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APARTHEID AND AIDS
1280 WORLD MEDICAL ASSOCIATION AND SOUTH AFRICA
SIR,-As a South African born physician who regards health as a human right, I must protest at the shameful defence of the Medical Association of South Africa (MASA) by the secretary-general of the World Medical Association (WMA). Dr Wynen (Oct 7, p 866), who also chairs the Belgian Medical Asssociation, judges MASA by its rhetoric, rather than by what it does. At the same time he tries to discredit the German organisation Verein Demokratischer Arztinnen und Arzte (VDAA), which is actually making a human rights statement. Even if MASA is a co-founder of WMA and has "closely cooperated in formulation of the Association’s philosophy and code of ethics" (Wynen’s letter) and "opposes discrimination on grounds of race, religion, social origin or political persuasion" (MASA’s own official position), the Association has been neglectful in applying those ethical codes in relation to political prisoners and it has been silent about the health-deprivation of the black population, especially in those rural areas which the South African government has declared "independent nation-states", to avoid responsibility. A medical organisation that really is interested in these matters has been formed in South Africa. The National Medical and Dental Association (NAMDA) has far more support from the world community than MASA does. It is WMA and the American, German, Belgian, and certain other white western medical associations that are isolated in their support for MASA. British, Canadian, and all African and Scandinavian medical associations (besides others) have resigned from WMA in the past 10-15 years. WMA’s constitution bars the eastern bloc association because it excludes government controlled or influenced medical associations from membership. Your correspondent seems to accept as human rights freedom of speech, association, and religion, for example, but not socialist ones such as free access to medical care, housing, and education. Over the past decade WMA has given constant comfort and support to MASA, an organisation that has done nothing to change the way medicine is practised and health care delivered in South Africa. In contrast, sports boycott and economic sanctions started to bring about some grudging concessions. WMA, which has been disaffiliated by the World Health Organisation, is now a small, white/western medical association rather than a truly world organisation in medicine.
COST-BENEFIT ANALYSIS AND PRENATAL DIAGNOSIS
SIR,-Alison Davis (Nov 4, p 1104), who has spina bifida, is by parts of the Royal College of Physicians’ report Prenatal Diagnosis and Genetic Screening: Community and Service Implications. To illustrate her objection she cites a paragraph from chapter 6 which, as published, reads: "Most analyses agree that screening and prenatal diagnosis programmes are wanted by the population and offer major fmancial advantages. The investment required is relatively modest and will conserve offended
NHS resources for other uses". Her omission of the underlined phrase suggests that her reading of the report has been (understandably) rather one-sided. The introduction of this section stressed that cost-benefit analysis limited to financial considerations "leads to serious misunderstandings by treating patient management and prenatal diagnosis as alternatives, when in fact they are complementary.., Outstanding benefits are an informed population, informed choice for couples at risk, the birth of healthy infants or of accepted affected ones [my emphasis], and the replacement of aborted fetuses with healthy infants". Fig Iclearly identifies informed parental choice as the main benefit, and its legend states that "the birth of an accepted affected child to informed parents is counted as a benefit". The issue was covered more generally in the chapter on ethical aspects. For example, para 8.6 reads: "While prenatal tests should not be pressed upon anyone, they should be made available, even to women who are completely opposed to abortion, since testing may provide welcome reassurance, or an informed choice to care for a child with a known handicap, or allow the option of abortion to be reconsidered..." And para 8.7, noting that cost and benefits need to be considered, says that "couples should never be pressed to choose termination of an affected pregnancy on grounds of costs". I cannot agree that the report promotes a "eugenic, fetal apartheid". On the contrary, it expresses concern for the care and personal fulfilment of all those born with a disability, and supports their right to a free choice of whether or not to use prenatal diagnosis themselves. Perinatal Centre, Department of Obstetrics and Gynaecology, University College and Middlesex School of Medicine, London WC1E 6HX
BERNADETTE MODELL, Secretary, RCP Working Party on Prenatal Diagnosis
3706 Winchester Dr at Airline Blvd,
Portsmouth, Virginia 23707, USA
JOHN DOMMISSE
APARTHEID AND AIDS
