represented on the Committee on Safety of Medicines. Is patient safety being put at risk in the decision making process offered by the commission? It is equally important that technically competent people participate in any appeal procedure by the companies against any regulatory decisions and also that these experts should be independent. T D GRIFFIN
London SW19 3AX
rejecting birth control it is hardly surprising that she hesitates to grasp this political hot potato, yet failure to do so will ultimately be fatal. But looking coldly into the future, all these arguments are probably futile. Uncontrollable population growth, escalating black on black violence, continued sanctions, political instability, and the advancing HIV epidemic guarantee the death of our academic medicine more surely than Mrs Venter ever could. ANDREW J BRUCE-CHWATT
I Smith T. Policies on drugs in the new Europe. Br Med J 1990;300:1476-7. (9 June.) 2 Griffin TD. Prospects for the pharmaceutical industrv in a single European market. London: PJB Publications, 1990.
Funding of South African government hospitals
Tygerberg Hospital, Tygerberg 7505, South Africa 1 Levenstein J. One struggle is over, another begins. Br Med J 1990;300:1419. (2 June.)
Symptomatic carotid ischaemic events
SIR,-I would like to clarify some of Professor Joseph Levenstein's comments in his news item concerning the ending of apartheid in South SIR,-We have evidence to support Dr Graeme J Hankey and Professor Charles P Warlow's safety African government hospitals.' No one would dispute the injustice, waste, and and financial considerations favouring duplex inefficiency of the old two tier system. That ultrasonography to image the carotid arteries in expenditure on primary health care has been patients with transient ischaemic attacks who are woefully inadequate has been evident for years, suitable for carotid endarterectomy.' In more than 4000 scans in the past 10 years and Mrs Venter is rightfully addressing this. Whether taking funds away from the teaching duplex scanning with imaging and Doppler hospitals is a sensible way of dealing with this is has proved to be an entirely safe outpatient another matter. Perhaps Professor Levenstein investigation, which takes about 20 minutes to would be better able than myself to explain to a produce accurate assessments of the origins of the patient requiring a pericardectomy that his or her internal carotid arteries.2 In 1987, a typical year, we scanned the carotid arteries of450 new patients, operation was no longer available. It may well be correct that the Cape's two 56 of whom also had carotid angiography, and teaching hospitals spend half the entire provincial performed 41 carotid endarterectomies. Angioallocation. What is not acknowledged is that the grams did not result in an endarterectomy in 22 peripheral hospitals generally can offer only patients, and endarterectomies were done on the rather basic care and that they routinely refer, for basis of duplex results alone in seven. Ultrasonography shows particularly well intraexample, simple mandible fractures (of which we alone treat some 1400 a year) to us for treatment, a plaque haemorrhage and atheromatous ulcers in distance of 500 km or more. Overloaded buses heterogenous plaques with worrying embolic from the Transkei and Ciskei (some 1000 km away) potential. Homogenous plaques, on the other decant their burden of suffering humanity on our hand, are generally fibrous and inactive.' Fine jets doorsteps almost daily, and we continue to treat of high velocity blood in severely stenosed arteries complex cases from the now independent Namibia. can be difficult to find by Doppler ultrasonography, This is hardly an ideal situation, but poor and an arteriogram may be needed to show if the support of outlying hospitals and the difficulty of artery beyond the stenosis is patent and hence attracting anyone (let alone specialists) into badly operable. The skills of the graduate technicians and paid government service in remote areas are the reasons. The implication that the teaching physicists who do our scans have improved with hospitals are wasting money on ivory castle, super experience, as has the technology, especially the high tech procedures must be rejected. In fact., new colour flow systems. SUSAN E A COLE academic medicine and research are rapidly MUNTHER I ALDOORI grinding to a halt as the supposedly tertiary care MICHAEL HORROCKS hospitals collapse under an escalating load of
ordinary problems.
