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European charter on environment and health
652
disability. Dr Nakajima stated that "human development was as important as human survival". Thus, the child survival programme is moving beyond an almost exclusive concern with mortality in under-fives to morbidity and disability in schoolchildren. Other essential elements in the continuum of health include the well-being of the mother in the prenatal period, and the crucial mother-child relation after birth. In Bangkok Dr Angela Petros-Barvazian of WHO spoke of a new concept that would remove the burden of the social and economic consequences of population growth from the shoulders of mothers. "Safe motherhood" is promoting the health advantages of having few children (who are far more likely to survive) during a reasonable age-range and at reasonable intervals. William Foege described the feedback inherent in the system-"money spent on family planning reduces infant mortality, while money spent on child survival reduces birth rates". The unique coordinating role of the Task Force for Child Survival was acknowledged at the conference. William Draper, Administrator of UNDP stated that "our close collaboration had far greater impact than our individual efforts". W. P. Rajagopalan, Vice-President of the World Bank, described the task-force’s efforts as "catalytic". This exercise in inter-agency collaboration is clearly a model for other such efforts in third-world development. Thus the accelerated global immunisation campaign which began in Bellagio in March, 1984, has not only greatly reduced the deaths of infants and young children, but has also moved beyond to the wellbeing of schoolchildren and the health of mothers. Maxwell Communication Corporation, New York City, New York, USA
Kenneth S. Warren
Medicine and the Law Fatal
case
of
undiagnosed
diabetes
In two recent Scottish cases, sheriff’s fatal accident inquiries have revealed defects, not just in the diagnosis of diabetes, but also in administrative arrangements in general practice. The first was in the National Health Service;’ the second relates to a Royal Air Force medical centre. In late May, 1988, two RAF doctors normally working at the centre at the Royal Air Force base at Leuchars-a general practice trainee with 2-3 months experience and an experienced general practitioner-were away, one on detachment and the other on leave. Squadron Leader D. A. Joy was the only doctor left at the base. He had qualified in 1979 but had been specialising in histopathology. After joining the RAF he was posted to Leuchars to gain experience of general practice but in May, 1988, he had never seen diabetes outside hospital. The list size was 3200 service personnel and dependants, and the medical team also had
medical
commitments to aviation medicine and to accidents and emergencies. There was no suggestion that the doctors’ duties were excessive but in May, 1988, the whole of this work load was being handled by one doctor with limited experience of general practice. At the inquiry on Dec 5,1989, the sheriff found this situation wholly
unsatisfactory. In the NHS the doctor would not have been permitted to act as a in general practice (though there are no requirements about experience for deputies in NHS general practice). The sheriff said that the RAF should assess demands on the time of its doctors quantitatively and evaluate the experience and qualifications required so that RAF medical services were not lower than those in the NHS. Periods of leave or detachment should be properly covered. The sheriff said that RAF Leuchars was now a training
principal
practice, which
meant there would always be two experienced doctors on the station and one under training. A trainee would not now be left on his own. RAF policy was under review and there was a movement in favour of not leaving untrained general practitioners in sole charge of medical centres. The sheriff was surprised to learn that this had been the situation. The mother of a girl aged 8 years had taken her to the medical centre in late May, 1988, and told the doctor that her child was drinking abnormally large quantities and that she had spots on her tongue. The doctor recorded a sore mouth, neck, and ears and headaches but made no note of fluid consumption. He diagnosed a viral infection. A urine glucose test was not done on that occasion or on the next visit. The child deteriorated and continued to drink large quantities of fluids. On May 31 she had difficulty in walking but it was not possible for her to be seen by the doctor. She was listless, her legs were sore, her mouth was dry, and her speech was slurred. She was seen by a non-medical assistant who prescribed an analgesic. On June 1, when she was seen by the doctor, blood was taken for a full count and viral tests. No urine specimen was taken. Amoxycillin was prescribed. On June 2 the child was very lethargic and was still drinking large quantities. On June 3 she was taken by ambulance to the RAF medical centre. She had lost a lot of weight and her eyes were sunken. She could hardly stand. The doctor deduced that the girl’s illness might be related to the fact that her mother and stepfather were in the throes of separating, and recommended that she be sent to stay with her grandmother. On June 4, the mother left the child asleep in the morning; she did not want to be in the house while her husband was there. During the day the child was incontinent and very dehydrated. When the mother returned in the early evening she found the child grey and staring, and the doctor directed that she be taken to Ninewells Hospital, Dundee, suspecting for the first time that the girl had diabetes. He did not mention this diagnosis to the hospital. On arrival at the hospital the child was comatose and ketoacidotic. Diabetes was immediately diagnosed but she died 50 minutes later.
