920
Letters to the Editor MENTAL-HEALTH CARE IN SOUTH AFRICA
SIR,-Your editorial (Sept. 3, p. 491) cites allegations made in a World Health Organisation report Apartheid and Mental Health Care’ in respect of psychiatrically ill Blacks in South Africa. It indicates that there is a case to answer. You mention that the information in the report is not based on first-hand experience but you do not indicate the extent to which this report is inaccurate. Much of the information comes from second-hand reports, newspaper stories, out-of-date sources, or documents emanating from organisations with no established reputation, and is either inaccurate or misleading. This does not prevent the authors of this document from making farreaching assertions which are difficult to refute, being in the form of inferences, probabilities, and insinuations. It is reprehensible that an organisation such as W.H.O., which enjoys such trust and prestige, should have given its imprimatur to this dubious document because this report is now being widely taken as authoritative. Accurate and up-to-date information is published,2’s and W.H.O. was given an open invitation by the South African Minister of Health to conduct a completely free and unrestricted examination of all aspects of the South African mental health services before the publication of this report. They did not avail themselves of this offer. This gives the lie to the idea being circulated that there is a ban on information about the South African psychiatric services. The Society of Psychiatrists of South Africa wishes to rebut that information it knows to be false and to comment on some of these misrepresentations. We cannot deal with all the issues raised in the W.H.O. report, and some are frankly political, and this is not the function of a non-political professional organisation. We do, however, feel that it is unwarranted to tie the apartheid tin to the tail of the psychiatric cat, no matter how much of a pleasing din it makes. The report states that a higher proportion of Black than White patients are admitted under certificate to psychiatric hospitals, insinuating that this is in some way connected with discrimination against Blacks. The figures indicate otherwise. From 1964 to 1976 White voluntary admissions rose from 2051 to 4700, whilst Black admissions increased from 187 to 4981.’ This increase is all the more remarkable to those who are familiar with local conditions because a much higher proportion of Blacks, particular those from country areas, become behaviourally disturbed (often uncontrollably) as a result of toxic, infective, or exhaustion syndromes. You state that there is no Black psychiatrist in South Africa. The Department of Health, all medical schools, and professional groups such as the Medical Association of South Africa, the Society of Psychiatrists of South Africa, and the South African National Council for Mental Health are very alive to this and have tried for years to recruit Black doctors to the specialty. Opportunities for training exist and bursaries are regularly advertised for Black psychiatrists, but no African has yet come forward. Your information is in any case incorrect. A Black (Coloured) psychiatrist has for several years occupied a post of senior lecturer and senior psychiatrist in the department of psychiatry of the University of Cape Town and a 1.
and Mental Health Care: a preliminary review by the W.H.O. Secretariat for the U.N. Special Committee Against Apartheid. Press Release WHO/15 of March 24,1977. 2. A Summary of Mental Health Facilities in the Republic of South Africa (3 volumes). Department of Health, Pretoria, 1977. 3. Report of the Department of Health 1975. Government Printer, Pretoria, 1975. 4. Annul report of the Department of Health 1976. Government Printer, Pre-
Apartheid
toria, 1976. 5. Comments on the Report of the World Health Organisation: Mental Health Services in South Africa. Department of Health, Pretoria, 1977. 6. Official figures supplied by the Department ofHealth, Pretoria.
