- Email: [email protected]
Paul Ehrlich's ingredients for success
CORRESPONDENCE
hepatitis B infection—the very areas where vaccination has the potential to do the most good. This failure is in spite of there being a strong argument that sponsoring vaccination programmes in developing countries might be a costeffective way for developed countries to reduce their own rates of hepatitis B infection.3 Any progress in drug treatment of or vaccination against HCV infection is, of course, welcome. However, no matter how dramatic the scientific breakthroughs, political and economic change will be needed before such advances can offer hope to the poorest countries. Research into effective affordable strategies for the prevention of HCV infection in developing countries is needed. Unfortunately, without the potential for profits from drug or vaccine sales, such research is likely to remain underfunded. Liam Smeeth Department of Epidemiology and Public Health, University College London Medical School, London WC1E 6BT, UK (e-mail [email protected]) 1 2 3
McConnell J. Hepatitis treatment moves on. Lancet 1998; 352: 964. WHO. Hepatitis B vaccination. Geneva: WHO, 1992. Gay NJ, Edmunds WJ. Developed countries could pay for hepatitis B vaccination in developing countries. BMJ 1998; 316: 1457.
Racism in the medical profession Sir—Like many other retired people I have begun to compose letters of encouragement or criticism of what The Lancet has published only to go fishing instead of finishing them, but I hope you will consider putting effort into two local human rights campaigns that are dear to my heart. The first is that of racisim within the medical profession. I know that you have highlighted this in the past but it is still widespread and is something of which we should be greatly ashamed. During my last task in the National Health Service as the postgraduate dean’s representative on appointment committees for specialist registrar posts, I have become aware that racism at appointment committees is now not great but in the shortlisting procedures it remains rife. Arising out of this is a matter, which is of much greater and wider importance: it is discrimination within our profession against people who are “not like us”. We, as doctors, like many other professions, continue to select as students and as young doctors in training at all grades and then
1712
eventually as consultants, people who are in our own image. We fail to select people of a wider background and culture, those who are better able to empathise with and gain the trust of the disadvantaged, the poor, the criminal, the alcoholic, the drug taker, the tramp, the unloved and the unloveable—all those who most need our help if we are ever to achieve equality of health care. It is far, far more difficult to be a competent prison medical officer than to be a specialist in palliative care, but we as a profession are a long way from recognising that.
inadequate resources and facilities for paediatric intensive care and ventilatory support in many dengue endemic areas in developing countries are serious shortcomings in the treatment of children with dengue shock syndrome. This point is conspicuously absent from the Rigau-Pérez and colleagues’ seminar. Meow-Keong Thong Department of Paediatrics, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia 1
P M S Gillam Postgraduate Medical Education Department, Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ, UK
2
3
Dengue shock syndrome and acute respiratory distress syndrome Sir—José Rigau-Pérez and colleagues’ seminar (Sept 19, p 971)1 on dengue and dengue haemorrhagic fever was timely and highlights the importance of this worldwide human viral disease transmitted by arthropod vectors. The seminar addresses unusual manifestations of dengue infection, such as dengue fever with severe haemorrhage, hepatic damage, pulmonary effusion, congestive cardiac failure, and encephalopathy. I would like to draw your attention to another severe manifestation of dengue shock syndrome which results in acute or adult respiratory distress syndrome (ARDS),2 as defined by Murray and co-workers.3 With this manifestation, first described in 1995, increased permeability of the alveolar-capillary membrane results in oedema in the alveoli and interstitial spaces which leads to a deterioration in pulmonary function.2 Dengue shock syndrome is reported to be the third leading cause of ARDS in the paediatric intensive care setting in a dengue endemic area after sepsis and pneumonia.4 There are two important implications of this manifestation. First, early restoration of adequate tissue perfusion is critical to prevent progression of dengue shock syndrome to ARDS. However, equal care must be exercised to avoid excessive fluid infusion after adequate volume replacement because fluid overload may result in ARDS. Second, this manifestation in children requires early recognition and appropriate treatment by means of intermittent positive pressure ventilation with positive end expiratory pressure.2,4 Although the benefits of effective prevention of dengue fever is clear,
4
Rigau-Pérez JG, Clark GG, Gubler DJ, et al. Dengue and dengue haemorrhagic fever. Lancet 1998; 352: 971–77. Lum LCS, Thong MK, Cheah YK, Lam SK. Dengue-associated adult respiratory distress syndrome. Ann Trop Paed 1995; 15: 335–39. Murray JF, Matthay MA, Luce JM, et al. An expanded definition of the adult acute respiratory distress syndrome. Am Rev Respir Dis 1988; 138: 720–23. Goh AYT, Chan PWK, Lum LCS, Roziah M. Incidence of acute respiratory distress syndrome: a comparison of two definitions. Arch Dis Child 1998; 79: 256–59.
