1354
Misconceptions on nutrition of refugees SIR,-We are disturbed by misconceptions about nutrition that seriously jeopardise the successful control of malnutrition in refugees and displaced persons. The United Nations coordinating body in nutrition, the UN Advisory Committee on Coordination, Sub Committee on Nutrition (ACC/SCN), has a working group on refugees and displaced people, which met on July 7 and 8,1992, and urged that we draw attention to these misconceptions. The group represents all the UN agencies concerned and several donor * governments and non-governmental organisations.* of staff and and inadequate Although shortages money organisation constrain the effective prevention and treatment of malnutrition among refugees and displaced people, the correction of misconceptions could save lives and safeguard health. Six serious misconceptions that need correction are: "Starving people can eat anything. "It is widely held that people who are starving will be very hungy and eat any food that can be supplied. This attitude is inhumane and incorrect. Even if hungry initially, people often do not consume adequate quantities of unvaried and unfamiliar foods for long enough. More importantly, starving people are often ill and may not have a good appetite. They will therefore languish in an emaciated state or get even sicker. Even someone well-nourished would fail to thrive on the monotonous diets of three or so commodities (eg, wheat, beans, and oil) that is all that is available, month in, month out, to many refugees and displaced people. And this is aside from the micronutrient deficiencies that often develop. This misconception starts, in part, from a failure to agree on explicit objectives for food assistancewhich should surely be to provide for health, welfare, and a reasonably decent existence and help in attaining an acceptable state of self-reliance and self-respect. "Children with diarrhoea should not be intensively fed."A view from many years ago, and from non-emergency situations, sometimes persists-namely, that children must be rehydrated (and diarrhoea prevented) before re-feeding. This policy is incorrect and, with severely malnourished children, it can be fatal. Any child with diarrhoea must be fed, if necessary with a liquid diet by nasogastric tube, at the same time as additional fluids are given. Even if the diarrhoea is profuse, some nutrients are absorbed and can start the recovery process. To begin feeding after rehydration will often be too late. "Refugees can manage with less. " This misconception dehumanises the refugee. It implies that, once uprooted, he or she no longer has the basic human rights to food, shelter, and care-that these are now offered as charitable acts and that refugees can (or should) make do on much less than non-refugees. In fact they will often need more than their normal food requirement at first if they have become malnourished and sick before arrival at a camp and need rehabilitation; and may suffer exposure from inadequate shelter. "Trading foods indicates that people do not need all of the rations. If the only food source is provided by camp organisers, these rations have to be adequate in all nutrients. This requires a mixed food basket, including fruits and vegetables. If this cannot be ensured then trading may have to be encouraged if refugees are not to become undernourished and deficient in micronutrients. The fact that some foods may be traded, to add variety to the diet, is no grounds for reducing the ration. ’;4 standard ration is suitable for all populations. " The recommended per caput calorie output for a refugee population should vary according to demographic composition, nutritional and health status of the population (allowing for an extra "catch-up" allowance where people are malnourished), the activity level the "
*The participants were: Dr B. Austveg (Norway), Dr M. Boelaert (Mededns sans Frontieres, Belgium), Dr G. Clugston (WHO), Dr J-C. Dillon (France), Mme M-J. Floret (DHA/UNDRO), Dr M. Gastellu-Etchegorry (Medecins sans Frontieses, France), Dr S. R. Gillespie (ACC/SCN), Mr L. Glensvig (UNHCR), Dr J. P. Greaves (UNICEF), Mrs N. Haidar (HDA/UNDRO), Mrs J. Katona-Apte (WFP), Mrs J. Koch (NGO Committee on UNICEF), Mr C. La Muniere (DHA/UNDRO), Dr S. Male (UNHCR), Dr J. B. Mason (ACC/SCN), Mrs M. Mokbel (WHO), Dr H. Schellenberg (Switzerland), Dr J. Seaman (Save the Children, UK), Dr F. Simmersbach (UN Food and Agriculture Organisation), Dr R. Waldman (WHO), and Dr L. Weingarmer (Germany).