ROGER N BAIRD
I find the assertion that medical school staff are unanimous in their demands for bigger and better tertiary care hospitals surprising. Certainly in our own large academic hospital I have found it impossible to locate one doctor who agreed with this (I did not ask the medical administrators). The implication that we are enjoying an inappropriate party is risible. Our academic hospital looks more like a combination of a mobile army surgical hospital unit and a baby rehydration station and leaks despairing and frustrated doctors to the private sector like a sieve. A recent advertisement for a replacement consultant for our unit brought no replies. That the South African government medical services badly need an overhaul is plain, but applying the coup de grace to the dying academic centres is unlikely to help. What is needed is a massive increase in funding of primary health care and the peripheral hospitals. How sad that in all her speeches Mrs Venter has not once referred to the need to consider the problems caused by the explosive growth of the black population. Given the fundamental nature of the social traditions
BMJ
VOLUME
301
28
JULY
1990
Bristol Royal Infirmary, Bristol BS2 8HW 1 Hankey GJ, Warlow CP. Symptomatic carotid ischaemic events: safest and most cost effective way of selecting patients for angiography, before carotid endarterectomy. Br Med 7 1990;300:1485-91. (9 June.) 2 Lusby RJ, Machleder HI, Jeans WD, et al. Vessel wall and blood flow dynamics in arterial disease. Philos Trans R Soc Lond
[Biol] 1981;294:231-9. 3 Aldoori MI, Baird RN, Al-Sam SZ, et al. Dtiplex scanning and plaque histology in cerebral ischaemia. European Journal of V'ascular Surgery 1987;1: 159-64.
The mental health of Asians in Britain SIR, - Dr Bernard Ineichen gives several possible reasons for the low levels of reported mental illness in Asians in Britain. ' He does not, however, mention the high rates of psychotic illness and the important differences found within this multiracial and multicultural group.
Several hospital based studies have examined admission rates for Asian patients. A study of first psychiatric admissions to three Manchester hospitals between 1973 and 1975 showed that the rate of schizophrenia in Asians was six times the rate in British born subjects.2 There was also an increased rate of admission for personality and sexual disorders, depressive neurosis, and other neurotic conditions. When all psychiatric admissions in England and Wales during 1971 were studied Asians had a lower than expected rate of admission,3 but along with other immigrant groups they had a higher rate of admission for schizophrenia than British natives. Most studies have treated Asians as a homogenous group. This is unfortunate not only because of their diversity of race and culture but because they come from different sectors of their societies. When comparisons have been made between races important differences have emerged. A study of first admission rates in south east England found that Indians had a rate of schizophrenia three times that of Pakistanis, who themselves had a rate similar to that of the native born.4 Differences in rates of neurotic symptoms and somatisation have also been reported among Asian groups.5 It seems that Asians share with other immigrant groups an increased risk of developing schizophrenia after arriving in England. This is vital information both for planning the health needs of the population and when considering the aetiology of the disease. In particular the finding of different rates of schizophrenia among Indians and Pakistanis may point to the factors causing increased susceptibility. It is therefore important that psychotic illness is not forgotten in any review of the mental health of an immigrant group. MICHAEL PHELAN
Maudsley Hospital, London SE5 8AZ 1 Ineichen B. The mental health of Asians in Britain. Br Med J 1990;300:1669-70. (30 June.) 2 Carpenter L, Brockington IF. A study of Asians, West Indians and Africans living in Manchester. BrJf Psychiatry 1980;137: 201-5. 3 Cochrane R. Mental illness in immigrants to England and Wales: an analysis of mental hospital admissions, 1971. Soc Psychiaty 1977;12:25-35. 4 Dean G, Walsh D, Downing H, Shelley E. First admissions of native-born and immigrants to psychiatric hospitals in south-east England. BrJ7 Psychiatry 1981;139:506-12. 5 Bhatt A, Tomenson B, Benjamin S. Transcultural patterns of somatization in primary care: a preliminary report. J Psychosom Res 1989;33:671-80.
