681
Letters
to
the Editor
VITAMIN-B12 DEFICIENCY IN ASIAN IMMIGRANTS SIR,-Dietary vitamin-B12 deficiency is now well recognised of megaloblastic anaemia amongst the Hindu immigrant community of Britain.1-3 These observations supersede Chanarin’s statement that "megaloblastic anaemia due to uncomplicated dietary deficiency have yet to be demonstrated in man",4 Megaloblastic anaemia due to religious proscription on food of animal origin has now become commonplace in certain districts of Britain. Parker-Williams’ identified more than 500 cases of dietary B12 depletion amongst the Asian immigrant population served by the Central Middlesex Hospital between 1970 and 1975. Indeed this problem is now seen so often as to prohibit the customary sequence of investigations used in European patients who present with megaloblastic anaemia. It seems unrealistic to investigate vitamin-B12 absorption in such subjects, and an optimal response to an oral physiological dose of vltamin-BI2 is conclusive evidence of a dietary origin for the as a cause
deficiency. The remarkable increase in this problem in Britain is due to theinflux of Asian immigrants from East Africa, 75% of whom are Gudjurati Hindus. Many of the patients are now being identified and treated in general practice without referral to
hospital. It is very curious that there is
no
folk-lore amongst the
population concerned to draw their attention to the untoward effects of their dietary customs. One can only assume that the methods of hygiene and packaging adopted in this country wash off all the residual vitamin B12 contaminating the vegetable produce. It is likely that megaloblastic ansemia is a predictable consequence of vegan dietary habits adopted in Britain. Accordmgly, tt seems appropriate to take the opportunity with every such patient to address other members of the family, particularly the mother or whoever cooks the family’s food, to draw their attention to this problem and to advise them to supplement their food with B,2. An ampoule of 1 mg of vitamin B12 emptied into the family dish once a month should suffice. If the media and Community Relations Commission are unable to convey this advice to those concerned, it is left to the doctor
do so. It seems absurd to accept this new disease entity as inevitable when it would have been eradicated by simple public-health measures had it come to our attention in the 1930s. The absurdity was recently highlighted by a patient, a woman of 36 with vitamin-B12 depletion whose husband had been investigated for the same condition 18 months earlier. Who did the doctor think was preparing the food? We could leave it for another year and wait for the children to turn up. Alternatively, with an intelligent concerted approach the largescale problem could be dealt with within 6 months. There is little doubt that it would prove cheaper than the costs entailed m rI’1,.
just from month to month, but from day to day and even in the course of a single interview. What a pity, then, that he should be so unjustifiably critical of the equally useful contributions of Dr Bush (July 31, p. 263) and especially of Dr McIntosh (Aug. 7, p. 300). Like Dr Bush, many of us engaged in the care of patients with malignant disease would like to continue total patient care beyond the point of anti-cancer therapy, whenever this is what the patient and his relatives would like, but are frequently prevented by the simple logistics of waiting-lists and lack of beds in our units. How Dr Simpson can describe such very fair comment as "misunderstanding the message" of his previous article (July 24, p. 192) is not clear to me. Dr Simpson’s strictures on Dr McIntosh’s excellent paper about patients’ awareness and desire for information are equally surprising. It is impossible for any of us with an interest in this subtle and sensitive area to study it or discuss it without a certain basic minimum of labelling and classification. Dr McIntosh told us in detail how, for the purposes of his study (which included prolonged observation to detect changing attitudes) he defined "knew" and how he defined "suspected". Dr Simpson first suggests that he does not approve of the use of such terms, implying that Dr McIntosh does not appreciate that they oversimplify the problem. Then he gives us two equally arbitrary, but more lengthy classifications of his own (or possibly of others, it is not very clear). Finally, he comes out with the remarkable statement that "Dr McIntosh’s study does not provide evidence to substantiate his conclusions". In this difficult area there is plenty of room for contributions from many quarters. From those with psychiatric training, with or without direct experience of caring for large numbers of cancer patients; from those without psychiatric training, but with many years experience of talking to cancer patients and their relatives; and from those, like Dr McIntosh, with no medical qualification, who undertake an unbiased and independent study, with no preconceptions, to try and determine what exactly is the result when a group of cancer patients, with a very mixed prognosis, is handled in a particular way by medical and nursing staff. I would have thought that those of us with a special interest in these problems were already quite sufficiently vulnerable to misquotation and misinterpretation without making matters worse by unreasonable criticism of each other. Institute of Radiotherapeutics and Oncology, Glasgow G11 6NT
THURSTAN B. BREWIN
to
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t’B"
Department of Hæmatology, St. George’s Hospital Medical School, London SW17 0QT
MICHAEL ROSE
PATIENT’S AWARENESS OF CANCER
SIR,-Dr Simpson (Sept. 4, p. 519) talks a lot of good sense, for example when he stresses that the extent to which a patient hows" about a serious diagnosis or prognosis may vary, not 1 Stewart, J. S., Roberts, P. D., Hoffbrand, A. V. Lancet, 1970, ii, 542. 2 Britt, R P., Harper, C., Spray, G. H. Q Jl Med. 1971, 40, 499. 3 Roberts, P. D., James, H., Petrie, A., Morgan, J. O., Hoffbrand, A. V. Br. med J 1973, iii, 67 4 Chanarin, I.The Megaloblastic Anæmias, p. 713. Ocford, 1969. 5 Parker-wilhams, J. Personal communication.
