treatment. An association was found between severe life events or difficulties and relapse. Further prospective studies are needed, controlling for intrapsychic factors-such as coping styles and mood disturbance. Despite methodological difficulties and inconsistent results much of the work so far described points to a complex relation between the psychological and somatic states of patients with cancer. A further challenge to dualistic thinking comes from the controversial results of recent work testing the effect of psychological treatment on the outcome of cancer. The results of a trial of psychotherapy in patients with advanced breast cancer by Spiegel and his colleagues in the United States have excited interest.27 The psychotherapy consisted of 90 minute group sessions each week that were led by trained therapists, one of whom had breast cancer in remission. The sessions concentrated on airing of feelings -facilitating the expression of grief, establishing emotional bonds between sufferers, and methods of coping with cancer. After 10 years' follow up the patients who had had therapy had lived twice as long as the controls (37 months compared with 19 months). The study had some problems, however, which included differences between treatment groups and lack of information about possible confounding factors-such as social network, life events, and personality factors. Also puzzling is why the effect of treatment should have become obvious only eight months after the end of psychotherapy. This was a small study and the results need cautious interpretation. Problems also arise in interpreting non-randomised studies of the effects of psychological or complementary therapies on disease process, which are biased by confounding physical and psychological differences between self selected samples.28 Further progress will depend on a better understanding of the interaction between the mind and the body. A relation between psychological factors and cancer could be mediated through behavioural factors such as smoking or diet or more directly through biological correlates of certain emotional states. In breast cancer several worthwhile and testable hypotheses have emerged. A relation between tumour oestrogen and progesterone status and psychosocial adjustment has recently been reported."9 Other possibilities include a relation between mood and concentrations of immunoglobulins,2' natural killer cells,"0 and prolactin.8' Whatever the nature of these interactions, doctors should be aware of the high rate of psychiatric morbidity in patients with breast cancer. A few will need psychiatric treatment, but others will benefit from other psychological interventions. The suggestion that the course of the cancer itself will be affected by such interventions is tantalising, but the evidence

remains inconclusive. Overemphasising a relation might lead to self blame by patients whose disease relapses. SIMON LOVESTONE Registrar in Psychiatry, Maudslev Hospital, London SE5 8AF THOMAS FAHY

Lecturer in Psychological Medicine, Institute of Psychiatry, King's College Hospital, London SE5 9RS (Correspondence to Dr Fahy) I Morris J, RovIe GT, Taylor I. Changes in the surgical management of early breast cancer in England. 7 R Soc Med 1989;82:12-4. 2 Palmier BV, Walsh GA, McKinna JA, Greening WIP. Adjuvant chemotherapy for breast cancer: side effects and quality of life. B,M7 1980;281:1594-7. 3 Dean C. Psvchiatric morbidity following mastectomy: preoperative prcdictors and tN yp of illness.

JPsvchosom Rts 1987;31:385-92. 4 Fallowfield LJ, Battm MI. Psychological welfare of patients with breast cancer. 7 R Soc Med

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1989;82:4-5. Consensus development conference: treatment of primary breast cancer. HAl7 1986;293:946-7. Ramirez AJ. Liaison psychiatry in a breast cancer unit. ] R Soc Med 1989;82:15-7. Watson N1. Psychological intervention with cancer patients: a rexview. I'sy>cholMed 1983;13:839-46. Spicgel D, Bloom JR. Grottp therapy and hypnosis reduce metastatic breast cattccr pain. I'sychosom Mfed 1983;45:333-9. WVatson MI, Denton S, Baum M, Greer S. Counselling breast cancer patients: a specialist nurse service. Counselling Psychologv Quarterly 1988;1:25-34. Vachon MiLS, Lyall WAL, Rogers J, Cochrane J, Freeman SJ. T he effectivcness of psychosocial support during post surgical treatment of breast cancer. Int] Psvchiatns Med 1982;11:365-72. Moore S, G(reer S. Psychological therapy Ior patients with cancer. London: Heinemann, 1990. Scherg H, Cramer 1, Blohmke M. Psychological factors and breast cancer: a critical re-evaluation of established hypotheses. Cancer Detect Prev 1981;4:165-71. Wirsching M, Stierlin H, Hoffman F, et al. Psychological identification of breast cancer patients before biopsy. ] Psychosom Res 1982;26: 1-10. Greer S. Psychological enquiry: a contribution to cancer research. Psvchol Med 1979;9:81-9. Blumberg E, West PAI, Ellis FW. A possible relationship between psychological factors and human cancer. Psvchosom.Aled 1954;16:277-86. Achtenberg J, Matthews-Simonton OC. Psychology of the exceptional cancer patient: a description of patients who outlive predicted life expectancies. PsYchotherapy Theory, Research and Practice

