hospitals. Security guards were rarely available, and nurse escorts could often not be arranged. The safety of on call rooms was also of great concern. Simple practical measures were reassuring: improved lighting and a spyhole and chain fitted to the door of an on call room had greatly reduced doctors' anxieties at one hospital. It is encouraging to see the prominence that Drs Schipperheijn and Dunne give to education in managing aggression. We believe, however, that it is essential not to allow educational approaches to overshadow the practical steps that hospitals can take to provide all staff with a safer working environment. CAMERON STARK
Department of Puiblic Health, Argyll and Clyde Health Board, Paisley PAl l)D BRIAN KIDD
Departntent of Psychiatry, Southerrn (eneral Hospital, Glasgoss (5 1 4TF Schipperheiin JA, Dunne FJ. Managing violence in psychiatric hospitals. BMJ 1991;303:71-2. (13 July.)
Review of neonatal screening programme for phenylketonuria SIR,-The review by Dr Isabel Smith and colleagues' was particularly timely as we have just reviewed the procedures for neonatal biochemical screening in Wandsworth. For 5'% of babies born in the first eight months of 1990 we found that results were not readily available. After contacting all the relevant agencies, including the hospitals of birth, many screening laboratories, and the health visitors, we were still unable to find results for 2% of infants. We can only assume that these children have not been tested. Dr Smith suggests that the national coverage "approaches 100%." This may well be true, but national averages can obscure large individual differences. She touches on this when mentioning Hunter et al's study of the apparent low uptake in Riverside. It is essential that someone monitors local screening services. In the increasingly fragmented health service, how is this to be done? As in many aspects of community child health, there are many people involved-the midwife who takes the sample, the laboratory that performs the test, the administrative staff who receive and pass on the result, the health visitor who is usually the professional receiving the result, the general practitioner or local clinic undertaking child health surveillance on the child, the district health authority responsible for the health of its residents, and the senior doctor in community child health. No one solution will be appropriate for all districts, but we suggest the following as a framework. (1) When the test is performed, it should be fully explained to the parent. In this way the parent is likely to request the result if it seems overdue. The result should be recorded in the parent held record at the earliest opportunity. (2) All results, including negatives, should be reported. This is still not universal practice. (3) The health visitor should be responsible for seeing that a result has been received for every child on her case load. This is not the same as checking that a sample has been taken. (4) If a result has not been received by the time a child is 1 month old at the latest a result should be sought, and if it cannot be found a sample should be taken without delay. (5) Depending on the sophistication of the local information system, either constant monitoring or regular spot checks should be made to ensure the system is working properly. (6) Someone needs to take overall responsibility for ensuring the system is working. In some
BMJ VOLUME 303
24 AUGUST 1991
districts this would fall to community paediatricians and in others to the departments of public health medicine. We would be interested to know the coverage figures for other districts. DAVID ELLIMAN JUNE GARNER
St George's Hospital, London SW 17 OQTF I Smith I, Cook I, Beasley M. Review of neonatal screening programme for phenylketonuria. BMJ 1991;303:333-5. (10 August.)
What now for IPPNW? SIR,-Having attended the 10th anniversary congress of International Physicians for the Prevention of Nuclear War (IPPNW), I was interested in Dr Richard Smith's editorial on the future of IPPNW.' Some points might be questioned: the total membership of the affiliated organisations is well over 200 000 but not quite 40 times the world's population, and, more seriously, not all would agree that IPPNW's tendency to elitism has been beneficial. With the ending of the cold war, in which IPPNW might indeed claim a share, the organisation's mission certainly needs to be redefined and extended beyond the prevention of nuclear war. As Dr Smith notes, doctors may find themselves on opposite sides in conventional war. The Gulf war shows that this is not necessarily so; at IPPNW's meeting in Stockholm influential speakers from Israel, Iraq, Palestine, Jordan, Egypt, and Turkey were agreed on the need for a zone free of nuclear, chemical, and biological weapons in the Middle East. Many of us support Haines's call for IPPNW and its affiliates to address the wider issues of global security.2 The affiliates in the United Kingdom, the Medical Campaign Against Nuclear Weapons and the Medical Association for Prevention of War, are working towards amalgamation and a relaunch with these issues in mind while continuing to press for a comprehensive ban on nuclear testing as a key step in eradicating nuclear weapons. Meanwhile, in Stockholm IPPNW's international council voted nem con to devote its resources (a) to preventing war, especially that using weapons of mass destruction, (b) to redirecting world resources from producing arms to promoting human wellbeing, and (c) to protecting the environment from preparations for war as well as from war itself. Environmental effects of military activity include radioactive and toxic pollution, some of it ozone depleting, and wastage of resources. The fuel burnt by the army worldwide in peacetime and used in producing arms contributes up to 6% of global emissions of carbon dioxide annually, adding appreciably to global warming through the greenhouse effect.' DOUGLAS HOLDSTOCK Medical Campaign Against Nuclear Weapons, London N 19 4DJ I Smith R. What now for IPPNW?