intake is intended to support, environmental temperature, and likely wastage in the chain from supply of food in a country to its consumption by individuals. In other words there is a range of requirements for dietary energy, which will depend on the circumstances, and use of a single figure is likely to lead to either deficit or wastage. The figure of 1900 kcal (commonly assumed to be of general application) often underestimates what is needed. "Energy adequacy means nutritional adequacy." The diet needs to be adequate in both quantity and quality, meeting requirements for calories, protein, and micronutrients. Where refugees are completely dependent on the ration provided-for example, in the early stages of an emergency or in closed camps, where trading for diversity cannot be ensured-the ration must be designed to meet the requirements of all nutrients in full. Often, a ration is designed to meet minimum energy requirements and micronutrients are left to look after themselves. How micronutrient needs are to be met must be made explicit, especially when the ration provided is calculated on the basis of fully meeting energy needs. Foods should be diverse and palatable, and the special needs of weaning children must be met. These and other issues are being addressed in a collaborative inter-agency revision of the 1978 manual The Management of Nutritional Emergencies in Large Populations, to be published soon by WHO. UN ACC Subcommittee on Nutrition, c/o World Health Organization, 1211 Geneva 27, Switzerland
JOHN MASON
WHO Nutrition Unit
GRAEME CLUGSTON
UNICEF Nutrition Cluster
PETER GREAVES
STUART GILLESPIE
Living kidney donors SIR,-Dr Najarian and colleagues (Oct 3, p 807) provide that the short-term and long-term risks to a healthy kidney donor are quite small. These data are very important since they lend support to the notion that increasing the use of living donors is safe. Indeed, several transplant centres are now successfully using emotionally related (though genetically reassurance
unrelated) donors.1 On the other hand, Najarian’s finding that
seven donors have died since 1988 is worrisome. I assume that these deaths were not all perioperative, since only five were reported between 1980 and 1991. It would be very helpful to know the details of these seven deaths if we are to prevent further tragedies. I doubt that these deaths were due to "relaxed eligibility criteria" as Najarian et al suggest, since staff at most transplant centres are still somewhat uncomfortable about the use of living donors.2 Furthermore, I am concerned that this suggestion, by such a respected transplant group, may inhibit the occasional acceptance of a donor at small or unknown added risk. Staff at transplant centres, though well intentioned, seem a little too paternalistic. In general, donors are excluded from the decision-making process with respect to their own suitability. Such an approach fails to consider that the decision to donate a kidney involves much more than an assessment of medical risks and benefits. Of at least equal importance are the values of the donor who may be willing to undertake whatever risks are necessary to restore the health of a loved one.3 For many, the value of a successful outcome would be immeasurable. Furthermore, Simmons et al4 at the University of Minnesota demonstrated that most living donors also benefit through meaningful and persistent feelings of increased self-worth and self-esteem. Najarian and his colleagues at the same university have done perhaps more than anyone to promote living donation. I believe that what is good for the recipient is often good for the donor. Therefore, although a medical evaluation is critical, the decision to donate should not be made on this basis alone. When a donor wants to accept risks that we think ill-advised, we do not have to accept that donor; but we do need to examine closely the values of the donor, realise that they may differ from our own, and try to understand his or her point of view.3 Hopefully, in so doing, we can achieve a
1355
balance between what is ethically acceptable to us and what is most University of Rochester School of Medicine. Rochester, New York 14607, USA
Third, specialist member
important to our patients. AARON SPITAL
1. Elick BA, Sutherland DER, Gillingham K, Najarian JS. Use of distant relatives and living unrelated donors: a strategy to increase the application of kidney transplantation to treat chronic renal failure. Transplant Proc 1990; 22: 343-44. 2. Spital A. Unconventional living kidney donors: attitudes and use among transplant centers. Transplantation 1989; 48: 243-48. 3. Spiral A. The ethics of unconventional living organ donation. Clin Transplant 1991; 5: 322-26. 4. Simmons RG, Marine SK, Simmons RL. Living related donors: costs and gains. In: Gift of life. New Brunswick: Transaction Books, 1987: 153-97.
