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PASSIVE SMOKING
888 A NEW KIND OF CHILD ABUSE
SiR,—Your March 19 editorial highlights the mistreatment of schoolchildren by the authorities in South Africa. There is another dimension to this form of child abuse, again with South African involvement. The children of Mozambique are suffering in the strife generated by insurgents whose backers, South Africa, want to destabilise the country. Besides the children who have died as a result of the war or who have been orphaned or who face famine or displacement from their homes by terrorist activities,> there is another kind of child victim. There has been widespread forced recruitment of children as young as 8 into insurgent bands. The average age of "recruits" into the insurgents (MNR) fell from 25 in 1978 to below 17 in 1984, a fall recorded in captured records. This reflects the scarcity of volunteers, the high desertion rate, and perhaps the belief that government troops would be less likely to fire on children. Some children are promised food or clothes but more typically they are threatened with death, a fate they have just seen meted out to others during the raid in which they were taken. Flogging and mutilation have been used to enforce discipline on the march to insurgent camps. Some children have testified that they were fed drugs or given marijuana to smoke before being sent out with assault groups to ambush vehicles, burn villages and health posts, and kill health workers, teachers, and villagers. A 12-year-old boy, Amaldo, was taken prisoner during an attack on Manhica in Maputo province on Jan 13, 1988. He was pressganged into the MNR and given weapons training during which he was forced to kill with a bayonet ten women who had tried to escape. He claimed that he had seen many children kill under the influence of drugs. "The people we have to kill are tied up and then they give us the bayonet and show us where to strike, usually here", and he indicated the throat. Jose, also 12, describes how insurgents appeared as his home and demanded to know if his father were a militiaman. Jose denied this but they killed his father, cut off an ear and three of Jose’s fingers. He was taken to an insurgent base and was tied to a tree by an arm for a week. He was then released to begin military training but he escaped. An 8-year-old boy, kidnapped in Gaza province, told a Mozambique News Agency reporter how he had been trained to assemble weapons and had participated in raids and murders. A sample group of 31 child victims who had escaped or been rescued have been assessed in Maputo by two doctors and a psychologist with a social worker to act as a temporary fostermother. Most of these children harboured memories of the torture, rape, and murder of family or friends that they had witnessed and all show signs of psychological trauma. Their recovery will be hindered not only by the lack of specialist skills in Mozambique but also by the wholesale rupture of family and community life that the strife is
creating.
contribute towards the cost". Is it not remarkable that we now see patients as a burden on the NHS? Prioritisation already exists in the NHS, but at least it is based on a clinical assessment of need not on value judgments about people’s life styles. Such an approach is open to the most dangerous prejudice and is medically indefensible. As McCormick and Skrabanek point out, if we start apportioning blame and responsibility to our patients we would have to include many AIDS sufferers and drug abusers-to which could be added people who eat unhealthy diets, those injured while playing sport, patients with venereal disease or cervical cancer associated with promiscuity, cases of self-injury or attempted suicide, and even patients who become ill as a result of treatment non-compliance. The Royal College presidents have acknowledged the dangers of prioritisation. I suggest that the form proposed by Sir Raymond is one of the more dangerous and should be rejected by doctors, regardless of their personal beliefs about the rights and wrongs of potentially unhealthy behaviour. Our role as doctors is to educate and treat, not to pass moral judgment. Royal Liverpool Hospital, Liverpool L7 8XP
D. N. ANDERSON PASSIVE SMOKING
SiR,—Your April 2 editorial on passive smoking is blatantly one-sided. The position surely is that the freedom of smokers to smoke whenever and wherever they want is steadily, year by year, being curtailed-and this curtailment is welcomed by non-smokers and accepted by smokers, against a background of increasing expectations with regard to air quality. The tide is running out on its own, so why try to make it go out faster by emotive and unscientific argument? To confuse the position by introducing such terms as "dangerous exposure" and to imply that increased urinary cotinine as evidence of uptake of nicotine amounts to proof of risk to health is to go well beyond the scientific evidence in relation to exposure to other people’s smoke. Consensuses by committees which consist of a mixed bag of experts are no substitute for scientific truth, particularly when complex statistical calculations are needed to distinguish between a nil extra risk and risk of developing lung cancer that is increased from 10 to 11-13 per 100 000 per annum, where exposure data are very unreliable, and where there is a proven basis for bias in the direction of exaggeration of the risk.1 Obviously the Independent Scientific Committee on Smoking and Health is more aware of the fragility of the scientific basis for the recommendations it has put forward in its fourth reportl than is your editorialist. FRANCIS J. C. ROE, 19 Marryat Road, London SWI9 5BB
Consultant to the Tobacco Advisory Council
1. Lee PN. Passive
Epsom District Hospital, Epsom, Surrey KT18 7FG
DEREK SUMMERFIELD
smoking and lung cancer association: A result of bias? Hum Toxicol 1987; 6: 517-24.
