1302
Western donors and the former Soviet Union
NHS trusts and Jehovah’s witnesses
SIR,—The republics of the former Soviet Union are faced with deteriorating health of their population, especially among the most vulnerable groups-children and the elderly. Although the picture varies greatly from region to region, overall there have been rises in infant mortality, preventable childhood diseases, and
SIR,- The National Health Service reforms have sharpened the focus on aspects of health-care provision previously not considered. One such is the care of Jehovah’s Witnesses, which has always caused concern to surgeons because of their refusal to accept human blood and blood products. Although this right must be respected and has even been incorporated into the NHS Patient’s Charter, there are instances where recovery is severely impeded by anaemia that could be treated by transfusion. One such example locally resulted in 6 extra weeks in hospital, three further operative interventions, 4 weeks of parenteral feeding, and two courses of synthetic erythropoietin-an extra expense of about 25 000. Who should pay? The purchasing authority disclaims responsibility because the patient, being a local resident, was included in the 1991-92 bulk contract for surgical services. The provider unit has borne the expense, which represents the cost of seven hip replacements. Although at no time was any effort spared to give the patient the best possible care within the constraints imposed by him, some trusts may become reluctant to operate on any non-emergency Jehovah’s Witness for fear of incurring extra
the
mortality. The low life expectancy of Russian men, the effects of drinking and smoking, and accidents at work, damage economic potential. Following on from the Bush summit in Washington in January, 1991, western donor states are meeting in Lisbon on May 23-24 to discuss the issues surrounding aid to the former Soviet Union. There are two main reasons to support the inclusion of health care in that general package. Firstly, any strategic intervention in the economic sector should take account of certain health-care issues, which if left to deteriorate could undermine the prospects of economic recovery. Secondly, it will be more costeffective to address some issues now, rather than let crisis situations develop that would then require massive humanitarian aid packages. This year intergovernmental agencies have sent in teams of medical experts and financial consultants to provide needs analyses. From this work we can now produce specific programmes that can be properly budgeted. Over the next two years effective programmes could be put in place at the following costs: family planning for US$20 million; nutrition for children and the aged for $20 million; and health information for$12 million. Overall, the health-care aid package could be contained within$420 million which is under 2% of the total package promised by G7. Current spending on health in the former Soviet Union is 3-4% of the gross national product (compared with 65% in the UK). These packages will be constructed to complement intervention in other sectors and provide model projects that can be replicated elsewhere. Certain areas offer scope for developing the necessary infrastructure and the ability to provide better practice and health outcomes at low costs. For instance, obstetrics is a high-cost sector because of the abortion rate. Providing proper family planning services would be a response to the need to limit family size that presents donor organisations with the challenge of making better use of alreadv committed resources. ROBERT J. MAXWELL, King’s Fund College, Patron, Association for the Promotion of Healthcare m King Edward’s Hospital Fund for London,
maternal
London W2 4HS, UK
the Former Soviet Union
Casualties of
election-year language
SIR,-Since my two favourite medical journals both
stem
from
liberal roots, I have come to accept the fact that their political editorial stance will lean to the left. This is true of your fortnightly Washington Perspective. However, in his March 7 column (p 604) Mr Greenberg strays beyond the bounds of good taste and stoops to name calling in a matter (John Frohnmayer’s firing as head of the National Endowment of the Arts) unrelated to any field of medicine unless it be urology. Greenberg’s description of the conservative Pat Buchanan as the "partly deodorised fascist of American politics" has no place in the pages of your journal. I suppose it represents Greenberg’s feeling that anyone who does not share his political persuasion is beyond the pale. Unfortunately in this day of rapidly shifting political sands, our terminology has become confused. We speak of conservatives as indicating the old-guard communists and even refer to them as rightists, which is a long way from the original use of right, centre, and left in the French Assembly. A few years ago, when it began to become apparent that socialism, especially in its more advanced stages, was not working, it became fashionable to refer to conservatives as Nazis. This came to a deserved sudden halt when Wm F. Buckley, Jr, on national television informed that outstanding human being Gore Vidal that the next time he called him (W. F. B.) a Nazi, he was going to punch him (G. V.) on the "goddamned nose". If I were Pat Buchanan I would be inclined to offer the same enlightenment to Daniel S. Greenberg. Millard-Henry Clinic, Skyline Drive,
P A,
One
Russellville, Arizona 72801, USA
CHAS F. WILKINS, JR
expense.