Specialist medical training and the European community SIR,-Ihave followed with interest the Chief Medical Officer’s’ (Dr Caiman) letter to all doctors in the UK and Brearley’s2 editorial on the European Commission’s challenge about the UK system of accreditation. Having graduated in France and successfully pursued postgraduate training in the UK, as well as having written an MD thesis on the free circulation of doctors within the European Community,3 I would like to comment. First, in continental Europe most specialists practise from their own premises, largely doing outpatient procedures that are funded by social insurances. A few of these specialists are hospital based and achieve promotion to the equivalent National Health Service (NHS) consultant grade according to poorly defined criteria, including several years of experience in hospital. Thus specialists are generally equivalent at most to experienced registrars in the UK and have not faced the competition for the senior registrar grade as is the norm for most specialist trainees in that country, with its subsequent corollaries: research publications, a second qualification, &c. Furthermore, hospital-training recognition visits are ahnost unheard of and the diversity of the provision of health care means that many patients are treated in the private sector, resulting in little exposure to specialist trainees in public hospitals. Specialists continue therefore to train on their own patients long after qualifying. Nowhere else on the European continent do trainees face such a wide clinical exposure as well as so many weekly hours of duty, as they do in the UK.4 On average, 1 year of training in the UK is equivalent to 3 years in continental Europe in terms of clinical experience, supervision, and medical education. This has long been recognised by the European Commission-both by its Consultative Committee for Medical Training5 and during correspondence with European members of parliament.6 The Commission’s position has been clear on the question of specialist training: the directives only define minimum criteria that member states must respect for the purposes of free circulation; however, member states are free to impose a higher level of specialist training for access to the specialty. Therefore the UK is not out of line with the European Community by using a consultant-led system mainly governed by accredited specialists. However, the question of the new General Medical Council register with the "T" suffix denoting accredited specialist training is more difficult to defend because it might discriminate against consultant grade specialists wishing to migrate to the UK from continental Europe. Second, the aim of the EC directives was to facilitate the free circulation of doctors within member states by defining minimum periods of specialist training (3, 4, or 5 years) as well as certificates of specialist training, to allow access to the legal privileges of a specialist in all member states (including access to social security systems). The word "completion" that is included in the title of the UK qualification does not mean the end of specialist training but a certain level of competence to allow access to the legal privileges of a specialist. European specialists can thus apply for senior registrar and consultant posts in this country in open competition with UK nationals, and thus the UK is not contravening the directives in any way. There is no specialist status per se in this country but the directives do not in any way oblige the UK to convert from a consultant-led to a specialist system. What is in question is the access to private practice in this country which is only accessible to the consultant grade.
manpower and quality of training within covered by these directives. Medical
states were not
unemployment has reached alarming proportions in some countries (France 6%, Germany 8%, Italy 173%), whereas it is almost unheard of in the UK (0.3%).4 Furthermore, medical schools in some countries (Germany, Netherlands, Spain) still have a student intake related to their educational capacities rather than to manpower needs.4 Continental Europe does not possess Royal Colleges responsible for the standards and structure of training as in the UK. There is consequently a wide variation in the quality of specialists, dependent on the university and the hospital from which they qualify. Again the European Commission has replied to European MPs who have raised this issue by saying that this is not covered by the directives and that they were not aware of any complaints by individual member states.6 I do not believe that most specialist trainees in the UK wish to exchange the consultant-led system for one with senior and junior specialists. The solution lies with the expansion of the consultant grade in the UK, an idea that has been exposed by the document "Achieving a Balance" and reiterated by Baigrie and Reed.’ Of course, a properly organised, continually assessed, and audited specialist training programme could be considerably shorter and could result in better trained specialists in the UK and would be welcomed by all. Birmingham Maternity Hospital, Birmingham B15 2TG, UK
LAWRENCE MASCARENHAS
1. Calman KC. Specialist medical training in the UK. London: Department of Health, 1992 (PL/CMO(92)13). 2. Brearley S. Specialist medical training and the European Community. BMJ 1992; 305: 661-62. 3. Mascarenhas LJ. Consequences de la libre circulation des médecins dans la CEE. Tours Medical Faculty 1986, Dec 15, no 175. 4. Brearley S. Medical manpower. BMJ 1991; 303: 1534-36. 5. Comite Consultatif Pour La Formation Des Medecins. Rapports, avis et Recommendations Adoptes par le Comite du 6 Avril 1979 au 31 Decembre 1984. Brussels: Commision Des Communautes Euorpeennes 1985, (III/D/1003/85-
FR). 6. Cresson E. Question Ecrite No 816/79 a la Commission des Communautes Europeennes.J Officiel Commun Eur 1978; no C 107/9. 7. Baigrie RJ, Reed MWR. Specialist training. BMJ 1992; 305: 1021.