Black medical practitioner is being trained as medical superintendent of a large new psychiatric hospital. There are in addition eight registrars of Indian origin in training at the University of Durban Medical School. You refer to "degrading conditions of squalor" in private institutions for Black psychiatric patients and intimates that these patients are not being properly cared for. We are not in a position to discuss the administrative and financial arrangements concerned, but full information about this is freely available and the institutions are open to responsible investigations. We can inform you, however, that these institutions cater for all population groups, that they only care for chronic psychiatric patients who have already been investigated and treated in State psychiatric hospitals, and who have been certified in need of care and supervision in terms of the Mental Health Act of 1973. They are under the direct control and supervision of the Department of Health, and the senior professional staff (nursing and medical) are seconded from that Department. Representatives of the Society of Psychiatrists have inspected these institutions over the past couple of years and have found no support for allegations of inadequate psychiatric care, exploitation of patients, or detention of patients for political reasons. Indeed we consider that the accommodation and services are even better in some than in certain State hospitals and their rehabilitation programmes are exceptional, resulting in a considerable discharge-rate in cases previously thought unable to respond to rehabilitation (10-15%). A committee of the International Red Cross paid an exploratory visit to a representative sample of South African psychiatric institutions in November and December, 1976, and have released a statement that they did not find any patients in hospital for other than medical reasons. You state that "rehabilitation of African pass law offenders seems to equate the non-observance of the apartheid laws with mental disorder". There is definite confusion here. There is legal provision for social welfare authorities (which in South Africa are separate from those responsible for health) to commit certain social misfits, vagrants, and the like to rehabilitation centres, but this is the sort of legislation which exists all over the world (and in respect of Whites in South Africa too) to deal with social problems. It has absolutely nothing to do with psychiatrically ill persons who fall under the Mental Health Act of 1973 (which, incidentally, is based on the British Mental Health Act and is one of the most advanced of its sort). Adequate legal safeguards are in any case built into the Mental Health Act to ensure that all involuntary patients can only be received in hospitals under a magistrate’s order, and detention for more than 42 days must be confirmed by a Supreme Court -
judge. One last correction needs to be made, showing once again the inaccuracies of the W.H.O. report. It is stated, that the Department of Health subsidises private institutions to the extent of one-third of the entire health budget of the State. The exact figure for 1975/76 is z 6 % . The Society of Psychiatrists, which is the representative body for psychiatrists in South Africa much as the American Psychiatric Association and the Royal College of Psychiatrists are in the U.S.A. and the U.K., is a subgroup of the Medical Association of South Africa, a non-racial professional body with no political affiliations or allegiances and with the same high moral and ethical standards as the British Medical Association. We feel that the incorrect assertions contained in the W.H.O. document are a slur on the integrity of the Society and its members, and we must disclaim them. As responsible members of the medical profession and with a lively sense of obligation to the public, we just would not tolerate the sorts of abuse alleged in the W.H.O. report. Our Society recognises that our mental health services have real deficiencies (and where in the world do they not?) but we are aware of these and strive to improve them. But to harness incorrect facts to a political bandwagon is neither appropriate nor constructive. Nor is credit given anywhere in the W.H.O. report for the very extensive and advanced psychiatric services given to all South
921 Africans without reference to colour or creed. In this respect South Africa is probably second to none on the African continent. Almost anything that takes place these days in South Africa is grist to the political mill, but we would urge the medical profession to insist on the same rigour and objectivity in obtaining facts and evaluating situations as they do in clinical practice. Since the W.H.O. document contains so many inaccuracies and misrepresentations, fairness would dictate that only a full on-the-spot investigation will do. The facts are available and the South African Government has made it clear that any organisation with a legitimate interest may inspect our mental health services, private or public, without let or hindrance. Let us trust they will do so. The supporting documents referred to2-s may not be readily available in other countries. Anyone who wishes to have them should contact the Department of Health, Private Bag X88, Pretoria 0001, South Africa.
Department of Psychiatry, University of Cape Town, Groote Shuur Hospital, Cape Town 7925, South Africa
L. S. GILLIS Chairman, Executive Committee,
Society of Psychiatrists of South Africa (M.A.S.A.)
