- Email: [email protected]
HELP FOR DEVELOPING COUNTRIES
1223
prosecution of major research, and in this it differs greatly from the American and continental systems. ,
Department of Pharmacology, University of Bath,
R. J. ANCILL
Bath BA2 7AY
INTERNMENT OF PALESTINIAN HEALTH WORKERS
SIR,-Dr McCarthy’s useful account of medical relief in Lebanon p. 1094) stresses the seriousness of the situation in the camps, where "hospital and clinic treatment used to be provided by the Palestinian Red Crescent Society... now banned in in the meantime Palestinians get the Israeli-occupied south;
(Nov. 13, refugee
...
inadequate or no health care". We were asked to visit Lebanon during late October by an AngloPeace in Lebanon and Israel. We found a desperate need for health care, due to the virtual destruction of the medical infrastructure, which is now being temporarily shored up by the external relief agencies. It.seems essential for the refugee community to resume responsibility for their own medical care, particularly since the Lebanese hospitals are reluctant to admit Palestinian refugees from the bombed camps. About 150 Palestinian nurses and health workers with between 15 and 20 doctors from the refugees’ hospitals and clinics are now interned by the Israelis, without any formal charges or access to legal representation. This was confirmed by several sources, including Christian Aid, Middle East Council of Churches, International Committee of Red Cross Societies, and the U.N. Relief and Welfare Agency, who also gave us the names of several medical prisoners. When we spoke to Colonel Adler and Dr Tulchinsky, who are responsible for civilian health care in Israeli occupied south Lebanon, they seemed to justify these detentions on the grounds that "they may have disguised terrorists as their patients". Our own attempt to visit Ansar internment camp was unsuccessful, as neither the camp commandant nor the chief medical officer, Dr Tamir, would agree to speak to us and we were refused entry. There are about 8000 prisoners in Ansar, including the nurses and doctors; it is a desolate place surrounded by barbed wire fences, a perimeter minefield, and a series of manned watchtowers. Most of the detainees have been in captivity under harsh conditions for five months. We are writing to ask Lancet readers to urge, by all available means, the release ofour colleagues so that they can return to medical work. If there is any contention that these detainees are being held for illegal activities they should be charged and given an open and fair trial.
Jewish organisation,
St Bartholomew’s Hospital, London EC1
MARTIN BIRNSTINGL
Institute of Child Health, London WC1
PAMELA ZINKIN
HELP FOR DEVELOPING COUNTRIES
SiR,—The article by Dr McLarty and colleagues (Oct. 9,
p. 810) pituitary tumours and blindness in Tanzania was most interesting and reminded me that I have not diagnosed a pituitary tumour in Nepal in thirteen years. Diagnostic blindness-or one of those fascinating geographical pathology puzzles that so often shed light on the pathogenesis of disease? With many regrets, I have to disagree with the suggestion that such patients should receive treatment abroad. This suggestion clearly reflects the frustration felt by many of us working in developing countries when we meet patients who would benefit from techniques that are not, and indeed should not be, available in
about
countries where resources are severely limited and where priorities in health care are very basic. It is attractive to send pituitary tumour patients to a sympathetic unit abroad. But who will pay the air fares for the patient and companions? In most developing countries, where family ties are so tight, it would be unthinkable for a person to travel alone. There might be other problems, too; neither patient or relative may be able
to speak English (or Italian or whatever). There may be taboos about foreign travel, especially if there is a risk of dying in a far-offforeign land with very different customs, culture, and religion. A more general objection is this. The public mind finds it hard to acknowledge that some conditions are curable whereas others are not (and the results in the five pituitary tumour patients treated overseas were not impressive). Surely local people will start asking
why Mr X was sent overseas for treatment and not Mrs Y? This will be even worse if only certain privileged groups, such as government employees, are sent, as happens in several countries I know. Rightly or wrongly, the public sense of social justice will be outraged. At the risk of being thought uncompassionate, I suggest that developing countries must live within their medical means, extending their health services as rapidly as possible within a well thought-out system of priorities that is appropriate to their needs. The main way in which overseas governments and other bodies can assist is by giving generous aid to carefully selected development projects. Only in this way can the majority of the people, and ultimately the individual, receive the maximum benefit from overseas interest and generosity. Shanta Bhawan Hospital, GPO Box 252,
Kathmandu, Nepal
JOHN DICKINSON
CONTROL OF ACUTE ZOLLINGER-ELLISON SYNDROME WITH INTRAVENOUS OMEPRAZOLE