SIR, - Dr Bernard Ineichen is right to emphasise in his first sentence the importance of recognising the heterogeneity to be found among British Asian people. ' An opportunity to document an aspect of this arose in Newham district in east London in 1982 when the local authority analysed the size of various subgroups of their Asian population by a classification of surnames from the electoral register similar to that described by Nicoll et al.2 A similar analysis of the names of patients admitted to the psychiatric hospital for Newham allowed the calculation of rough admission rates for the three predominant Asian groups in the borough. During the year 21 Moslems out of an estimated population of 6329, 19 Hindus out of 8854, and five Sikhs out of 5080 were admitted. This gives one year prevalences per 100000 population of 331 8, 214-6, and 98-4 respectively. These differences were significant (X'=6-98) df=2; p
London SW19 3AX
rejecting birth control it is hardly surprising that she hesitates to grasp this political hot potato, yet failure to do so will ultimately be fatal. But looking coldly into the future, all these arguments are probably futile. Uncontrollable population growth, escalating black on black violence, continued sanctions, political instability, and the advancing HIV epidemic guarantee the death of our academic medicine more surely than Mrs Venter ever could. ANDREW J BRUCE-CHWATT
I Smith T. Policies on drugs in the new Europe. Br Med J 1990;300:1476-7. (9 June.) 2 Griffin TD. Prospects for the pharmaceutical industrv in a single European market. London: PJB Publications, 1990.
Funding of South African government hospitals
Tygerberg Hospital, Tygerberg 7505, South Africa 1 Levenstein J. One struggle is over, another begins. Br Med J 1990;300:1419. (2 June.)
Symptomatic carotid ischaemic events
SIR,-I would like to clarify some of Professor Joseph Levenstein's comments in his news item concerning the ending of apartheid in South SIR,-We have evidence to support Dr Graeme J Hankey and Professor Charles P Warlow's safety African government hospitals.' No one would dispute the injustice, waste, and and financial considerations favouring duplex inefficiency of the old two tier system. That ultrasonography to image the carotid arteries in expenditure on primary health care has been patients with transient ischaemic attacks who are woefully inadequate has been evident for years, suitable for carotid endarterectomy.' In more than 4000 scans in the past 10 years and Mrs Venter is rightfully addressing this. Whether taking funds away from the teaching duplex scanning with imaging and Doppler hospitals is a sensible way of dealing with this is has proved to be an entirely safe outpatient another matter. Perhaps Professor Levenstein investigation, which takes about 20 minutes to would be better able than myself to explain to a produce accurate assessments of the origins of the patient requiring a pericardectomy that his or her internal carotid arteries.2 In 1987, a typical year, we scanned the carotid arteries of450 new patients, operation was no longer available. It may well be correct that the Cape's two 56 of whom also had carotid angiography, and teaching hospitals spend half the entire provincial performed 41 carotid endarterectomies. Angioallocation. What is not acknowledged is that the grams did not result in an endarterectomy in 22 peripheral hospitals generally can offer only patients, and endarterectomies were done on the rather basic care and that they routinely refer, for basis of duplex results alone in seven. Ultrasonography shows particularly well intraexample, simple mandible fractures (of which we alone treat some 1400 a year) to us for treatment, a plaque haemorrhage and atheromatous ulcers in distance of 500 km or more. Overloaded buses heterogenous plaques with worrying embolic from the Transkei and Ciskei (some 1000 km away) potential. Homogenous plaques, on the other decant their burden of suffering humanity on our hand, are generally fibrous and inactive.' Fine jets doorsteps almost daily, and we continue to treat of high velocity blood in severely stenosed arteries complex cases from the now independent Namibia. can be difficult to find by Doppler ultrasonography, This is hardly an ideal situation, but poor and an arteriogram may be needed to show if the support of outlying hospitals and the difficulty of artery beyond the stenosis is patent and hence attracting anyone (let alone specialists) into badly operable. The skills of the graduate technicians and paid government service in remote areas are the reasons. The implication that the teaching physicists who do our scans have improved with hospitals are wasting money on ivory castle, super experience, as has the technology, especially the high tech procedures must be rejected. In fact., new colour flow systems. SUSAN E A COLE academic medicine and research are rapidly MUNTHER I ALDOORI grinding to a halt as the supposedly tertiary care MICHAEL HORROCKS hospitals collapse under an escalating load of
ordinary problems.
