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More deaths from Rift Valley fever in Saudi Arabia and Yemen
POLICY AND PEOPLE
More deaths from Rift Valley fever in Saudi Arabia and Yemen ccording to a statement released by the Saudi Health Ministry on Oct 16, 76 people have died from an outbreak of Rift Valley fever and 408 people had contracted the disease. In neighbouring Yemen, health officials said on Oct 14 that 70 people have died from the disease. At a press conference on Oct 14 government ministers including, the Yemeni Minister of Health, Abdullah Abdulwali Nashir, and the Saudi Minister of Health, Osama bin Abdulmajeed Shobokshi, said that a joint field team would be formed to tackle the epidemic. According to Saudi Arabian health officials the outbreak began in southern coastal province of Jizan and in the Al Quenfadah and Asir health regions of Saudi Arabia. Officials stated that 96% of cases, mostly adult men, were in Jizan and adjacent regions—80% of them were Saudi citizens and the rest were Yemenis. The epicentre of the outbreak is Wadi Mawr, the El-Zuhrah district in
A
the Hodeidah Governorate. The reported case-fatality rate in Saudi Arabia is about double that of Yemen,
Rights were not granted to include this image in electronic media. Please refer to the printed journal. It’s safer under the net
but Douglas Klaucke, a WHO epidemiologist, cautions that the mortality rate in Yemen might be higher compared with Saudia Arabia because the affected Yemeni population might have inadequate immunity to fight the disease. Rift Valley fever is a mosquitoborne zoonotic viral disease that mainly affects cattle, sheep, camels,
and goats. Humans become infected with the virus either by mosquito bite or by contact with the blood or body fluids of infected animals. Although both Yemen and Saudi Arabia have stepped up control measures, including the spraying of mosquito-infected areas along their common border and restriction of movement of domestic animals, the increasing number of mosquitoes as a result of seasonal rains is cause for concern for both countries. Last week WHO launched a US$975 000 appeal to support control efforts and rehabilitate the affected communities in Yemen. These are the first reported cases of Rift Valley fever outside Africa since the disease was first identified there in 1930. “In the long run”, says Klaucke, “there is a danger of the extension of this disease into other countries in the Arabian peninsula and then on farther north into Asia and possibly Europe”. Khabir Ahmad
Standard of care for alternative medicine ow should a practitioner of “alternative” medicine be judged? Against the skills of others in the same field or those of orthodox medical practitioners? A landmark case reported on Oct 4 (2000 4 All ER 181) has for the first time considered this important issue in the UK. A fit 32-year-old man had sought traditional Chinese herbal treatment for multiple benign lipomas (for which western medicine offered only surgery). After he had taken nine doses on alternate days of a traditional Chinese decoction made from 12 herbs, liver failure developed and he died on Jan 20, 1995. The inquest heard evidence that one of the herbs (Dictamnus dasycarpus or Bai Xian Pi) might be hepatotoxic. At trial, medical experts from both sides agreed that the ingredients were biologically active but not toxic, individually or collectively. The preparation had produced an idiosyncratic and rare fatal reaction. The judge found that the herbs had been of acceptable quality. Dismissing the widow’s claim, the judge said that even if a reasonably competent orthodox general medical practitioner had read the literature he or she would not have concluded that the preparation was too hazardous to prescribe. The defendant said that he did not consult journals or books on modern medi-
H
1422
cine but Chinese publications suggested that these herbs were safe. The judge explained that when the court adjudicates on the standard of care in cases of this type it must “have regard to the fact that the practitioner is practising his art alongside orthodox medicine and the implications of this fact”. However , the defendant could not be judged by the standard of orthodox medicine because he did not hold himself out to be such a person. Nonethless, where a practitioner prescribed a remedy, chemical or herbal: ● He held himself out “as competent to practise within a system of law and medicine which will review the standard of care he has given”. ● It would not be enough simply to say that a remedy is traditional and believed not to be harmful. ● He must recognise the probability that anyone having an adverse reaction to an alternative remedy may well be treated in an orthodox hospital. The incident may be published in an orthodox medical journal so “an alternative practitioner must take steps to satisfy himself that there has not been any adverse report in such journals on the remedy which ought to affect the use he makes of it”. This would be satisfied by subscribing to an association which searches the literature and circulates relevant
information otherwise the practitioner will not have discharged his duty to inform himself and may act at his peril”. What experts should be called at a trial of this sort? A claim against an alternative practitioner for negligent prescribing may succeed if an expert in the relevant specialty can “prove that the defendant has failed to exercise the skill and care appropriate to that art”. The relevant orthodox specialty here was held to be general practice but neither side had called a GP to give evidence on what he or she would have deduced from relevant “letters and articles in The Lancet” (a journal that has published on the hepatoxicity of some Chinese herbal remedies). In fact the experts included a consultant physician and a dermatologist (claimant) and a pathologist, and a past president of the Register of Chinese Herbal Medicine (defendant) The judge rejected the claimant’s submission that the defendant should have been warned there were risks; the risk was too low to have warranted this and disclosure would probably not have dissuaded the patient. The death was a tragic accident but could not be regarded as the fault of the defendant practitioner. Diana Brahams
