- Email: [email protected]
Netherlands
1433
this experience will be carried into specialties (such as orthopaedic surgery) where care of the elderly is an important part of clinical work but where no specific provision is usually made in postgraduate education for learning the principles of modern geriatric practice. As a consultant career, working as a PSRE has particular attractions for doctors who enjoy a generalist and community-oriented approach to hospital medicine. Traditional geriatric medicine has not enjoyed enthusiastic recruitment among British medical graduates and a survey of career preferences has shown that few graduates view a career practising exclusively among the elderly as an attractive
option.6 Fears,
based on anecdotes from 25 years ago, that charged with looking after both young and old will necessarily neglect the latter are irrelevant now that there is appropriate higher medical training aimed at consultant posts carrying specified responsibility for medical services for the elderly. Scientifically there is no basis for separating the elderly from the rest of adult patients. Ageing is a continuous and exponential process from early puberty onwards,’ and there is growing evidence that the origins of much disease and disability in old age lie with habits and environment much earlier in life. The separation of the elderly and their doctors is therefore illogical from the point of view of developing appropriate research and teaching programmes. We have described elsewhere the use made of the integrated units in the Newcastle undergraduate teaching programme.8 Among the advantages of integration is the pattern of working relationships it generates. One of the more disagreeable features of the development of geriatric medicine in the United Kingdom has been the isolation, sometimes embittered and embattled, of the traditional geriatrician from his consultant colleagues.9 Geriatricians have long felt that they and their patients are disadvantaged in terms of facilities and staffing, whereas consultants in other medical specialties may find their access to rehabilitation, long-stay, and other geriatric services too indirect. Under the Newcastle arrangements the consultants providing the geriatric service share the facilities and junior staffing with their other medical colleagues, who in return know that their patients have direct and unimpeded access to geriatric facilities as part of the working principle of integration. Perhaps the most significant aspect of this relationship is that the PSRE is as dependent on the efficient working of the medical reception units as are his colleagues in other medical specialties, and is seen to be so. Working relationships, however, also impose potential constraints on the scope for integration. The pooling of beds and the forming of consultant teams does require a degree of personal trust and cooperation between individuals which, sadly, is not universally found in the hospital service. Also, for the benefits of integration to be fully realised, it is important for the PSRE to provide a sufficiently weighty contribution to the consultant team on the reception unit to ensure that medical and nursing practice there does evolve towards that appropriate for units with geriatric responsibilities. This might not occur if the consultant teams are too large and leadership too diffuse. doctors
Mrs M. Davidson carried out the survey work while scheme for administrative support to clinical units.
supported by a DHSS
Round the World From
DRUGS FOR THE THIRD WORLD
Werkgroep Medische Ontwikkelingssamenwerking (WEMOS) (Committee for Medical Development Cooperation) is a voluntary organisation, created in 1980 and supported by the Netherlands Government’s National Committee for Development Cooperation, whose purpose is to instruct the public and those working in medical services about health care and needs in developing countries. Last month in Amsterdam WEMOS, in conjunction with the Royal Tropical Institute, the Dutch Organisation for International Development Cooperation (NOVIB), and the University of Amsterdam, organised a congress on The Netherlands and the Drug Supply in the Third World. Dr Sanjaya Lall, an economist who addressed the meeting, had formerly taken a strong line against the drug firms’ marketing activities in the Third World and he had argued for wider and closer control by governments. Dr Lall’s assessment of events in India had caused him to adopt a more tolerant view. The multinational manufacturers supplied innovation, quality control, and research. The banning of brand names was a deterrent to innovation. Dr Lall maintained that drug prices fell when patents lapsed or when new drugs of the same kind came on the market-though not everyone at the meeting agreed with him. Dianna Melrose, the Oxfam campaigner, gave Dr Lall a robust answer. The Third World gained little from pharmaceutical innovation, since only about 1% of drug research and development was beneficial in the relief of Third World diseases. A policy for the introduction of generic names was certainly feasible, as events in Sri Lanka had demonstrated. Dr Lall’s disappointing change in attitude was, in Ms Melrose’s to the ears of the multinationals. In March WEMOS had lodged with NEFARMA (the association of the Dutch pharmaceutical industry) a series of complaints against AKZO: Organon, the Dutch transnational company, which was held to have breached the code of the International Federation of Pharmaceutical Manufacturers’ Associations. Among the complaints was the assertion that Organon sold drugs in the Third World which were no longer, or rarely, prescribed by doctors in the Netherlands. Taking advantage of the lack of objective information available to doctors and health workers in the Third World, Organon was advertising and promoting the use of these drugs. Organon’s claims about the efficacy, safety, and working of anabolic steroids were not based on reliable analysis of the latest medical opinion. WEMOS proposed that Organon should, as far as possible, standardise its methods throughout the world in order to offset the impression that drugs which were no longer or seldom used in the .developed countries were still sold in the Third World. Organon should limit the range of use of anabolic steroids (especially for women and children) to scientifically sound indications.