1977;14:416-22. 17 Derogatis LR, Abeloff MNB, Melisaratos N. Psychological coping mechanisms and survival time in metastatic breast cancer. A.4MA4 1979;242:1504-8. 18 Cassileth BR, Lush EJ, Millcr DS, est al. Psychological correlates of survival in advanccd malignant

disease. ,N\ Ingl]MlAted 1985;312:1551-5. 19 Greer S, Morris T, I'ettingale KVW. Psychological response to breast cancer: effect on outcome.

Lancet 1979;ii:785-7. 20 Greer S, Morris r I',ettingalc KW, Haybittle JL. Psychological response to breast cancer and fifteen year outcome. Lancet 1990;335:49-50. 21 Pettingale KW, Philalithis A, Tee DEH, Greer S. The biological correlates of psychological responses to breast cancer. ] Psychosom Res 1981;25:453-8. 22 Greer S, Morris F. Psychological attribtites of women who develop breast catcer--a controlled study. 7 Psvchosom Res 1975;19:147-53. 23 Jacobs IJ, Charles E. L,ife events and occurrence of cancer in childreni. PsYchosom Med 1980;42: 11-25. 24 Funch DP, Marshall J. TIhe role of stress, social support and age in survival frrom brcast cancer. ] Psvclhosom Res 1983;27:77-83. 25 Jones DR, (ioldblatt P1), ILeou DA. Bereasement and cancer. Some data ot1 deaths of sp)uses from the longitudinal study of Office of Population Censuses and Surseys. BM7 1984;289:461-4. 26 Ramirez A, Craig TJ, W'atson JP, Fentimen IS. Stress and relapsc itn breast cancer. BM1l

1989;298:291-3.

27 Spiegel D, Kraemer HC, Bloom JR, Gottheil E. Effect of psychosocial treatment on sursisal of patients with metastatic breast cancer. Lancet 1989;ii:888-91. 28 Bagenal FS, Easton DF, Harris E, Chilvers CED, McElwain TJ. Survival of patients with breast cancer attending Bristol Cancer Help Centre. Lancet 1990;336:606-10. 29 Ravazi D, Farvacques C,, Delvattx N, et al. Psychosocial correlates of oestrogen and progesterone receptors in breast cancer. Lancet 1990;335:931-3. 30 Greer S, Brady NI. Natural killer cells: one possible link between cancer and the mind. Stress Medicine 1988;4:105-11. 31 Shafie S, Brootks SC. Effect of prolactin on growth and estrogen receptor letel of human breast cancer (,MCF-7). Cancer Res 1977;37:792-9.

Health research in developing countries Each should have a programme of essential national health research Dr Lamin Kurubally obtained a master's degree in public health from the United States. He returned home to West Africa wanting to carry out epidemiological research in the pursuit of improved public health. A group of villagers approached him because of their concern over the amount of mental illness in young people. lie wanted to study this but had no resources. His grant proposal was turned down because his review of the literature was poor and his budget for capital items was too large. The only library to which he had access had only a few out of date textbooks, the one departmental computer had no uninterruptable power supply 1220

so was constantly damaged by electricity fluctuations, and the photocopier was broken and the nearest technician was 600 kilometres away. The government wanted him to work on controlling diarrhoea, which an international agency was willing to fund. His government salary was inadequate to support his family, so he started private family practice in the evenings to supplement it. This fiction contains many of the elements that face all researchers in developing countries-problems on which a commission on health research for development has recently reported.' The commission comprised a group of eminent BMJ VOLUME 302