Paul Ehrlich’s ingredients for success Sir—In the “Nobel Chronicles” (Aug 22, p 661),1 Tonse N K Raju informs us that Nobel Prize Winner Paul Ehrlich’s four G’s for success were: Geld (money), Geduld (patience), Geschick (cleverness), and Gluck (luck). For someone who spent his life researching immunity and disease, it is both astonishing and ironic that Ehrlich overlooked a fifth (and no less vital) ingredient for success: Gesundheit (health). His co-winner, Elie Metchnikoff, who nearly committed suicide after his brother’s death from cancer and his first wife’s death from tuberculosis, would no doubt have included Gesundheit in any formula for success. Avi Israeli Hadassah Medical Organization, Kiryat Hadassah, PO Box 12000, 11-91120 Jerusalem, Israel 1
Raju Tonse NK. The Nobel Chronicles. 1908: Elie Metchnikoff (1845–1916) and Paul Ehrlich (1854–1915). Lancet 1998; 352: 661.
DEPARTMENT OF ERROR ∆F508 heterozygosity and asthma: Author’s reply—In this letter by Morten Dahl and colleagues (Sept 19, p 986), the third sentence of the first paragraph should have read: However . . . ∆F508 carriers had lower forced expiratory volume in 1 s (FEV1) % predicted and forced vital capacity (FVC) % predicted than non-carriers.
THE LANCET • Vol 352 • November 21, 1998
hepatitis B infection—the very areas where vaccination has the potential to do the most good. This failure is in spite of there being a strong argument that sponsoring vaccination programmes in developing countries might be a costeffective way for developed countries to reduce their own rates of hepatitis B infection.3 Any progress in drug treatment of or vaccination against HCV infection is, of course, welcome. However, no matter how dramatic the scientific breakthroughs, political and economic change will be needed before such advances can offer hope to the poorest countries. Research into effective affordable strategies for the prevention of HCV infection in developing countries is needed. Unfortunately, without the potential for profits from drug or vaccine sales, such research is likely to remain underfunded. Liam Smeeth Department of Epidemiology and Public Health, University College London Medical School, London WC1E 6BT, UK (e-mail [email protected]) 1 2 3
McConnell J. Hepatitis treatment moves on. Lancet 1998; 352: 964. WHO. Hepatitis B vaccination. Geneva: WHO, 1992. Gay NJ, Edmunds WJ. Developed countries could pay for hepatitis B vaccination in developing countries. BMJ 1998; 316: 1457.
Racism in the medical profession Sir—Like many other retired people I have begun to compose letters of encouragement or criticism of what The Lancet has published only to go fishing instead of finishing them, but I hope you will consider putting effort into two local human rights campaigns that are dear to my heart. The first is that of racisim within the medical profession. I know that you have highlighted this in the past but it is still widespread and is something of which we should be greatly ashamed. During my last task in the National Health Service as the postgraduate dean’s representative on appointment committees for specialist registrar posts, I have become aware that racism at appointment committees is now not great but in the shortlisting procedures it remains rife. Arising out of this is a matter, which is of much greater and wider importance: it is discrimination within our profession against people who are “not like us”. We, as doctors, like many other professions, continue to select as students and as young doctors in training at all grades and then
1712
eventually as consultants, people who are in our own image. We fail to select people of a wider background and culture, those who are better able to empathise with and gain the trust of the disadvantaged, the poor, the criminal, the alcoholic, the drug taker, the tramp, the unloved and the unloveable—all those who most need our help if we are ever to achieve equality of health care. It is far, far more difficult to be a competent prison medical officer than to be a specialist in palliative care, but we as a profession are a long way from recognising that.
