433
1/610. Furthermore, between 1975 and 1988 (the last available data) only 5,3% of graduates from the Israeli medical colleges were Arabs, despite the fact that they composed 15.5% of the population at graduation age. This means that their share among medical graduates reached not more that 34% of what it should have been if an equitable system had prevailed. This representation rate is, for example, less than that of black graduates in the USA who attained 39% of their share of the population at graduation age. It is not surprising therefore to see many Arab students pursue their education abroad. Not more than a quarter of Arab physicians graduate from Israeli universities. If the Arabs relied on acquiring education only in Israeli universities, then the ratio of physicians per head of population would have been 1/2980. As Arab physicians who graduated from foreign medical schools began to enter the labour market (in relatively large numbers) various mechanisms were established to hamper their progress. In 1987 a new law required such graduates to pass a special pre-internship examination. This is different from the licensing examination that immigrant physicians who have practised abroad have to pass. So far success rates for the former examination, which mostly Arabs sit, averages 15%, whereas for the latter, which mainly Jews sit, the rates are around 70%. No alternative is provided for those who fail the examination repeatedly. Since the Israeli economy is unable to sustain a larger health-care system, we believe that Arab graduates should be given the chance to compete on equal footing with other Israeli doctors. Much has been done to absorb Jewish immigrants. For example, in 1990 the Ministry of Health opened special workshops to help 1000 immigrant physicians to pass the examinations. Moreover, an interministerial committee prepared a plan to absorb 2000 immigrant physicians. However, nothing similar had been done to help Arab physicians who completed their studies in Eastern European countries. We believe that it is time governmental attention is paid to advancing the cause of Arab citizens who have contributed much since the establishment of the State. In Israel-ie, a state in which two groups live (Jews and Arabs)—an equitable treatment is needed to create harmonious relations, characterised by mutual understanding rather than domination. This is especially timely as Israel and its Arab neighbours are communities the ratio is
embarking on peace negotiations. Galilee Society, PO Box 92, Rama 30055, Israel
HATIM KANAANEH
Are there too many medical beds? SIR,-Malcolm Dean (Jan 18, p 170) predicts that physicians and geriatricians may not be as enthusiastic in their response to the important and valuable report from the Audit Commission’ as were the surgeons to its report on day surgery. I suggest that they might well respond equally positively to many of its recommendations, but with their characteristic caution, which would be justified on at least three grounds. First, in the experience of most geriatricians, and perhaps physicians, complaints from patients and relatives that discharge is too soon (or at all) outnumber complaints that it is unduly delayed. Second, being by nature less optimistic than surgeons, geriatricians might envisage the possibility of a finance gap in the implementation of the Commission’s recommendations, resulting in hospital down-bedding preceding, and possibly not matched by, the upgrading of community sevices. Third, the "any port in a storm" role of the district general hospital needs to be defended, because it is often very difficult to know in advance which apparently "low-tech" elderly patient with a respiratory infection or heart failure will turn into a "hi-tech" patient needing advanced
diagnostic
facilities and
access to
other
specialties.
But the
ships
have to be able to set sail for other ports when the storm subsides, so that berths become available Department of Geriatric Medicine, Addenbrookes Hospital, Cambridge CB2 2QQ, UK
to
other vessels in distress.