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researchers, mostly from developing countries, who collected information, held meetings, and commissioned special papers over three years. The report contains the all too familiar description of the inequalities of health between and within countries, but what is more striking and less familiar is the inequity of the distribution for funding of research both between and within countries. Most assistance (79%) with all forms of development is bilateral, directly from one country to another, but only 5% of this is targeted on health services. The worldwide investment in health research is $30bn, but only 5% of this is spent on health problems of developing countries, where 93% of the years of potential life are lost. How does the commission aim to rectify the situation? It recommends a programme of essential national health research for each developing country, addressing both problems specific to each country and global problems. International partnerships need to be strengthened and new ones forged to help the programme, for which funds must be found. The commission recommends that at least 2% of national health expenditure should be invested in the programme and that at least 5% of all grants should go to research. These recommendations follow a strong argument for the value of health research as an important long term investment in development. The committee points out that this investment appreciates over time, whereas many short term aid programmes depreciate. It is difficult to argue with the logic and conclusions. The report, however, is brief, presumably to maximise readership, and therefore leaves some concerns about the method of achieving the aims. A key element for Lamin was the fact that the community identified a health problem and asked for help. If research specific to a country is to be successful this will be crucial to its success. How will this be done? Most of the communities in Africa still see ill health in terms of spirits or witchcraft, a perception at odds with Western models. Most of the doctors in these countries have been brought up to

subscribe to the Western model of health and to reject the community's view. Can this be reconciled to produce research specific to a country that is based on real community needs? Current success in scientific research is measured in publications. Will international peer reviewed journals consider this form of locally relevant research suitable? Will research workers be happy to embark on work that may be published, and recognised, only locally? This all assumes that there are some local health research workers available. Lamin may have to give up research in the near future to earn money in private practice. It is all too familiar: government employees in developing countries cannot afford to do research because they are overburdened with routine duties and their spare time is needed to generate income. Will international and bilateral aid organisations be persuaded to underwrite research workers' careers in the long term? Can this be done without undermining purely clinical workers? Perhaps governments need to consider paying supplements to promising researchers to give them the time to pursue their ideas. Indeed, the similarity of the commission's recommendations to the Brandt report reminds one of the question, "When will the crumbs fall from Brandt's table?" It seems that the commission is already addressing implementation of its recommendations. A task force has been set up to coordinate fund raising, and the World Health Organisation has taken up one of the points raised by the commission in starting a new programme on tuberculosis. Let's hope that Lamin gets something out of all this. ANDREW J HALL Senior Lecturer, Communicable Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT 1 Commission on Health Research for Development. Health research: essential link to equity in development. Oxford: Oxford University Press, 1990.

Doctors and the European Community The agenda lengthens The completion of the European single market at the end of 1992 may change many aspects of economic and social life in Britain, but a single market for doctors has existed almost unnoticed since 1977. Medical directives which became effective in that year entitled doctors who are European Community nationals and who hold primary medical qualifications awarded in a member state of the community to practise in any member state. The completion of the single market will not change this. Despite alarmist predictions implementation of the medical directives did not lead to a massive influx into Britain of doctors from other European Community countries, and the number migrating remained low for almost a decade. Recently the situation has been changing rapidly, and over 1000 practitioners from other European Community countries have been registered by the General Medical Council in each of the past two years. Though most of these doctors intend to return to their countries of origin after a period of training, a recent survey by the Department of Health suggested that almost a fifth are seeking permanent careers in Britain. The directives require member states to recognise the basic and specialist medical qualifications awarded by other member states by giving them the same effect as they give to their own BMJ VOLUME 302

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qualifications. All European Community nationals with basic medical qualifications from a European Community country are thus entitled to full registration with the General Medical Council, without having completed an internship year if their national regulations do not require one. The position regarding specialist qualifications has been widely misunderstood. The title of specialist is not protected in Britain, and any doctor may legally describe himself or herself as a specialist. There is thus no effect to be given to a specialist diploma acquired in another European Community country. General practice is different: doctors who have completed the two year vocational training prescribed in the general practitioner's directive have a right to establish themselves as general practitioner principals in Britain. Intense competition for positions in general practice has, however, prevented any substantial migration of trained general practitioners. The Treaty of Rome, to which Britain acceded in 1973, established a market in which goods, people, services, and capital could circulate freely. It did not aim at a political or monetary union and did not deal with health and social affairs except in so far as they were relevant to a free market. The structure of the European Commission reflects the original aims of the community and does not include a directorate for 1221