The sheriff concluded that a moderately competent doctor would have realised that the girl’s increased fluid consumption indicated diabetes or a urinary tract infection, and a dipstick test for urinary glucose would have been done. The doctor should have appreciated that the child’s condition was worsening and that she had classic symptoms of diabetes. Had diabetes been diagnosed on June 1 the child might have lived. Diana Brahams 1. Brahams D. Death of a child from undiagnosed diabetes. Lancet
1990, 335: 595-96
Noticeboard European
charter
on
environment and health
Growing perception that links between environment and health have not been sufficiently perceived at international, national, and local levels and hence not addressed at the planning stage of new developments led 32 countries of the European region of the World Health Organisation to formulate a charter on environment and health. The charter, which was approved at a ministerial conference in Frankfurt in December, lays down that the health of individuals and communities should take clear precedence over considerations of economy and trade. Priority areas for attention include: global disturbances to the environment; urban development, planning, and renewal; food safety; the control of persistent chemicals and hazardous wastes; biotechnology; contingency planning for accidents; and the introduction of cleaner technologies. There are plans to have the charter translated into the languages of the region, to hold a workshop (and then subregional seminars) on the implementation of this charter, to establish a regional advisory committee, and to study the feasibility of a European centre for environment and health. The
charter, and detailed commentary
on
it, and other relevant material
may be obtained from the Regional Office for Europe, World Health Organisation, 8 Sherfigsveg, 2100 Copenhagen, Denmark.
disability. Dr Nakajima stated that "human development was as important as human survival". Thus, the child survival programme is moving beyond an almost exclusive concern with mortality in under-fives to morbidity and disability in schoolchildren. Other essential elements in the continuum of health include the well-being of the mother in the prenatal period, and the crucial mother-child relation after birth. In Bangkok Dr Angela Petros-Barvazian of WHO spoke of a new concept that would remove the burden of the social and economic consequences of population growth from the shoulders of mothers. "Safe motherhood" is promoting the health advantages of having few children (who are far more likely to survive) during a reasonable age-range and at reasonable intervals. William Foege described the feedback inherent in the system-"money spent on family planning reduces infant mortality, while money spent on child survival reduces birth rates". The unique coordinating role of the Task Force for Child Survival was acknowledged at the conference. William Draper, Administrator of UNDP stated that "our close collaboration had far greater impact than our individual efforts". W. P. Rajagopalan, Vice-President of the World Bank, described the task-force’s efforts as "catalytic". This exercise in inter-agency collaboration is clearly a model for other such efforts in third-world development. Thus the accelerated global immunisation campaign which began in Bellagio in March, 1984, has not only greatly reduced the deaths of infants and young children, but has also moved beyond to the wellbeing of schoolchildren and the health of mothers. Maxwell Communication Corporation, New York City, New York, USA
Kenneth S. Warren
Medicine and the Law Fatal
case
of
undiagnosed
diabetes
In two recent Scottish cases, sheriff’s fatal accident inquiries have revealed defects, not just in the diagnosis of diabetes, but also in administrative arrangements in general practice. The first was in the National Health Service;’ the second relates to a Royal Air Force medical centre. In late May, 1988, two RAF doctors normally working at the centre at the Royal Air Force base at Leuchars-a general practice trainee with 2-3 months experience and an experienced general practitioner-were away, one on detachment and the other on leave. Squadron Leader D. A. Joy was the only doctor left at the base. He had qualified in 1979 but had been specialising in histopathology. After joining the RAF he was posted to Leuchars to gain experience of general practice but in May, 1988, he had never seen diabetes outside hospital. The list size was 3200 service personnel and dependants, and the medical team also had
medical
commitments to aviation medicine and to accidents and emergencies. There was no suggestion that the doctors’ duties were excessive but in May, 1988, the whole of this work load was being handled by one doctor with limited experience of general practice. At the inquiry on Dec 5,1989, the sheriff found this situation wholly
