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Duty on child-abuse expert witnesses
much better balanced is needed. The modular General Education Diploma’ proposed by the National Commission on Education would provide exactly that. As a former dean of a medical school I would strongly emphasise the value of a good grounding in the arts and humanities for those who will specialise in science. John Walton National Commission on Education, 344-54 Gray’s Inn Road, London WC1X 8BP, UK
1 Learning to succeed. London: Heinemann, 1993.
Duty on child-abuse expert witnesses SiR-Brahams (Sept 17, p 810) proposes that all medical reports in child abuse cases should be disclosed to the court. She rightly states that the adversarial system in the UK encourages opposing sides to seek out experts expected to be helpful to them, and their abandonment of those whose evidence proves unhelpful. In criminal cases only the defence enjoy this luxury. The Crown is now required to disclose all opinions, whether helpful or detrimental to its case.
No such obligation is imposed on the defence, with the result that the defence can seek as many opinions as it chooses and only use those that suit its purposes. We are aware of cases in which six or seven opinions have been obtained, but only the most helpful opinion is disclosed. We have also been involved in cases in which the defence had requested advice, but had provided only a heavily edited version of events so that a distorted opinion was produced. The expert was then compelled to modify or completely reverse his/her opinion when the full facts were disclosed in court.
This
policy is surely an abuse of medical or scientific expertise? Should not all expert evidence be disclosed to the court, and not merely in child abuse cases? If a "fishing expedition" has been undertaken, this fact should be disclosed in court preventing this abuse of the expert witness system, and ultimately of justice. M A Green, J C Clark, C M
Milroy
Department of Forensic Pathology, University of Sheffield Medico-Legal Centre, Sheffield S3 7ES, UK
of diarrhoea. Esrey3 reviewed these studies as part of the WHO series on potential interventions for childhood diarrhoea. He showed from data of seven studies that the median reduction in diarrhoea frequency after fly control was 40%. This was the largest reduction achieved for any type of intervention that the series addressed (including promotion of breastfeeding and improving water supply and sanitation). He pointed out, however, that, most of these fly control studies were flawed (as was the case for the other interventions reviewed). He did not recommend better designed studies to confirm these promising results; instead, he concluded that fly control was not a feasible diarrhoea intervention in developing countries because available control methods were not sustainable. By linking and confusing these two distinct issues, Esrey effectively dismissed fly reduction from the agenda for diarrhoeal disease control. In view of the encouraging results from previous fly control studies and the proven effectiveness of yeast-baited traps, rigorously designed investigations are urgently needed in areas where a high frequency of childhood diarrhoea is associated with high fly density. Esrey did not consider yeastbaited traps, which may well be a sustainable form of control in developing countries. This need has been identified by other.’,’ Because it is commonly believed that flies cannot be controlled in a sustainable fashion, the impact of fly control on diarrhoeal diseases in different epidemiological situations has not been investigated. In fact, flies can be rapidly and safely controlled in the short term through insecticide application. Insecticide use could have particular relevance in humanitarian emergencies such as the Rwandan conflict in which thousands of people have died from diarrhoeal diseases, including shigellosis. Rwanda is just one example where short-term fly control might reduce diarrhoea morbidity and mortality. Because of the cost and the rapid emergence of resistance, indiscriminate use of insecticide would not be suitable for long-term fly control in residential areas, although targeted use may be justified in places such as food markets. If fly control can be shown to substantially reduce diarrhoea incidence, then the development of simple community-based fly-control strategies, such as yeast-baited traps, will be justified for long-term sustainable control. Fly control can no longer be ignored as a potential diarrhoea intervention in developing countries.
frequency
DC
Chavasse, U Blumenthal, P Kolsky
London School of
Hygiene
and
Tropical Medicine,
London WC1E 7HT, UK
Fly control in prevention of diarrhoeal disease 1
Cohen D, Green M, Block C, et al. Reduction of transmission of houseflies (Musca domestica). Lancet 1991; 337: 993-97. Bern C, Martines J, de Zoysa I, Glass RI. The magnitude of the global problem of diarrhoeal disease: a ten year update. Bull World Health Organ 1992; 70: 705-14. Esrey SA. Interventions for the control of diarrhoeal diseases among young children: fly control. Geneva: WHO, WHO/CDD/91.37, 1991. Black RE, Lanata CF. Epidemiology of diarrhoeal diseases in developing countries. In: Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL, eds. Infections of the gastrointestinal tract. New York: Raven Press (in press). Levine OS, Levine MM. Houseflies (Musca domestica) as mechanical vectors of shigellosis. Rev Infect Dis 1991; 13: 688-96.
SiR-Cohen and colleagues’ reported that after a 64% reduction in housefly density, clinic visits for diarrhoeal disease in Israeli soldiers decreased by 42% overall and by 85% specifically for shigellosis. Fly control was achieved with previously untested yeast-baited fly traps. These cheap and simple traps were placed strategically around a military camp where unsanitary conditions prevailed (Cohen, personal communication). This study has important implications for child health in developing countries, since diarrhoea kills over 3 million children per year world wide2 and the search for sustainable interventions that can be implemented by communities themselves remains a priority. It is, therefore, surprising that in the three years since the
4
publication of Cohen and colleagues’ report there has
Temazepam toxicity precipitated by disulfiram
been
not
of the effectiveness of yeastthorough baited fly traps in reducing childhood diarrhoea in developing countries, perhaps because fly control is regarded as an unsuitable intervention for diarrhoeal disease control. In the past, several studies (mostly from developed countries) attempted to measure the impact of fly control on a
shigellosis by control of
2
3
5
assessment
SIR-A 34-year-old unemployed male had a 2-year history of excessive alcohol consumption (at least 25 units per day). 2 weeks before admission he agreed to stop drinking and his general practitioner commenced vitamin supplements and disulfiram (800 mg on the first day, reducing over 5 days to 1231
1 Learning to succeed. London: Heinemann, 1993.
Duty on child-abuse expert witnesses SiR-Brahams (Sept 17, p 810) proposes that all medical reports in child abuse cases should be disclosed to the court. She rightly states that the adversarial system in the UK encourages opposing sides to seek out experts expected to be helpful to them, and their abandonment of those whose evidence proves unhelpful. In criminal cases only the defence enjoy this luxury. The Crown is now required to disclose all opinions, whether helpful or detrimental to its case.