B.MJ 1991;303:145-6. (20
two years previously, the awesome aftermath of the Persian Gulf war, and considerable ferment within the organisation about how it could best address environmental questions-the 10th congress was certainly a critical juncture for the federation. IPPNW seemed more in robust health than in crisis. Eight new affiliates joined the federation in Stockholm, bringing the number of countries represented to 76, with over 200000 physician members worldwide. IPPNW has been growing most rapidly in the Third World, and more physicians from Third World countries were present in Stockholm than at any preceding IPPNW congress. A real global maturity and willingness to critically review and refine the organisation's direction were in evidence. Complacency about the nuclear threat is far from justified. Thus far no superpower nuclear warheads have been dismantled, and the recently concluded START treaty will merely bring strategic nuclear weapons back to numbers which exceed their levels a decade ago when the START negotiations began. Global nuclear military infrastructures, nuclear weapon and missile proliferation, growing disparities between rich and poor, and growing environmental threats to security combine with a continued qualitative arms race to maintain a nuclear risk that is largely unabated. And given the increasingly destructive power of modern weaponry, non-nuclear war is effectively a weapon of mass destruction. In Stockholm, IPPNW defined clear and bold new directions. The organisation will broaden its concern to include all forms of war and their prevention. IPPNW's central task remains the prevention of war. In this, as a medical organisation, it stands alone, and this task is as vital as ever. There are many credible and effective organisations in many countries addressing a range of environmental issues. Delegates in Stockholm agreed that the unique mission, the "ecological niche" of IPPNW, apart from working for the prevention of war, was to address the effects of war and militarism on the environment, an area which hardly any other major international organisation is addressing. Much of IPPNW's strength and effectiveness derives from its ability to unite diverse physicians from around the world on a highly focused and critically important agenda. As the organisation continues to flourish and consolidate the richness and diversity of its membership, it still needs a carefully crafted and sharp edge. Two specific projects now bearing fruit are the IPPNW global commission on the health and environmental effects of nuclear weapons production, which has just released the first comprehensive global assessment of nuclear weapons testing, and the Satelife project, a satellite communications project enabling physicians around the world, especially in poor and remote areas, to communicate rapidly and cheaply. The direction and challenges set in Stockholm will ensure that the organisation continues to make a vital contribution to safeguarding the life and health of our planet and its inhabitants. TILMAN RUFF International Physicians for the Prevention of Nuclear War, Cambridge, Massachusetts 02142-1096,
USA
July.) 2 Haines A. Global security: a role for health professionals. PSR Quarterly 1991;1:89-95. 3 Renner M. Assessing the military's war on the environment. In: Brown LR, ed. State of the world 1991. New York: W W Norton, 1991:132-52.