Should the rest of the community pay for the beliefs of the minority-or should the Jehovah’s Witnesses be encouraged to contribute to such extra costs, either through their organisation or through an insurance scheme? Taunton and Somerset Taunton TA1 5DA, UK
Hospital,
CHARLES D. COLLINS
Vitamin A and childhood A
morbidity
SIR,-Dr Arthur and colleagues (Feb 8, p 361) show that vitamin supplementation reduced the severity but not the frequency of
infection among Ghanaian children. Several other workers have reported the same results and offered various explanations for the apparent discrepancy between these findings—ie, the previously reported increased risk of infectious disease in xerophthalmic children, and the large reduction in childhood mortality seen in most randomised trials of vitamin A prophylaxis.1-s The main reason seems to have escaped discussion: the sample sizes of these trials were inadequate to detect the fairly small impact vitamin A would have on mild, frequent infectious episodes. Diarrhoea is a cogent example and is especially relevant since several community-based mortality studies that examined the issue showed that vitamin A prophylaxis significantly reduced death from
(presumably severe) diarrhoea.3,4 Diarrhoea is generally defmed as three to four loose stools in a day. Children in rural, impoverished third world settings generally have four episodes of diarrhoea every year. Since observational studies suggest a doubling of the risk of diarrhoea in xerophthahnic children, those with clinically detectable vitamin A deficiency would have eight diarrhoeal episodes annually. Because the prevalance of active xerophthalmia is generally 2-3%, halving the rate of diarrhoea among children with xerophthalmia will have a negligible impact on the rate of diarrhoea in the childhood community in general: No of diarrhoeal
Normal
Xerophthalmia
4
4+4
episodes
yearly
Prevalence of xerophthalinia Proportion of diarrhoeal 4 x 0.02___ episodes associated with xerophthalmia : (0-98 x 4) + (0-02 x 8)
Hence, if vitamin
2%
=0 02
supplementation prevented the excess diarrhoeal episodes among xerophthalmic children it would reduce the overall incidence of diarrhoea by only 2%. This percentage is very different from the proportion of deaths attributable to xerophthalmia, in which the relative risk of death is four to ten times higher among mildly xerophthalmic children6 (as opposed to a diarrhoeal relative risk of 2); and in which any increase in risk of diarrhoea among subclinical cases of vitamin A deficiency would be A
negligible. The impact of vitamin A supplementation on childhood mortality must be mediated through its impact on the severity of
Western donors and the former Soviet Union
NHS trusts and Jehovah’s witnesses
SIR,—The republics of the former Soviet Union are faced with deteriorating health of their population, especially among the most vulnerable groups-children and the elderly. Although the picture varies greatly from region to region, overall there have been rises in infant mortality, preventable childhood diseases, and
SIR,- The National Health Service reforms have sharpened the focus on aspects of health-care provision previously not considered. One such is the care of Jehovah’s Witnesses, which has always caused concern to surgeons because of their refusal to accept human blood and blood products. Although this right must be respected and has even been incorporated into the NHS Patient’s Charter, there are instances where recovery is severely impeded by anaemia that could be treated by transfusion. One such example locally resulted in 6 extra weeks in hospital, three further operative interventions, 4 weeks of parenteral feeding, and two courses of synthetic erythropoietin-an extra expense of about 25 000. Who should pay? The purchasing authority disclaims responsibility because the patient, being a local resident, was included in the 1991-92 bulk contract for surgical services. The provider unit has borne the expense, which represents the cost of seven hip replacements. Although at no time was any effort spared to give the patient the best possible care within the constraints imposed by him, some trusts may become reluctant to operate on any non-emergency Jehovah’s Witness for fear of incurring extra
the
mortality. The low life expectancy of Russian men, the effects of drinking and smoking, and accidents at work, damage economic potential. Following on from the Bush summit in Washington in January, 1991, western donor states are meeting in Lisbon on May 23-24 to discuss the issues surrounding aid to the former Soviet Union. There are two main reasons to support the inclusion of health care in that general package. Firstly, any strategic intervention in the economic sector should take account of certain health-care issues, which if left to deteriorate could undermine the prospects of economic recovery. Secondly, it will be more costeffective to address some issues now, rather than let crisis situations develop that would then require massive humanitarian aid packages. This year intergovernmental agencies have sent in teams of medical experts and financial consultants to provide needs analyses. From this work we can now produce specific programmes that can be properly budgeted. Over the next two years effective programmes could be put in place at the following costs: family planning for US$20 million; nutrition for children and the aged for $20 