- Email: [email protected]
Health care for adolescents
the nomenclature has not changed, but some chemists do seem to have accepted some flexibility for the puposes of
Gilks C, Adam A, Otieno L, Mwongera F, Amir M, Paul J. HIV infection in acute medical admissions in Kenyatta hospital: 1988/89 compared to 1992. 9th International Conference on AIDS (June 6-11, 1993); abstr B37-2379. Stanford JL, Grange JM, Pozniak A. Is Africa lost? Lancet 1991; 338: 557-58.
2
simplicity. David C
Hooper
3
Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
Health
Impact
of HIV in sub-Saharan Africa
SIR-Planners and policy makers are at last recognising yet another unresolvable dimension to the HIV epidemic-the progressive and potentially disastrous impact on the healthcare system itself. Your May 27 editorial (p 1315) asks what this impact will be in sub-Saharan Africa. You also wonder why it has taken the health sector so long to ask that question. We disagree that the explanation lies in secrecy and inertia, for that implies a wilful process. Is it not a general problem in developing countries that pressing needs must be satisfied with inadequate resources and that crisis management has to take the place of planning? There may well have been a widespread inability to see beyond HIV as a sexually transmitted disease because the priority is to prevent new infection. But this has never been a conspiracy. The impact is likely to be more severe than you predict. HIV clusters in cities, which consume more health care pro rata than rural areas; this will amplify the impact in highprevalence regions. Preoccupation with AIDS misses at least half the true burden of HIV-related disease and death by excluding early clinical events.’ Whilst demand for services will continue to rise, supply is likely to remain static or even fall; there is no surplus to deal with additional demand, regardless of cause. Our data from Kenya2 show displacement of resources by HIV-infected patients, with adverse consequences for those with "background" disease that has not diminished in scale with the HIV epidemic. It is important to distinguish between people with AIDS, those who are HIV positive, and those who are HIV negative. For the first two groups the objectives of healthcare interventions must be clearly identified and strategies for achieving these objectives must be rigorously evaluated, otherwise we are simply throwing money at the problem, money that could usefully be spent upon the third group. Those who are HIV negative may well wish to know how the HIV epidemic is changing the health-care agenda in their country. You call for a start to be made by recording and reporting the essential data that we lack. The long-term goal must be to develop strategies to deal with an unmeetable demand for health care in the most impoverished continent in the world. Operational issues become critical as health-sector reform and rationalisation of care are taken up in Africa. With support from the UK Overseas Development Administration we are considering how these processes may be influenced or even driven by the HIV epidemic and how equitable solutions can be formulated and implemented. The challenge of HIV in Africa is daunting. It is easy to be overwhelmed and give up, saying Africa is lost.3 Yet even in countries such as Uganda which are so badly affected by HIV-related disease and death, health care continues to be provided in most areas. In the words of a fund-raising badge recently produced by the AIDS Support Organisation of Uganda (TASO) "No hope? Just cope". Our role in the West must be to facilitate that coping process.
care
SIR-In your
for adolescents
April
22 editorial you refer to teenagers too
often being neglected
or ignored by the medical profession. Adolescent medicine, it has been said, should become a medical subspecialty so that young people can receive proper attention. You also say, as highlighted by Dann (May 27, p 1371), that "adolescents deserve primary care that is attentive to their special needs". In the pharmacy department at this hospital, we carried out a study aimed at patients and carers in an anticoagulant outpatient clinic setting (32 patients aged 6 months to 22 years). Our aims were to determine the present approach of health professionals towards providing information to children and to determine the age group thought most appropriate to begin inclusion of the child in the counselling
process. We found that in
only 31% of cases was the information directed towards the patient, yet 63% of those completing
questionnaires wanted the children to be involved. The important finding was that the patients and carers regarded the 8-10 year age group as the most appropriate age at which to include the child in the counselling process. 81 % wanted the information provided as a combination of written and verbal; this has been shown to be the preferred method for presentation of information.’ 67% of information in our study was presented in this way, which is a favourably high percentage in comparison with another study (28%), based in an adult anticoagulant outpatient clinic.2 We believe that recognition of the information needs of patients at all ages is important to the success of therapy. With increased recognition of the participation of children in their own medical care3 we should tailor our approach appropriately and adopt a more informative approach
the
most
towards children and adolescents. *Niall O’Sullivan, Sean Turner,
Tony Nunn
Pharmacy Department, Alder Hey Children’s Hospital, Liverpool L12 2AP, UK Weinman J.
1 2
3
Providing written information for patients: psychological considerations. J R Soc Med 1990; 83: 300-02. O’Sullivan NJ, Braidwood CC, Mottram DR, et al. A patient information leaflet for patients receiving anticoagulant drugs. In: UKCPA National Spring Symposium, 1995. Hinkley, UK: 20-21 (abstr). Gillick v Wisbech and W Norfolk AHA (1985), 3ALL ER 402 HL.
Rugby injuries
*Charles F Gilks, David Haran
who have watched the World Cup rugby games, particularly England vs Western Samoa and South Africa vs Western Samoa, will not agree with Edgar’s statement (June 10 commentary): "Paradoxically at the international level, where the game is fastest and most spectacular, evidence shows that fitness and experience considerably reduce the injury rate." The injury rate was so high that England used up all replacement forwards and ended up with two scrum halves on the field. Few clubs have a full complement of replacement forwards, and if this injury rate were to happen at club level games would never be
Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
completed.
1
Gilks CF. The clinical challenge of the HIV epidemic in the developing world. Lancet 1993; 342: 1037-39.
