MEDICINE ON THE WEST BANK OF THE JORDAN

450 but there was no evidence of increased enterovirus during this time. Cipto Mangunkusumo, Sumber Waras, Husada Hospitals; NAMRU-2, Jakarta Detachment, Cipto Mangunkusumo Hospital;

and

and National Institute of Health Research and Development,

Jakarta, Indonesia

activity

VACCINATION AND IMMUNISATION ACCEPTANCE-RATES DEC.

31, 1976,

FOR CHILDREN BORN IN

(%) AT

1974

SUMARMO H. WULUR

E. JAHJA D. J. GUBLER T. S. SUTOMENGGOLO J. SULIANTI SAROSO

IF I WERE A DEAN

SIR,-Dr Brooks (Jan. 21,

140) implies that a student intelligent enough to get good "A-levels" is only likely to be interested in research. This has not been my experience. Few students

p.

leave clinical medicine, and most surgical registrars-to take one example-have to be pushed hard to leave the wards for a research year. The intelligent student is more able to stand back and take the larger view, and is likely, therefore, to be more aware of and responsive to the patient as a person with problems, than is the less intelligent student who finds the basic mechanics of history-taking and examination more difficult. The more intelligent also tends to work faster and more accurately, and therefore has more time to talk about personal problems and to get to know the patient as a person. I am not suggesting that all take the trouble to do so, and this certainly has to be encouraged. However, the opposite generalisation is certainly false. Dr Brooks’ student, like most, is interested in caring for the sick, but is not quite so enthusiastic about "the complex interrelationship between pathophysiological disorders, psychological and behaviour processes, and social environment". Thank goodness that, despite the insidious invasion of this jargon, medicine now attracts students of higher calibre than ever before. Hopefully, their combined intelligence will improve medical thinking, and thus medical education. or

young doctors wish

to

Lewisham Hospital, London SE13 6LH

DAVID NEGUS

EQUAL OPPORTUNITY AND THE SALMON STRUCTURE

SIR,-By law men and women now have equal opportunities in all occupations. Nursing has always been a career which has attracted the most intelligent, able, and willing of our womenfolk. The Salmon structure was supposed to bring a career structure for nursing. Why is it, therefore, that an increasing and disproportionate number of senior posts in the nursing establishment are being filled by male nurses? General

Hospital, Birmingham B4 6NH

GEORGE T. WATTS

IMMUNISATION LEVELS AND THE COMPUTER

SIR,--We have read with interest the letters about

our

We accept the point made by all your correspondents-that computer systems are only one element in a com-

paper.’

plex problem. Nevertheless, our suggestion that computers make a recognisable contribution receives support from the data and conclusions of Dr Williams2 and Dr Sutherland and Mr Young.3 Further evidence has now come to hand in the shape of "league tables" prepared by the Department of Health and 1. Bussey, A. L., Holmes, B. S. Lancet, 1977, ii, 970. 2. Williams, B. T. ibid p. 1366 3. Sutherland, A , Young, E.J. ibid. Jan. 7, 1978, p. 45.

* Rates for tetanus were as for diphtheria± 0-1%.

Social Security.4 The tables relate to primary courses of vaccination and immunisation against measles, diphtheria, whooping-cough, tetanus, and poliomyelitis completed by Dec. 31, 1976, for children born in 1974 (equivalent to our index year plus two). These data are presented in a similar form to that used in our paper, relating the number of completed courses for each disease to 1974 live births and expressing the result as a percentage acceptance-rate for each of the 14 regions and 90 areas in England. From a questionnaire returned in 1977 by all 90 area medical officers in England (in connection with a separate study of the efficacy of the measles-vaccination programme) we have been able to identify 33 A.H.A.S which used computers from 1974 to 1976 throughout their area and 24 which did not. The remaining 33 A.H.A.S used computers in only part of their territory or for part of the time. Discarding these 33, we have used the D.H.S.S. data to compare the acceptance-rates for the population served by computers with the rates for the population where computers were not used (see table). For all five immunisation programmes the mean acceptance-rate for the computer-serviced populations was greater than the average for England, the reverse being true for the non-computer population. Moreover, in the computer population acceptance-rates for measles are 21 -6% higher than in the non-computer population, for diphtheria 10-1% higher, for tetanus 9.9% higher, for poliomyelitis 12.6% higher, and even for whooping-cough 8-8% higher. While accepting the statistical reservations relating to migration, area populations, and reporting deficiencies attached to their figures by the D.H.S.S., we believe that these national data support our suggestion that computers do make a difference. A. L. BUSSEY West Sussex Area Health Authority, B. S. HOLMES Goring, Sussex BN12 4NQ

