Editor's Choice Editor’s choice

Acts of no mercy

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4384 (Published 11 August 2010) Cite this as: BMJ 2010;341:c4384
  1. Tony Delamothe, deputy editor, BMJ
  1. tdelamothe{at}bmj.com

    Painted between 1915 and 1920, this week’s medical classic is free of asylum seekers and demented patients. Instead the main subject matter of “Acts of Mercy” is orphans and convalescent soldiers (doi:10.1136/bmj.c4349). Who should be the proper beneficiaries of our mercy these days? This week’s journal provides some pointers.

    Margaret McCartney chronicles the health care provided, or rather not provided, for the 3000 asylum seekers held in the UK’s 11 immigration removal centres (doi:10.1136/bmj.c4106). Only the UK Borders Agency seems to have a good word to say for the services they are providing.

    The mental health charity Mind thinks that the centres lack mental healthcare resources and specific guidelines about what they should be providing. One of the 100 or so doctors who work for the charity Medical Justice told McCartney of the “gross mismanagement of diabetes and tuberculosis, failure to recognise and treat serious mental illness, and restraint and denial of privacy during highly confidential consultations when taken to outpatients.”

    Although the UK Borders Agency’s guidance says that minors should be detained only in exceptional circumstances, at least 1315 children were detained at three removal centres during 2008 and 2009. The public protested immediately when a baby girl was placed in the care of Dungavel removal centre in May, and McCartney thinks that public pressure might be the way to effect improvements.

    Despite the presumption that detainees will be shackled for hospital visits, removal centres are not prisons, and the responsibility for health care remains with the Home Office. Responsibilities for prison health care were transferred from the Home Office to the NHS several years ago. If this led to improvements—and anecdotally, at least, it seems that it has—then shouldn’t this transfer be urgently considered for asylum seekers’ health care?

    Anthropologists talk about “the other,” and in 21st century Britain, asylum seekers are our other, licensing us to persecute them as we see fit. But what explains the punishment meted out to some patients with dementia, who are as well known to us as our parents, and may even be our parents?

    In his personal view, a doctor writes of what happened to his “dear old dad, 72, a physically fit and robust man of late, [who] has Alzheimer’s disease, we think” (doi:10.1136/bmj.c4310). Despite seeing a series of consultants a firm diagnosis is never made. On his first admission his wife “specials” him because of staff shortages. He’s discharged with assurances that his GP has been informed and that follow-up arrangements have been made. In fact, neither has happened. Two doctors counsel strongly against night sedation, yet others prescribe it, with predictable results. Back home, crisis management stops at 9 pm, so the only option is to dial 999 and subject the patient “to another harrowing period of inpatient mismanagement.”

    The author concludes: try not to get dementia and if a relative or friend develops it, gear yourself up for a very tough time and ask your family, friends, and neighbours to rally round. The health service may not be much use.

    And to avoid dementia? Ritchie and colleagues’ cohort study suggests that increasing reading ability and consumption of fruit and vegetables and eliminating depression and diabetes would probably have the biggest effect on reducing the incidence of the disease (doi:10.1136/bmj.c3885). However, editorialists Tobias Kurth and Giancarlo Logroscino argue that it is too early for prevention programmes that target these factors, given the uncertainty of causality and lack of proof that such interventions would actually work (doi:10.1136/bmj.c4201).

    While waiting for the science of dementia to catch up there is scope for more public pressure—this time for the universal adoption of a humane patient pathway for people with dementia.


    Cite this as: BMJ 2010;341:c4384


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