inadequate resources and facilities for paediatric intensive care and ventilatory support in many dengue endemic areas in developing countries are serious shortcomings in the treatment of children with dengue shock syndrome. This point is conspicuously absent from the Rigau-Pérez and colleagues’ seminar. Meow-Keong Thong Department of Paediatrics, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia 1
P M S Gillam Postgraduate Medical Education Department, Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ, UK
2
3
Dengue shock syndrome and acute respiratory distress syndrome Sir—José Rigau-Pérez and colleagues’ seminar (Sept 19, p 971)1 on dengue and dengue haemorrhagic fever was timely and highlights the importance of this worldwide human viral disease transmitted by arthropod vectors. The seminar addresses unusual manifestations of dengue infection, such as dengue fever with severe haemorrhage, hepatic damage, pulmonary effusion, congestive cardiac failure, and encephalopathy. I would like to draw your attention to another severe manifestation of dengue shock syndrome which results in acute or adult respiratory distress syndrome (ARDS),2 as defined by Murray and co-workers.3 With this manifestation, first described in 1995, increased permeability of the alveolar-capillary membrane results in oedema in the alveoli and interstitial spaces which leads to a deterioration in pulmonary function.2 Dengue shock syndrome is reported to be the third leading cause of ARDS in the paediatric intensive care setting in a dengue endemic area after sepsis and pneumonia.4 There are two important implications of this manifestation. First, early restoration of adequate tissue perfusion is critical to prevent progression of dengue shock syndrome to ARDS. However, equal care must be exercised to avoid excessive fluid infusion after adequate volume replacement because fluid overload may result in ARDS. Second, this manifestation in children requires early recognition and appropriate treatment by means of intermittent positive pressure ventilation with positive end expiratory pressure.2,4 Although the benefits of effective prevention of dengue fever is clear,
4
Rigau-Pérez JG, Clark GG, Gubler DJ, et al. Dengue and dengue haemorrhagic fever. Lancet 1998; 352: 971–77. Lum LCS, Thong MK, Cheah YK, Lam SK. Dengue-associated adult respiratory distress syndrome. Ann Trop Paed 1995; 15: 335–39. Murray JF, Matthay MA, Luce JM, et al. An expanded definition of the adult acute respiratory distress syndrome. Am Rev Respir Dis 1988; 138: 720–23. Goh AYT, Chan PWK, Lum LCS, Roziah M. Incidence of acute respiratory distress syndrome: a comparison of two definitions. Arch Dis Child 1998; 79: 256–59.
Paul Ehrlich’s ingredients for success Sir—In the “Nobel Chronicles” (Aug 22, p 661),1 Tonse N K Raju informs us that Nobel Prize Winner Paul Ehrlich’s four G’s for success were: Geld (money), Geduld (patience), Geschick (cleverness), and Gluck (luck). For someone who spent his life researching immunity and disease, it is both astonishing and ironic that Ehrlich overlooked a fifth (and no less vital) ingredient for success: Gesundheit (health). His co-winner, Elie Metchnikoff, who nearly committed suicide after his brother’s death from cancer and his first wife’s death from tuberculosis, would no doubt have included Gesundheit in any formula for success. Avi Israeli Hadassah Medical Organization, Kiryat Hadassah, PO Box 12000, 11-91120 Jerusalem, Israel 1
Raju Tonse NK. The Nobel Chronicles. 1908: Elie Metchnikoff (1845–1916) and Paul Ehrlich (1854–1915). Lancet 1998; 352: 661.
DEPARTMENT OF ERROR ∆F508 heterozygosity and asthma: Author’s reply—In this letter by Morten Dahl and colleagues (Sept 19, p 986), the third sentence of the first paragraph should have read: However . . . ∆F508 carriers had lower forced expiratory volume in 1 s (FEV1) % predicted and forced vital capacity (FVC) % predicted than non-carriers.
THE LANCET • Vol 352 • November 21, 1998