estimate, music
2
Hospital In-patient Enquiry
of
Physicians. Medical
1979.
Summary tables London: HM Stationery Office,
1982.
3. Evans JG. Institutional care. In- Arie T, ed Health care of the elderly. London: Croom Helm, 1981· 176-93 4. Horrocks P The case for geriatric medicine as an age-related specialty. In: Isaacs B, ed. Recent advances in geriatric medicine 2 London. Churchill, 1982: 259-77. 5. Evans JG. Care of the elderly in a defined community. In: Hodkinson HM, Graham JM, eds. The skills of geriatric medicine London- Department of Health and Social
Security (in press)
REFERENCES
Report of the working party of the Royal College elderly Lancet 1977, i: 1092-95.
Correspondents
Netherlands
R, Parsons D, Pearson R The determinants of doctor’s career decisions. Institute of manpower studies report to the DHSS and Scottish Home and Health Departments London: HM Stationery Office, 1979. 7. Evans JG. The biology of human ageing In: Dawson AM, Compston N, Besser GM, eds. Recent advances in medicine 18 London- Churchill, 1981· 17-38. 8. Evans J. The Newcastle undergraduate programme. In: Evans JG, Caird FI, eds. Advanced geriatric medicine 2 London: Pitman, 1982: 50-54. 9. Editorial. Incompat.ble physicians. Lancet 1974; n: 139-40. 6. Hutt
1.
our
care
of the
this experience will be carried into specialties (such as orthopaedic surgery) where care of the elderly is an important part of clinical work but where no specific provision is usually made in postgraduate education for learning the principles of modern geriatric practice. As a consultant career, working as a PSRE has particular attractions for doctors who enjoy a generalist and community-oriented approach to hospital medicine. Traditional geriatric medicine has not enjoyed enthusiastic recruitment among British medical graduates and a survey of career preferences has shown that few graduates view a career practising exclusively among the elderly as an attractive
option.6 Fears,
based on anecdotes from 25 years ago, that charged with looking after both young and old will necessarily neglect the latter are irrelevant now that there is appropriate higher medical training aimed at consultant posts carrying specified responsibility for medical services for the elderly. Scientifically there is no basis for separating the elderly from the rest of adult patients. Ageing is a continuous and exponential process from early puberty onwards,’ and there is growing evidence that the origins of much disease and disability in old age lie with habits and environment much earlier in life. The separation of the elderly and their doctors is therefore illogical from the point of view of developing appropriate research and teaching programmes. We have described elsewhere the use made of the integrated units in the Newcastle undergraduate teaching programme.8 Among the advantages of integration is the pattern of working relationships it generates. One of the more disagreeable features of the development of geriatric medicine in the United Kingdom has been the isolation, sometimes embittered and embattled, of the traditional geriatrician from his consultant colleagues.9 Geriatricians have long felt that they and their patients are disadvantaged in terms of facilities and staffing, whereas consultants in other medical specialties may find their access to rehabilitation, long-stay, and other geriatric services too indirect. Under the Newcastle arrangements the consultants providing the geriatric service share the facilities and junior staffing with their other medical colleagues, who in return know that their patients have direct and unimpeded access to geriatric facilities as part of the working principle of integration. Perhaps the most significant aspect of this relationship is that the PSRE is as dependent on the efficient working of the medical reception units as are his colleagues in other medical specialties, and is seen to be so. Working relationships, however, also impose potential constraints on the scope for integration. The pooling of beds and the forming of consultant teams does require a degree of personal trust and cooperation between individuals which, sadly, is not universally found in the hospital service. Also, for the benefits of integration to be fully realised, it is important for the PSRE to provide a sufficiently weighty contribution to the consultant team on the reception unit to ensure that medical and nursing practice there does evolve towards that appropriate for units with geriatric responsibilities. This might not occur if the consultant teams are too large and leadership too diffuse. doctors
Mrs M. Davidson carried out the survey work while scheme for administrative support to clinical units.