MORTALITY ASSOCIATED WITH THE PILL little alarm, has attended the publication from the Oral Contraception Study of the Royal College of General Practitioners (Oct. 8, p. 727). One principal finding in that paper was that the ratio of the mortality-rate in ever-users to that in controls, attributable to all diseases of the circulatory system, was approximately 5, and that this result was statistically significant at the level of 0.01. The report notes that this and other associated ratios were approximate and were based on small numbers, but it did not estimate the resulting imprecision, a point noted in your accompanying editorial. A statement of the confidence limits
SIR,-Considerable publicity, and
finite rate ratio. The lower limits bear out the reported levels of statistical significance. The seemingly dramatic ratio of 5, underpinned by the striking level (0.01) of statistical significance, may well range from a value as low as 1.6 to an infinitely high value, when confidence limits are considered. Pill optimists and pill pessimists alike may draw ammunition from that statement, but what real meaning should it convey to the uncommitted? I think that the lesson is simply that where a condition is rare, the increased risk of its occurrence in an individual due to the voluntary adoption of a course of medication is not rationally to be measured by a ratio of rates of occurrence. Rate ratios in such circumstances are highly uncertain and are highly irrelevant, and both of those properties follow from the rarity of the condition. The criterion of relevancy answers the question: "How much worse off (in respect of this particular condition) is the woman who decides to take the pill?" If she has a risk of dying of 5/100 000 each year without the pill, and 26/100 000 with it, her chance of survival declines from 99 995/100 000 to 99 974/100 000, which is an absolute reduction of 21 x 10-5 or a relative reduction of virtually the same extremely small amount. It is regrettable that so few journalists, and surprising that so few epidemiologists, appear to take this rational view of the situation. But hot news will always evaporate cold reason.
Department of Community Medicine, University of Manchester,
DOUGLAS MAY
Manchester M13 9PT
no
CONFIDENCE LIMITS OF RATE RATIOS IN R.C.G.P. STUDY
undefined.
SIR,-Evidence on the relation of diet to coronary heart-disand other vascular disorders, has been assessed indepen-
ease
dently by 18 national committees. Each has advised reduction in the consumption of saturated fat, either by the population as a whole (14/18) or by groups considered to be at high risk (4/18) of which women on oral contraceptives is one. Partial substitution of saturated by polyunsaturated fat is recommended by 16/18 committees and restriction of cholesterol intake by 16/18. A "fat switch" may be particularly important in reducing platelet adhesiveness and aggregation, and thus a tendency to thrombus formation. However, routine measurement of the concentration of blood lipids is not yet practical and there are also difficulties over the interpretation of this concentration. There is no cut-off point between normal and abnormal, and assessment of the significance of any level must take account of other risk factors, including inherited predisposition, smoking habit, raised blood-pressure and increased permeability of the arterial wall. It has been shown that these are not important in people who habitually eat a healthy diet and thus have a low plasma-cholesterol, becoming so only when they migrate and change their dietary habits. Women who choose to continue with oral contraceptives should be given advice about smoking and have their bloodpressures recorded, but should also be given a clear explanation of the recommended diet. This could be done by the family doctor, a practice nurse or the family-planning clinic. This practice may reduce the incidence of vascular complications but the
which can be ascribed to these ratios helps to put the matter into perspective. Using a simulation method-based on the assumptions that the observed (and published) numbers of deaths are equal to the "expected" numbers and that the numbers "observed" in hypothetical replications of the study follow Poisson distributions with those expectations-I have estimated the confidence limits (see table, together with details extracted from the R.C.G.P. paper). The method I used is simplistic, but it provides a reasonable guide to the limits. The "undefined" upper limits arise because the numbers of controls were extremely small and thus in many replications (e.g., in more than 50 out of 10 000 for I.C.D. code 390-458) the "observed" number was zero, yielding an indefinite or in-
by laboratory
matter
should be put to the test and monitored of lipid levels and platelet func-
measurements
tion.
