I escaped the syndrome first described in my tribe by Dr Cicely Williams34 was simply because my educated parents took the same steps that Professor Marsden described from Brazil: I was fed with beans, eggs, milk, minced meat, and Ovaltine. Less fortunate relatives of my age whose parents also had three children in less than three years, and of whom it was also said "afor ese kwasiorkor, " went on to develop kwashiorkor because they could only afford to be fed with maize products such as akasa and kenky. The sibling positional word became almost invariably associated with the syndrome Cicely Williams was investigating, and although the term kwasiorkor was occasionally attached to a child who never went on to get the disease, whenever the syndrome kwashiorkor was seen in a child there was, more likely than not, very close proximity to a younger sibling. Exceptions occurred when children were orphaned, regardless of sibling positioning, or in multiple births. A further argument in support of Professor Marsden relates to what has come to be known as the adult kwashiorkor syndrome, in which diarrhoea, pitting oedema, hepatomegaly, dermatopathy, mental apathy, and hair changes result from protein energy malnutrition as, for example, in the creatorrhoea and steatorrhoea in severe alcoholic chronic pancreatitis. It is known that the syndrome in the adult is completely reversible with appropriate treatment and protein energy replacement. F I D KONOTEY-AHULU

Cromwell Hospital, London SW5 OTU 1 Waterston T. Kwashiorkor. BMJ 1990;301:1276. (1 December.) 2 Marsden PD. Kwashiorkor. BMJ 1990;301:1036-7. (3 November.) 3 Williams CD. A nutritional disease of childhood associated with a maize diet. Arch Dis Child 1933;8:423-8. 4 Williams CD. Kwashiorkor-a nutritional disease of children associated with a maize diet. Lancet 1935;ii: 1151-2.

Ambulance response times SIR,-We were concerned to read Mr John Warden's report that the time allowed for ambulances to respond to urgent calls from general practitioners is to be relaxed.' We have reviewed one week of emergency work by South Glamorgan Ambulance Service. The 999 system was used to initiate 318 journeys. The service transported 121 trauma patients, 36 of whom were admitted, and 195 non-trauma patients, 105 of whom were admitted. Urgent calls from general practitioners resulted in 234 ambulance journeys: 22 trauma patients, eight of whom were admitted, and 212 non-trauma patients, 209 of whom were admitted. General practitioners thus generally perform an effective filtering mechanism for acute medical care, leading to a more efficient use of the emergency ambulance service. There were 20 cases of acute myocardial infarction during the study. The nine patients who used the 999 system were attended to on average 12 minutes later whereas the 11 patients who called their general practitioner first had a significantly slower mean activation and response time of 53-8 minutes (p