N. K. CONI
1. Audit Commission. Lying m wait. the use of medical beds in acute hospitals. London. HM Stationery Office, 1992.
Long reports SIR,-Whatever current or past editors may say or think about medical journals and their contents (Jan 25, p 249)-as a consumer I know what I want from The Lancet. For me, the practising physician, the hallmark of a good paper is one that changes my view of things and especially changes my practice. Every week I read two general journals and between one and three specialist journals and I feel pleased if I can identify a paper that fulfils my requirements. Every week I attend and contribute to a journal club and review a specialist journal in my field and can rarely find more than one paper per issue with a clinical message of merit to share with my
colleagues. I think the editor of The Lancet should be applauded, firstly for taking the trouble to ask the consumer what he wants (Jan 4, p 33), and secondly for publishing papers that will undoubtedly change medical practice. Length and breadth are often irrelevant to the
satisfaction that can be obtained. Department of Cardiology, Royal Hallamshire Hospital,
K. S. CHANNER
Sheffield S10 2JF, UK
Glutaraldehyde allergy in endoscopy units SIR,-We have received several complaints of symptoms from health services’ staff who use glutaraldehyde, especially those in endoscopy units. In 1991 we sent 169 questionnaires to nurses in seventeen hospitals that we visited in our area. We received 167 replies. 65% of those who replied reported symptoms and 38 % had two or more. The major complaints were eye irritation 49%, skin discoloration or irritation 41%,’ headache 36%, and cough or shortness of breath 34%The complaints were reported in all seventeen hospitals, and were not related to smoking habits, atopic status, or duration of exposure. In two hospitals, environmental measurement of glutaraldehyde in air had been done and levels were below the UK occupational exposure standard, which currently is 0-2 parts per million (10 min time-weighted average).3 In the UK the Control of Substances Hazardous to Health Regulations 1988require the users of such substances to assess health risks and to reduce exposure. Simple control measures such as chemical substitution are at present impracticable for glutaraldehyde, so other methods should be considered. Cleaning of endoscopes in vertical tubes rather than horizontal trays, the closed transfer of glutaraldehyde to cleaning units, and similar precautions for disposal should reduce the exposure considerably. I. M. CALDER L. P. WRIGHT D. GRIMSTONE
Health and Safety Executive, Luton LU1 1PP, UK 1. Fowler
JF. Allergic contact dermatitis from glutaraldehyde exposure. J Occup Med
1989; 31: 852-53. 2. Wiggins P, McCurdy PA, Zeidenberg W. Epistaxis due to glutaraldehyde exposure. J Occup Med 1989; 31: 854-56. 3. Health and Safety Executive, health and safety guidance note EH40/90: occupational exposure limits. London: HSE, 1990. 4. Control of Substances Hazardous to Health
Regulations 1988: approved code of practice control of substances hazardous to health and approved code of practice control of carcinogenic substances. London: HM Stationery Office, 1988.
Research in
developing
countries
SIR,-As a specialist in tropical diseases, Dr Patel and Dr Araya’s article (Jan 11, p 110) about the lack of research in developing countries because there are too few trained personnel struck a responsive chord. I have benefited greatly from collaboration with and the hospitality of many fine scientists in South America, the Caribbean, and African and Asian countries. Thus, when I was offered the directorship of health sciences of the Rockefeller Foundation in 1977 I was pleased that I might be able to do something about the tragic difficulties so ably described by Patel and Araya. Since its founding in 1913 the Foundation has tried many strategies to support medical research and researchers in the developing world. Training in the developed world has always been
1/610. Furthermore, between 1975 and 1988 (the last available data) only 5,3% of graduates from the Israeli medical colleges were Arabs, despite the fact that they composed 15.5% of the population at graduation age. This means that their share among medical graduates reached not more that 34% of what it should have been if an equitable system had prevailed. This representation rate is, for example, less than that of black graduates in the USA who attained 39% of their share of the population at graduation age. It is not surprising therefore to see many Arab students pursue their education abroad. Not more than a quarter of Arab physicians graduate from Israeli universities. If the Arabs relied on acquiring education only in Israeli universities, then the ratio of physicians per head of population would have been 1/2980. As Arab physicians who graduated from foreign medical schools began to enter the labour market (in relatively large numbers) various mechanisms were established to hamper their progress. In 1987 a new law required such graduates to pass a special pre-internship examination. This is different from the licensing examination that immigrant physicians who have practised abroad have to pass. So far success rates for the former examination, which mostly Arabs sit, averages 15%, whereas for the latter, which mainly Jews sit, the rates are around 70%. No alternative is provided for those who fail the examination repeatedly. Since the Israeli economy is unable to sustain a larger health-care system, we believe that Arab graduates should be given the chance to compete on equal footing with other Israeli doctors. Much has been done to absorb Jewish immigrants. For example, in 1990 the Ministry of Health opened special workshops to help 1000 immigrant physicians to pass the examinations. Moreover, an interministerial committee prepared a plan to absorb 2000 immigrant physicians. However, nothing similar had been done to help Arab physicians who completed their studies in Eastern European countries. We believe that it is time governmental attention is paid to advancing the cause of Arab citizens who have contributed much since the establishment of the State. In Israel-ie, a state in which two groups live (Jews and Arabs)—an equitable treatment is needed to create harmonious relations, characterised by mutual understanding rather than domination. This is especially timely as Israel and its Arab neighbours are communities the ratio is
embarking on peace negotiations. Galilee Society, PO Box 92, Rama 30055, Israel
HATIM KANAANEH
Are there too many medical beds? SIR,-Malcolm Dean (Jan 18, p 170) predicts that physicians and geriatricians may not be as enthusiastic in their response to the important and valuable report from the Audit Commission’ as were the surgeons to its report on day surgery. I suggest that they might well respond equally positively to many of its recommendations, but with their characteristic caution, which would be justified on at least three grounds. First, in the experience of most geriatricians, and perhaps physicians, complaints from patients and relatives that discharge is too soon (or at all) outnumber complaints that it is unduly delayed. Second, being by nature less optimistic than surgeons, geriatricians might envisage the possibility of a finance gap in the implementation of the Commission’s recommendations, resulting in hospital down-bedding preceding, and possibly not matched by, the upgrading of community sevices. Third, the "any port in a storm" role of the district general hospital needs to be defended, because it is often very difficult to know in advance which apparently "low-tech" elderly patient with a respiratory infection or heart failure will turn into a "hi-tech" patient needing advanced
diagnostic
facilities and
access to
other
specialties.