SIR,-Dr McIntosh presented evidence for the view that "a conservative policy" of informing cancer patients of their diagnosis and prognosis was preferable to a policy of "routinely informing all patients". Two main reasons for such a policy were given: of the 65 patients who either knew or suspected that they had cancer, only 14% wanted to know their prognosis, and of those who suspected that they had cancer, only 32% would have liked confirmation of their diagnosis. The second reason was that patients used a variety of strategies to obtain information informally from staff, and Dr McIntosh argued that it was preferable that patients, control the amount of information they received by these means than be the recipients of unsolicited and possibly unwelcome facts. I would like to challenge these conclusions on three grounds: (1) Dr McIntosh’s evidence can be used to present a different picture: although most patients did not wish their suspicions of cancer to be confirmed, almost a third did want to know the diagnosis. Furthermore, it is stated that patients did not, in the main, wish to know their prognosis. But this did not mean that they required no information at all on this subject. "What they wanted was a progress report or assessment of the involvement of the disease". We are not told what proportion of patients was successful in obtaining such information. So those who are classified as not wishing to have their hopes des-
Letters
to
the Editor
VITAMIN-B12 DEFICIENCY IN ASIAN IMMIGRANTS SIR,-Dietary vitamin-B12 deficiency is now well recognised of megaloblastic anaemia amongst the Hindu immigrant community of Britain.1-3 These observations supersede Chanarin’s statement that "megaloblastic anaemia due to uncomplicated dietary deficiency have yet to be demonstrated in man",4 Megaloblastic anaemia due to religious proscription on food of animal origin has now become commonplace in certain districts of Britain. Parker-Williams’ identified more than 500 cases of dietary B12 depletion amongst the Asian immigrant population served by the Central Middlesex Hospital between 1970 and 1975. Indeed this problem is now seen so often as to prohibit the customary sequence of investigations used in European patients who present with megaloblastic anaemia. It seems unrealistic to investigate vitamin-B12 absorption in such subjects, and an optimal response to an oral physiological dose of vltamin-BI2 is conclusive evidence of a dietary origin for the as a cause
deficiency. The remarkable increase in this problem in Britain is due to theinflux of Asian immigrants from East Africa, 75% of whom are Gudjurati Hindus. Many of the patients are now being identified and treated in general practice without referral to
hospital. It is very curious that there is
no
folk-lore amongst the
population concerned to draw their attention to the untoward effects of their dietary customs. One can only assume that the methods of hygiene and packaging adopted in this country wash off all the residual vitamin B12 contaminating the vegetable produce. It is likely that megaloblastic ansemia is a predictable consequence of vegan dietary habits adopted in Britain. Accordmgly, tt seems appropriate to take the opportunity with every such patient to address other members of the family, particularly the mother or whoever cooks the family’s food, to draw their attention to this problem and to advise them to supplement their food with B,2. An ampoule of 1 mg of vitamin B12 emptied into the family dish once a month should suffice. If the media and Community Relations Commission are unable to convey this advice to those concerned, it is left to the doctor
do so. It seems absurd to accept this new disease entity as inevitable when it would have been eradicated by simple public-health measures had it come to our attention in the 1930s. The absurdity was recently highlighted by a patient, a woman of 36 with vitamin-B12 depletion whose husband had been investigated for the same condition 18 months earlier. Who did the doctor think was preparing the food? We could leave it for another year and wait for the children to turn up. Alternatively, with an intelligent concerted approach the largescale problem could be dealt with within 6 months. There is little doubt that it would prove cheaper than the costs entailed m rI’1,.