SIR,-Colonel Dickinson (Nov 4, p 1102) writes: "Some people be unduly susceptible to hyperthermia on exercise even in moderate conditions". I am sure that he is right. In 1943 I was working on effects of heat in soldiers at 68 British General Hospital at Shaiba, near Basra, where the midday shade temperature could be as high as 60°C (140°F). We successfully treated twelve cases of hyperpyrexia (heatstroke) with rectal temperatures above 41-5’C. In no case was there a history of excessive exposure to the sun or of unusually hard physical work/ Sweating seemed suddenly to have stopped, for no reason that we seem to
SiR,—To persuade South Africa to abolish its apartheid policy measures have been taken by the international community, including economic sanctions. The harm done by sanctions to the several
South African economy is obvious. As economic activity has slowed down, unemployment, especially in the black community, has risen. For the unemployed poverty and hunger are harsh realities while for those lucky enough to have jobs income remains quite high. Prostitution has become a way of redistributing income and for many families it is the only way to avoid starvation. With prostitution, however, has come AIDS: it is estimated that HIV infection is doubling every 5-8 months. On one calculation 85% of sexually active blacks could be infected with HIV by 1996; most would proceed to AIDS and die, leaving millions of children without parents. Although economic sanctions have speeded up some measures of reform in South Africa they are now harming the very people they were intended to help. Furthermore insidious voices are already being heard saying the government should stop all reform processes and anti-AIDS campaigns and just "sit it out" for the next few years. A further consequence of an ailing economy is the unavailability of funding for those who wish to curb the spread of AIDS via educational and other programmes. AIDS Advisory Group, Potchefstroom University for Christian Higher Education, Potchefstroom 2520, South Africa
HEATSTROKE AND THE ARMED FORCES
A. T. VILJOEN
could determine. There may have been a psychological element. I remember one soldier who was waiting in a transit camp for movement orders, doing no physical work; he went for a sleep after lunch and at teatime was found unconscious and hyperpyrexial. A transit camp in the desert is a situation of unparalleled boredom. Discussions in your columns have used vague terms such as "heat illness" and "heat catastrophe" and do not distinguish between hyperpyrexia and the completely different syndrome of dehydration and circulatory collapse ("heat exhaustion") due to heavy sweating and salt depletion. People with heat exhaustion, who tend to be hypothermic, may also die unless treated quickly. I believe that in this condition also there are differences in susceptibility, perhaps because some people conserve salt more than others. All men were supposed to take salt tablets. As might be expected under the conditions in which we were working there were large numbers of heat casualties, including some in Indian soldiers. At that time there were about a million men in the Persia-Iraq Force. The question therefore arises, just as it does with
SIR,-As a South African born physician who regards health as a human right, I must protest at the shameful defence of the Medical Association of South Africa (MASA) by the secretary-general of the World Medical Association (WMA). Dr Wynen (Oct 7, p 866), who also chairs the Belgian Medical Asssociation, judges MASA by its rhetoric, rather than by what it does. At the same time he tries to discredit the German organisation Verein Demokratischer Arztinnen und Arzte (VDAA), which is actually making a human rights statement. Even if MASA is a co-founder of WMA and has "closely cooperated in formulation of the Association’s philosophy and code of ethics" (Wynen’s letter) and "opposes discrimination on grounds of race, religion, social origin or political persuasion" (MASA’s own official position), the Association has been neglectful in applying those ethical codes in relation to political prisoners and it has been silent about the health-deprivation of the black population, especially in those rural areas which the South African government has declared "independent nation-states", to avoid responsibility. A medical organisation that really is interested in these matters has been formed in South Africa. The National Medical and Dental Association (NAMDA) has far more support from the world community than MASA does. It is WMA and the American, German, Belgian, and certain other white western medical associations that are isolated in their support for MASA. British, Canadian, and all African and Scandinavian medical associations (besides others) have resigned from WMA in the past 10-15 years. WMA’s constitution bars the eastern bloc association because it excludes government controlled or influenced medical associations from membership. Your correspondent seems to accept as human rights freedom of speech, association, and religion, for example, but not socialist ones such as free access to medical care, housing, and education. Over the past decade WMA has given constant comfort and support to MASA, an organisation that has done nothing to change the way medicine is practised and health care delivered in South Africa. In contrast, sports boycott and economic sanctions started to bring about some grudging concessions. WMA, which has been disaffiliated by the World Health Organisation, is now a small, white/western medical association rather than a truly world organisation in medicine.
