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BMJ No 7120 Volume 315 Press Releases Saturday 29 November 1997 Embargoed: 00.01 hrs 28 November 1997 UK time Health care in prisons needs more integration with NHS Health care in prisons needs more integration with NHS(The quality of health care in prison: results of a year's programme of semistructured inspections)The Health Care Service for prisoners aims to provide care equivalent to that provided by the NHS, but does it? In a paper in this week's BMJ, Reed and Lyne reveal the results of an inspection of health care facilities in 19 British prisons. They find that in prisons, particularly where the primary care service is contracted in from the NHS, provisions are broadly equivalent to NHS care, however in many other prisons the quality of services is low. The authors note that the commissioning of health care and monitoring of services in prisons are inadequate. Some doctors are poorly trained for the work that they do and arrangements for continuing professional development are unnecessarily weak. They also find that in a few prisons, some care failed to reach proper ethical standards. Reed and Lyne conclude that the NHS should be more closely involved in both the commissioning and the provision of health care in prisons. See Paper (full text) (Reed and Lyne) p 1420 Contact:
tel: 0171 273 4640 Problems of TB programmes in prisons(Pitfalls of tuberculosis programmes in prisons)The prevalence of tuberculosis in prisons in the former Soviet Union, is often between five and fifty times greater than the national average. In developing countries, tuberculosis is a major cause of death in prisons with mortality rates as high as 24 per cent. In this week's BMJ, Reyes and Coninx argue that when it comes to treating TB in prisons, it may be better to do nothing than to do something badly. The authors observe that prisoners and prisons present difficulties for health care staff trying to implement the WHO's recommended treatment strategy for tuberculosis - "directly observed treatment - short course". This is due to the poor conditions in prisons; overcrowding; demoralised and underfunded prison health services and the unofficial power structures that flourish in prisons. Reyes and Coninx conclude that it would be better not to implement tuberculosis treatment in prisons at all, if courses of treatment cannot be completed. Not finishing courses, encourages the development of multidrug resistant tuberculosis that is then transmitted from inside the prison to outside, as prisoners are released and have contact with their families and wider community. See Education and debate (Nicholl and Turner) p 1447
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tel: 00 41 22 730 2396 Dr Rudi Coninx tel: 00 41 22 730 2725 In a linked editorial in this week's BMJ, Levy advocates that the prison health service should provide an opportunity for inmates to receive medical care in an otherwise disordered life. "Doing time" could make a difference through improved nutrition; reduced consumption of tobacco, drugs and alcohol, alongside remedial education programmes and job training.
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5609 Abuse of American prisoners in medical experiments(They were cheap and available)From the early years of this century, the use of prison inmates as raw material for medical experiments became an increasingly valuable component of American scientific research, reveals Hornblum in a paper in this week's BMJ. He suggests that the second world war was a watershed for human experimentation in prisons in the US, as the practice grew to attracting hundreds of researchers, funded by universities and pharmaceutical companies. It seems that American physicians and researchers believed that the Nuremberg Code only applied to Nazi scientists and thus postwar American research grew rapidly, and prisoners became the backbone of a lucrative system. Until the mid-1970s, uneducated and financially desperate prisoners "volunteered" for medical experiments that ranged from tropical and sexually transmitted disease, to polio, cancer and chemical warfare.
See Education and debate (Hornblum) p 1437
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tel: 001 215 204 1248 Even when the guns fall silent weapons injuries continue apace(Weapons injuries during and after period of conflict: retrospective analysis)The continued availability of weapons in societies that have undergone armed conflict, is obviously a risk factor of sustained violence, but what impact do these weapons have on injuries once the conflict has ended? In this week's BMJ, Meddings examines injuries in an anonymous region*, both during and post-conflict, where no attempt at mass disarmament was made. The author found that once the war had ended, the number of weapons injuries only fell by one third and that more people died of weapons injuries each month, during the post-conflict period. The injuries were caused by guns, bombs, shells, grenades and mines (anti-personnel and anti-tank). Meddings concludes that the continued availability of such weapons, is a factor in social destabilisation. The author suggests policy makers and those governments who are concerned with the arms trade, should give greater consideration to trade in arms, in light of the evidence in this study. *The principles of neutrality and impartiality by which the International Committee of the Red Cross (ICRC) operates, precludes identification of the location of the region; disclosure may have security implications for activities of the ICRC in the country concerned.
See Paper (full text) (Meddings) p 1417
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tel: 00 41 22 730 2628
Defining what levels of injury are acceptable in the field(Abhorrent weapons and "superfluous injury or unnecessary suffering": from field surgery to law)Drawing on his own experience of treating landmine victims in Afghanistan and Cambodia, in this week's BMJ, Coupland attempts to translate a field surgeon's concept of abhorrent weapons into a legal determination of "superfluous injury or unnecessary suffering", as defined in 1977 Protocol 1, additional to the Geneva Conventions of 1949. Coupland explains the parameters of the SIrUS project, which recognises that the effects on human beings of weapons used by armies are now bad enough and that anything worse should be prevented. The project comprises a group of experts who have worked to define criteria which draw a difference between the effects of conventional weapons and those that cause "superfluous injury and unnecessary suffering". The author calls upon the international medical and academic communities to endorse these proposed criteria, in an effort to discourage governments from continued research and development of new means of warfare.