SIR,-Omeprazole, a substituted benzimidazole, is a potent, longacting inhibitor of acid secretion.] Preliminary results with oral omeprazole in patients with Zollinger-Ellison syndrome were presented in Stockholm in June, 1982.2 We report experience with intravenous omeprazole in a case of acute Zollinger-Ellison syndrome not responding to high-dose cimetidine. A 37-year-old man whose father had multiple endocrine neoplasia was admitted to hospital in June, 1982, with a perforated jejunal ulcer. A 40 cm jejunal resection was done with end-to-end anastomosis. Postoperative investigations disclosed pituitary dysfunction, hyperparathyroidism, and Zollinger-Ellison syndrome (severe diarrhoea, multiple duodenal ulcerations, basal acid concentration >100 mmol/l, basal acid output [BAO] >110 mmol/h, serum gastrin about 1000 pg/ml, on several samples). During the course of this investigation, gastric hypersecretion was not controlled by intravenous cimetidine 2.4 g daily. After an episode of gastrointestinal haemorrhage the patient was transferred to our intensive care unit critically ill with fever and right-upper-quadrant abdominal tenderness. A localised peritonitis with a perforated jejunal ulcer was found at operation. A jejunostomy was performed. A few days later, a parathyroid adenoma was removed with no change in acid hypersecretion. Despite cimetidine infusion 4 -8 g daily, hourly gastric aspiration ’
volume and BAO remained above 250 ml and 20 mmol/h respectively. A proximal occlusion led to resection of a perforated jejunal segment with end-to-end anastomosis. Cimetidine infusion was stopped and i.v. omeprazole 60 mg three times daily was started. In the hour following the first injection, the pH of the gastric juice rose from 1 to 4-5 5 and BAO fell to zero. With this therapeutic regimen, daily gastric aspiration volume, which previously exceeded 4 litres, fell to 1 litre and the gastric pH remained above 4. The patient improved markedly and oral feeding was resumed. Omeprazole was then given orally 90 mg twice daily. 12 h after each dose there was no free acid; continuous intragastric monitoring showed the pH to be permanently above 6. 1 month later, the omeprazole dose was reduced to 90 mg once a day with no significant change in acid output. No side-effects were observed. In this patient with acute Zollinger-Ellison syndrome not controlled by cimetidine, intravenous omeprazole proved to be very 1. Olbe L,
2.
Haglund U, Leth R, Lind T, Cedeberg C, Ekenved G, Elander B, Fellenius E, Lundborg P, Wallmark B. Effects of substituted benzimidazole (H 149/94) on gastric acid secretion in humans. Gastroenterology 1982; 83: 193-98. Lamers CBH, Rune S, Hamberger B, Moberg S, Olbe L, Lind T. Experience with omeprazole in the Zollinger-Ellison syndrome. In: Symposium on Substituted Benzimidazole at World Congress of Gastroenterology (Stockholm, June 16, 1982).
prosecution of major research, and in this it differs greatly from the American and continental systems. ,
Department of Pharmacology, University of Bath,
R. J. ANCILL
Bath BA2 7AY
INTERNMENT OF PALESTINIAN HEALTH WORKERS
SIR,-Dr McCarthy’s useful account of medical relief in Lebanon p. 1094) stresses the seriousness of the situation in the camps, where "hospital and clinic treatment used to be provided by the Palestinian Red Crescent Society... now banned in in the meantime Palestinians get the Israeli-occupied south;
(Nov. 13, refugee
...
inadequate or no health care". We were asked to visit Lebanon during late October by an AngloPeace in Lebanon and Israel. We found a desperate need for health care, due to the virtual destruction of the medical infrastructure, which is now being temporarily shored up by the external relief agencies. It.seems essential for the refugee community to resume responsibility for their own medical care, particularly since the Lebanese hospitals are reluctant to admit Palestinian refugees from the bombed camps. About 150 Palestinian nurses and health workers with between 15 and 20 doctors from the refugees’ hospitals and clinics are now interned by the Israelis, without any formal charges or access to legal representation. This was confirmed by several sources, including Christian Aid, Middle East Council of Churches, International Committee of Red Cross Societies, and the U.N. Relief and Welfare Agency, who also gave us the names of several medical prisoners. When we spoke to Colonel Adler and Dr Tulchinsky, who are responsible for civilian health care in Israeli occupied south Lebanon, they seemed to justify these detentions on the grounds that "they may have disguised terrorists as their patients". Our own attempt to visit Ansar internment camp was unsuccessful, as neither the camp commandant nor the chief medical officer, Dr Tamir, would agree to speak to us and we were refused entry. There are about 8000 prisoners in Ansar, including the nurses and doctors; it is a desolate place surrounded by barbed wire fences, a perimeter minefield, and a series of manned watchtowers. Most of the detainees have been in captivity under harsh conditions for five months. We are writing to ask Lancet readers to urge, by all available means, the release ofour colleagues so that they can return to medical work. If there is any contention that these detainees are being held for illegal activities they should be charged and given an open and fair trial.
