1194
Services for migrant drug abusers SIR,- The issues you raise in your editorial on mental health services for migrants in Europe are pertinent to our concerns about migration by people with serious drug problems. Those working with such people in London have noted an increasing number originating from Italy. A substantial proportion are HIV-positive. This experience led to a study day on the issues raised and the establishment of an Anglo/Italian drugs and HIV network. The network has considered the service needs of Italian drug users in the UK and developed several initiatives to respond to these needs. It has also undertaken assesment of the number of Italian drug users in Greater London with the methods developed by the Drug Indicators Project.1 The experience of drug user migration is not unique to the UK. However, there has been little research to identify migration trends, the factors that influence migration, and the implications for the provision of services to drug users from other countries and cultures. We believe that as Europe becomes more integrated and there is greater movement across national boundaries, this will become a matter of some importance for those providing health and social services, and for those concerned with public health. We are therefore initiating a research project with colleagues in Italy to look at these specific issues. It is hoped that a parallel study with colleagues in the Netherlands and Germany will also be undertaken. SCODA Hatton Garden, London EC1N 8ND
MAURICE LIPSEDGE DAVID TURNER
1. Hartnoll R, Daviaud E, Lewis R, Mitcheson M. Drug problems: assessing local needs. London: Drug Indicators Project, 1985.
High mortality among recipients of bought living-unrelated donor kidneys SIR,-Dr Salahudeen and colleagues’ report (Sept 22, p 725) prompts me as an Indian and a citizen of Bombay to confess to a sense of shame which the depravity of commerce in organ transplantation has brought about. Although Salahudeen and
colleagues’ observations basically reflect the state of affairs in Bombay, I would emphasise that most of my colleagues in India involved in renal transplantation observe the requisite ethical and professional standards. Thus for the misdeeds of some let not the us be tarred with the same brush in the minds of your readers. I would also comment on the issue of "rewarded gifting". This is nothing but a terminological subterfuge meant to obfuscate the real issue. Call it what you will, it still remains in the realm of commercialisation, which surely is unacceptable. Such practice is still socially exploitative and adds to the malpractices in the profession. The use of any kind of "paid" donor hinders cadaver organ donation programmes and is a setback to live-related donor programmes. I urge your readers not to be beguiled by this notion. rest of
B. N.
Ben Nevis, B. Desai Road,
Bombay 400036, India
the kit had proved useful during the emergency phases of drought, famine, or war, it was the list of drugs that had been most helpful for individuals, organisations, and countries. An emergency drug list
guide donor responses. The kit has lately been revised by WHO and other UN agencies and other bodies, and the results of field tests have been incorporated in the final revision. The "new emergency health kit"’ is designed to meet the needs of populations with disrupted or no medical facilities. To facilitate distribution on site the new kit consists of different sets of drugs and medical supplies-ten identical basic units for 1000 people each and one supplementary unit for 10 000. The basic unit is for health workers with limited training, and it permits the running of a small peripheral health unit offering simple outpatient care, including disinfection, dressings, and record keeping. Of the twelve drugs, non are injectable, and treatment guidelines based on symptoms have been developed to facilitate the training of personnel. The supplementary unit contains material for a population of 10 000 for about three months and is to be used only by professional health workers. It contains no drugs or supplies from the basic units and can only be used when the basic items are available. A manual describing the standard treatment regimens for target diseases5 is included. Renewable supplies and equipment are intended for a support and referral station for the peripheral units, with facilities for the filtration and chlorination of water and for the sterilisation of instruments, syringes, and dressings. The unit also includes infusion sets, nasogastric tubes, and catheters. Health services can be decentralised by the use of basic health care clinics and the basic units. The first referral level should be staffed with professional health workers, usually medical assistants or doctors, who will use drugs, supplies, and equipment from both units. The units have not been designed to enable these health workers to treat rare diseases or to do major surgery: for such patients a second level of referral is needed, such as those normally found in the national health care system, and referral procedures should be arranged with the local health authorities. A booklet’ describing the kit and providing more background information, basic treatment guidelines, and useful addresses is available through the WHO publications service or directly from the WHO Action Programme on Essential Drugs. The kit can be provided from major pharmaceutical suppliers, most of whom will have stock ready for shipment within 48 hours. can
Programme on Essential World Health Organisation, 1211 Geneva 27, Switzerland Action
Drugs,
H. V. HOGERZEIL
1. Autier P, Férir M-C, Hairapetien A, et al. Drug supply in the aftermath of the 1988 Armenian earthquake. Lancet 1990; 335: 1388-90. 2. WHO emergency health kit: standard drugs and clinic equipment for 10 000 persons for 3 months. Geneva. WHO, 1984. 3. Simmonds S, Mamdani M. Essential drug lists and health relief management. Trop Doctor 1988; 18: 155-58. 4. The new emergency health kit. Geneva: WHO, 1990. (DAP/90.1). 5 Clinical guidelines: diagnostic and treatment manual. Paris: Médecins sans Frontières, 1988.