ROGER N BAIRD
I find the assertion that medical school staff are unanimous in their demands for bigger and better tertiary care hospitals surprising. Certainly in our own large academic hospital I have found it impossible to locate one doctor who agreed with this (I did not ask the medical administrators). The implication that we are enjoying an inappropriate party is risible. Our academic hospital looks more like a combination of a mobile army surgical hospital unit and a baby rehydration station and leaks despairing and frustrated doctors to the private sector like a sieve. A recent advertisement for a replacement consultant for our unit brought no replies. That the South African government medical services badly need an overhaul is plain, but applying the coup de grace to the dying academic centres is unlikely to help. What is needed is a massive increase in funding of primary health care and the peripheral hospitals. How sad that in all her speeches Mrs Venter has not once referred to the need to consider the problems caused by the explosive growth of the black population. Given the fundamental nature of the social traditions
BMJ
VOLUME
301
28
JULY
1990
Bristol Royal Infirmary, Bristol BS2 8HW 1 Hankey GJ, Warlow CP. Symptomatic carotid ischaemic events: safest and most cost effective way of selecting patients for angiography, before carotid endarterectomy. Br Med 7 1990;300:1485-91. (9 June.) 2 Lusby RJ, Machleder HI, Jeans WD, et al. Vessel wall and blood flow dynamics in arterial disease. Philos Trans R Soc Lond
[Biol] 1981;294:231-9. 3 Aldoori MI, Baird RN, Al-Sam SZ, et al. Dtiplex scanning and plaque histology in cerebral ischaemia. European Journal of V'ascular Surgery 1987;1: 159-64.
The mental health of Asians in Britain SIR, - Dr Bernard Ineichen gives several possible reasons for the low levels of reported mental illness in Asians in Britain. ' He does not, however, mention the high rates of psychotic illness and the important differences found within this multiracial and multicultural group.
Several hospital based studies have examined admission rates for Asian patients. A study of first psychiatric admissions to three Manchester hospitals between 1973 and 1975 showed that the rate of schizophrenia in Asians was six times the rate in British born subjects.2 There was also an increased rate of admission for personality and sexual disorders, depressive neurosis, and other neurotic conditions. When all psychiatric admissions in England and Wales during 1971 were studied Asians had a lower than expected rate of admission,3 but along with other immigrant groups they had a higher rate of admission for schizophrenia than British natives. Most studies have treated Asians as a homogenous group. This is unfortunate not only because of their diversity of race and culture but because they come from different sectors of their societies. When comparisons have been made between races important differences have emerged. A study of first admission rates in south east England found that Indians had a rate of schizophrenia three times that of Pakistanis, who themselves had a rate similar to that of the native born.4 Differences in rates of neurotic symptoms and somatisation have also been reported among Asian groups.5 It seems that Asians share with other immigrant groups an increased risk of developing schizophrenia after arriving in England. This is vital information both for planning the health needs of the population and when considering the aetiology of the disease. In particular the finding of different rates of schizophrenia among Indians and Pakistanis may point to the factors causing increased susceptibility. It is therefore important that psychotic illness is not forgotten in any review of the mental health of an immigrant group. MICHAEL PHELAN
Maudsley Hospital, London SE5 8AZ 1 Ineichen B. The mental health of Asians in Britain. Br Med J 1990;300:1669-70. (30 June.) 2 Carpenter L, Brockington IF. A study of Asians, West Indians and Africans living in Manchester. BrJf Psychiatry 1980;137: 201-5. 3 Cochrane R. Mental illness in immigrants to England and Wales: an analysis of mental hospital admissions, 1971. Soc Psychiaty 1977;12:25-35. 4 Dean G, Walsh D, Downing H, Shelley E. First admissions of native-born and immigrants to psychiatric hospitals in south-east England. BrJ7 Psychiatry 1981;139:506-12. 5 Bhatt A, Tomenson B, Benjamin S. Transcultural patterns of somatization in primary care: a preliminary report. J Psychosom Res 1989;33:671-80.
SIR, - Dr Bernard Ineichen is right to emphasise in his first sentence the importance of recognising the heterogeneity to be found among British Asian people. ' An opportunity to document an aspect of this arose in Newham district in east London in 1982 when the local authority analysed the size of various subgroups of their Asian population by a classification of surnames from the electoral register similar to that described by Nicoll et al.2 A similar analysis of the names of patients admitted to the psychiatric hospital for Newham allowed the calculation of rough admission rates for the three predominant Asian groups in the borough. During the year 21 Moslems out of an estimated population of 6329, 19 Hindus out of 8854, and five Sikhs out of 5080 were admitted. This gives one year prevalences per 100000 population of 331 8, 214-6, and 98-4 respectively. These differences were significant (X'=6-98) df=2; p