just from month to month, but from day to day and even in the course of a single interview. What a pity, then, that he should be so unjustifiably critical of the equally useful contributions of Dr Bush (July 31, p. 263) and especially of Dr McIntosh (Aug. 7, p. 300). Like Dr Bush, many of us engaged in the care of patients with malignant disease would like to continue total patient care beyond the point of anti-cancer therapy, whenever this is what the patient and his relatives would like, but are frequently prevented by the simple logistics of waiting-lists and lack of beds in our units. How Dr Simpson can describe such very fair comment as "misunderstanding the message" of his previous article (July 24, p. 192) is not clear to me. Dr Simpson’s strictures on Dr McIntosh’s excellent paper about patients’ awareness and desire for information are equally surprising. It is impossible for any of us with an interest in this subtle and sensitive area to study it or discuss it without a certain basic minimum of labelling and classification. Dr McIntosh told us in detail how, for the purposes of his study (which included prolonged observation to detect changing attitudes) he defined "knew" and how he defined "suspected". Dr Simpson first suggests that he does not approve of the use of such terms, implying that Dr McIntosh does not appreciate that they oversimplify the problem. Then he gives us two equally arbitrary, but more lengthy classifications of his own (or possibly of others, it is not very clear). Finally, he comes out with the remarkable statement that "Dr McIntosh’s study does not provide evidence to substantiate his conclusions". In this difficult area there is plenty of room for contributions from many quarters. From those with psychiatric training, with or without direct experience of caring for large numbers of cancer patients; from those without psychiatric training, but with many years experience of talking to cancer patients and their relatives; and from those, like Dr McIntosh, with no medical qualification, who undertake an unbiased and independent study, with no preconceptions, to try and determine what exactly is the result when a group of cancer patients, with a very mixed prognosis, is handled in a particular way by medical and nursing staff. I would have thought that those of us with a special interest in these problems were already quite sufficiently vulnerable to misquotation and misinterpretation without making matters worse by unreasonable criticism of each other. Institute of Radiotherapeutics and Oncology, Glasgow G11 6NT
THURSTAN B. BREWIN
to
,.."..",,,,,..,t
t’B"
Department of Hæmatology, St. George’s Hospital Medical School, London SW17 0QT
MICHAEL ROSE
PATIENT’S AWARENESS OF CANCER
SIR,-Dr Simpson (Sept. 4, p. 519) talks a lot of good sense, for example when he stresses that the extent to which a patient hows" about a serious diagnosis or prognosis may vary, not 1 Stewart, J. S., Roberts, P. D., Hoffbrand, A. V. Lancet, 1970, ii, 542. 2 Britt, R P., Harper, C., Spray, G. H. Q Jl Med. 1971, 40, 499. 3 Roberts, P. D., James, H., Petrie, A., Morgan, J. O., Hoffbrand, A. V. Br. med J 1973, iii, 67 4 Chanarin, I.The Megaloblastic Anæmias, p. 713. Ocford, 1969. 5 Parker-wilhams, J. Personal communication.
SIR,-Dr McIntosh presented evidence for the view that "a conservative policy" of informing cancer patients of their diagnosis and prognosis was preferable to a policy of "routinely informing all patients". Two main reasons for such a policy were given: of the 65 patients who either knew or suspected that they had cancer, only 14% wanted to know their prognosis, and of those who suspected that they had cancer, only 32% would have liked confirmation of their diagnosis. The second reason was that patients used a variety of strategies to obtain information informally from staff, and Dr McIntosh argued that it was preferable that patients, control the amount of information they received by these means than be the recipients of unsolicited and possibly unwelcome facts. I would like to challenge these conclusions on three grounds: (1) Dr McIntosh’s evidence can be used to present a different picture: although most patients did not wish their suspicions of cancer to be confirmed, almost a third did want to know the diagnosis. Furthermore, it is stated that patients did not, in the main, wish to know their prognosis. But this did not mean that they required no information at all on this subject. "What they wanted was a progress report or assessment of the involvement of the disease". We are not told what proportion of patients was successful in obtaining such information. So those who are classified as not wishing to have their hopes des-