See Education and debate (Coupland) p 1450
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tel: 00 41 22 730 2217 Beyond the medical impact of landmines(Antipersonnel landmines: facts, fiction and priorities)In a paper in this week's BMJ, Giannou recognises that the problem of landmines is not simply one of treating and rehabilitating the people that they injure. The author notes that landmines not only injure individuals, they render agricultural land unusable and roads unpassable, leading to wider socio-economic repercussions, that damage the fragile economies of nations trying to recover after conflicts. For each area affected, the priorities, such as mine clearance, mines awareness programmes, health services and repairing the economic infrastructure, need to be identified and action targeted to avoid a resumption of conflict. To this end, the author identifies the "mines information system", devised by the International Committee of the Red Cross, which aims to assist the many agencies involved in areas of conflict to assess the priorities and co-ordinate their efforts.
See Education and debate (Giannou) p 1453 Contact:
tel: 00 41 22 734 6001
Blinding laser weapons(Still available on the battlefield)In an editorial in this week's BMJ, Marshall considers the impact of laser weapons in modern warfare, and despite their restricted use, there are still devices which could potentially blind infantry on today's battlefields.
See Editorial (Marshall) p 1392 Contact: Two papers in this week's BMJ consider the adherence and cost-effectiveness of tuberculosis treatments. The effectiveness of strategies to promote adherence to TB treatment(Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment)Many patients with tuberculosis do not complete their treatment and this leads to needless suffering and death. In this week's BMJ, Volmink and Garner, determine which strategies to promote adherence are effective. Strategies include:- reminder cards sent to patients who have defaulted on clinic visits; help for patients from lay health workers; a monetary incentive offered to patients; health education and increased supervision of staff in TB clinics. All these approaches seemed to improve adherence. The authors suggest that there is a need for rigorous evaluations of other innovations and in particular those that are feasible in the developing world.
See Paper (abstract only) (Volmink and Garner) p 1403 Contact:
tel: 00 27 21 938 0438 Directly observed treatment for TB is cheaper than conventional treatment(Comparison of cost-effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa)Delivering care for the growing numbers of patients with TB is difficult when budgets are severely constrained. In this week's BMJ, Floyd et al show that community based directly observed treatment (DOTS), recently implemented in a rural district of South Africa, is nearly three times cheaper, is more cost effective and less demanding of hospital services than a more conventional approach. See Paper (abstract only) (Floyd et al) p 1407
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0151 708 9393 Review of trials confirms toxicity of Lariam(Mefloquine to prevent malaria: a systematic review of trials)In this week's BMJ, Croft and Garner confirm the theoretical efficacy of mefloquine in preventing malaria infection (first available to European travellers in 1985, as Lariam). The authors' study also reveals levels of high toxicity and that study participants were more likely to withdraw from taking mefloquine than from taking placebo, which could be due to side effects of the prophylaxis, such as insomnia and fatigue. Croft and Garner conclude that their review suggests that the effectiveness of mefloquine is limited by low adherence.
See Paper (abstract only) (Croft and Garner) p 1412 Contact: Polio disables as many as landmines in Afghanistan(Household survey of locomotor disability caused by poliomyelitis and landmines in Afghanistan)In this week's BMJ, Lambert et al reveal the high levels of polio amongst the population in Kandahar in south eastern Afghanistan. The authors state that polio is one of the leading causes of disability in the country, only four years before the target set by WHO for its worldwide eradication of the disease. They suggest that polio vaccine coverage should be a high priority and that mines awareness programmes should not be the focus for women, who spend most of their time indoors.
See Paper (full text) (Lambert et al) p 1424 Contact: Vincent Slypen, Handicap International, Belgium t: 00 32 2 280 1601 Other materials in this week's BMJ include:- Tajikistan: no pay, no careSee Education and debate (Veeken) p 1460 Sudan: eating dust and returning to dustSee Education and debate (Veeken) p 1458
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tel: 00 31 2052 08700 Africa in the 21st century: can despair be turned to hope?Logie and Benatar reveal that more money is spent on debt servicing than on health and education in sub-Saharan Africa, an area where two thirds of people are desperately poor. The authors call on the industrialised world to acknowledge the adverse role the play in Africa - effective debt relief for the 20 poorest countries has a price tag of $5.5 billion, the cost of building EuroDisney.
See Education and debate (Logie and Benatar) p 1444 Contact: Embargoes that endanger health - Doctors should oppose themAn analysis of the effect of trade embargoes on health, in countries such as Cuba.
See Editorial (Delamothe) p 1393 Contact:
tel: 0171 383 6006 South Africa: does a truth commission promote social reconciliation?See Editorial (Summerfield) p 1393
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tel: 0171 813 7777 Embargo: 00.01 hrs Friday 28 November 1997 Please contact Public Affairs Division for the text of the paper & the authors for further comment For further information, please contact:
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