1 Smith R. What now for IPPNW? BMJ 1991;303:145-6. (20 July.)
Better mental health services SIR,-The recent editorial regarding the recent 10th anniversary world congress of International Physicians for the Prevention of Nuclear War,' however, demands response. It describes the organisation as being now in crisis, the victim of its own success. I must disagree. Given the tremendous changes in Europe and the US-Soviet relations since the ninth congress
SIR,-Ms Ros Hepplewhite of MIND takes exception' to-my recommendation that mentally ill patients would benefit from a "personal physician" and that an increased number of consultant psychiatrists is needed to serve them.2 She then proceeds to give several reasons to support my case. She quotes the report by MIND, People First,' which says that many patients do not find
471
Department of Puiblic Health, Argyll and Clyde Health Board, Paisley PAl l)D BRIAN KIDD
Departntent of Psychiatry, Southerrn (eneral Hospital, Glasgoss (5 1 4TF Schipperheiin JA, Dunne FJ. Managing violence in psychiatric hospitals. BMJ 1991;303:71-2. (13 July.)
Review of neonatal screening programme for phenylketonuria SIR,-The review by Dr Isabel Smith and colleagues' was particularly timely as we have just reviewed the procedures for neonatal biochemical screening in Wandsworth. For 5'% of babies born in the first eight months of 1990 we found that results were not readily available. After contacting all the relevant agencies, including the hospitals of birth, many screening laboratories, and the health visitors, we were still unable to find results for 2% of infants. We can only assume that these children have not been tested. Dr Smith suggests that the national coverage "approaches 100%." This may well be true, but national averages can obscure large individual differences. She touches on this when mentioning Hunter et al's study of the apparent low uptake in Riverside. It is essential that someone monitors local screening services. In the increasingly fragmented health service, how is this to be done? As in many aspects of community child health, there are many people involved-the midwife who takes the sample, the laboratory that performs the test, the administrative staff who receive and pass on the result, the health visitor who is usually the professional receiving the result, the general practitioner or local clinic undertaking child health surveillance on the child, the district health authority responsible for the health of its residents, and the senior doctor in community child health. No one solution will be appropriate for all districts, but we suggest the following as a framework. (1) When the test is performed, it should be fully explained to the parent. In this way the parent is likely to request the result if it seems overdue. The result should be recorded in the parent held record at the earliest opportunity. (2) All results, including negatives, should be reported. This is still not universal practice. (3) The health visitor should be responsible for seeing that a result has been received for every child on her case load. This is not the same as checking that a sample has been taken. (4) If a result has not been received by the time a child is 1 month old at the latest a result should be sought, and if it cannot be found a sample should be taken without delay. (5) Depending on the sophistication of the local information system, either constant monitoring or regular spot checks should be made to ensure the system is working properly. (6) Someone needs to take overall responsibility for ensuring the system is working. In some
BMJ VOLUME 303
24 AUGUST 1991
districts this would fall to community paediatricians and in others to the departments of public health medicine. We would be interested to know the coverage figures for other districts. DAVID ELLIMAN JUNE GARNER
St George's Hospital, London SW 17 OQTF I Smith I, Cook I, Beasley M. Review of neonatal screening programme for phenylketonuria. BMJ 1991;303:333-5. (10 August.)
What now for IPPNW? SIR,-Having attended the 10th anniversary congress of International Physicians for the Prevention of Nuclear War (IPPNW), I was interested in Dr Richard Smith's editorial on the future of IPPNW.' Some points might be questioned: the total membership of the affiliated organisations is well over 200 000 but not quite 40 times the world's population, and, more seriously, not all would agree that IPPNW's tendency to elitism has been beneficial. With the ending of the cold war, in which IPPNW might indeed claim a share, the organisation's mission certainly needs to be redefined and extended beyond the prevention of nuclear war. As Dr Smith notes, doctors may find themselves on opposite sides in conventional war. The Gulf war shows that this is not necessarily so; at IPPNW's meeting in Stockholm influential speakers from Israel, Iraq, Palestine, Jordan, Egypt, and Turkey were agreed on the need for a zone free of nuclear, chemical, and biological weapons in the Middle East. Many of us support Haines's call for IPPNW and its affiliates to address the wider issues of global security.2 The affiliates in the United Kingdom, the Medical Campaign Against Nuclear Weapons and the Medical Association for Prevention of War, are working towards amalgamation and a relaunch with these issues in mind while continuing to press for a comprehensive ban on nuclear testing as a key step in eradicating nuclear weapons. Meanwhile, in Stockholm IPPNW's international council voted nem con to devote its resources (a) to preventing war, especially that using weapons of mass destruction, (b) to redirecting world resources from producing arms to promoting human wellbeing, and (c) to protecting the environment from preparations for war as well as from war itself. Environmental effects of military activity include radioactive and toxic pollution, some of it ozone depleting, and wastage of resources. The fuel burnt by the army worldwide in peacetime and used in producing arms contributes up to 6% of global emissions of carbon dioxide annually, adding appreciably to global warming through the greenhouse effect.' DOUGLAS HOLDSTOCK Medical Campaign Against Nuclear Weapons, London N 19 4DJ I Smith R. What now for IPPNW?