MEDICINE ON THE WEST BANK OF THE JORDAN

SIR,—Politics in the Middle East

are difficult and delicate without the boat rocked enough being by the medical profession, which traditionally crosses frontiers and knows no discrimination. All people like to be governed by their ownwhether they are Scots, Israelis, or Palestinians-but this desire for self-government should not be used as a cloak for obscuring the truth. Your Round the World piece entitled "Palestinian Doctors Wait for a Settlement" (Feb. 4, p. 261) is misleading and unbalanced, and its concluding paragraph is frankly inaccurate. Between 1967 and 1975 the population of the West Bank increased from 600 000 to 675 000. In this period the infantmortality rate fell to 36 per 1000, which is by far the lowest in any Arab country. Lebanon is next in line with 59 deaths per 1000, and the highest is Saudi Arabia with 157 per 1000.

Health Statistics: vaccination and immunisation acceptance 31 December 1976 for children born in 1974. D.H.S.S. Statistics and Research Division, Blackpool, October, 1977.

4. Community rates at

451 In 1967 there

were

65 doctors, but the number fell

to

48

by

the end of that year. By 1975 there were 126 doctors in Government institutions, and in addition there were 138 private practitioners. The numbers of both groups have increased since then. There has been no change in the number of hospitals on the West Bank, but sixteen new departments have been

opened

in the

existing

ones

since 1967. In that year the

number of operations was 6000; in 1975 it was more than 11000. 11.5% of births were in hospital in 1967; in 1975 this percentage was 32. As far back as 1970 the World Health Organisation declared the West Bank a malaria-free area. All these figures come from official W.H.O., Jordanian, and Israeli sources. The increased number of doctors are mainly young Palestinians who, contrary to your statement, were usually trained in Egypt. Some of the specialists from the West Bank have indeed emigrated because pastures are greener elsewhere. Medical emigration is not confined to the West Bank, however. It takes place from Israel and also from the U.K. (where incidentally, many doctors think standards are falling and "that nothing will get better until there is a political settlement"). A free society cannot exist without a free Press; democracy cannot survive without a responsible Press. Publication of an unsigned article politically doctored and factually misleading does not help democracy or the long-overdue settlement of the Palestinian question. S.C.I.P. Research Unit, Bedford College, London NW1 4NS

PETER BEACONSFIELD

children in East Jerusalem. I have myself treated a number of Arab doctors in Israeli hospitals, and if relations were really "frosty" why did they come to Israel when they could equally well have gone to Jordan via the open bridge? Altogether I gained the impression that relations between Arabs and Jews in the medicosocial field were surprisingly good, in some cases almost congenial. Can your Round the World correspondent substantiate his statement that "doctors are bitter because they believe their standards in 1967 were high, but that any development since then has been actively suppressed". How high, and what evidence for active suppression? 29 Bancroft Avenue, London N2 0AR

MARGOT SHINER

NON-APPEARANCE OF INJECTED FIBROBLAST INTERFERON IN CIRCULATION

SIR,-Human leucocyte interferon is usually given by intramuscular (i.m.) injection, both for reasons of safety and because, after i.m. injection, interferon persists in the serum.1 In our experience human interferon prepared in cultured human embryo fibroblasts2,3 differs from leucocyte interferon in many properties, but when the clearance of crude concentrated preparations of human interferon from the rabbit circulatory system was studied, fibroblast and leucocyte interferons behaved identically.4 In contrast after injection of partially purified fibroblast interferon i.m. in man, in doses comparable with those used in studies with leucocyte interferon, we were SERUM LEVELS OF INTERFERON AFTER INTRAMUSCULAR