2. Fourth
1. Summerfield D.
Mozambique:
Health and
war.
Lancet
1988; i: 360.
Report on the Independent Scientific Committee on Smoking and Health (chairman, Sir Peter Froggatt). London: HM Stationery Office, 1988: 67.
BILINGUAL CONSULTATION
PENALISING SMOKERS AND DRINKERS
SIR,-Like Professor McCormick and Dr Skrabanek (March 19, p 649) I read with alarm the Jan 21 Guardian version of Sir Raymond Hoffenberg’s evidence to the House of Commons Social Services Select Committee in which the president of the Royal College of Physicians seemed to be recommending charges for health care based on patients’ habits. Earlier this year Sir Raymond and two other Royal College presidents, in appealing to the Government for urgent financial support for the National Health Service, had rejected prioritisation of health care as being dangerous and seemed to support the notion of health care being equally available to all regardless of personal background. I am not reassured by Sir Raymond’s reply (March 19, p 649), stating that he was referring to an increase in taxation on alcohol and tobacco, for he clearly states his belief that "people who use the Health Service through personal abuse of that nature should be required to
a!R,—1 share many ot the sentiments expressed m Dr hbden and
colleagues’ article (Feb 13, p 347) and in the ensuing correspondence (March 19, p 648). We are reminded by Dr Dave and Dr Hill-Smith that misunderstandings can arise in any doctor-patient communication, such misunderstandings are compounded a hundred-fold by a language barrier. Professional interpreters with paramedical training are essential in many cases and certainly preferable to enlisting children as translators. Regrettably, even in the presence of the most proficient interpreter, confidentiality between doctor and patient is marred if not destroyed. I would endorse therefore the recommendation by Dr Samra and colleagues that "the patients of the ethnic minority communities should recognise that it is in their interest to be familiar and feel comfortable with the language of the land". The problems of minority groups who speak little or no English have been highlighted by the House of Commons Home Affairs
SiR,—Your March 19 editorial highlights the mistreatment of schoolchildren by the authorities in South Africa. There is another dimension to this form of child abuse, again with South African involvement. The children of Mozambique are suffering in the strife generated by insurgents whose backers, South Africa, want to destabilise the country. Besides the children who have died as a result of the war or who have been orphaned or who face famine or displacement from their homes by terrorist activities,> there is another kind of child victim. There has been widespread forced recruitment of children as young as 8 into insurgent bands. The average age of "recruits" into the insurgents (MNR) fell from 25 in 1978 to below 17 in 1984, a fall recorded in captured records. This reflects the scarcity of volunteers, the high desertion rate, and perhaps the belief that government troops would be less likely to fire on children. Some children are promised food or clothes but more typically they are threatened with death, a fate they have just seen meted out to others during the raid in which they were taken. Flogging and mutilation have been used to enforce discipline on the march to insurgent camps. Some children have testified that they were fed drugs or given marijuana to smoke before being sent out with assault groups to ambush vehicles, burn villages and health posts, and kill health workers, teachers, and villagers. A 12-year-old boy, Amaldo, was taken prisoner during an attack on Manhica in Maputo province on Jan 13, 1988. He was pressganged into the MNR and given weapons training during which he was forced to kill with a bayonet ten women who had tried to escape. He claimed that he had seen many children kill under the influence of drugs. "The people we have to kill are tied up and then they give us the bayonet and show us where to strike, usually here", and he indicated the throat. Jose, also 12, describes how insurgents appeared as his home and demanded to know if his father were a militiaman. Jose denied this but they killed his father, cut off an ear and three of Jose’s fingers. He was taken to an insurgent base and was tied to a tree by an arm for a week. He was then released to begin military training but he escaped. An 8-year-old boy, kidnapped in Gaza province, told a Mozambique News Agency reporter how he had been trained to assemble weapons and had participated in raids and murders. A sample group of 31 child victims who had escaped or been rescued have been assessed in Maputo by two doctors and a psychologist with a social worker to act as a temporary fostermother. Most of these children harboured memories of the torture, rape, and murder of family or friends that they had witnessed and all show signs of psychological trauma. Their recovery will be hindered not only by the lack of specialist skills in Mozambique but also by the wholesale rupture of family and community life that the strife is
creating.
