Treatment of refugees in European countries of asylum SIR,-We should be aware that harsh practices against asylum seekersiz do not only arise in the UK. There is also a new tendency, by shortening asylum procedures, to restrict access to asylum and
are made. I believe that free circulation of doctors between these two countries will remain the exception unless there is a concerted European Community effort to allow exchanges of medical students. This will probably only come about in practice when substantial population migration takes place between the member states.
frighten away applicants. In Austria, which after the opening of eastern European countries’ borders has seen increased migration through and from these countries, there have been frequent cases of mistreatment. These include refusal of medical treatment, detention under inhuman conditions, and, at least in one proven case, rape by an official. While treating refugees at this hospital my colleagues and I have seen that patients, especially those who have been tortured, have suffered most from their experiences during asylum procedures. Changes in symptoms of depression and post-traumatic stress disorder induced by therapy were often minor in comparison with those induced by changes in asylum status or their social situation. In addition, during official interviews patients were often unable to report the details of their persecution and torture experiences that are necessary for legal reasons in their application for asylum because of dissociation from the experience enhanced by the pressures of asylum procedures. Especially for those who have been most severely persecuted, it seems to be more and more difficult to get asylum under present legislation. A way to protect tortured and traumatised refugees from further damaging experiences needs to be found, including fast-track procedures in countries of asylum. Physicians should have a part in this venture. University Hospital for Psychiatry,
1190 Vienna, Austria
C, Summerfield D. Asylum seekers in British pnsons Lancet 1991; 338: 1212. 2. Summerfield D, Gorst-Unsworth C, Bracken P, Tonge V, Forrest D, Hinshelwood G Detention in the UK of tortured refugees Lancet 1991; 338: 58. 1. Gorst-Unsworth
SIR,-I qualified in France and I believe that I am one of the first French nationals to have successfully pursued postgraduate training in obstetrics and gynaecology in the UK. When comparing the two systems substantial differences emerge. In France, medical training lasts six years and is followed by two years as a resident. After this a thesis has to be written and submitted to the university of origin to obtain the basic qualification (MD) and registration. The curriculum is national and medical students have clinical responsibilities from the fourth year (extemat). Postgraduate medical training lasts an average of four years, after which one may practise in the private sector as a specialist. Its access is conditioned by a selective examination (internat) that is held yearly in the various French regions. Choice of the specialties is determined by the number of training posts and one’s rank in this examination, as well as one’s seniority. There is no specialty exit examination and training is confined to the same region. Only a few specialists continue training to become consultants in the teaching hospitals (CHUs), and these are recruited by invitation from existing consultants. As a result most French specialists practise in the private sector.’ In France, patients refer themselves directly to specialists of their choice, and the national health service (Caisses Nationales d’Assurance Maladie) reimburses three-quarters of the sole standard fee charged by most specialists. Additional insurance policies, subscribed to by most patients, refund the remainder. Thus there is no great advantage for the average patient to use the public sector.2 These facts are responsible for the large differences between postgraduate training in the UK and France. On average, one year of training in the UK is equivalent to three years in France in respect of clinical experience, supervision, and medical education. Paid study leave in France is exceptional. Having worked in both countries, I think that it is important that these differences are recognised by employers and employees when
Acute Services Unit,
Northampton General Hospital. Northampton NN1 5BD, UK
1. Brearley S. Medical education. BMJ 1992, 304: 41-44. 2. Amouretti M, Beraud C, Saint Martin E. Medical audit in France from ideal to reality BMJ 1992; 304: 428-30.
Obstetrics in developing countries SIR,-Dr Potts (June 20, p 1531) refers to the Drs Hamlin and the fistula repair service in Ethiopia. Every year for the past 23 years I have acted as locum for this service and have also taken part in rural health care. Ethiopia is a vast country with much fertile land-60% of the country is arable, with only 11 % being cultivated. Underpopulation means that people are isolated within their own country--an Ethiopian is, on average, 21 days walk from an all-weather road. Scarcity of people makes transport and communication difficult. The obstetric history of patients attending the Addis Ababa Fistula Hospital shows that the stillbirth rate for labour-causing fistula was 92-7%, and that over 70% of these women have no living children. Such women are desperate for children. They and all women need the kind of total health care (curative and preventative) provided by hospitals like Attat in a rural area of Ethiopia. The preventative programmes in that hospital and its community have incorporated better education, especially for women, better antenatal care, better use of available resources such as traditional birth attendants’ and other health-care workers, and the use of maternity waiting areas.2.3 These areas are a type of hostel built close to the hospital where women thought to be at risk are advised by the health-care team to reside in the last few weeks of pregnancy. Difficulties of travel and consequent delay are avoided when urgent management of labour is needed. In 1982-90 in the areas covered by Attat health-care programmes, there has been a striking reduction in crude birth rate from 38 to 16-6 per thousand population, and in fertility rate from 159 to 77 per thousand fertile women.’ These decreases are due to an immunisation programme, with more children surviving, and to the use of natural family planning. This method, which is acceptable to the people, is taught in the womens’ groups in the villages. Birmingham Maternity Hospital, Queen Elizabeth Medical Centre, Edgbaston, Birmingham B152TG, UK
1. Brennan M Training traditional birth attendants. Postgrad Doctor 2. Attat Hospital annual reports. Attat: Attat Hospital, 1980-89.
3. Poovan P, Kifle F. Kwast BE. A maternity waiting home reduces obstetric catastrophes. World Health Forum 1990; 11: 440-45. 4 Webster F Evaluation of the public health and development programme Artat Hospital, 1982 to 1990 Attat: Attat Hospital, 1990.
Influence of The Lancet
sampling SIR,-In 1991, The Lancet published two important papers about adverse effects of chorionic villus sampling (CVS).’,2 Our impression was that the articles, especially the first, had made an impact on both the public and medical professionals. Thus we audited uptake of CVS done during 1989-91 in the south-west of England for karyotyping because of maternal age. All such CVS samples are analysed at the Southwestern Region Cytogenetics Centre. The number of samples processed for the three years showed no reduction in 1991; in fact there was a sligtll increase (1989, 133 samples; 1990, 132; and 1991, 149). However. when the numbers were compared quarterly for the three years. differences occurred. Over the three years, the mean number of