SIR,-I would have taken your article on the occupied West Bank of the Jordan as factual had I not just returned from a six months’ working period in Israel. As it is, I believe that the report shows a distinct political bias, which is regrettable. I am anxious to relate my impression of medicine as it is practised in Israel in relation to its Arab neighbours as one who believes that medicine and politics should be kept apart. Having worked in three major hospitals in Israel (including the Hadassah Hospital), visited and lectured in nearly all the other hospitals, including those in Gaza and in East Jerusalem, I did not gain the impression that money is freely available to any medical services. On the contrary, Government spending on hospital equipment is restricted, and many of my Israeli colleagues work in conditions which we would not accept in the U.K. This is not so of the Hadassah but then this hospital is largely financed by voluntary organisations abroad and not by the Government of Israel. In other hospitals too donations for special apparatus and laboratory equipment from world Jewry have helped to raise the standard of the services given to the public, Jews and Arabs, which would otherwise not have been possible. Is there any good reason why similar donations cannot be made to West Bank hospitals by the infinitely richer Arab nations? Arabs, not only from Israel, the West Bank, and Gaza but curiously from most of the neighbouring countries can be seen in appreciable numbers in the corridors of any Israeli hospital, in the wards, and the outpatient clinics, and those referred from these three areas are treated for a nominal fee. It has been my privilege to treat many Arab children and I regard it as a sign of confidence and faith on the part of Arab mothers (who are reputed to be good mothers) who are bringing their children to Israeli hospitals for treatment, which is willingly offered and greatfully received. On my visit to Gaza I was accompanied by one of many specialists from Israel on a routine visit to the main Gaza hospital. Any other patients requir-

ing more complex investigations

are sent to

specialist

centres

in Israel, and I believe that this holds true for the West Bank as well. Two well-known paediatricians in Israel, both friends of mine, take weekly sessions at special clinics for Arab

INJECTION

N.T.=not

OF FIBROBLAST

(F)

OR LEUCOCYTE

(L)

INTERFERON

tested.

unable to detect interferon in serum at any time after injection. The only exception, in six patients (eleven injections) was when one patient received 1.8x107 units in a single injection. Between 1 and 6 h post-injection, interferon levels of 10-20 units/ml of serum were found. Another patient who, when given 3 x 106 units of fibroblast interferon i.m., showed no antiviral activity in the circulation, was found to have serum levels of about 100 units/ml 3 h after injections of 3 x 106 units of leucocyte interferon (kindly supplied by Prof. K. Cantell, Helsinki). The table shows typical titres. Perhaps the most likely explanation is that fibroblast interferon is less stable than leucocyte interferon in the blood. To test this, about 100 units/ml of both interferons were added to freshly prepared human serum, and incubated for up to 6 h at 37 °C. Both interferons lost activity, but whereas the leucocyte interferon retained 50% of its activity after 6 h incubation, only 16% of the fibroblast interferon activity remained. Thus it seems likely that fibroblast interferon would be inactivated 1. 2.

Cantell, K., Pyhälä, L., Strander, H. J. gen. Virol. 1974, 22, 453. Desmyter, J., Ray, M. B., De Groote, J., Bradburne, A. F., Desmet, V. J., Edy, V. G., Billiau, A., De Somer, P., Mortelmans, J. Lancet, 1976, ii,

645. 3. Weimar, W.,

4.

Heijtink, R. A., Schalm, S. W., Van Blankenstein, M., Schellekens, H., Masurel, N., Edy, V. G., Billiau, A., De Somer, P. ibid. 1977, ii, 1282. Edy, V. G., Billiau, A., De Somer, P. J. infect. Dis. 1976, 133, suppl. A18.