·
University of Edinburgh, 21 Buccleuch Place, Edinburgh EH8 9LN
R. W. D. TURNER
SIR,-The report from the R.C.G.P. Oral Contraceptive Study is open to several criticisms. The study began in 1968. The smoking habits of the women were those "at entry". We seem to
be asked
to
believe that 46 000
women
retained
un-
Letters to the Editor MENTAL-HEALTH CARE IN SOUTH AFRICA
SIR,-Your editorial (Sept. 3, p. 491) cites allegations made in a World Health Organisation report Apartheid and Mental Health Care’ in respect of psychiatrically ill Blacks in South Africa. It indicates that there is a case to answer. You mention that the information in the report is not based on first-hand experience but you do not indicate the extent to which this report is inaccurate. Much of the information comes from second-hand reports, newspaper stories, out-of-date sources, or documents emanating from organisations with no established reputation, and is either inaccurate or misleading. This does not prevent the authors of this document from making farreaching assertions which are difficult to refute, being in the form of inferences, probabilities, and insinuations. It is reprehensible that an organisation such as W.H.O., which enjoys such trust and prestige, should have given its imprimatur to this dubious document because this report is now being widely taken as authoritative. Accurate and up-to-date information is published,2’s and W.H.O. was given an open invitation by the South African Minister of Health to conduct a completely free and unrestricted examination of all aspects of the South African mental health services before the publication of this report. They did not avail themselves of this offer. This gives the lie to the idea being circulated that there is a ban on information about the South African psychiatric services. The Society of Psychiatrists of South Africa wishes to rebut that information it knows to be false and to comment on some of these misrepresentations. We cannot deal with all the issues raised in the W.H.O. report, and some are frankly political, and this is not the function of a non-political professional organisation. We do, however, feel that it is unwarranted to tie the apartheid tin to the tail of the psychiatric cat, no matter how much of a pleasing din it makes. The report states that a higher proportion of Black than White patients are admitted under certificate to psychiatric hospitals, insinuating that this is in some way connected with discrimination against Blacks. The figures indicate otherwise. From 1964 to 1976 White voluntary admissions rose from 2051 to 4700, whilst Black admissions increased from 187 to 4981.’ This increase is all the more remarkable to those who are familiar with local conditions because a much higher proportion of Blacks, particular those from country areas, become behaviourally disturbed (often uncontrollably) as a result of toxic, infective, or exhaustion syndromes. You state that there is no Black psychiatrist in South Africa. The Department of Health, all medical schools, and professional groups such as the Medical Association of South Africa, the Society of Psychiatrists of South Africa, and the South African National Council for Mental Health are very alive to this and have tried for years to recruit Black doctors to the specialty. Opportunities for training exist and bursaries are regularly advertised for Black psychiatrists, but no African has yet come forward. Your information is in any case incorrect. A Black (Coloured) psychiatrist has for several years occupied a post of senior lecturer and senior psychiatrist in the department of psychiatry of the University of Cape Town and a 1.
and Mental Health Care: a preliminary review by the W.H.O. Secretariat for the U.N. Special Committee Against Apartheid. Press Release WHO/15 of March 24,1977. 2. A Summary of Mental Health Facilities in the Republic of South Africa (3 volumes). Department of Health, Pretoria, 1977. 3. Report of the Department of Health 1975. Government Printer, Pretoria, 1975. 4. Annul report of the Department of Health 1976. Government Printer, Pre-
Apartheid
toria, 1976. 5. Comments on the Report of the World Health Organisation: Mental Health Services in South Africa. Department of Health, Pretoria, 1977. 6. Official figures supplied by the Department ofHealth, Pretoria.
