Pakistan A QUANTUM LEAP FOR COMMUNITY PSYCHIATRY

1445

New Zealand UPHEAVALS IN MEDICAL RESEARCH

MEDICAL research in New Zealand is undergoing major some controversy and argument. Revelations about unethical research at the cervical cancer inquiry! prompted the Department of Health to initiate an overhaul of ethical committees in New Zealand. Simultaneously, a review committee studied the organisation and funding of biomedical and health systems research and made recommendations for sweeping

reorganisation amid

changes. Before the cervical cancer inquiry nobody save researchers wanting their proposals approved paid much attention to ethics committees. The Department of Health had official oversight but in practice knew little about them. By 1987, when the inquiry took place, there were wide regional variations in the composition and functioning of ethics committees. The judge conducting the inquiry expressed grave misgivings about the conduct of the ethics committee of the National Women’s one of fifty-two research proposals was turned down in 10 years, and consent forms were seldom used. The judge interviewed women whose files showed that they had been included in two or even three research projects, usually without their knowledge. She recommended the immediate disbandment of the committee and set down guidelines for the proper conduct of ethics committees in the future, basing many of her recommendations on the evidence of Prof A. V. Campbell, a visiting professor of biomedical ethics from Edinburgh, and Dr J. V. Hodge, director of the Medical Research Council of New Zealand.2 After discussions with area health boards and the Medical Research Council, the Department of Health issued a national standard for ethics committees in late 1988.3 According to a New Zealand medical ethicist, this moved New Zealand committees away from the traditional institution-based British model and "closer to the (bio) medical ethics committees of many US institutions".4 The standard specifies that half the membership of the committee should be lay people who can provide "ethical expertise; medical/scientific understanding of health research; nursing experience; a Maori perspective; patient advocacy; women’s health perspective", and that the chairperson must be one of the lay members. An ethics committee must approve all research that involves human subjects, compares an established procedure

Hospital, Auckland. Only

(whether therapeutic or non-therapeutic) with procedures which established, or includes access to health records. In the area of treatment, all significant shifts from established protocols must go to the ethics committee and all protocols must be submitted to the ethics committee before being formally adopted. The committees are instructed to maintain a critical position on scientific validity, seeking review of protocols where they have not been to an external funding agency. After approval, research will be regularly monitored, and results must be published, at least to the ethics committee. The informed consent of participants in research is mandatory. The new guidelines have not won universal approval. There has been a heated correspondence in the columns of the New Zealand Medical Journal between researchers and the Health Department, the Medical Research Council has set in motion its own review, and the country’s largest area health board, Auckland (the one under scrutiny at the Cervical Cancer Inquiry), is refusing to conform-to the considerable annoyance of the Department of Health. The objections to the standard are so far essentially theoretical. No-one can point to a well-planned research protocol that has actually been turned down under the new rules. But the new standard has been issued in a climate of public suspicion about are not

1.

2

Anonymous. New Zealand: recall of women with untreated cervical abnormalities. Lancet 1989; i: 608-09. Cartwright S. Report of the Committee of Inquiry into Allegations Concerning the

Treatment of Cervical Cancer at National Women’s Hospital and into other Related Matters. Auckland: 1988, 144-70. 3. Standard for Ethical Committees Established to Review Research and Treatment Protocols. Wellington Department of Health, 1988 4. Gillett G. The new ethical committees: their nature and role. N Z Med J1989; 102: 314-15.

medical research. In the wake of the cervical cancer inquiry, medical academics report that hospital patients are less willing to participate in teaching and research. Consequently there is a mood of defensiveness and apprehension among researchers. Some doctors have doubted the competence of lay committee members to understand the scientific aspects of research proposals. Dr J. M. Neutze, the cardiologist-in-charge at Auckland’s Greenlane Hospital, writes that: "Taken literally the instructions would require the committees to replace the judgment and integrity of medical practice. Committee members would need to have a profound knowledge of research and medical practice, the wisdom of Solomon, and a capacity for an enormous workload."5 There is also some resistance to the concept of referring treatment protocols to ethics committees. Dr Alan Gray, medical director of the Cancer Society of New Zealand, says the standard does not recognise problems that arise in the area of cancer treatments "... surgeons encountering an unusual lesion for which an established protocol does not exist, can hardly be expected to close the patient pending a meeting of the Ethical Committee. Even more important, however, clinicians may simply stop preparing