COLABAWALLA,
Hon gen sec, National Kidney Foundation
(India)
Emergency health kits SiR,—I would like to respond to Dr Cohen’s letter on drug donations to Sudan (Sept 22, p 745) and to the paper on the 1988 Armenian earthquake, which stated that only 30% of drugs sent as emergency relief were immediately usable, and that nearly 20% were useless or expired.’ The World Health Organisation is aware of the risk of insufficient correlation between need and supply and lack of coordination between donor agencies. In 1984 WHO described an emergency health kit, which contained two lists of essential drugs and one of basic medical equipment for emergencies.2 The main objective was to facilitate emergency relief. This kit, developed by WHO with the UN High Commissioner for Refugees (UNHCR) and the London School of Hygiene and Tropical Medicine, has been adopted by several organisations. A 1987 evaluation of experience with the WHO kit3 showed that while
Ethical committees? SIR,-I read with much sympathy the musings of your Oct 6 editorial on medical ethics. Should medicine turn the other cheek? I think not. The time has come for research workers to resist the encroachment of ethics committees. Sooner or later these researchers must be prepared to stand up and be counted. In an article on orphan drugs and the difficulties in their introduction I wrote:’ "Next comes the ethical committee: what is its track record, how liberal is it and is it amenable to reason?" This last phrase is of vital importance to the future of these bodies. I continued "Seeking permission from such a body is, in itself, taking a risk. If the committee says ’yes’ the doctor is really no better off, if it says ’no’ both he and his patient are irretrievably baulked; but to bypass the committee, the doctor must be convinced of his own intellectual integrity and also that his patient is conversant with his course of action." In the course of the past thirty-five years I have introduced three new therapies for the treatment of that previously fatal condition, Wilson’s disease. These drugs have saved many
1195
lives throughout the world. Two, penicillamine and trientine, are approved and can be found in the pharmacopoeia of many countries; the third, ammonium tetrathiomolybdate, remains experimental. Would the first use of any of these have been approved by the average ethics committee? I doubt it with the information on toxicity available at the time of their first administration to patients-a single test dose of the first two for myself. With the more speculative tetrathiomolybdate I took the compound for a week but it seems unlikely that even this would have convinced any ethics committee. But such a rejection would have resulted in the loss of several lives with no blame attributable to the committee. I believe that medical research is already being retarded by such bureaucracy, and the subjecting of observational and non-invasive procedures to committees is, in my view, ridiculous. While some constraint should be placed on unjustified experiments on patients the honest and competent research worker should not be subjected to unnecessary harassment or blocked in his efforts to advance the frontiers of knowledge. It is probable that the lay and legal members of ethics committees have never seen a sick human being in bed; they may be as much interested in their own reputations as in the safety of the patient. now
here is whether their desire to die is so overwhelming as to necessitate the legalisation of euthanasia. I was bom with myelomeningocele spina bifida and am confined to a wheelchair. Babies with my degree of disability are generally aborted now, and Parliament has just ratified a decision to allow abortion up to birth on the grounds of such disabilities. Those who fail to be detected in time are frequently allowed to die in the manner of Baby J, without their consent, and thus outside the ambit of even the VES’ criteria. I believe that doctors should be concentrating on treating their patients rather than projecting opinions on what constitutes a "worthwhile" or "not worthwhile" life. The hospice movement gives ample evidence of the fact that it is possible to kill pain without killing patients, and that even terminal conditions and incurable handicaps (such as mine) are not incompatible with a full life. 35 Stileham Bank, Milborne St Andrew, Blandford Forum, Dorset DT11 0LE, UK 1. Anon.