THE LANCET • Vol 356 • October 21, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
More deaths from Rift Valley fever in Saudi Arabia and Yemen ccording to a statement released by the Saudi Health Ministry on Oct 16, 76 people have died from an outbreak of Rift Valley fever and 408 people had contracted the disease. In neighbouring Yemen, health officials said on Oct 14 that 70 people have died from the disease. At a press conference on Oct 14 government ministers including, the Yemeni Minister of Health, Abdullah Abdulwali Nashir, and the Saudi Minister of Health, Osama bin Abdulmajeed Shobokshi, said that a joint field team would be formed to tackle the epidemic. According to Saudi Arabian health officials the outbreak began in southern coastal province of Jizan and in the Al Quenfadah and Asir health regions of Saudi Arabia. Officials stated that 96% of cases, mostly adult men, were in Jizan and adjacent regions—80% of them were Saudi citizens and the rest were Yemenis. The epicentre of the outbreak is Wadi Mawr, the El-Zuhrah district in
A
the Hodeidah Governorate. The reported case-fatality rate in Saudi Arabia is about double that of Yemen,
Rights were not granted to include this image in electronic media. Please refer to the printed journal. It’s safer under the net
but Douglas Klaucke, a WHO epidemiologist, cautions that the mortality rate in Yemen might be higher compared with Saudia Arabia because the affected Yemeni population might have inadequate immunity to fight the disease. Rift Valley fever is a mosquitoborne zoonotic viral disease that mainly affects cattle, sheep, camels,
and goats. Humans become infected with the virus either by mosquito bite or by contact with the blood or body fluids of infected animals. Although both Yemen and Saudi Arabia have stepped up control measures, including the spraying of mosquito-infected areas along their common border and restriction of movement of domestic animals, the increasing number of mosquitoes as a result of seasonal rains is cause for concern for both countries. Last week WHO launched a US$975 000 appeal to support control efforts and rehabilitate the affected communities in Yemen. These are the first reported cases of Rift Valley fever outside Africa since the disease was first identified there in 1930. “In the long run”, says Klaucke, “there is a danger of the extension of this disease into other countries in the Arabian peninsula and then on farther north into Asia and possibly Europe”. Khabir Ahmad
Standard of care for alternative medicine ow should a practitioner of “alternative” medicine be judged? Against the skills of others in the same field or those of orthodox medical practitioners? A landmark case reported on Oct 4 (2000 4 All ER 181) has for the first time considered this important issue in the UK. A fit 32-year-old man had sought traditional Chinese herbal treatment for multiple benign lipomas (for which western medicine offered only surgery). After he had taken nine doses on alternate days of a traditional Chinese decoction made from 12 herbs, liver failure developed and he died on Jan 20, 1995. The inquest heard evidence that one of the herbs (Dictamnus dasycarpus or Bai Xian Pi) might be hepatotoxic. At trial, medical experts from both sides agreed that the ingredients were biologically active but not toxic, individually or collectively. The preparation had produced an idiosyncratic and rare fatal reaction. The judge found that the herbs had been of acceptable quality. Dismissing the widow’s claim, the judge said that even if a reasonably competent orthodox general medical practitioner had read the literature he or she would not have concluded that the preparation was too hazardous to prescribe. The defendant said that he did not consult journals or books on modern medi-
H
1422
cine but Chinese publications suggested that these herbs were safe. The judge explained that when the court adjudicates on the standard of care in cases of this type it must “have regard to the fact that the practitioner is practising his art alongside orthodox medicine and the implications of this fact”. However , the defendant could not be judged by the standard of orthodox medicine because he did not hold himself out to be such a person. Nonethless, where a practitioner prescribed a remedy, chemical or herbal: ● He held himself out “as competent to practise within a system of law and medicine which will review the standard of care he has given”. ● It would not be enough simply to say that a remedy is traditional and believed not to be harmful. ● He must recognise the probability that anyone having an adverse reaction to an alternative remedy may well be treated in an orthodox hospital. The incident may be published in an orthodox medical journal so “an alternative practitioner must take steps to satisfy himself that there has not been any adverse report in such journals on the remedy which ought to affect the use he makes of it”. This would be satisfied by subscribing to an association which searches the literature and circulates relevant
information otherwise the practitioner will not have discharged his duty to inform himself and may act at his peril”. What experts should be called at a trial of this sort? A claim against an alternative practitioner for negligent prescribing may succeed if an expert in the relevant specialty can “prove that the defendant has failed to exercise the skill and care appropriate to that art”. The relevant orthodox specialty here was held to be general practice but neither side had called a GP to give evidence on what he or she would have deduced from relevant “letters and articles in The Lancet” (a journal that has published on the hepatoxicity of some Chinese herbal remedies). In fact the experts included a consultant physician and a dermatologist (claimant) and a pathologist, and a past president of the Register of Chinese Herbal Medicine (defendant) The judge rejected the claimant’s submission that the defendant should have been warned there were risks; the risk was too low to have warranted this and disclosure would probably not have dissuaded the patient. The death was a tragic accident but could not be regarded as the fault of the defendant practitioner. Diana Brahams
THE LANCET • Vol 356 • October 21, 2000
For personal use only. Not to be reproduced without permission of The Lancet.