Drug safety monitoring
in
Europe
made on SIR,-Your report (Oct 24, p 1028) refers the performance of the WHO programme on drug monitoring, and particularly that "the WHO centre rarely produces an ADR [adverse drug reaction] signal on which regulatory action could be taken". The WHO programme was set up to create signals from internationally pooled data from spontaneous ADR reporting, from 36 countries. The centre regularly produces such signals, which are circulated to programme members, and many are evaluated by experts designated by the national centres themselves. Each national centre can also request database searches or initiate them via an on-line connection that is free of charge. In addition there is the quarterly mailing of output documents that are designed to allow for each checking that signals are not missed. More recently, the centre has published some of the signals, in an endeavour to alert the medical profession to those that seem to have strong causal relations and do not appear in most drug compendia. WHO signals cannot be used directly for regulatory action. They are merely suspicions of problems with drugs. Moreover, they need to be evaluated against drug use to determine incidence. Thus, unless a causal relation in individual cases is certain, only the most serious reports of previously unknown reactions can lead to immediate regulatory action. Thankfully these are rare, and their rarity should not be used as a criticism of the WHO programme. Efficient signal generation has technical difficulties. Data received and transmitted by national centres are often incomplete or even inaccurate because of poor original reporting and transcription errors, for example. These cause delay while they are followed up. Some national centres take some time to provide data on new drug products and transmit their ADR data. Few such centres have taken advantage of on-line data input and advice on error checks. All these difficulties would apply to any type of international database. Years to comments
Misconceptions on nutrition of refugees SIR,-We are disturbed by misconceptions about nutrition that seriously jeopardise the successful control of malnutrition in refugees and displaced persons. The United Nations coordinating body in nutrition, the UN Advisory Committee on Coordination, Sub Committee on Nutrition (ACC/SCN), has a working group on refugees and displaced people, which met on July 7 and 8,1992, and urged that we draw attention to these misconceptions. The group represents all the UN agencies concerned and several donor * governments and non-governmental organisations.* of staff and and inadequate Although shortages money organisation constrain the effective prevention and treatment of malnutrition among refugees and displaced people, the correction of misconceptions could save lives and safeguard health. Six serious misconceptions that need correction are: "Starving people can eat anything. "It is widely held that people who are starving will be very hungy and eat any food that can be supplied. This attitude is inhumane and incorrect. Even if hungry initially, people often do not consume adequate quantities of unvaried and unfamiliar foods for long enough. More importantly, starving people are often ill and may not have a good appetite. They will therefore languish in an emaciated state or get even sicker. Even someone well-nourished would fail to thrive on the monotonous diets of three or so commodities (eg, wheat, beans, and oil) that is all that is available, month in, month out, to many refugees and displaced people. And this is aside from the micronutrient deficiencies that often develop. This misconception starts, in part, from a failure to agree on explicit objectives for food assistancewhich should surely be to provide for health, welfare, and a reasonably decent existence and help in attaining an acceptable state of self-reliance and self-respect. "Children with diarrhoea should not be intensively fed."A view from many years ago, and from non-emergency situations, sometimes persists-namely, that children must be rehydrated (and diarrhoea prevented) before re-feeding. This policy is incorrect and, with severely malnourished children, it can be fatal. Any child with diarrhoea must be fed, if necessary with a liquid diet by nasogastric tube, at the same time as additional fluids are given. Even if the diarrhoea is profuse, some nutrients are absorbed and can start the recovery process. To begin feeding after rehydration will often be too late. "Refugees can manage with less. " This misconception dehumanises the refugee. It implies that, once uprooted, he or she no longer has the basic human rights to food, shelter, and care-that these are now offered as charitable acts and that refugees can (or should) make do on much less than non-refugees. In fact they will often need more than their normal food requirement at first if they have become malnourished and sick before arrival at a camp and need rehabilitation; and may suffer exposure from inadequate