UK
J. M. WALSHE
Withholding of life saving treatment. Lancet 1990, 336: 1121.
Risk of burns during rapid-rate magnetic stimulation in presence of electrodes
Broome Lodge,
Hemingford Grey, Cambridgeshire PE18 9BN,
ALISON DAVIS
SIR,-A magnetic stimulator capable of stimulating at rates up to Hz, developed by Cadwell Laboratories Inc (Kennewick, Washington)l promises to expand the applications of commercially available stimulators. The first reported transcranial application of this rapid-rate magnetic stimulator was for hemispheric dominance in language.2 Trains of stimuli were delivered over different scalp positions while the subjects counted aloud. The duration of the trains and the intensity and frequency of stimuli were increased until speech was arrested (at 10 s stimuli with 80% of maximum output intensity at 16 Hz). All the volunteers were continuously monitored by electroencephalography (EEG) with silver/silver60
1. Walshe JM. Health 177-79.
orphans: the academic viewpoint. J R Coll Physicians 1988; 22:
Assisted death SIR,-Jean Davies’ letter (Oct 20, p 1012) raises worrying spectres in view of the decisions to allow abortion up to birth for handicap and to withhold life-saving treatment from severely handicapped Baby J.’ Davies asserts that in the Netherlands euthanasia is "never undertaken at the request of anyone but the patient incurably ill and suffering intolerably". That is demonstrably untrue in the UK. BabyJ is incapable of consenting to the judge’s decision that he should not deliberately be given life-saving treatment, and Dr Malcolm Chiswick (Sunday Times, Oct 21) and Prof Peter Dunn (Sunday Correspondent, Oct 21) both admit that on average a similar decision is taken about a handicapped baby once a month in their respective hospitals. It is not BabyJ who says he has no quality of life, but able bodied people making the decision on his behalf. Exactly the same judgment is, of course, being made about fetuses who would be handicapped at birth and who are therefore aborted. There are important implications here for all people with disabilities. If being unable to dissent is presumed to equate with a tacit complicity with the doctor’s preference for death, no handicapped person is safe. The difficulties seem to rest on the two necessary conditions for euthanasia proposed by the Voluntary Euthanasia Society-a wish to die and an incurable illness. My contention is that both can be shown to be irrelevant and that neither is sufficient to justify the dispatch of the patient. A strongly expressed wish to die is generally not linked with an incurable illness or disability. Presumably the VES is not suggesting that every depressed patient who wants to die should have a right to expect his wish to be granted. It would usually be assumed that such a wish-however firmly held-was irrational, and that once the depression lifted a satisfactory quality of life could (possibly with much assistance) be established. Even if that seemed unlikely, most doctors would be reluctant to actively kill a physically healthy patient, even one who thought that his mental pain was intolerable. Most handicapped people do not wish to die and value their, albeit restricted, lives. Of those who do not many are depressed for the same reasons as are able-bodied people. Their disabilities would have nothing to do with such misery, but its incidental presence not only could but also would put them firmly in the category regarded as potential candidates for euthanasia. There are undoubtedly some handicapped or seriously ill people who wish to die because of their physical condition. The question
chloride surface electrodes. One volunteer had a burn under one EEG electrode and we thought that this might have been caused by heating due to currents induced in the electrode during magnetic stimulation. To test this explanation we mimicked the study design by magnetically stimulating the arm of one of us with trains of
Skin temperature changes
during magnetic stimulation.