supported by a DHSS
Round the World From
DRUGS FOR THE THIRD WORLD
Werkgroep Medische Ontwikkelingssamenwerking (WEMOS) (Committee for Medical Development Cooperation) is a voluntary organisation, created in 1980 and supported by the Netherlands Government’s National Committee for Development Cooperation, whose purpose is to instruct the public and those working in medical services about health care and needs in developing countries. Last month in Amsterdam WEMOS, in conjunction with the Royal Tropical Institute, the Dutch Organisation for International Development Cooperation (NOVIB), and the University of Amsterdam, organised a congress on The Netherlands and the Drug Supply in the Third World. Dr Sanjaya Lall, an economist who addressed the meeting, had formerly taken a strong line against the drug firms’ marketing activities in the Third World and he had argued for wider and closer control by governments. Dr Lall’s assessment of events in India had caused him to adopt a more tolerant view. The multinational manufacturers supplied innovation, quality control, and research. The banning of brand names was a deterrent to innovation. Dr Lall maintained that drug prices fell when patents lapsed or when new drugs of the same kind came on the market-though not everyone at the meeting agreed with him. Dianna Melrose, the Oxfam campaigner, gave Dr Lall a robust answer. The Third World gained little from pharmaceutical innovation, since only about 1% of drug research and development was beneficial in the relief of Third World diseases. A policy for the introduction of generic names was certainly feasible, as events in Sri Lanka had demonstrated. Dr Lall’s disappointing change in attitude was, in Ms Melrose’s to the ears of the multinationals. In March WEMOS had lodged with NEFARMA (the association of the Dutch pharmaceutical industry) a series of complaints against AKZO: Organon, the Dutch transnational company, which was held to have breached the code of the International Federation of Pharmaceutical Manufacturers’ Associations. Among the complaints was the assertion that Organon sold drugs in the Third World which were no longer, or rarely, prescribed by doctors in the Netherlands. Taking advantage of the lack of objective information available to doctors and health workers in the Third World, Organon was advertising and promoting the use of these drugs. Organon’s claims about the efficacy, safety, and working of anabolic steroids were not based on reliable analysis of the latest medical opinion. WEMOS proposed that Organon should, as far as possible, standardise its methods throughout the world in order to offset the impression that drugs which were no longer or seldom used in the .developed countries were still sold in the Third World. Organon should limit the range of use of anabolic steroids (especially for women and children) to scientifically sound indications.
estimate, music
2
Hospital In-patient Enquiry
of
Physicians. Medical
1979.
Summary tables London: HM Stationery Office,
1982.
3. Evans JG. Institutional care. In- Arie T, ed Health care of the elderly. London: Croom Helm, 1981· 176-93 4. Horrocks P The case for geriatric medicine as an age-related specialty. In: Isaacs B, ed. Recent advances in geriatric medicine 2 London. Churchill, 1982: 259-77. 5. Evans JG. Care of the elderly in a defined community. In: Hodkinson HM, Graham JM, eds. The skills of geriatric medicine London- Department of Health and Social
Security (in press)
REFERENCES
Report of the working party of the Royal College elderly Lancet 1977, i: 1092-95.
Correspondents
Netherlands
R, Parsons D, Pearson R The determinants of doctor’s career decisions. Institute of manpower studies report to the DHSS and Scottish Home and Health Departments London: HM Stationery Office, 1979. 7. Evans JG. The biology of human ageing In: Dawson AM, Compston N, Besser GM, eds. Recent advances in medicine 18 London- Churchill, 1981· 17-38. 8. Evans J. The Newcastle undergraduate programme. In: Evans JG, Caird FI, eds. Advanced geriatric medicine 2 London: Pitman, 1982: 50-54. 9. Editorial. Incompat.ble physicians. Lancet 1974; n: 139-40. 6. Hutt
1.
our
care
of the