shelter. "Trading foods indicates that people do not need all of the rations. If the only food source is provided by camp organisers, these rations have to be adequate in all nutrients. This requires a mixed food basket, including fruits and vegetables. If this cannot be ensured then trading may have to be encouraged if refugees are not to become undernourished and deficient in micronutrients. The fact that some foods may be traded, to add variety to the diet, is no grounds for reducing the ration. ’;4 standard ration is suitable for all populations. " The recommended per caput calorie output for a refugee population should vary according to demographic composition, nutritional and health status of the population (allowing for an extra "catch-up" allowance where people are malnourished), the activity level the "
*The participants were: Dr B. Austveg (Norway), Dr M. Boelaert (Mededns sans Frontieres, Belgium), Dr G. Clugston (WHO), Dr J-C. Dillon (France), Mme M-J. Floret (DHA/UNDRO), Dr M. Gastellu-Etchegorry (Medecins sans Frontieses, France), Dr S. R. Gillespie (ACC/SCN), Mr L. Glensvig (UNHCR), Dr J. P. Greaves (UNICEF), Mrs N. Haidar (HDA/UNDRO), Mrs J. Katona-Apte (WFP), Mrs J. Koch (NGO Committee on UNICEF), Mr C. La Muniere (DHA/UNDRO), Dr S. Male (UNHCR), Dr J. B. Mason (ACC/SCN), Mrs M. Mokbel (WHO), Dr H. Schellenberg (Switzerland), Dr J. Seaman (Save the Children, UK), Dr F. Simmersbach (UN Food and Agriculture Organisation), Dr R. Waldman (WHO), and Dr L. Weingarmer (Germany).
intake is intended to support, environmental temperature, and likely wastage in the chain from supply of food in a country to its consumption by individuals. In other words there is a range of requirements for dietary energy, which will depend on the circumstances, and use of a single figure is likely to lead to either deficit or wastage. The figure of 1900 kcal (commonly assumed to be of general application) often underestimates what is needed. "Energy adequacy means nutritional adequacy." The diet needs to be adequate in both quantity and quality, meeting requirements for calories, protein, and micronutrients. Where refugees are completely dependent on the ration provided-for example, in the early stages of an emergency or in closed camps, where trading for diversity cannot be ensured-the ration must be designed to meet the requirements of all nutrients in full. Often, a ration is designed to meet minimum energy requirements and micronutrients are left to look after themselves. How micronutrient needs are to be met must be made explicit, especially when the ration provided is calculated on the basis of fully meeting energy needs. Foods should be diverse and palatable, and the special needs of weaning children must be met. These and other issues are being addressed in a collaborative inter-agency revision of the 1978 manual The Management of Nutritional Emergencies in Large Populations, to be published soon by WHO. UN ACC Subcommittee on Nutrition, c/o World Health Organization, 1211 Geneva 27, Switzerland
JOHN MASON
WHO Nutrition Unit
GRAEME CLUGSTON
UNICEF Nutrition Cluster
PETER GREAVES
STUART GILLESPIE
Living kidney donors SIR,-Dr Najarian and colleagues (Oct 3, p 807) provide that the short-term and long-term risks to a healthy kidney donor are quite small. These data are very important since they lend support to the notion that increasing the use of living donors is safe. Indeed, several transplant centres are now successfully using emotionally related (though genetically reassurance
unrelated) donors.1 On the other hand, Najarian’s finding that
seven donors have died since 1988 is worrisome. I assume that these deaths were not all perioperative, since only five were reported between 1980 and 1991. It would be very helpful to know the details of these seven deaths if we are to prevent further tragedies. I doubt that these deaths were due to "relaxed eligibility criteria" as Najarian et al suggest, since staff at most transplant centres are still somewhat uncomfortable about the use of living donors.2 Furthermore, I am concerned that this suggestion, by such a respected transplant group, may inhibit the occasional acceptance of a donor at small or unknown added risk. Staff at transplant centres, though well intentioned, seem a little too paternalistic. In general, donors are excluded from the decision-making process with respect to their own suitability. Such an approach fails to consider that the decision to donate a kidney involves much more than an assessment of medical risks and benefits. Of at least equal importance are the values of the donor who may be willing to undertake whatever risks are necessary to restore the health of a loved one.3 For many, the value of a successful outcome would be immeasurable. Furthermore, Simmons et al4 at the University of Minnesota demonstrated that most living donors also benefit through meaningful and persistent feelings of increased self-worth and self-esteem. Najarian and his colleagues at the same university have done perhaps more than anyone to promote living donation. I believe that what is good for the recipient is often good for the donor. Therefore, although a medical evaluation is critical, the decision to donate should not be made on this basis alone. When a donor wants to accept risks that we think ill-advised, we do not have to accept that donor; but we do need to examine closely the values of the donor, realise that they may differ from our own, and try to understand his or her point of view.3 Hopefully, in so doing, we can achieve a