SIR-Those of
us
This is not just an anecdotal one-off observation. In my of 67 rugby players with broken necks injured between 1952 and 1982, I wrote: "greater skill does not protect, as
study
187
Gilks C, Adam A, Otieno L, Mwongera F, Amir M, Paul J. HIV infection in acute medical admissions in Kenyatta hospital: 1988/89 compared to 1992. 9th International Conference on AIDS (June 6-11, 1993); abstr B37-2379. Stanford JL, Grange JM, Pozniak A. Is Africa lost? Lancet 1991; 338: 557-58.
2
simplicity. David C
Hooper
3
Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
Health
Impact
of HIV in sub-Saharan Africa
SIR-Planners and policy makers are at last recognising yet another unresolvable dimension to the HIV epidemic-the progressive and potentially disastrous impact on the healthcare system itself. Your May 27 editorial (p 1315) asks what this impact will be in sub-Saharan Africa. You also wonder why it has taken the health sector so long to ask that question. We disagree that the explanation lies in secrecy and inertia, for that implies a wilful process. Is it not a general problem in developing countries that pressing needs must be satisfied with inadequate resources and that crisis management has to take the place of planning? There may well have been a widespread inability to see beyond HIV as a sexually transmitted disease because the priority is to prevent new infection. But this has never been a conspiracy. The impact is likely to be more severe than you predict. HIV clusters in cities, which consume more health care pro rata than rural areas; this will amplify the impact in highprevalence regions. Preoccupation with AIDS misses at least half the true burden of HIV-related disease and death by excluding early clinical events.’ Whilst demand for services will continue to rise, supply is likely to remain static or even fall; there is no surplus to deal with additional demand, regardless of cause. Our data from Kenya2 show displacement of resources by HIV-infected patients, with adverse consequences for those with "background" disease that has not diminished in scale with the HIV epidemic. It is important to distinguish between people with AIDS, those who are HIV positive, and those who are HIV negative. For the first two groups the objectives of healthcare interventions must be clearly identified and strategies for achieving these objectives must be rigorously evaluated, otherwise we are simply throwing money at the problem, money that could usefully be spent upon the third group. Those who are HIV negative may well wish to know how the HIV epidemic is changing the health-care agenda in their country. You call for a start to be made by recording and reporting the essential data that we lack. The long-term goal must be to develop strategies to deal with an unmeetable demand for health care in the most impoverished continent in the world. Operational issues become critical as health-sector reform and rationalisation of care are taken up in Africa. With support from the UK Overseas Development Administration we are considering how these processes may be influenced or even driven by the HIV epidemic and how equitable solutions can be formulated and implemented. The challenge of HIV in Africa is daunting. It is easy to be overwhelmed and give up, saying Africa is lost.3 Yet even in countries such as Uganda which are so badly affected by HIV-related disease and death, health care continues to be provided in most areas. In the words of a fund-raising badge recently produced by the AIDS Support Organisation of Uganda (TASO) "No hope? Just cope". Our role in the West must be to facilitate that coping process.
care
SIR-In your
for adolescents
April
22 editorial you refer to teenagers too
often being neglected
or ignored by the medical profession. Adolescent medicine, it has been said, should become a medical subspecialty so that young people can receive proper attention. You also say, as highlighted by Dann (May 27, p 1371), that "adolescents deserve primary care that is attentive to their special needs". In the pharmacy department at this hospital, we carried out a study aimed at patients and carers in an anticoagulant outpatient clinic setting (32 patients aged 6 months to 22 years). Our aims were to determine the present approach of health professionals towards providing information to children and to determine the age group thought most appropriate to begin inclusion of the child in the counselling
process. We found that in
only 31% of cases was the information directed towards the patient, yet 63% of those completing
questionnaires wanted the children to be involved. The important finding was that the patients and carers regarded the 8-10 year age group as the most appropriate age at which to include the child in the counselling process. 81 % wanted the information provided as a combination of written and verbal; this has been shown to be the preferred method for presentation of information.’ 67% of information in our study was presented in this way, which is a favourably high percentage in comparison with another study (28%), based in an adult anticoagulant outpatient clinic.2 We believe that recognition of the information needs of patients at all ages is important to the success of therapy. With increased recognition of the participation of children in their own medical care3 we should tailor our approach appropriately and adopt a more informative approach
the
most
towards children and adolescents. *Niall O’Sullivan, Sean Turner,
Tony Nunn
Pharmacy Department, Alder Hey Children’s Hospital, Liverpool L12 2AP, UK Weinman J.
1 2
3
Providing written information for patients: psychological considerations. J R Soc Med 1990; 83: 300-02. O’Sullivan NJ, Braidwood CC, Mottram DR, et al. A patient information leaflet for patients receiving anticoagulant drugs. In: UKCPA National Spring Symposium, 1995. Hinkley, UK: 20-21 (abstr). Gillick v Wisbech and W Norfolk AHA (1985), 3ALL ER 402 HL.
Rugby injuries
*Charles F Gilks, David Haran
who have watched the World Cup rugby games, particularly England vs Western Samoa and South Africa vs Western Samoa, will not agree with Edgar’s statement (June 10 commentary): "Paradoxically at the international level, where the game is fastest and most spectacular, evidence shows that fitness and experience considerably reduce the injury rate." The injury rate was so high that England used up all replacement forwards and ended up with two scrum halves on the field. Few clubs have a full complement of replacement forwards, and if this injury rate were to happen at club level games would never be
Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
completed.
1
Gilks CF. The clinical challenge of the HIV epidemic in the developing world. Lancet 1993; 342: 1037-39.
SIR-Those of
us
This is not just an anecdotal one-off observation. In my of 67 rugby players with broken necks injured between 1952 and 1982, I wrote: "greater skill does not protect, as
study
187