Black medical practitioner is being trained as medical superintendent of a large new psychiatric hospital. There are in addition eight registrars of Indian origin in training at the University of Durban Medical School. You refer to "degrading conditions of squalor" in private institutions for Black psychiatric patients and intimates that these patients are not being properly cared for. We are not in a position to discuss the administrative and financial arrangements concerned, but full information about this is freely available and the institutions are open to responsible investigations. We can inform you, however, that these institutions cater for all population groups, that they only care for chronic psychiatric patients who have already been investigated and treated in State psychiatric hospitals, and who have been certified in need of care and supervision in terms of the Mental Health Act of 1973. They are under the direct control and supervision of the Department of Health, and the senior professional staff (nursing and medical) are seconded from that Department. Representatives of the Society of Psychiatrists have inspected these institutions over the past couple of years and have found no support for allegations of inadequate psychiatric care, exploitation of patients, or detention of patients for political reasons. Indeed we consider that the accommodation and services are even better in some than in certain State hospitals and their rehabilitation programmes are exceptional, resulting in a considerable discharge-rate in cases previously thought unable to respond to rehabilitation (10-15%). A committee of the International Red Cross paid an exploratory visit to a representative sample of South African psychiatric institutions in November and December, 1976, and have released a statement that they did not find any patients in hospital for other than medical reasons. You state that "rehabilitation of African pass law offenders seems to equate the non-observance of the apartheid laws with mental disorder". There is definite confusion here. There is legal provision for social welfare authorities (which in South Africa are separate from those responsible for health) to commit certain social misfits, vagrants, and the like to rehabilitation centres, but this is the sort of legislation which exists all over the world (and in respect of Whites in South Africa too) to deal with social problems. It has absolutely nothing to do with psychiatrically ill persons who fall under the Mental Health Act of 1973 (which, incidentally, is based on the British Mental Health Act and is one of the most advanced of its sort). Adequate legal safeguards are in any case built into the Mental Health Act to ensure that all involuntary patients can only be received in hospitals under a magistrate’s order, and detention for more than 42 days must be confirmed by a Supreme Court -
judge. One last correction needs to be made, showing once again the inaccuracies of the W.H.O. report. It is stated, that the Department of Health subsidises private institutions to the extent of one-third of the entire health budget of the State. The exact figure for 1975/76 is z 6 % . The Society of Psychiatrists, which is the representative body for psychiatrists in South Africa much as the American Psychiatric Association and the Royal College of Psychiatrists are in the U.S.A. and the U.K., is a subgroup of the Medical Association of South Africa, a non-racial professional body with no political affiliations or allegiances and with the same high moral and ethical standards as the British Medical Association. We feel that the incorrect assertions contained in the W.H.O. document are a slur on the integrity of the Society and its members, and we must disclaim them. As responsible members of the medical profession and with a lively sense of obligation to the public, we just would not tolerate the sorts of abuse alleged in the W.H.O. report. Our Society recognises that our mental health services have real deficiencies (and where in the world do they not?) but we are aware of these and strive to improve them. But to harness incorrect facts to a political bandwagon is neither appropriate nor constructive. Nor is credit given anywhere in the W.H.O. report for the very extensive and advanced psychiatric services given to all South
921 Africans without reference to colour or creed. In this respect South Africa is probably second to none on the African continent. Almost anything that takes place these days in South Africa is grist to the political mill, but we would urge the medical profession to insist on the same rigour and objectivity in obtaining facts and evaluating situations as they do in clinical practice. Since the W.H.O. document contains so many inaccuracies and misrepresentations, fairness would dictate that only a full on-the-spot investigation will do. The facts are available and the South African Government has made it clear that any organisation with a legitimate interest may inspect our mental health services, private or public, without let or hindrance. Let us trust they will do so. The supporting documents referred to2-s may not be readily available in other countries. Anyone who wishes to have them should contact the Department of Health, Private Bag X88, Pretoria 0001, South Africa.
Department of Psychiatry, University of Cape Town, Groote Shuur Hospital, Cape Town 7925, South Africa
L. S. GILLIS Chairman, Executive Committee,
Society of Psychiatrists of South Africa (M.A.S.A.)
