, Mrs Brahams (Nov 16, p 1262) notes that the workshop on legal procedures for investigating unexpected death recorded concern about the uneven standards of necropsies done outside the UK. The uneven standard of necropsies performed within the UK would also have been a suitable subject for discussion. It is still the practice in some areas for necropsies to be undertaken by general practitioners who are police surgeons or others with no proper training in histopathology and who are unable to undertake microscopical examination of specimens. Coroners may be happy with the reports
...’"
.4,,+0.
Royal Manchester Children’s Hospital, University of Manchester School of Medicine, Pendlebury, Nr Manchester M27 1HA, UK
D. I. K. EVANS
Coroners and coronaries
Westminster Coroner’s Court, London SW1 P 2ED, UK
PAUL A. KNAPMAN
Malnutrition in Iraq SIR,-Professor Waterlow (Nov 23, p 1336) questions the conclusions reached by Dr Sata and colleagues (Nov 9, p 1202) about malnutrition in Iraq, and demands more details on infant mortality. A major international investigation into health care in Iraq provided reliable data on this point.l In Basra, for instance, infant mortality for children under one year more than tripled from an average of 24 deaths per 1000 live births to 80 during the first eight months of 1991. The rise in the northern areas is even more striking-a fourfold increase from 25 to 103 per 1000. Among children under 5, mortality is up from an average of 28 to 104 per 1000 live births. Furthermore the international investigators announced that 900 000 Iraqi children are suffering from malnutrition. Waterlow’s suggestion that the United Nations should monitor trends of infant and child mortality in Iraq during the continuation of the sanctions contravenes basic principles of preventive medicine. There is compelling evidence that economic sanctions against Iraq have led to dangerous shortage of essential commodities, including food and medicine. Immediate action, rather than statistical analyses, is what is needed to avert a public health disaster in that country. Economic sanctions should be relaxed to permit adequate importation of food and medicine. International obligations towards innocent civilians should not be mixed with political retribution against their leaders. 81 Guilford Street, London WC1 N 3BG, UK 1. Perera
M. K. SHARIEF
J A legacy of war blights Iraqi care. Hosp Doctor 1991 (Nov 21): 28-29.
Confidentiality and IVF SIR,-Mrs Brahams’ suggestion (Dec 7, p 1449) that the Attorney-General agree "to a simple non-prosecution agreement" to get round a defect in the law on confidentiality and in-vitro fertilisation (IVF) until that law can be changed is sensible. The application of this law would be dangerous and could even contribute to the death of a woman who has been treated in a licenced IVF unit which is at present precluded from giving details to another doctor or hospital about possible life-threatening complications such as an ectopic pregnancy or severe ovarian hyperstimulation. Furthermore, it is nonsense for non-IVF personnel ranging from porters and domestic staff to audit clerks and accountants, to fall under the statutory licensing provisions, in view of their huge numbers and rapid turn-over. Regional IVF Unit, St Mary’s Hospital, Manchester M13 0JH, UK
B. A. LIEBERMAN
S:R,—Malcolm Dean (London Perspective, Nov 30, p 1383) makes valuable comments on the UK Government’s inaction on tobacco. One factor omitted is of increasing political importancenamely, inflation. The weighting of tobacco in the retail prices index (RPI) is 31/1000,’ so a 31 % rise in the price of tobacco will add 1% to the rate of inflation; the 15-9% rise last yearl contributed 0-5% to the inflation rate. Tobacco consumption is sensitive to price-as governments are to inflation. Until tobacco products are removed from the RPI we are unlikely to see significant tax-driven price rises. We are aiming to make tobacco a product consumed by a decreasing minority and its presence in the RPI is an anachronism.
they receive from these doctors; but there is no audit of coroner’s necropsies. As a haematologist, I cannot understand why postmortem examinations done for the coroner are not all undertaken by histopathologists with training in both general and forensic pathology. This 19th century practice should surely be brought up
Department of Public Health Medicine, Sheffield Health Authority, Sheffield S11 8EU, UK
SiR,—Dr Moulton and Mr Pennycook (Nov 23, p 1336) note that in Scotland certification of sudden death without necropsy is more likely than it is in England and Wales. I am no epidemiologist, but their observation might explain why the mortality rate from ruptured aortic aneurysm (ICD 441.3) (a cause of death probably likely to mimic a death from coronary heart disease [CHD]) in Scotland is half that in England. Moreover, I believe that the necropsy rate in England and Wales is two and a half times that in Scotland. I just wonder whether, to reach Government targets of decreasing the incidence of CHD in Scotland by the year 2000, it might be cheapest to employ more pathologists.