B.MJ 1991;303:145-6. (20
two years previously, the awesome aftermath of the Persian Gulf war, and considerable ferment within the organisation about how it could best address environmental questions-the 10th congress was certainly a critical juncture for the federation. IPPNW seemed more in robust health than in crisis. Eight new affiliates joined the federation in Stockholm, bringing the number of countries represented to 76, with over 200000 physician members worldwide. IPPNW has been growing most rapidly in the Third World, and more physicians from Third World countries were present in Stockholm than at any preceding IPPNW congress. A real global maturity and willingness to critically review and refine the organisation's direction were in evidence. Complacency about the nuclear threat is far from justified. Thus far no superpower nuclear warheads have been dismantled, and the recently concluded START treaty will merely bring strategic nuclear weapons back to numbers which exceed their levels a decade ago when the START negotiations began. Global nuclear military infrastructures, nuclear weapon and missile proliferation, growing disparities between rich and poor, and growing environmental threats to security combine with a continued qualitative arms race to maintain a nuclear risk that is largely unabated. And given the increasingly destructive power of modern weaponry, non-nuclear war is effectively a weapon of mass destruction. In Stockholm, IPPNW defined clear and bold new directions. The organisation will broaden its concern to include all forms of war and their prevention. IPPNW's central task remains the prevention of war. In this, as a medical organisation, it stands alone, and this task is as vital as ever. There are many credible and effective organisations in many countries addressing a range of environmental issues. Delegates in Stockholm agreed that the unique mission, the "ecological niche" of IPPNW, apart from working for the prevention of war, was to address the effects of war and militarism on the environment, an area which hardly any other major international organisation is addressing. Much of IPPNW's strength and effectiveness derives from its ability to unite diverse physicians from around the world on a highly focused and critically important agenda. As the organisation continues to flourish and consolidate the richness and diversity of its membership, it still needs a carefully crafted and sharp edge. Two specific projects now bearing fruit are the IPPNW global commission on the health and environmental effects of nuclear weapons production, which has just released the first comprehensive global assessment of nuclear weapons testing, and the Satelife project, a satellite communications project enabling physicians around the world, especially in poor and remote areas, to communicate rapidly and cheaply. The direction and challenges set in Stockholm will ensure that the organisation continues to make a vital contribution to safeguarding the life and health of our planet and its inhabitants. TILMAN RUFF International Physicians for the Prevention of Nuclear War, Cambridge, Massachusetts 02142-1096,
USA
July.) 2 Haines A. Global security: a role for health professionals. PSR Quarterly 1991;1:89-95. 3 Renner M. Assessing the military's war on the environment. In: Brown LR, ed. State of the world 1991. New York: W W Norton, 1991:132-52.
1 Smith R. What now for IPPNW? BMJ 1991;303:145-6. (20 July.)
Better mental health services SIR,-The recent editorial regarding the recent 10th anniversary world congress of International Physicians for the Prevention of Nuclear War,' however, demands response. It describes the organisation as being now in crisis, the victim of its own success. I must disagree. Given the tremendous changes in Europe and the US-Soviet relations since the ninth congress
SIR,-Ms Ros Hepplewhite of MIND takes exception' to-my recommendation that mentally ill patients would benefit from a "personal physician" and that an increased number of consultant psychiatrists is needed to serve them.2 She then proceeds to give several reasons to support my case. She quotes the report by MIND, People First,' which says that many patients do not find
471