Top temperature change from baseline under surface electrode applied to arm, in response to 40 magnetic stimuli applied at frequencies of O’ 25 to 4 Hz and at 100% output intensity
Bottom maximal temperature increase as function of number of at 100% output intensity and 1 Hz frequency and as function of output intensity (40 stimuli at 1 Hz)
magnetic stimuli
Services for migrant drug abusers SIR,- The issues you raise in your editorial on mental health services for migrants in Europe are pertinent to our concerns about migration by people with serious drug problems. Those working with such people in London have noted an increasing number originating from Italy. A substantial proportion are HIV-positive. This experience led to a study day on the issues raised and the establishment of an Anglo/Italian drugs and HIV network. The network has considered the service needs of Italian drug users in the UK and developed several initiatives to respond to these needs. It has also undertaken assesment of the number of Italian drug users in Greater London with the methods developed by the Drug Indicators Project.1 The experience of drug user migration is not unique to the UK. However, there has been little research to identify migration trends, the factors that influence migration, and the implications for the provision of services to drug users from other countries and cultures. We believe that as Europe becomes more integrated and there is greater movement across national boundaries, this will become a matter of some importance for those providing health and social services, and for those concerned with public health. We are therefore initiating a research project with colleagues in Italy to look at these specific issues. It is hoped that a parallel study with colleagues in the Netherlands and Germany will also be undertaken. SCODA Hatton Garden, London EC1N 8ND
MAURICE LIPSEDGE DAVID TURNER
1. Hartnoll R, Daviaud E, Lewis R, Mitcheson M. Drug problems: assessing local needs. London: Drug Indicators Project, 1985.
High mortality among recipients of bought living-unrelated donor kidneys SIR,-Dr Salahudeen and colleagues’ report (Sept 22, p 725) prompts me as an Indian and a citizen of Bombay to confess to a sense of shame which the depravity of commerce in organ transplantation has brought about. Although Salahudeen and
colleagues’ observations basically reflect the state of affairs in Bombay, I would emphasise that most of my colleagues in India involved in renal transplantation observe the requisite ethical and professional standards. Thus for the misdeeds of some let not the us be tarred with the same brush in the minds of your readers. I would also comment on the issue of "rewarded gifting". This is nothing but a terminological subterfuge meant to obfuscate the real issue. Call it what you will, it still remains in the realm of commercialisation, which surely is unacceptable. Such practice is still socially exploitative and adds to the malpractices in the profession. The use of any kind of "paid" donor hinders cadaver organ donation programmes and is a setback to live-related donor programmes. I urge your readers not to be beguiled by this notion. rest of
B. N.
Ben Nevis, B. Desai Road,
Bombay 400036, India
the kit had proved useful during the emergency phases of drought, famine, or war, it was the list of drugs that had been most helpful for individuals, organisations, and countries. An emergency drug list
guide donor responses. The kit has lately been revised by WHO and other UN agencies and other bodies, and the results of field tests have been incorporated in the final revision. The "new emergency health kit"’ is designed to meet the needs of populations with disrupted or no medical facilities. To facilitate distribution on site the new kit consists of different sets of drugs and medical supplies-ten identical basic units for 1000 people each and one supplementary unit for 10 000. The basic unit is for health workers with limited training, and it permits the running of a small peripheral health unit offering simple outpatient care, including disinfection, dressings, and record keeping. Of the twelve drugs, non are injectable, and treatment guidelines based on symptoms have been developed to facilitate the training of personnel. The supplementary unit contains material for a population of 10 000 for about three months and is to be used only by professional health workers. It contains no drugs or supplies from the basic units and can only be used when the basic items are available. A manual describing the standard treatment regimens for target diseases5 is included. Renewable supplies and equipment are intended for a support and referral station for the peripheral units, with facilities for the filtration and chlorination of water and for the sterilisation of instruments, syringes, and dressings. The unit also includes infusion sets, nasogastric tubes, and catheters. Health services can be decentralised by the use of basic health care clinics and the basic units. The first referral level should be staffed with professional health workers, usually medical assistants or doctors, who will use drugs, supplies, and equipment from both units. The units have not been designed to enable these health workers to treat rare diseases or to do major surgery: for such patients a second level of referral is needed, such as those normally found in the national health care system, and referral procedures should be arranged with the local health authorities. A booklet’ describing the kit and providing more background information, basic treatment guidelines, and useful addresses is available through the WHO publications service or directly from the WHO Action Programme on Essential Drugs. The kit can be provided from major pharmaceutical suppliers, most of whom will have stock ready for shipment within 48 hours. can
Programme on Essential World Health Organisation, 1211 Geneva 27, Switzerland Action
Drugs,
H. V. HOGERZEIL
1. Autier P, Férir M-C, Hairapetien A, et al. Drug supply in the aftermath of the 1988 Armenian earthquake. Lancet 1990; 335: 1388-90. 2. WHO emergency health kit: standard drugs and clinic equipment for 10 000 persons for 3 months. Geneva. WHO, 1984. 3. Simmonds S, Mamdani M. Essential drug lists and health relief management. Trop Doctor 1988; 18: 155-58. 4. The new emergency health kit. Geneva: WHO, 1990. (DAP/90.1). 5 Clinical guidelines: diagnostic and treatment manual. Paris: Médecins sans Frontières, 1988.
