Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Attention Deficit Disorder unrecognised
- Brian Boettcher (18 December 1999)
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Can Richard Smith do something about the roads ?
- John Hopkins (18 December 1999)
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Drugs in prisons
- Karl Schmidt (20 December 1999)
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Most professionals in learning disability are highly committed
- Sheila Hollins (23 December 1999)
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Making medicine marginalised friendly: Need for appropriate intervention
- Subbiah Arunachalam (29 December 1999)
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Liberation Paradigm
- Bernard Nwulu (5 January 2000)
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Those caring for the marginalised need to be encouraged.
- Oyepeju Raji (11 January 2000)
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Medicine and the marginalised
- Robert Frankford (16 January 2000)
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Medicine for the marginalised? All doctors should be taught and tested
- Neill Simpson (17 January 2000)
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Re: Medicine for the marginalised? All doctors should be taught and tested
- Neill Simpson (21 January 2000)
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Ultimate marginalisation is being systematically sought out and destroyed before birth
- Joyce Carter (27 January 2000)
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Brian Boettcher, Consultant Psychiatrist Shelton Hospital, Shrewsbury, UK
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I would point out that learning disorders should clearly include Attention Deficit Disorder as it was not mentioned by Aspray TJ, Francis RM, Tyrer SP, Quilliam SJ. when they wrote of 'Patients with learning disability in the community' in BMJ 1999; 318: 476-477. ADD and ADHD is often found in marginalised populations when looked for, such as in prisons, the homeless,and substance abuse populations. However it has to be diagnosed first by health care workers. Social services and medical personel often do not have much interest in this condition I find, and are busy dealing with other issues. The recognition of the disorder gives added explaination and depth to the understanding of the individual before them. There is then the realisation that this person is not just being 'difficult' or 'rebellious' and a more sympathetic hearing and explaination of, for example, the needed form filling or medication taking follows. The concern that Richard Smith expresses in his article about The Marginalised is most worthwhile and is what feminism is all about now. It a subject that my homeland, Australia, is trying to deal with in various groups but especially in Koori peoples as they have been marginalised to 200 years. Dr Brian Boettcher
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John Hopkins, General Practitioner Darlington
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Not for the first time, the BMJ's Editorial line says that which needs to be said. Richard Smith's article about Medicine and the marginalised shows balance and moral courage. It is interesting to note that within hours of its publication the Government has undertaken to cancel Britain's Third World debt. Can we anticipate further influence of this sort? John Hopkins |
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Karl Schmidt
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Thank you for the above editorial. One can only agree with you that "the marginalised deserve the best, not the poorest care". What worries me, however, is that you complain about "addictive prisoners are denied access to clean needles and pure drugs". I feel that clean needles and pure drugs are not the answer, surely, what is necessary is to get them over their addictions, yes, to cure them. It looks to me that prisons are ideally placed to achieve drug cure, but not by providing access to clean needles and pure drugs, but by providing access to an appropriate curative programme. Prisons appear ideal places where to achieve drug cure, but not by providing access to achieve drug cure. Of course, many drug addict prisoners will initially not wish to be cured. However, some will wish to come off drugs. Others will follow. But to supply drugs is not an answer. Comprehensive curative treatment programmes are those that firstly overcome the drug withdrawal syndrome (and not with methadone which prevents the curative process occuring speedily). We have used what I like to call BEST, or brain electro- stimulation transcutaneously to prevent or treat the drug withdrawal syndrome. Our very low elapse rate has been 10% in two years. BEST has been shown to rekindle endorphine output, an event suppressed by drug addiction, including methadone. Researches have been carried out in this country, (Prof M Besser and his team at St Bartholomew's Hospital, by Prof H Ashton at the University of Newcastle-upon-Tyne), at the University of California, in Japan and Russia. I feel relapses have mostly occurred, though at the above very low rate, because we had not initially practised the necessary 3 times weekly follow -up for two years. The electro stimulation, of which the client is in charge, also called NET, or TENS, overcomes the drug withdrawal syndrome by rekindling endorphin and serotonin production. Prisons would be, in my view, the ideal situation where such a curative process can be executed which must address itself to all four dimensions of the human personality, the biological as outlined, the psychological, the social and the existential, spiritual or religious, the aim of our 12 element treatment programme with admission to the programme for one month only, but intense follow-up 3 times weekly for two years as mentioned above (in or outside prisons). Research papers, an Essay and a United Nations submission are available. Dr Karl Schmidt |
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Sheila Hollins