1355
balance between what is ethically acceptable to us and what is most University of Rochester School of Medicine. Rochester, New York 14607, USA
Third, specialist member
important to our patients. AARON SPITAL
1. Elick BA, Sutherland DER, Gillingham K, Najarian JS. Use of distant relatives and living unrelated donors: a strategy to increase the application of kidney transplantation to treat chronic renal failure. Transplant Proc 1990; 22: 343-44. 2. Spital A. Unconventional living kidney donors: attitudes and use among transplant centers. Transplantation 1989; 48: 243-48. 3. Spiral A. The ethics of unconventional living organ donation. Clin Transplant 1991; 5: 322-26. 4. Simmons RG, Marine SK, Simmons RL. Living related donors: costs and gains. In: Gift of life. New Brunswick: Transaction Books, 1987: 153-97.
Specialist medical training and the European community SIR,-Ihave followed with interest the Chief Medical Officer’s’ (Dr Caiman) letter to all doctors in the UK and Brearley’s2 editorial on the European Commission’s challenge about the UK system of accreditation. Having graduated in France and successfully pursued postgraduate training in the UK, as well as having written an MD thesis on the free circulation of doctors within the European Community,3 I would like to comment. First, in continental Europe most specialists practise from their own premises, largely doing outpatient procedures that are funded by social insurances. A few of these specialists are hospital based and achieve promotion to the equivalent National Health Service (NHS) consultant grade according to poorly defined criteria, including several years of experience in hospital. Thus specialists are generally equivalent at most to experienced registrars in the UK and have not faced the competition for the senior registrar grade as is the norm for most specialist trainees in that country, with its subsequent corollaries: research publications, a second qualification, &c. Furthermore, hospital-training recognition visits are ahnost unheard of and the diversity of the provision of health care means that many patients are treated in the private sector, resulting in little exposure to specialist trainees in public hospitals. Specialists continue therefore to train on their own patients long after qualifying. Nowhere else on the European continent do trainees face such a wide clinical exposure as well as so many weekly hours of duty, as they do in the UK.4 On average, 1 year of training in the UK is equivalent to 3 years in continental Europe in terms of clinical experience, supervision, and medical education. This has long been recognised by the European Commission-both by its Consultative Committee for Medical Training5 and during correspondence with European members of parliament.6 The Commission’s position has been clear on the question of specialist training: the directives only define minimum criteria that member states must respect for the purposes of free circulation; however, member states are free to impose a higher level of specialist training for access to the specialty. Therefore the UK is not out of line with the European Community by using a consultant-led system mainly governed by accredited specialists. However, the question of the new General Medical Council register with the "T" suffix denoting accredited specialist training is more difficult to defend because it might discriminate against consultant grade specialists wishing to migrate to the UK from continental Europe. Second, the aim of the EC directives was to facilitate the free circulation of doctors within member states by defining minimum periods of specialist training (3, 4, or 5 years) as well as certificates of specialist training, to allow access to the legal privileges of a specialist in all member states (including access to social security systems). The word "completion" that is included in the title of the UK qualification does not mean the end of specialist training but a certain level of competence to allow access to the legal privileges of a specialist. European specialists can thus apply for senior registrar and consultant posts in this country in open competition with UK nationals, and thus the UK is not contravening the directives in any way. There is no specialist status per se in this country but the directives do not in any way oblige the UK to convert from a consultant-led to a specialist system. What is in question is the access to private practice in this country which is only accessible to the consultant grade.