protocols".6 The lack of an injunction in the standard to encourage research has also been criticised. Some doctors regard this as the first and central task of ethics committees.’ Dr Neutze fears that "inadequately informed committees will place such artificial constraints on research that clinicians will simply give Up".8 The Health Department has reacted firmly, but with evident irritation, to most of the criticisms. Dr Karen Poutasi, until recently chief medical officer in the Department, says that the prime function of the ethics committees is not to encourage research but to review ethics; the scientific review will have usually taken place before this, although there is no reason why ethics committees should not provide scientific review providing they contain that

competence.9 The Department also believes "the ability of lay people has been underestimated" and questions how the subjects of research will understand enough to consent if researchers cannot make their protocols comprehensible to the lay members of ethics committees. A lay chair is needed, it believes, at a time when public confidence has been "profoundly shaken". The Department, though disappointed by the overall response of the medical profession, agrees that there are some areas where the standard needs to be improved-such as the overseeing of multicentre trials and general-practitioner-based research and the lack of a central appeal body. All chairpersons of newly constituted ethics committees will meet this month to discuss what the calls "enhancement" of the standard. However, if Auckland’s defection from the standard cannot be resolved, the Minister of Health might intervene with a direction to comply.

Department

21

Albany Road,

Herne Bay, Auckland, New Zealand

SANDRA CONEY

Pakistan A

QUANTUM LEAP FOR COMMUNITY PSYCHIATRY

IF

community psychiatry is to be more than an empty slogan, it something more than treatment for mental disorders being available outside hospital. It might mean that the driving energy for the service, instead of coming entirely from specialised staff, is derived from the community being served-power from the people. When a person with a mental health problem may be persuaded to seek medical help by a retired teacher on the village health committee, by a schoolboy working in conjunction with a village elder, by the multi-purpose health worker on his routine visit, by the Imam in the local mosque, and even by the faith-healer at the local shrine, community mental health has surely come of age. must mean

JM A standard for ethical committees N Z Med J 1989; 102: 111. Gray AJ, Heslop BF. Medical research- who minds the minders? NZ Med J 1989; 102:

5. Neutze

6.

54. 7. Harris EA Ethics committees. N Z

8.

Med J 1989; 102: 325 Neutze JM. Letter to secretary. Medical Research Council of New Zealand, March 20,

1989. 9. Poutasi KO. A standard for ethical

committees.

NZ

Med J 1989;

102: 170.

1446 The mental health problems are acute psychosis, epilepsy, drug dependence, depression, and mental subnormality; the place is Pakistan. An enormous expansion has occurred since the services were first described on these pages: medical officers have now been trained from every province in the country, and the school programme has spread across the nation and is carried forward by

the teachers themselves-who have formed the All-Pakistan Teachers Movement for Mental Health.2 The genie is out of the lamp, and will never go back inside. Although the school programme has had a deep impact on the basic health units (BHUs) that serve each village, the reason that it will continue lies in the effects it has had on the schools themselves. While the former is of great interest to doctors in public health, the latter are surely of great interest to psychiatrists. As might be expected, the BHUs experience a great increase in referrals of patients with mental health troubles after the campaign opens in each school, but this increase should be seen in a context of a twofold increase in referrals for general medical care. The paradox is complete: psychiatry has made general medicine respectable. If psychosis and depression can be treated medically, then maybe haemorrhoids and jaundice can be as well. And as more village women come to the BHUs for childbirth, the programme may be expected to achieve the primary prevention of many cases of subnormality and epilepsy. None of this accounts for the enthusiasm for the programme which seems to affect teachers and pupils equally. The teachers say that they feel closer to the children and now know more about them as people; some even claim that the children are dressing with more care and achieving better grades. The children are perhaps excited 1. Pakistan revolution

2.

in

mental health

Wig N, Murthy S, Harding T. Psychiatry 1981, 23: 275-80.

In AUTuMN; the

care.

Lancet 1987, i: 736.

