Letters

Caring for marginalised people

Appropriate external intervention is needed

All doctors should be taught and tested

Leadership and strategy are needed to support those who provide care

Appropriate external intervention is needed

EDITORMedicine usually fails marginalised people, as Smith observed.¹ But it is not just medicine that fails them. Every technology invented so far has failed them and will continue to do so. Information and communication technologies have exacerbated the divide between rich and poor nations and have also further marginalised those who are already marginalised within nations.² Reverend Jesse Jackson has drawn attention to how these technologies have led to a deepening of the racial divide in the United States.³

In analysing papers published by medical researchers in India I found that much of the research carried out there has not been done in the areas in which it is most needed, such as respiratory diseases, diarrhoeal diseases, and ophthalmological disorders. A comparatively large amount of research is being carried out in the areas of cancer and cardiovascular diseases, although these are not significant causes of morbidity and mortality in India.⁴

The idea of paying special attention to "the poor and mean and lowly" has been emphasised throughout human history by noble souls like Jesus Christ and in recent times by Mahatma Gandhi and Mother Teresa. Yet it is something that is consistently forgotten by most of the rest of us.

Both human nature and technology need appropriate external intervention if they are to work in a manner that is beneficial to the mass of humanity. For Smith, the appropriate external intervention that can drive medicine in the right direction is found in "professional and political leadership, unceasing commitment from the top, a clear vision of what is needed, resources, and a strategic approach"; and the intervention that can correct human nature is for doctors to rediscover the religious underpinning of medicine "while operating in an increasingly secular world." I could not agree with Smith more.

In support of his case, Smith quotes from Corinthians. Gandhi said: "Recall the face of the poorest and the weakest man whom you have seen and ask yourself if the steps you contemplate are going to be of any use to him. Will he gain anything by it? Will it restore to him control over his own life and destiny?"

Subbiah Arunachalam, distinguished fellow. 
M S Swaminathan Research Foundation, Chennai, 600 113, India subbiah_a{at}yahoo.com

All doctors should be taught and tested

EDITORSmith drew attention to the mismatch between the health needs of people with learning disabilities and the response of the medical profession: "Unfortunately those who care for marginalised groups themselves become marginalised."¹

Recruitment to the psychiatry of learning disability has always been low, except in parts of the country with dynamic, research oriented leaders. Despite the high level of skill required to practise psychiatry with patients who have difficulties communicating and despite the scope for research, it is not a high status specialty.

I doubt that young doctors will flock to a specialty that Smith says is staffed by "people, often inspired by religious faith . . . willing to devote themselves" and by "others . . . who cannot find places in the more popular parts of medicine and who drift reluctantly" into caring for marginalised groups. These extreme reasons for choosing a career exist but most specialist registrars in the psychiatry of learning disability report that the main determinant of their choice was that they had had high quality training during their rotation as a senior house officer in psychiatry.² Young doctors rarely consider a career in this specialty until they discover how rewarding it is to develop skills (especially in communication) that few other doctors have.

All doctors should have good quality teaching on how to deliver general medical care to people with learning disabilities. All royal colleges should test the competence of doctors in their specialty to deliver medical care to people with learning disabilities. Candidates for postgraduate examinations should expect to fail if they are unable to demonstrate competence in delivering care to patients with learning disabilities. All medical schools and all royal colleges should teach and test these skills.

Neill Simpson, honorary secretary. 
Faculty of Psychiatry of Learning Disability, Royal College of Psychiatrists, London SW1X 8PG Neill_Simpson{at}compuserve.com

Leadership and strategy are needed to support those who provide care

EDITORI read Smith's editorial on providing medical care for marginalised people with relief.¹ For the past two years I have been struggling to set up a service for some of the marginalised groups identified in his editorial. As a service providing care for homeless people and travellers we have an excess of clients with addiction problems and with learning disabilities; we also treat refugees. These groups do get a poorer standard of care when they are treated within mainstream services. One of the root causes of this is an unwillingness or, more realistically, an inability to adapt services to the needs of members of these groups. This is why services such as ours have been set up, and although we do not have the resources that standard services do, we try to provide a user friendly service adapted to meet the needs of our patients. Although our patients receive an inferior service because we do not have the breadth of a modern general practice, members of marginalised groups do at least have access to some form of primary care, and things can only get better.

I have no religious motivation, just an overwhelming desire to see people treated fairly and also the knowledge that what we are doing is cost effective both financially and socially. Perhaps I have become marginalised: I work half time in "ordinary general practice" and most of the work that I have done caring for marginalised people has been unpaid. However, my colleagues have supported me and the service has received limited funding from the local primary care group and the health authority, but it has been like swimming through treacle. Thus, I wholeheartedly back Smith's call for "professional and political leadership, unceasing commitment from the top, a clear vision of what is needed, resources, and a strategic approach." A decent service for marginalised people should not be dependent on mad buggers like me.

Catherine Hewitt, medical director. 
Maple Healthcare Project, Northampton NN1 4HL