million; and health information for$12 million. Overall, the health-care aid package could be contained within$420 million which is under 2% of the total package promised by G7. Current spending on health in the former Soviet Union is 3-4% of the gross national product (compared with 65% in the UK). These packages will be constructed to complement intervention in other sectors and provide model projects that can be replicated elsewhere. Certain areas offer scope for developing the necessary infrastructure and the ability to provide better practice and health outcomes at low costs. For instance, obstetrics is a high-cost sector because of the abortion rate. Providing proper family planning services would be a response to the need to limit family size that presents donor organisations with the challenge of making better use of alreadv committed resources. ROBERT J. MAXWELL, King’s Fund College, Patron, Association for the Promotion of Healthcare m King Edward’s Hospital Fund for London,
maternal
London W2 4HS, UK
the Former Soviet Union
Casualties of
election-year language
SIR,-Since my two favourite medical journals both
stem
from
liberal roots, I have come to accept the fact that their political editorial stance will lean to the left. This is true of your fortnightly Washington Perspective. However, in his March 7 column (p 604) Mr Greenberg strays beyond the bounds of good taste and stoops to name calling in a matter (John Frohnmayer’s firing as head of the National Endowment of the Arts) unrelated to any field of medicine unless it be urology. Greenberg’s description of the conservative Pat Buchanan as the "partly deodorised fascist of American politics" has no place in the pages of your journal. I suppose it represents Greenberg’s feeling that anyone who does not share his political persuasion is beyond the pale. Unfortunately in this day of rapidly shifting political sands, our terminology has become confused. We speak of conservatives as indicating the old-guard communists and even refer to them as rightists, which is a long way from the original use of right, centre, and left in the French Assembly. A few years ago, when it began to become apparent that socialism, especially in its more advanced stages, was not working, it became fashionable to refer to conservatives as Nazis. This came to a deserved sudden halt when Wm F. Buckley, Jr, on national television informed that outstanding human being Gore Vidal that the next time he called him (W. F. B.) a Nazi, he was going to punch him (G. V.) on the "goddamned nose". If I were Pat Buchanan I would be inclined to offer the same enlightenment to Daniel S. Greenberg. Millard-Henry Clinic, Skyline Drive,
P A,
One
Russellville, Arizona 72801, USA
CHAS F. WILKINS, JR
expense.
Should the rest of the community pay for the beliefs of the minority-or should the Jehovah’s Witnesses be encouraged to contribute to such extra costs, either through their organisation or through an insurance scheme? Taunton and Somerset Taunton TA1 5DA, UK
Hospital,
CHARLES D. COLLINS
Vitamin A and childhood A
morbidity
SIR,-Dr Arthur and colleagues (Feb 8, p 361) show that vitamin supplementation reduced the severity but not the frequency of
infection among Ghanaian children. Several other workers have reported the same results and offered various explanations for the apparent discrepancy between these findings—ie, the previously reported increased risk of infectious disease in xerophthalmic children, and the large reduction in childhood mortality seen in most randomised trials of vitamin A prophylaxis.1-s The main reason seems to have escaped discussion: the sample sizes of these trials were inadequate to detect the fairly small impact vitamin A would have on mild, frequent infectious episodes. Diarrhoea is a cogent example and is especially relevant since several community-based mortality studies that examined the issue showed that vitamin A prophylaxis significantly reduced death from
(presumably severe) diarrhoea.3,4 Diarrhoea is generally defmed as three to four loose stools in a day. Children in rural, impoverished third world settings generally have four episodes of diarrhoea every year. Since observational studies suggest a doubling of the risk of diarrhoea in xerophthahnic children, those with clinically detectable vitamin A deficiency would have eight diarrhoeal episodes annually. Because the prevalance of active xerophthalmia is generally 2-3%, halving the rate of diarrhoea among children with xerophthalmia will have a negligible impact on the rate of diarrhoea in the childhood community in general: No of diarrhoeal
Normal
Xerophthalmia
4
4+4
episodes
yearly
Prevalence of xerophthalinia Proportion of diarrhoeal 4 x 0.02___ episodes associated with xerophthalmia : (0-98 x 4) + (0-02 x 8)
Hence, if vitamin
2%
=0 02
supplementation prevented the excess diarrhoeal episodes among xerophthalmic children it would reduce the overall incidence of diarrhoea by only 2%. This percentage is very different from the proportion of deaths attributable to xerophthalmia, in which the relative risk of death is four to ten times higher among mildly xerophthalmic children6 (as opposed to a diarrhoeal relative risk of 2); and in which any increase in risk of diarrhoea among subclinical cases of vitamin A deficiency would be A
negligible. The impact of vitamin A supplementation on childhood mortality must be mediated through its impact on the severity of