KEITH NEAL
1. Johnson R. Fall in meat and cheese prices helps to cut RPI. Financial Times 1991; Aug 17: 4.
SIR,-Apart from the huge amounts of money spent by the industry on promotion and the enormous leverage that industry has on the government because of the revenue (over c22 billion) that tobacco sales bring, it is interesting to note the subsidies handed out by the European Community. In 1971 the EC paid 330 million to tobacco growers in Italy, Germany, France, and Belgium (written reply to a House of Commons question in July this year). By 1990, with the membership of Greece, Spain, and Portugal, this had risen to c957 million, of which 14 % is paid by the UK. Of the European tobacco crop about 10% is exported to developing countries. Apparently we are unable to stop these subsidies since the Treaty of Rome includes tobacco under the Common Agricultural Policy.
tobacco
D. EUSTACE S. MONEY
St Thomas’s Hospital, London SE1 7EH, UK
Doctors and manslaughter SIR,-Mrs Brahams’ report (Nov 9, p 1198) reminds me of a mistake I made when I was a final-year medical student in Brussels in 1986. Under a junior doctor’s guidance, I injected methotrexate into a patient’s spine in Belgium’s leading cancer institute. It was late in the day, with no methotrexate on the hospital wards, so I had hurried to the pharmacy, got the vials in a box, and thrown away the wrappings while walking back. Under a modicum of supervision I prepared the syringes, did the lumbar puncture, and injected the substance. About an hour later a more experienced junior doctor noted that the empty vials were for intravenous, not intrathecal use. The vials were not so labelled, though the medication box I retrieved from the rubbish bin was. The junior doctors were inclined to forget the incident without even putting a note in the chart, but as a compulsive legal-minded American I documented both the episode and my hours spent on the telephone consulting with senior physicians. They knew no way to palliate the error and avoid arachnoiditis, transverse myelitis, or worse. I was told that the patient experienced unusual back pain with paraesthesia a week later, but eventually recovered from the iatrogenic insult. Medical errors do occur. It is difficult to decide at what point their gross or reckless nature constitutes a criminal offence. 3033 Bateman St, Berkeley, California 94705, USA
LANCE MONTAUK
Investigating death SIR,-In her comments on the 6th Annual Bar Conference, Mrs Brahams (Nov 16, p 1262) notes that the workshop on legal procedures for investigating unexpected death recorded concern about the uneven standards of necropsies done outside the UK. The uneven standard of necropsies performed within the UK would also have been a suitable subject for discussion. It is still the practice in some areas for necropsies to be undertaken by general practitioners who are police surgeons or others with no proper training in histopathology and who are unable to undertake microscopical examination of specimens. Coroners may be happy with the reports
...’"
.4,,+0.
Royal Manchester Children’s Hospital, University of Manchester School of Medicine, Pendlebury, Nr Manchester M27 1HA, UK
D. I. K. EVANS
Coroners and coronaries
Westminster Coroner’s Court, London SW1 P 2ED, UK
PAUL A. KNAPMAN
Malnutrition in Iraq SIR,-Professor Waterlow (Nov 23, p 1336) questions the conclusions reached by Dr Sata and colleagues (Nov 9, p 1202) about malnutrition in Iraq, and demands more details on infant mortality. A major international investigation into health care in Iraq provided reliable data on this point.l In Basra, for instance, infant mortality for children under one year more than tripled from an average of 24 deaths per 1000 live births to 80 during the first eight months of 1991. The rise in the northern areas is even more striking-a fourfold increase from 25 to 103 per 1000. Among children under 5, mortality is up from an average of 28 to 104 per 1000 live births. Furthermore the international investigators announced that 900 000 Iraqi children are suffering from malnutrition. Waterlow’s suggestion that the United Nations should monitor trends of infant and child mortality in Iraq during the continuation of the sanctions contravenes basic principles of preventive medicine. There is compelling evidence that economic sanctions against Iraq have led to dangerous shortage of essential commodities, including food and medicine. Immediate action, rather than statistical analyses, is what is needed to avert a public health disaster in that country. Economic sanctions should be relaxed to permit adequate importation of food and medicine. International obligations towards innocent civilians should not be mixed with political retribution against their leaders. 81 Guilford Street, London WC1 N 3BG, UK 1. Perera
M. K. SHARIEF
J A legacy of war blights Iraqi care. Hosp Doctor 1991 (Nov 21): 28-29.
Confidentiality and IVF SIR,-Mrs Brahams’ suggestion (Dec 7, p 1449) that the Attorney-General agree "to a simple non-prosecution agreement" to get round a defect in the law on confidentiality and in-vitro fertilisation (IVF) until that law can be changed is sensible. The application of this law would be dangerous and could even contribute to the death of a woman who has been treated in a licenced IVF unit which is at present precluded from giving details to another doctor or hospital about possible life-threatening complications such as an ectopic pregnancy or severe ovarian hyperstimulation. Furthermore, it is nonsense for non-IVF personnel ranging from porters and domestic staff to audit clerks and accountants, to fall under the statutory licensing provisions, in view of their huge numbers and rapid turn-over. Regional IVF Unit, St Mary’s Hospital, Manchester M13 0JH, UK
B. A. LIEBERMAN