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Your Christmas editorial highlighted the marginalisation of people with learning disabilities and suggested that religious faith was a major driver for professionals called to work in this field. A recent survey of specialist registrars training in the psychiatry of learning disability found that most attributed their choice of specialty to experience in an SHO placement in learning disability. A smaller number chose learning disability because of family experience(Carvill et al, 1999). Whatever the driver, the majority of professionals in this field are highly committed people who have made a positive choice to try and make a difference to people's lives. At a national seminar to launch the strategy review of learning disability services on 20th December, the Under Secretary of State for Social Services, John Hutton, encouraged the 90 policy makers, professionals and service users present to 'aim for the sky' in an attempt to end the social exclusion of people with learning disabilities. I welcome your editorial for bringing these issues to a wider audience. Sheila Hollins,
1. Smith R. Dec (1999) BMJ 2. Carvill S., Marston G., Hollins S., Psychiatric Bulletin (1999), 23, 86-89. |
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Subbiah Arunachalam, Distinguished Fellow M S Swaminathan Research Foundation, Chennai, 600 113, India
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Medicine usually fails the marginalised people, observes Richard Smith [1]. Not just medicine. Every technology man has invented so far has done that and will continue to do that. In recent writings I have shown how information and communication technologies (ICTs) have exacerbated not only the rich-poor divide between nations but also further marginalises the already marginalised people within nations [2]. Rev. Jesse Jacksons has drawn attention to how ICTs have led to deepening the racial divide in the USA [3]. A few years ago, I had shown with ample data on morbidity and mortality and research papers published by Indian medical researchers that much of medical research carried out in India is not in areas where it is most needed [4]. It pays to work on rich man's diseases! The idea of paying special attention to "the poor and mean and lowly" has been emphasised all through human history by noble souls like Jesus Christ, and in recent times, Mahatma Gandhi and Mother Teresa. Yet it is a belief that is constantly forgotten by most of the rest of us. Both human nature and technology need appropriate external intervention if they were to behave in a manner that is beneficial to the large mass of humanity. For Richard Smith, the appropriate external intervention that can drive medicine in the right direction is in the package "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 cannot agree with him more. In support of his case, Smith quotes from the Corinthians. Let me recall what Gandhi had 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?" References 1. Smith R. Medicine and the marginalised. BMJ 1999; 319:1589-1590 2. Arunachalam S. Information and knowledge in the age of electronic communication: a developing country perspective. Journal of Information Science, 1999; 25: 465-476. 3. Rev. Jesse Jackson Jr. quoted by Donna Ladd in The Village Voice. http://villagevoice.com/columns/9929/ladd.html 4. Arunachalam S. How relevant is medical research done in India? - A study based Medline. Current Science 1997. 72:912-922. [The views expressed here are entirely my own and I am not on the pay of any organisation. Absolutely no competing interests. - Subbiah Arunachalam] |
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Bernard Nwulu, Conaultant Psychiatrist Rampton Hospital Retford
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Thanks for reminding us of what medicine is about. The religious underpinning of medicine has for long been ignored. St. Paul who wrote the letter to the Corinthians you cited was a rich man, a politician by the name of Saul of Tarsus. After his dramatic conversion on the road to Damascus, he gave up everything and spent the rest of his life working with and for the marginalised. He thus followed the footsteps of his Master who came for the poor and not for the rich. Those people "who drift into the care of marginalised people" and become marginalised themselves, as you put it, could they be today's real disciples? Could they have discovered the religious underpinning of medicine you advocate? It is for linking religion with medicine and "the poor, the mean and lowly" that I applaud your editorial. By so doing, you join the ranks of Gutierrez1 and Boof, liberation theologians. They talk of "the option for the poor" in the context of a struggle; you talk of marginalization in the context of democracy. Apart from the means, I wonder if you are not all saying the same thing, since ill health and poverty are mutually reinforcing and can generate a vicious cycle of deterioration and suffering. Just as you caution that for a change "we will need more than exhortation from the pulpit", liberation theologians advocate compassion and leadership in the struggle against poverty, in the struggle for a better life here and now, and refuse the orthodoxy that lets the poor believe that their miserable lives are the will of God and that they will be rewarded by a better life in a life to come2 . Your recommended action to drive medicine is a good liberation orthopraxis. Certainly, services need improving for the marginalised patient groups you mentioned. In an era of globalization, I think we ought to look also further a field, so that we do not forget. Professor Haines3 in the other editorial, Joining together to combat poverty: everybody welcome and needed, paints a chilling picture. The world's 225 richest people have combined wealth equivalent to the annual income of the poorest 2.5 billion (nearly half of the world's population. Around 1.3 billion people live in absolute, grinding poverty on less than $1 per day. This is despite the overall growth of the world economy, which doubled in the 25 years before 1998 to $24 trillion. Of the 4.4 billion people in developing countries nearly three fifths lack access to sanitation, a third don't have clean water, about a fifth have no health care, and a fifth do not have enough dietary energy and protein. Marginalization does not come any worse than this! "God can be seen in the face of a starving black child...It is not their innocence, their holiness, their religious perfection, that makes them look like God. It is their suffering, their oppression, the fact that they have been sinned against." 4 Blessed are the merciful! 1 Gutierrez A., A theology of Liberation, 1973 Orbis Books, Maryknoll, NY 2 Davidmann M., Liberation Theology: Basis- Past- Present- Future, Copyright Manfred Davidmann 2nd edition, 1994 3 eBMJ- Haines et al 320(7226) Dec 1999. 4 Nolan A., God in South Africa: the challenge of the gospel, Cape Town: David Philip, 1988 p.67 |