No such obligation is imposed on the defence, with the result that the defence can seek as many opinions as it chooses and only use those that suit its purposes. We are aware of cases in which six or seven opinions have been obtained, but only the most helpful opinion is disclosed. We have also been involved in cases in which the defence had requested advice, but had provided only a heavily edited version of events so that a distorted opinion was produced. The expert was then compelled to modify or completely reverse his/her opinion when the full facts were disclosed in court.
This
policy is surely an abuse of medical or scientific expertise? Should not all expert evidence be disclosed to the court, and not merely in child abuse cases? If a "fishing expedition" has been undertaken, this fact should be disclosed in court preventing this abuse of the expert witness system, and ultimately of justice. M A Green, J C Clark, C M
Milroy
Department of Forensic Pathology, University of Sheffield Medico-Legal Centre, Sheffield S3 7ES, UK
of diarrhoea. Esrey3 reviewed these studies as part of the WHO series on potential interventions for childhood diarrhoea. He showed from data of seven studies that the median reduction in diarrhoea frequency after fly control was 40%. This was the largest reduction achieved for any type of intervention that the series addressed (including promotion of breastfeeding and improving water supply and sanitation). He pointed out, however, that, most of these fly control studies were flawed (as was the case for the other interventions reviewed). He did not recommend better designed studies to confirm these promising results; instead, he concluded that fly control was not a feasible diarrhoea intervention in developing countries because available control methods were not sustainable. By linking and confusing these two distinct issues, Esrey effectively dismissed fly reduction from the agenda for diarrhoeal disease control. In view of the encouraging results from previous fly control studies and the proven effectiveness of yeast-baited traps, rigorously designed investigations are urgently needed in areas where a high frequency of childhood diarrhoea is associated with high fly density. Esrey did not consider yeastbaited traps, which may well be a sustainable form of control in developing countries. This need has been identified by other.’,’ Because it is commonly believed that flies cannot be controlled in a sustainable fashion, the impact of fly control on diarrhoeal diseases in different epidemiological situations has not been investigated. In fact, flies can be rapidly and safely controlled in the short term through insecticide application. Insecticide use could have particular relevance in humanitarian emergencies such as the Rwandan conflict in which thousands of people have died from diarrhoeal diseases, including shigellosis. Rwanda is just one example where short-term fly control might reduce diarrhoea morbidity and mortality. Because of the cost and the rapid emergence of resistance, indiscriminate use of insecticide would not be suitable for long-term fly control in residential areas, although targeted use may be justified in places such as food markets. If fly control can be shown to substantially reduce diarrhoea incidence, then the development of simple community-based fly-control strategies, such as yeast-baited traps, will be justified for long-term sustainable control. Fly control can no longer be ignored as a potential diarrhoea intervention in developing countries.
frequency
DC
Chavasse, U Blumenthal, P Kolsky
London School of
Hygiene
and
Tropical Medicine,
London WC1E 7HT, UK
Fly control in prevention of diarrhoeal disease 1
Cohen D, Green M, Block C, et al. Reduction of transmission of houseflies (Musca domestica). Lancet 1991; 337: 993-97. Bern C, Martines J, de Zoysa I, Glass RI. The magnitude of the global problem of diarrhoeal disease: a ten year update. Bull World Health Organ 1992; 70: 705-14. Esrey SA. Interventions for the control of diarrhoeal diseases among young children: fly control. Geneva: WHO, WHO/CDD/91.37, 1991. Black RE, Lanata CF. Epidemiology of diarrhoeal diseases in developing countries. In: Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL, eds. Infections of the gastrointestinal tract. New York: Raven Press (in press). Levine OS, Levine MM. Houseflies (Musca domestica) as mechanical vectors of shigellosis. Rev Infect Dis 1991; 13: 688-96.
SiR-Cohen and colleagues’ reported that after a 64% reduction in housefly density, clinic visits for diarrhoeal disease in Israeli soldiers decreased by 42% overall and by 85% specifically for shigellosis. Fly control was achieved with previously untested yeast-baited fly traps. These cheap and simple traps were placed strategically around a military camp where unsanitary conditions prevailed (Cohen, personal communication). This study has important implications for child health in developing countries, since diarrhoea kills over 3 million children per year world wide2 and the search for sustainable interventions that can be implemented by communities themselves remains a priority. It is, therefore, surprising that in the three years since the
4
publication of Cohen and colleagues’ report there has
Temazepam toxicity precipitated by disulfiram
been
not
of the effectiveness of yeastthorough baited fly traps in reducing childhood diarrhoea in developing countries, perhaps because fly control is regarded as an unsuitable intervention for diarrhoeal disease control. In the past, several studies (mostly from developed countries) attempted to measure the impact of fly control on a
shigellosis by control of
2
3
5
assessment
SIR-A 34-year-old unemployed male had a 2-year history of excessive alcohol consumption (at least 25 units per day). 2 weeks before admission he agreed to stop drinking and his general practitioner commenced vitamin supplements and disulfiram (800 mg on the first day, reducing over 5 days to 1231