unsatisfactory. In the NHS the doctor would not have been permitted to act as a in general practice (though there are no requirements about experience for deputies in NHS general practice). The sheriff said that the RAF should assess demands on the time of its doctors quantitatively and evaluate the experience and qualifications required so that RAF medical services were not lower than those in the NHS. Periods of leave or detachment should be properly covered. The sheriff said that RAF Leuchars was now a training
principal
practice, which
meant there would always be two experienced doctors on the station and one under training. A trainee would not now be left on his own. RAF policy was under review and there was a movement in favour of not leaving untrained general practitioners in sole charge of medical centres. The sheriff was surprised to learn that this had been the situation. The mother of a girl aged 8 years had taken her to the medical centre in late May, 1988, and told the doctor that her child was drinking abnormally large quantities and that she had spots on her tongue. The doctor recorded a sore mouth, neck, and ears and headaches but made no note of fluid consumption. He diagnosed a viral infection. A urine glucose test was not done on that occasion or on the next visit. The child deteriorated and continued to drink large quantities of fluids. On May 31 she had difficulty in walking but it was not possible for her to be seen by the doctor. She was listless, her legs were sore, her mouth was dry, and her speech was slurred. She was seen by a non-medical assistant who prescribed an analgesic. On June 1, when she was seen by the doctor, blood was taken for a full count and viral tests. No urine specimen was taken. Amoxycillin was prescribed. On June 2 the child was very lethargic and was still drinking large quantities. On June 3 she was taken by ambulance to the RAF medical centre. She had lost a lot of weight and her eyes were sunken. She could hardly stand. The doctor deduced that the girl’s illness might be related to the fact that her mother and stepfather were in the throes of separating, and recommended that she be sent to stay with her grandmother. On June 4, the mother left the child asleep in the morning; she did not want to be in the house while her husband was there. During the day the child was incontinent and very dehydrated. When the mother returned in the early evening she found the child grey and staring, and the doctor directed that she be taken to Ninewells Hospital, Dundee, suspecting for the first time that the girl had diabetes. He did not mention this diagnosis to the hospital. On arrival at the hospital the child was comatose and ketoacidotic. Diabetes was immediately diagnosed but she died 50 minutes later.
The sheriff concluded that a moderately competent doctor would have realised that the girl’s increased fluid consumption indicated diabetes or a urinary tract infection, and a dipstick test for urinary glucose would have been done. The doctor should have appreciated that the child’s condition was worsening and that she had classic symptoms of diabetes. Had diabetes been diagnosed on June 1 the child might have lived. Diana Brahams 1. Brahams D. Death of a child from undiagnosed diabetes. Lancet
1990, 335: 595-96
Noticeboard European
charter
on
environment and health
Growing perception that links between environment and health have not been sufficiently perceived at international, national, and local levels and hence not addressed at the planning stage of new developments led 32 countries of the European region of the World Health Organisation to formulate a charter on environment and health. The charter, which was approved at a ministerial conference in Frankfurt in December, lays down that the health of individuals and communities should take clear precedence over considerations of economy and trade. Priority areas for attention include: global disturbances to the environment; urban development, planning, and renewal; food safety; the control of persistent chemicals and hazardous wastes; biotechnology; contingency planning for accidents; and the introduction of cleaner technologies. There are plans to have the charter translated into the languages of the region, to hold a workshop (and then subregional seminars) on the implementation of this charter, to establish a regional advisory committee, and to study the feasibility of a European centre for environment and health. The
charter, and detailed commentary
on
it, and other relevant material
may be obtained from the Regional Office for Europe, World Health Organisation, 8 Sherfigsveg, 2100 Copenhagen, Denmark.