manpower and quality of training within covered by these directives. Medical
states were not
unemployment has reached alarming proportions in some countries (France 6%, Germany 8%, Italy 173%), whereas it is almost unheard of in the UK (0.3%).4 Furthermore, medical schools in some countries (Germany, Netherlands, Spain) still have a student intake related to their educational capacities rather than to manpower needs.4 Continental Europe does not possess Royal Colleges responsible for the standards and structure of training as in the UK. There is consequently a wide variation in the quality of specialists, dependent on the university and the hospital from which they qualify. Again the European Commission has replied to European MPs who have raised this issue by saying that this is not covered by the directives and that they were not aware of any complaints by individual member states.6 I do not believe that most specialist trainees in the UK wish to exchange the consultant-led system for one with senior and junior specialists. The solution lies with the expansion of the consultant grade in the UK, an idea that has been exposed by the document "Achieving a Balance" and reiterated by Baigrie and Reed.’ Of course, a properly organised, continually assessed, and audited specialist training programme could be considerably shorter and could result in better trained specialists in the UK and would be welcomed by all. Birmingham Maternity Hospital, Birmingham B15 2TG, UK
LAWRENCE MASCARENHAS
1. Calman KC. Specialist medical training in the UK. London: Department of Health, 1992 (PL/CMO(92)13). 2. Brearley S. Specialist medical training and the European Community. BMJ 1992; 305: 661-62. 3. Mascarenhas LJ. Consequences de la libre circulation des médecins dans la CEE. Tours Medical Faculty 1986, Dec 15, no 175. 4. Brearley S. Medical manpower. BMJ 1991; 303: 1534-36. 5. Comite Consultatif Pour La Formation Des Medecins. Rapports, avis et Recommendations Adoptes par le Comite du 6 Avril 1979 au 31 Decembre 1984. Brussels: Commision Des Communautes Euorpeennes 1985, (III/D/1003/85-
FR). 6. Cresson E. Question Ecrite No 816/79 a la Commission des Communautes Europeennes.J Officiel Commun Eur 1978; no C 107/9. 7. Baigrie RJ, Reed MWR. Specialist training. BMJ 1992; 305: 1021.
Drug safety monitoring
in
Europe
made on SIR,-Your report (Oct 24, p 1028) refers the performance of the WHO programme on drug monitoring, and particularly that "the WHO centre rarely produces an ADR [adverse drug reaction] signal on which regulatory action could be taken". The WHO programme was set up to create signals from internationally pooled data from spontaneous ADR reporting, from 36 countries. The centre regularly produces such signals, which are circulated to programme members, and many are evaluated by experts designated by the national centres themselves. Each national centre can also request database searches or initiate them via an on-line connection that is free of charge. In addition there is the quarterly mailing of output documents that are designed to allow for each checking that signals are not missed. More recently, the centre has published some of the signals, in an endeavour to alert the medical profession to those that seem to have strong causal relations and do not appear in most drug compendia. WHO signals cannot be used directly for regulatory action. They are merely suspicions of problems with drugs. Moreover, they need to be evaluated against drug use to determine incidence. Thus, unless a causal relation in individual cases is certain, only the most serious reports of previously unknown reactions can lead to immediate regulatory action. Thankfully these are rare, and their rarity should not be used as a criticism of the WHO programme. Efficient signal generation has technical difficulties. Data received and transmitted by national centres are often incomplete or even inaccurate because of poor original reporting and transcription errors, for example. These cause delay while they are followed up. Some national centres take some time to provide data on new drug products and transmit their ADR data. Few such centres have taken advantage of on-line data input and advice on error checks. All these difficulties would apply to any type of international database. Years to comments