contribute towards the cost". Is it not remarkable that we now see patients as a burden on the NHS? Prioritisation already exists in the NHS, but at least it is based on a clinical assessment of need not on value judgments about people’s life styles. Such an approach is open to the most dangerous prejudice and is medically indefensible. As McCormick and Skrabanek point out, if we start apportioning blame and responsibility to our patients we would have to include many AIDS sufferers and drug abusers-to which could be added people who eat unhealthy diets, those injured while playing sport, patients with venereal disease or cervical cancer associated with promiscuity, cases of self-injury or attempted suicide, and even patients who become ill as a result of treatment non-compliance. The Royal College presidents have acknowledged the dangers of prioritisation. I suggest that the form proposed by Sir Raymond is one of the more dangerous and should be rejected by doctors, regardless of their personal beliefs about the rights and wrongs of potentially unhealthy behaviour. Our role as doctors is to educate and treat, not to pass moral judgment. Royal Liverpool Hospital, Liverpool L7 8XP
D. N. ANDERSON PASSIVE SMOKING
SiR,—Your April 2 editorial on passive smoking is blatantly one-sided. The position surely is that the freedom of smokers to smoke whenever and wherever they want is steadily, year by year, being curtailed-and this curtailment is welcomed by non-smokers and accepted by smokers, against a background of increasing expectations with regard to air quality. The tide is running out on its own, so why try to make it go out faster by emotive and unscientific argument? To confuse the position by introducing such terms as "dangerous exposure" and to imply that increased urinary cotinine as evidence of uptake of nicotine amounts to proof of risk to health is to go well beyond the scientific evidence in relation to exposure to other people’s smoke. Consensuses by committees which consist of a mixed bag of experts are no substitute for scientific truth, particularly when complex statistical calculations are needed to distinguish between a nil extra risk and risk of developing lung cancer that is increased from 10 to 11-13 per 100 000 per annum, where exposure data are very unreliable, and where there is a proven basis for bias in the direction of exaggeration of the risk.1 Obviously the Independent Scientific Committee on Smoking and Health is more aware of the fragility of the scientific basis for the recommendations it has put forward in its fourth reportl than is your editorialist. FRANCIS J. C. ROE, 19 Marryat Road, London SWI9 5BB
Consultant to the Tobacco Advisory Council
1. Lee PN. Passive
Epsom District Hospital, Epsom, Surrey KT18 7FG
DEREK SUMMERFIELD
smoking and lung cancer association: A result of bias? Hum Toxicol 1987; 6: 517-24.
2. Fourth
1. Summerfield D.
Mozambique:
Health and
war.
Lancet
1988; i: 360.
Report on the Independent Scientific Committee on Smoking and Health (chairman, Sir Peter Froggatt). London: HM Stationery Office, 1988: 67.
BILINGUAL CONSULTATION
PENALISING SMOKERS AND DRINKERS
SIR,-Like Professor McCormick and Dr Skrabanek (March 19, p 649) I read with alarm the Jan 21 Guardian version of Sir Raymond Hoffenberg’s evidence to the House of Commons Social Services Select Committee in which the president of the Royal College of Physicians seemed to be recommending charges for health care based on patients’ habits. Earlier this year Sir Raymond and two other Royal College presidents, in appealing to the Government for urgent financial support for the National Health Service, had rejected prioritisation of health care as being dangerous and seemed to support the notion of health care being equally available to all regardless of personal background. I am not reassured by Sir Raymond’s reply (March 19, p 649), stating that he was referring to an increase in taxation on alcohol and tobacco, for he clearly states his belief that "people who use the Health Service through personal abuse of that nature should be required to
a!R,—1 share many ot the sentiments expressed m Dr hbden and
colleagues’ article (Feb 13, p 347) and in the ensuing correspondence (March 19, p 648). We are reminded by Dr Dave and Dr Hill-Smith that misunderstandings can arise in any doctor-patient communication, such misunderstandings are compounded a hundred-fold by a language barrier. Professional interpreters with paramedical training are essential in many cases and certainly preferable to enlisting children as translators. Regrettably, even in the presence of the most proficient interpreter, confidentiality between doctor and patient is marred if not destroyed. I would endorse therefore the recommendation by Dr Samra and colleagues that "the patients of the ethnic minority communities should recognise that it is in their interest to be familiar and feel comfortable with the language of the land". The problems of minority groups who speak little or no English have been highlighted by the House of Commons Home Affairs