MORTALITY ASSOCIATED WITH THE PILL little alarm, has attended the publication from the Oral Contraception Study of the Royal College of General Practitioners (Oct. 8, p. 727). One principal finding in that paper was that the ratio of the mortality-rate in ever-users to that in controls, attributable to all diseases of the circulatory system, was approximately 5, and that this result was statistically significant at the level of 0.01. The report notes that this and other associated ratios were approximate and were based on small numbers, but it did not estimate the resulting imprecision, a point noted in your accompanying editorial. A statement of the confidence limits
SIR,-Considerable publicity, and
finite rate ratio. The lower limits bear out the reported levels of statistical significance. The seemingly dramatic ratio of 5, underpinned by the striking level (0.01) of statistical significance, may well range from a value as low as 1.6 to an infinitely high value, when confidence limits are considered. Pill optimists and pill pessimists alike may draw ammunition from that statement, but what real meaning should it convey to the uncommitted? I think that the lesson is simply that where a condition is rare, the increased risk of its occurrence in an individual due to the voluntary adoption of a course of medication is not rationally to be measured by a ratio of rates of occurrence. Rate ratios in such circumstances are highly uncertain and are highly irrelevant, and both of those properties follow from the rarity of the condition. The criterion of relevancy answers the question: "How much worse off (in respect of this particular condition) is the woman who decides to take the pill?" If she has a risk of dying of 5/100 000 each year without the pill, and 26/100 000 with it, her chance of survival declines from 99 995/100 000 to 99 974/100 000, which is an absolute reduction of 21 x 10-5 or a relative reduction of virtually the same extremely small amount. It is regrettable that so few journalists, and surprising that so few epidemiologists, appear to take this rational view of the situation. But hot news will always evaporate cold reason.
Department of Community Medicine, University of Manchester,
DOUGLAS MAY
Manchester M13 9PT
no
CONFIDENCE LIMITS OF RATE RATIOS IN R.C.G.P. STUDY
undefined.
SIR,-Evidence on the relation of diet to coronary heart-disand other vascular disorders, has been assessed indepen-
ease
dently by 18 national committees. Each has advised reduction in the consumption of saturated fat, either by the population as a whole (14/18) or by groups considered to be at high risk (4/18) of which women on oral contraceptives is one. Partial substitution of saturated by polyunsaturated fat is recommended by 16/18 committees and restriction of cholesterol intake by 16/18. A "fat switch" may be particularly important in reducing platelet adhesiveness and aggregation, and thus a tendency to thrombus formation. However, routine measurement of the concentration of blood lipids is not yet practical and there are also difficulties over the interpretation of this concentration. There is no cut-off point between normal and abnormal, and assessment of the significance of any level must take account of other risk factors, including inherited predisposition, smoking habit, raised blood-pressure and increased permeability of the arterial wall. It has been shown that these are not important in people who habitually eat a healthy diet and thus have a low plasma-cholesterol, becoming so only when they migrate and change their dietary habits. Women who choose to continue with oral contraceptives should be given advice about smoking and have their bloodpressures recorded, but should also be given a clear explanation of the recommended diet. This could be done by the family doctor, a practice nurse or the family-planning clinic. This practice may reduce the incidence of vascular complications but the
which can be ascribed to these ratios helps to put the matter into perspective. Using a simulation method-based on the assumptions that the observed (and published) numbers of deaths are equal to the "expected" numbers and that the numbers "observed" in hypothetical replications of the study follow Poisson distributions with those expectations-I have estimated the confidence limits (see table, together with details extracted from the R.C.G.P. paper). The method I used is simplistic, but it provides a reasonable guide to the limits. The "undefined" upper limits arise because the numbers of controls were extremely small and thus in many replications (e.g., in more than 50 out of 10 000 for I.C.D. code 390-458) the "observed" number was zero, yielding an indefinite or in-
by laboratory
matter
should be put to the test and monitored of lipid levels and platelet func-
measurements
tion.
·
University of Edinburgh, 21 Buccleuch Place, Edinburgh EH8 9LN
R. W. D. TURNER
SIR,-The report from the R.C.G.P. Oral Contraceptive Study is open to several criticisms. The study began in 1968. The smoking habits of the women were those "at entry". We seem to
be asked
to
believe that 46 000
women
retained
un-