COST-BENEFIT ANALYSIS AND PRENATAL DIAGNOSIS
SIR,-Alison Davis (Nov 4, p 1104), who has spina bifida, is by parts of the Royal College of Physicians’ report Prenatal Diagnosis and Genetic Screening: Community and Service Implications. To illustrate her objection she cites a paragraph from chapter 6 which, as published, reads: "Most analyses agree that screening and prenatal diagnosis programmes are wanted by the population and offer major fmancial advantages. The investment required is relatively modest and will conserve offended
NHS resources for other uses". Her omission of the underlined phrase suggests that her reading of the report has been (understandably) rather one-sided. The introduction of this section stressed that cost-benefit analysis limited to financial considerations "leads to serious misunderstandings by treating patient management and prenatal diagnosis as alternatives, when in fact they are complementary.., Outstanding benefits are an informed population, informed choice for couples at risk, the birth of healthy infants or of accepted affected ones [my emphasis], and the replacement of aborted fetuses with healthy infants". Fig Iclearly identifies informed parental choice as the main benefit, and its legend states that "the birth of an accepted affected child to informed parents is counted as a benefit". The issue was covered more generally in the chapter on ethical aspects. For example, para 8.6 reads: "While prenatal tests should not be pressed upon anyone, they should be made available, even to women who are completely opposed to abortion, since testing may provide welcome reassurance, or an informed choice to care for a child with a known handicap, or allow the option of abortion to be reconsidered..." And para 8.7, noting that cost and benefits need to be considered, says that "couples should never be pressed to choose termination of an affected pregnancy on grounds of costs". I cannot agree that the report promotes a "eugenic, fetal apartheid". On the contrary, it expresses concern for the care and personal fulfilment of all those born with a disability, and supports their right to a free choice of whether or not to use prenatal diagnosis themselves. Perinatal Centre, Department of Obstetrics and Gynaecology, University College and Middlesex School of Medicine, London WC1E 6HX
BERNADETTE MODELL, Secretary, RCP Working Party on Prenatal Diagnosis
3706 Winchester Dr at Airline Blvd,
Portsmouth, Virginia 23707, USA
JOHN DOMMISSE
APARTHEID AND AIDS
SIR,-Colonel Dickinson (Nov 4, p 1102) writes: "Some people be unduly susceptible to hyperthermia on exercise even in moderate conditions". I am sure that he is right. In 1943 I was working on effects of heat in soldiers at 68 British General Hospital at Shaiba, near Basra, where the midday shade temperature could be as high as 60°C (140°F). We successfully treated twelve cases of hyperpyrexia (heatstroke) with rectal temperatures above 41-5’C. In no case was there a history of excessive exposure to the sun or of unusually hard physical work/ Sweating seemed suddenly to have stopped, for no reason that we seem to
SiR,—To persuade South Africa to abolish its apartheid policy measures have been taken by the international community, including economic sanctions. The harm done by sanctions to the several
South African economy is obvious. As economic activity has slowed down, unemployment, especially in the black community, has risen. For the unemployed poverty and hunger are harsh realities while for those lucky enough to have jobs income remains quite high. Prostitution has become a way of redistributing income and for many families it is the only way to avoid starvation. With prostitution, however, has come AIDS: it is estimated that HIV infection is doubling every 5-8 months. On one calculation 85% of sexually active blacks could be infected with HIV by 1996; most would proceed to AIDS and die, leaving millions of children without parents. Although economic sanctions have speeded up some measures of reform in South Africa they are now harming the very people they were intended to help. Furthermore insidious voices are already being heard saying the government should stop all reform processes and anti-AIDS campaigns and just "sit it out" for the next few years. A further consequence of an ailing economy is the unavailability of funding for those who wish to curb the spread of AIDS via educational and other programmes. AIDS Advisory Group, Potchefstroom University for Christian Higher Education, Potchefstroom 2520, South Africa
HEATSTROKE AND THE ARMED FORCES
A. T. VILJOEN
could determine. There may have been a psychological element. I remember one soldier who was waiting in a transit camp for movement orders, doing no physical work; he went for a sleep after lunch and at teatime was found unconscious and hyperpyrexial. A transit camp in the desert is a situation of unparalleled boredom. Discussions in your columns have used vague terms such as "heat illness" and "heat catastrophe" and do not distinguish between hyperpyrexia and the completely different syndrome of dehydration and circulatory collapse ("heat exhaustion") due to heavy sweating and salt depletion. People with heat exhaustion, who tend to be hypothermic, may also die unless treated quickly. I believe that in this condition also there are differences in susceptibility, perhaps because some people conserve salt more than others. All men were supposed to take salt tablets. As might be expected under the conditions in which we were working there were large numbers of heat casualties, including some in Indian soldiers. At that time there were about a million men in the Persia-Iraq Force. The question therefore arises, just as it does with