INFORMING PATIENTS

922 THIRD WORLD DEBT CRISIS

SIR,-Dr Summerfield’s essay (Sept 2, p 551) is a stunningly naive exercise in neo-marxist economic illiteracy. If Summerfield had prescribed leeches to treat gout you would have dismissed his article out of hand, yet you printed a commentary that recommends equally outdated, discredited, and harmful therapy for the maladies of underdeveloped economies. Summerfield’s only accurate assertions are that the debt burden is blocking development and, in so doing, hurts the poorest people in the countries the most, and that this crisis was created by irresponsible western bankers and corrupt domestic elites. His statistical substantiation is impressive, but this insight is neither original nor any longer a topic of debate. The question facing us now is what to do-and it is here that Summerfield’s piece collapses. He criticises International Monetary Fund austerity packages because they "specify the abolition of government subsidies for basic foodstuffs, medicines, school books, and so on". In other words, he is recommending that third world nations borrow more money and dig themselves deeper into debt to prolong a period of artificial prosperity and so make the eventual reckoning even more painful. Subsidies cannot be maintained indefmitely; costs spiral out of control, as in any government exercise which attempts to repeal the free market, until the government is forced to default on its debt or end subsidies. Summerfield also defends "the public wage bill", a code phrase for fat salaries to the unproductive elites (now ensconced in debt-financed air-conditioned high-rise accommodation) who conspired to create this mess at the expense of the poor people in the fields. The solution is not to repeal the free market but to straighten out kinks in the economy so that the nation can develop and the people can raise their income enough to buy food at real world prices-and the first step in that process is to eliminate the web of government subsidies and distortions which discourage food production by farmers. In a classic exposition of the intellectually flaccid "dependency theory", Summerfield goes on to tie this all to the supposed 500-year-old continuous conspiracy by the western world, somehow dating all the way back to slavery, to keep the third world nations impoverished. Every study that has attempted to measure "dependency" has discovered (to its great disappointment) that the more dependent nations (such as Mexico) develop faster than the less dependent ones. Summerfield proposes that debt-ridden nations "turn away from the dominant development paradigms, to direct economic activity away from the international markets and towards the real needs of their peoples". This is known as the "Albanian model" of development (see also Cuba and North Korea): isolation, distortion, stagnation, and perpetual poverty. Summerfield has done for debt what Marx did for capitalism, brilliantly enumerating its problems and proposing a vague, poisonous "cure". 2125

Lynwood,

Champaign,

Illinois 61821, USA

ERIC KROCK

INFORMING PATIENTS

SIR,-Dr Tattersall (July 29, p 280) and Dr Pelosi (Sept 2, p 564) report that they send to patients copies of their letters to general practitioners. I too believe that parents (or patients)—except in exceptional circumstances-have the right to know my assessment of their problem. I have completed a pilot study of parents’ (patients’) reaction and response to my sending them copies of all correspondence (mostly to the family doctor) relating to their care. Along with my letter of explanation and a copy of the outpatient letter, I asked parents by questionnaire whether they found the practice helpful or unhelpful, whether it made them worried or less worried, and whether they wished the practice to be repeated on future occasions. They were also requested to discuss any concerns or misunderstandings with myself, or their family doctor, by telephone. Of 253 families questioned, 225 responded. Of these, 222 replied that the practice was helpful, made them less worried, and wished it to be repeated. 2 found it helpful and wished it to be repeated, but they had been worried by a letter with a hospital franking mark until

they knew the content. 1 family found the letter helpful and caused less worry, but they did not wish it to be repeated. I have received twenty-seven telephone calls, mainly expressing interest and requesting further information. Three general practitioners were unhappy with the practice, mainly because they felt that the consultant’s opinion should be exclusive to them. With this practice, I have not needed to change the letter I would have written in other circumstances. I have not excluded any patient. Occasional discrepancies between what families understood at the consultation and what was written in the letters have been easily resolved. The hospital administration had concerns in respect of the medicolegal implications. I consider the practice will improve doctor/patient relationships and reduce the need to resort to the law courts. I accept that patients might find medical terms difficult to understand and that doctors might have to modify their letters. Nevertheless, I believe that the benefits of this practice greatly exceed the disadvantages and problems. After all, parents have the right to know what we are doing to them and for them; and why not in writing? Children’s Hospital, Birmingham B16 8ET

GEORGE RYLANCE

MATURE ENTRANTS TO MEDICINE

SiR,—Iwas interested to read the details of the survey done by Mr Wakeford (Sept 16, p 679). Presumably the reply to the telephone inquiry that his research assistant received from our medical school was included in the "equivocal" group. In view of this he is correct in his conclusion that would-be applicants should write for formal information. Three years ago Leeds Medical School decided to increase the number of mature students (aged 21-30) to about 10% of the intake and our number of entrants in this category has been 11 in 1987,12 in 1988, and 18 in 1989. We conduct a considerable correspondence with potential mature applicants, giving full details of our policy and offering advice and encouragement to many excellent candidates. I would wish to support Wakeford’s suggestion that medical schools should consider increasing the number of mature entrants. My main concern is related to the fees they will have to pay in the future. Most mature applicants do not qualify for a mandatory local education authority grant and are therefore self-funding. Increased "economic" fees, as proposed by the Government, will do more than any admissions policy to curtail the entry of these students to medical school. Medical School, Leeds LS2 9JT

PETER D. HOWDLE

LOCAL APPLICATION OF HYPEROSMOLAR GLUCOSE SOLUTION IN TUBAL PREGNANCY

SiR,—Conservative management of tubal pregnancy by local of prostaglandinsl can cause severe systemic complicationsand methotrexate can produce uncontrolled local necrosis. We have attempted to induce local necrobiosis and thus spontaneous healing in unruptured tubal pregnancies by injecting a hyperosmolar glucose solution through a laparoscope. The project was approved by the university ethical committee and all patients gave informed consent. 18 patients with an unruptured tubal pregnancy and a human chorionic gonadotropin instillation

(HCG) urinary concentration of 5000 IU/1 or under were randomly assigned to treatment with either prostaglandin (n = 9) or glucose (n = 9). Prostaglandin was applied as described by Egarter and Russlein.2 In the patients treated with glucose, about 15 ml (range, 10-20 ml) of a 50% solution was instilled. Prostaglandin treatment was successful in 8 of 9 patients. HCG excretion ceased after 17 (6) days. 1 patient with persistent HCG excretion and imminent tubal rupture underwent relaparoscopy and salpingotomy. Glucose treatment was successful in all 9 patients. HCG excretion ceased after 19 (9) days. Patients treated with glucose were subjectively well after the procedure, while 6 of 9 treated with prostaglandin reported