COLABAWALLA,
Hon gen sec, National Kidney Foundation
(India)
Emergency health kits SiR,—I would like to respond to Dr Cohen’s letter on drug donations to Sudan (Sept 22, p 745) and to the paper on the 1988 Armenian earthquake, which stated that only 30% of drugs sent as emergency relief were immediately usable, and that nearly 20% were useless or expired.’ The World Health Organisation is aware of the risk of insufficient correlation between need and supply and lack of coordination between donor agencies. In 1984 WHO described an emergency health kit, which contained two lists of essential drugs and one of basic medical equipment for emergencies.2 The main objective was to facilitate emergency relief. This kit, developed by WHO with the UN High Commissioner for Refugees (UNHCR) and the London School of Hygiene and Tropical Medicine, has been adopted by several organisations. A 1987 evaluation of experience with the WHO kit3 showed that while
Ethical committees? SIR,-I read with much sympathy the musings of your Oct 6 editorial on medical ethics. Should medicine turn the other cheek? I think not. The time has come for research workers to resist the encroachment of ethics committees. Sooner or later these researchers must be prepared to stand up and be counted. In an article on orphan drugs and the difficulties in their introduction I wrote:’ "Next comes the ethical committee: what is its track record, how liberal is it and is it amenable to reason?" This last phrase is of vital importance to the future of these bodies. I continued "Seeking permission from such a body is, in itself, taking a risk. If the committee says ’yes’ the doctor is really no better off, if it says ’no’ both he and his patient are irretrievably baulked; but to bypass the committee, the doctor must be convinced of his own intellectual integrity and also that his patient is conversant with his course of action." In the course of the past thirty-five years I have introduced three new therapies for the treatment of that previously fatal condition, Wilson’s disease. These drugs have saved many
1195
lives throughout the world. Two, penicillamine and trientine, are approved and can be found in the pharmacopoeia of many countries; the third, ammonium tetrathiomolybdate, remains experimental. Would the first use of any of these have been approved by the average ethics committee? I doubt it with the information on toxicity available at the time of their first administration to patients-a single test dose of the first two for myself. With the more speculative tetrathiomolybdate I took the compound for a week but it seems unlikely that even this would have convinced any ethics committee. But such a rejection would have resulted in the loss of several lives with no blame attributable to the committee. I believe that medical research is already being retarded by such bureaucracy, and the subjecting of observational and non-invasive procedures to committees is, in my view, ridiculous. While some constraint should be placed on unjustified experiments on patients the honest and competent research worker should not be subjected to unnecessary harassment or blocked in his efforts to advance the frontiers of knowledge. It is probable that the lay and legal members of ethics committees have never seen a sick human being in bed; they may be as much interested in their own reputations as in the safety of the patient. now
here is whether their desire to die is so overwhelming as to necessitate the legalisation of euthanasia. I was bom with myelomeningocele spina bifida and am confined to a wheelchair. Babies with my degree of disability are generally aborted now, and Parliament has just ratified a decision to allow abortion up to birth on the grounds of such disabilities. Those who fail to be detected in time are frequently allowed to die in the manner of Baby J, without their consent, and thus outside the ambit of even the VES’ criteria. I believe that doctors should be concentrating on treating their patients rather than projecting opinions on what constitutes a "worthwhile" or "not worthwhile" life. The hospice movement gives ample evidence of the fact that it is possible to kill pain without killing patients, and that even terminal conditions and incurable handicaps (such as mine) are not incompatible with a full life. 35 Stileham Bank, Milborne St Andrew, Blandford Forum, Dorset DT11 0LE, UK 1. Anon.