But the
ships
have to be able to set sail for other ports when the storm subsides, so that berths become available Department of Geriatric Medicine, Addenbrookes Hospital, Cambridge CB2 2QQ, UK
to
other vessels in distress.
N. K. CONI
1. Audit Commission. Lying m wait. the use of medical beds in acute hospitals. London. HM Stationery Office, 1992.
Long reports SIR,-Whatever current or past editors may say or think about medical journals and their contents (Jan 25, p 249)-as a consumer I know what I want from The Lancet. For me, the practising physician, the hallmark of a good paper is one that changes my view of things and especially changes my practice. Every week I read two general journals and between one and three specialist journals and I feel pleased if I can identify a paper that fulfils my requirements. Every week I attend and contribute to a journal club and review a specialist journal in my field and can rarely find more than one paper per issue with a clinical message of merit to share with my
colleagues. I think the editor of The Lancet should be applauded, firstly for taking the trouble to ask the consumer what he wants (Jan 4, p 33), and secondly for publishing papers that will undoubtedly change medical practice. Length and breadth are often irrelevant to the
satisfaction that can be obtained. Department of Cardiology, Royal Hallamshire Hospital,
K. S. CHANNER
Sheffield S10 2JF, UK
Glutaraldehyde allergy in endoscopy units SIR,-We have received several complaints of symptoms from health services’ staff who use glutaraldehyde, especially those in endoscopy units. In 1991 we sent 169 questionnaires to nurses in seventeen hospitals that we visited in our area. We received 167 replies. 65% of those who replied reported symptoms and 38 % had two or more. The major complaints were eye irritation 49%, skin discoloration or irritation 41%,’ headache 36%, and cough or shortness of breath 34%The complaints were reported in all seventeen hospitals, and were not related to smoking habits, atopic status, or duration of exposure. In two hospitals, environmental measurement of glutaraldehyde in air had been done and levels were below the UK occupational exposure standard, which currently is 0-2 parts per million (10 min time-weighted average).3 In the UK the Control of Substances Hazardous to Health Regulations 1988require the users of such substances to assess health risks and to reduce exposure. Simple control measures such as chemical substitution are at present impracticable for glutaraldehyde, so other methods should be considered. Cleaning of endoscopes in vertical tubes rather than horizontal trays, the closed transfer of glutaraldehyde to cleaning units, and similar precautions for disposal should reduce the exposure considerably. I. M. CALDER L. P. WRIGHT D. GRIMSTONE
Health and Safety Executive, Luton LU1 1PP, UK 1. Fowler
JF. Allergic contact dermatitis from glutaraldehyde exposure. J Occup Med
1989; 31: 852-53. 2. Wiggins P, McCurdy PA, Zeidenberg W. Epistaxis due to glutaraldehyde exposure. J Occup Med 1989; 31: 854-56. 3. Health and Safety Executive, health and safety guidance note EH40/90: occupational exposure limits. London: HSE, 1990. 4. Control of Substances Hazardous to Health
Regulations 1988: approved code of practice control of substances hazardous to health and approved code of practice control of carcinogenic substances. London: HM Stationery Office, 1988.
Research in
developing
countries
SIR,-As a specialist in tropical diseases, Dr Patel and Dr Araya’s article (Jan 11, p 110) about the lack of research in developing countries because there are too few trained personnel struck a responsive chord. I have benefited greatly from collaboration with and the hospitality of many fine scientists in South America, the Caribbean, and African and Asian countries. Thus, when I was offered the directorship of health sciences of the Rockefeller Foundation in 1977 I was pleased that I might be able to do something about the tragic difficulties so ably described by Patel and Araya. Since its founding in 1913 the Foundation has tried many strategies to support medical research and researchers in the developing world. Training in the developed world has always been