A model for rural

psychiatric

services

Indian J

of mists and mellow

DAVID GOLDBERG

University of Manchester

England Now

season

by their role as active participants in the programme, instead of their usual passive role. The certainly vote with their feet, since absenteeism is down by as much as 50% in some schools. They devote enormous energy to the preparation of wall-charts and posters, and see to it that every letter posted in the village is stamped with a mental health slogan. Collaboration between religious healers and psychiatrists is not a new idea in developing countries. What is original to Pakistan is that these healers are issued with the same coloured case-identification cards as are used by the multipurpose health workers. One healer said that, although he thought that his results with hysteria were better than those obtained by the BHU, he had never done well with epilepsy or drug dependence, and was pleased to have his religious help for these patients supplemented by medication from the BHUs. Orthodox psychiatrists often object that working with faith-healers gives the healers a legitimacy that they do not deserve; but if enough patients receive treatment who would not otherwise have done so, the price is surely worth paying. Developments in Pakistan should be seen in the wider context of provision of mental health services based in primary care in a part of the world not usually noted for medical innovation. The leadership provided by the East Mediterranean Regional Office of WHO has allowed the countries of the region to coordinate their efforts. Pakistan may have taken the lead, but Democratic Yemen, Yemen, Afghanistan, and Iran are not far behind. Moslem may not speak to Hindu, but a movement that began in India2 has entered the Islamic world, and has even been improved by it. When rehabilitation schemes for those with chronic psychoses also derive their power from the people, community psychiatry will have crossed its last frontier. The crossing may yet be made in Pakistan.

fruitfulness; of

difficult, and the first evening was reminiscent of that dreadful first day in the dissecting room, twenty years ago-flesh everywhere but armed now only with a piece of charcoal instead of a scalpel. But at last the anatomy is coming in useful, as they always said it would.

evenings drawing in and clocks going back; of Heathrow closed owing to fog; and of that peculiarly British phenomenon, the evening class, for which a quarter of a million Londoners register every year. But what to choose? London must surely be the evening-class capital of the world; and this year the soon-to-be-abolished Inner London Education Authority has provided a cornucopia rich in choice. Languages are the staple of all evening classes. But not here just the French, Spanish, Greek, and Italian for next year’s package holiday; and not here only the languages of the European Community (the provision for which would put the future national curriculum to shame). For those searching for their roots there are Cornish and Gaelic, and for the more exotically minded there are

Amharic, Catalan, Euskera, Farsi, Ibo, Kweyol, Patwa, Putonghua, Romany, Somali, Sylheti, Tigrinya, Twi, Yiddish, Yoruba, and Zulu. And if academic linguistics doesn’t appeal, then try French through Cooking or Cultural German. Music also gets a broad range-everything from Introductory Bagpipes (mercifuly conducted on the top floor of a disused school), through Bamboo Pipes (Including Making), Gamelan, Gregorian Chant and Lute, to Sitar and Steel Band. Some of the courses are immensely practical, although Woodworking for Beekeepers hardly fits any stereotype of modem inner-city life. Some courses are clearly to be taken in pairs: thus Christmas Cookery Preparation would be nicely complemented by the Workshop on Christmas Stress. Perhaps the only course in which a high drop-out rate may be regarded as a mark of success rather than failure is the one entitled Preparing for your own Death. So what did I enrol for? Well, Introduction to Painting and Drawing was full, and so I was sent along to Life Drawing for Beginners. Explaining the receipt marked "model" was a bit

*

*

*

WHEN I was a medical administrator I felt the need to keep my clinical hand in, so I did holiday locums in general practice. These locums were of an unusual type. My approach was to write to a single-handed doctor in the Scottish Highlands and offer him a free holiday for a week or two. Free? Yes, I accepted expenses but took no pay. That way, both sides avoided the attentions of the taxman. The Highland doctors mostly jumped at the chance. There was one practice that covered two of the Shetland Isles, which had an extraordinarily foreign atmosphere. The isolation made the work demanding, but it also made it satisfying. The worst feature was the journey to the second island-fortunately it was a small island and required few visits-because it meant eight hair-raising miles in an open boat through rough seas. The main reason for the infrequency of the calls was that the resident nurse had previously been stationed in Labrador and so could cope with practically everything. She thus matched the doctor, who was not only highly competent but also greatly loved by all his patients. There was no reason to vary any of his treatments. During a locum in the Western Isles I found that the health of many of the patients was sometimes better than that of the doctor I was replacing, who had been too fond of the whisky for too long. He was another who was popular, but for a different reason; he had a good number of his patients on whisky as therapy. So here there was perhaps need to vary my host’s treatment, but I did not. What I did was to polish the wording of my First Law of Locum-tenancy, which states that you must in no way contradict a doctor who cannot back. To do so can only mar his status with his patients, and it can do you no good. You will soon be gone; you have no status at all. answer