UK
J. M. WALSHE
Withholding of life saving treatment. Lancet 1990, 336: 1121.
Risk of burns during rapid-rate magnetic stimulation in presence of electrodes
Broome Lodge,
Hemingford Grey, Cambridgeshire PE18 9BN,
ALISON DAVIS
SIR,-A magnetic stimulator capable of stimulating at rates up to Hz, developed by Cadwell Laboratories Inc (Kennewick, Washington)l promises to expand the applications of commercially available stimulators. The first reported transcranial application of this rapid-rate magnetic stimulator was for hemispheric dominance in language.2 Trains of stimuli were delivered over different scalp positions while the subjects counted aloud. The duration of the trains and the intensity and frequency of stimuli were increased until speech was arrested (at 10 s stimuli with 80% of maximum output intensity at 16 Hz). All the volunteers were continuously monitored by electroencephalography (EEG) with silver/silver60
1. Walshe JM. Health 177-79.
orphans: the academic viewpoint. J R Coll Physicians 1988; 22:
Assisted death SIR,-Jean Davies’ letter (Oct 20, p 1012) raises worrying spectres in view of the decisions to allow abortion up to birth for handicap and to withhold life-saving treatment from severely handicapped Baby J.’ Davies asserts that in the Netherlands euthanasia is "never undertaken at the request of anyone but the patient incurably ill and suffering intolerably". That is demonstrably untrue in the UK. BabyJ is incapable of consenting to the judge’s decision that he should not deliberately be given life-saving treatment, and Dr Malcolm Chiswick (Sunday Times, Oct 21) and Prof Peter Dunn (Sunday Correspondent, Oct 21) both admit that on average a similar decision is taken about a handicapped baby once a month in their respective hospitals. It is not BabyJ who says he has no quality of life, but able bodied people making the decision on his behalf. Exactly the same judgment is, of course, being made about fetuses who would be handicapped at birth and who are therefore aborted. There are important implications here for all people with disabilities. If being unable to dissent is presumed to equate with a tacit complicity with the doctor’s preference for death, no handicapped person is safe. The difficulties seem to rest on the two necessary conditions for euthanasia proposed by the Voluntary Euthanasia Society-a wish to die and an incurable illness. My contention is that both can be shown to be irrelevant and that neither is sufficient to justify the dispatch of the patient. A strongly expressed wish to die is generally not linked with an incurable illness or disability. Presumably the VES is not suggesting that every depressed patient who wants to die should have a right to expect his wish to be granted. It would usually be assumed that such a wish-however firmly held-was irrational, and that once the depression lifted a satisfactory quality of life could (possibly with much assistance) be established. Even if that seemed unlikely, most doctors would be reluctant to actively kill a physically healthy patient, even one who thought that his mental pain was intolerable. Most handicapped people do not wish to die and value their, albeit restricted, lives. Of those who do not many are depressed for the same reasons as are able-bodied people. Their disabilities would have nothing to do with such misery, but its incidental presence not only could but also would put them firmly in the category regarded as potential candidates for euthanasia. There are undoubtedly some handicapped or seriously ill people who wish to die because of their physical condition. The question
chloride surface electrodes. One volunteer had a burn under one EEG electrode and we thought that this might have been caused by heating due to currents induced in the electrode during magnetic stimulation. To test this explanation we mimicked the study design by magnetically stimulating the arm of one of us with trains of
Skin temperature changes
during magnetic stimulation.
Top temperature change from baseline under surface electrode applied to arm, in response to 40 magnetic stimuli applied at frequencies of O’ 25 to 4 Hz and at 100% output intensity
Bottom maximal temperature increase as function of number of at 100% output intensity and 1 Hz frequency and as function of output intensity (40 stimuli at 1 Hz)
magnetic stimuli