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Oyepeju Raji, Specialist Registrar / Honorary Lecturer South West London Community NHS Trust, Joan Bicknell Centre, Springfield Hospital, London SW17 7DJ
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Dear Editor, This article has a positive subheading which is at odds with your description of those who care for marginalised people as 'perhaps being marginal themselves in some way...'. I wonder if this is evidence based. I think to be described as 'drifting reluctantly' because of 'inability to find a place in more popular parts of medicine' is the kind of image that generates the outcome with which you closed the paragraph. I believe that I made a positive informed decision (as many of my peers) to work towards improving this 'cinderella' image, which requires dedication. I think some excellent people who are not themselves marginalised in anyway, who can find places in the more popular parts of medicine and without religious inspiration commit themselves to caring in this way. The penultimate paragraph of this article is rather discouraging and would contribute to keeping the care of those marginalised just that. |
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Robert Frankford
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Sir, Your editorial "Medicine and the marginalised" [BMJ 1999;319: 1589-1590] is welcome and timely. You note the difficulties of access to health care by those with learning difficulties and dementia. In Ontario there is a complex process of obtaining photo health cards, which inevitably exacerbates the problems you discuss. Dr Robert Frankford
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Neill Simpson
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Editor - Richard Smith drew attention to the mismatch between the health needs of people with learning disabilities and the response of the medical profession (1). "Unfortunately those who care for marginalised groups themselves become marginalised". Recruitment to 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 communication problems, and despite the scope for research, the status of the specialty is not high. So how to proceed? I doubt if young doctors would flock to choose a career which Smith says is staffed by "people, often inspired by religious faith... willing to devote themselves..." and "others... who cannot find places in the more popular parts of medicine and who drift reluctantly...". These extremes of career choice exist, but most Specialist Registrars in Psychiatry of Learning Disability report (2) that the main determinant of their career choice was their experience of high-quality SHO training during a psychiatry rotational training scheme. Young doctors rarely consider a career in the specialty until they discover how rewarding it is to develop skills (especially in communication) that few other doctors have. My vision of what is needed is that all doctors should have good quality teaching on delivering general medical care to people with learning disabilities. All Royal Colleges should test the competence of doctors to deliver medical care in each specialty to people with learning disabilities. Candidates for postgraduate exams should expect to fail if they are unable to demonstrate competence in their specialty with patients with learning disabilities. This would require all medical schools and all Royal Colleges to teach and test these skills. Dr Neill Simpson, PhD, MB, ChB, MRCPsych, MSc, Cert Health Econ, Cert
MHS
References 1 Smith R. Medicine and the marginalised. British Medical Journal, 1999, 319, 1589-1590 2 Carvill S., Marston G., Hollins S. "Tell me what you want, what you really, really want!". Trainee attitudes within the Faculty of Psychiatry of Learning Disability. Psychiatric Bulletin, 1998. |
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Neill Simpson
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Full (revised) version of the second reference is: Carvill S, Marston G, Hollins S (1999) Trainee attitudes within the Faculty of Psychiatry of Learning Disability. Psychiatric Bulletin, 23, 86 -89. |
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Joyce Carter
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I was very pleased to read your editorial in the Christmas edition of the British Medical Journal (1), and in particular your reference to human rights of people with learning difficulties. Interestingly, in the same week another journal published a letter that drew attention to the inequity of provision of screening for Down`s Syndrome (2). It seems to me that the ultimate marginalisation by society that any group can face is that of being systematically sought out and destroyed before birth. The purpose of antenatal screening for Down`s Syndrome, as I understand it, is so that the risk of a foetus being born with this syndrome can be estimated and the parents can decide whether or not to opt for further tests and ultimately termination of the pregnancy if the foetus is deemed to have the syndrome. It is not difficult to see that there could be a connection between this and possible discrimination by the medical profession against people with learning disabilities (1). In the past the British Medical Journal has published papers that discuss antenatal screening for Down`s Syndrome without reference to the human rights of people with Down`s Syndrome (3)(4). In view of the stance that you take in your editorial, will this practice now stop? It is also interesting to speculate whether or not health providers are in breach of the Disability Discrimination Act 1995 (5) if the treatment that they provide to people with learning disabilities is poorer than that provided to the general population (1). But marginalised people do not usually have the resources to undertake legal battles, so it might be some time before this is established through the courts. References 1. Smith R. Medicine and the marginalised. British Medical Journal 1999; 319: 1589-90 (18-25 December 1999) 2. Boyd P, Chamberlain P. Down`s Syndrome screening. Lancet 1999; 354: 2171 (letter) (18-25 December 1999) 3. Steer P. Recent advances: obstetrics. British Medical Journal 1995; 311: 1209-1212 4. Vyas S. Screening for Down`s Syndrome. British Medical Journal 1994; 309: 753-4 5. Disability Discrimination Act 1995. Code of practice. Rights of access. Goods, facilities, services and premises. London: Department for Eduction and Employment, 1999 |
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