Jewish organisation,
St Bartholomew’s Hospital, London EC1
MARTIN BIRNSTINGL
Institute of Child Health, London WC1
PAMELA ZINKIN
HELP FOR DEVELOPING COUNTRIES
SiR,—The article by Dr McLarty and colleagues (Oct. 9,
p. 810) pituitary tumours and blindness in Tanzania was most interesting and reminded me that I have not diagnosed a pituitary tumour in Nepal in thirteen years. Diagnostic blindness-or one of those fascinating geographical pathology puzzles that so often shed light on the pathogenesis of disease? With many regrets, I have to disagree with the suggestion that such patients should receive treatment abroad. This suggestion clearly reflects the frustration felt by many of us working in developing countries when we meet patients who would benefit from techniques that are not, and indeed should not be, available in
about
countries where resources are severely limited and where priorities in health care are very basic. It is attractive to send pituitary tumour patients to a sympathetic unit abroad. But who will pay the air fares for the patient and companions? In most developing countries, where family ties are so tight, it would be unthinkable for a person to travel alone. There might be other problems, too; neither patient or relative may be able
to speak English (or Italian or whatever). There may be taboos about foreign travel, especially if there is a risk of dying in a far-offforeign land with very different customs, culture, and religion. A more general objection is this. The public mind finds it hard to acknowledge that some conditions are curable whereas others are not (and the results in the five pituitary tumour patients treated overseas were not impressive). Surely local people will start asking
why Mr X was sent overseas for treatment and not Mrs Y? This will be even worse if only certain privileged groups, such as government employees, are sent, as happens in several countries I know. Rightly or wrongly, the public sense of social justice will be outraged. At the risk of being thought uncompassionate, I suggest that developing countries must live within their medical means, extending their health services as rapidly as possible within a well thought-out system of priorities that is appropriate to their needs. The main way in which overseas governments and other bodies can assist is by giving generous aid to carefully selected development projects. Only in this way can the majority of the people, and ultimately the individual, receive the maximum benefit from overseas interest and generosity. Shanta Bhawan Hospital, GPO Box 252,
Kathmandu, Nepal
JOHN DICKINSON
CONTROL OF ACUTE ZOLLINGER-ELLISON SYNDROME WITH INTRAVENOUS OMEPRAZOLE
SIR,-Omeprazole, a substituted benzimidazole, is a potent, longacting inhibitor of acid secretion.] Preliminary results with oral omeprazole in patients with Zollinger-Ellison syndrome were presented in Stockholm in June, 1982.2 We report experience with intravenous omeprazole in a case of acute Zollinger-Ellison syndrome not responding to high-dose cimetidine. A 37-year-old man whose father had multiple endocrine neoplasia was admitted to hospital in June, 1982, with a perforated jejunal ulcer. A 40 cm jejunal resection was done with end-to-end anastomosis. Postoperative investigations disclosed pituitary dysfunction, hyperparathyroidism, and Zollinger-Ellison syndrome (severe diarrhoea, multiple duodenal ulcerations, basal acid concentration >100 mmol/l, basal acid output [BAO] >110 mmol/h, serum gastrin about 1000 pg/ml, on several samples). During the course of this investigation, gastric hypersecretion was not controlled by intravenous cimetidine 2.4 g daily. After an episode of gastrointestinal haemorrhage the patient was transferred to our intensive care unit critically ill with fever and right-upper-quadrant abdominal tenderness. A localised peritonitis with a perforated jejunal ulcer was found at operation. A jejunostomy was performed. A few days later, a parathyroid adenoma was removed with no change in acid hypersecretion. Despite cimetidine infusion 4 -8 g daily, hourly gastric aspiration ’
volume and BAO remained above 250 ml and 20 mmol/h respectively. A proximal occlusion led to resection of a perforated jejunal segment with end-to-end anastomosis. Cimetidine infusion was stopped and i.v. omeprazole 60 mg three times daily was started. In the hour following the first injection, the pH of the gastric juice rose from 1 to 4-5 5 and BAO fell to zero. With this therapeutic regimen, daily gastric aspiration volume, which previously exceeded 4 litres, fell to 1 litre and the gastric pH remained above 4. The patient improved markedly and oral feeding was resumed. Omeprazole was then given orally 90 mg twice daily. 12 h after each dose there was no free acid; continuous intragastric monitoring showed the pH to be permanently above 6. 1 month later, the omeprazole dose was reduced to 90 mg once a day with no significant change in acid output. No side-effects were observed. In this patient with acute Zollinger-Ellison syndrome not controlled by cimetidine, intravenous omeprazole proved to be very 1. Olbe L,
2.
Haglund U, Leth R, Lind T, Cedeberg C, Ekenved G, Elander B, Fellenius E, Lundborg P, Wallmark B. Effects of substituted benzimidazole (H 149/94) on gastric acid secretion in humans. Gastroenterology 1982; 83: 193-98. Lamers CBH, Rune S, Hamberger B, Moberg S, Olbe L, Lind T. Experience with omeprazole in the Zollinger-Ellison syndrome. In: Symposium on Substituted Benzimidazole at World Congress of Gastroenterology (Stockholm, June 16, 1982).