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RATIONING OF MEDICAL CARE
1392 FORTIFICATION OF FOODS FOR REFUGEES
SiR,—We join Dr Seaman and Dr Rivers (March 27, p 1204) in expressing concern about nutritional deficiency diseases, including vitamin A deficiency, scurvy, and anaemia, among refugees. The commodities commonly distributed to refugees include cereals, legumes, skim milk powder, and oil, all of which are poor sources of vitamins A and C. It is said to be logistically impossible to provide fresh foods to large refugee populations. To satisfy nutritional requirements, either refugees must produce or purchase fresh food their food should be fortified. Food fortification may be the only solution in the many situations where large numbers of refugees are finding it impossible to obtain fresh food. Food fortification is not novel; experience in several countries has shown that it can alleviate specific nutritional deficiencies.1,2 Food fortification should be seriously considered by the international agencies responsible for feeding refugees. It would be easy to introduce, presenting minimal technological problems, would secure acceptance, and could easily be monitored. Skim milk powder and edible oils may be suitable vehicles for fortification. Most skim milk powder is already fortified with vitamins A and D and could also be fortified with a vitamin C derivative, ascorbyl palmitate. Edible oil is highly suitable as a vehicle for ascorbyl palmitate and retinol palmitate, as they are both fat soluble. Ascorbyl palmitate together with tocopherol are already used by the food industry as antioxidants. Where virtually the entire food-aid package provided to refugees is derived from existing long-term surpluses in the west, fortification at source may be feasible. Packaging practices introduce logistical problems for food fortification for specific populations. These problems would not be insurmountable with sufficient forward planning and organisation. Given the extent of nutritional deprivation by refugee populations world wide, immediate responses are required. or
Refugee Studies Programme, University of Oxford, 21 St Giles, Oxford OX1 3LA; and Department of Biological and Molecular Sciences, Oxford Polytechnic
patients.2 The costs of medical care have not come under control, and the number of individuals denied care, or whose care is reduced, continues to rise. If the recommendations of the UK Government’s white-paper Working for Patients are introduced damage to the doctor-patient relationship is inevitable and the effect would be even more drastic than it has been in the US. The ability of physicians to ration care would be reduced, and certainly they would be in a poorer position to decided in a diminished doctor-patient relationship a patient would be less accepting of a doctor’s decision, and the doctor would be less willing to undertake the responsibility of decision making. The British Government, spurred on by its success in privatising industry and in stimulating competition in business, is unlikely to be so successful with the delivery of medical care because, no matter what, rationing will be needed. Moreover, if rationing is to be just, it must be done by doctors-and doctors must be guided by their professional ethics. Introducing more competition erodes the ethical standard of its providers. In the US this is apparent most vividly in hospitals: originally created for a charitable purpose, they now must compete in the marketplace to survive, and their services to patients have become a secondary issue. Not long ago the Economist stated: "Some kinds of public spending-most defense budgets for example-seem to involve great waste; others-like health-seem to achieve better value for money than their public counterparts". Is it not probable that the vital element in this difference between the value to the British Government of its expenditures on defence and health is the difference beween British physicians and their ethics and the business ethos of munitions-makers? Thus medical ethics have an economic value, which is unlikely to be taken into account in the calculations of economists. Quadrangle, Elm 3101, 3300 Darby Road, HENRY A. SHENKIN
Haverford, Pennsylvania 19041, USA 1. Evans RW. Health
B. E. HARRELL-BOND C. J. K. HENRY KEN WILSON
1. Hetzel BS. Iodine deficiency disorders (IDD) and their eradication. Lancet 1983; ii: 1126-29. 2. Arroyave G, Mejia LA, Aguilar JR. The effect of vitamin A fortification of sugar on the serum vitamin A levels of preschool Guatemalan children: a longtitudinal evaluation. Am J Clin Nutr 1981; 34: 41-49.
RATIONING OF MEDICAL CARE
SIR,-Nations which finance access to medical care for their citizens can never afford all that could be consumed so rationing becomes inevitable.1 In the United States, which devoted 11-5% of its 1988 gross national product (GNP) to a medical care system organised to respond to consumer demand, rationing is accomplished by the marketplace method of denying access. 37 million people have no health insurance, and many more are underinsured. The UK utilises only 6% of GNP for a system that provides universal access and responds to professionally defined needs, with rationing left to doctors. The government funds the National Health Service (NHS), turning the money over to doctors to spend. Rationing is also achieved by waiting-lists for nonemergency care. Nevertheless the British system is more just and more humane than the US one. It was the dissatisfaction created by patients needing to queue that led the UK government to change from administering the NHS to managing it, in an effort to improve efficiency. Now the Government, rather than increase funding of the NHS (even if to a level still below that of other advanced nations), proposes to increase efficiency by introducing more competition among medical care providers. Some of the planned measures would also reduce the autonomy of clinicians, a factor generally recognised as essential to the maintenance of doctors’ ethical code. Experience in the US has shown that competition in the delivery of medical care has been damaging to the doctor-patient relationship and has reduced the responsibility doctors feel for
care technology and the inevitability of resource allocation and rationing decisions I. JAMA 1983; 249: 2047-53. 2. Shenkin HA Clinical practice and cost containment. New York: Praeger Scientific,
1986. 3. Schwartz WB, Aaron HJ. Rationing hospital 1984; 310: 52-56.
care:
lessons from Britain. N
Engl J Med
ADVERTISING DRUGS TO THE PUBLIC
SIR,-Pharmaceutical promotion directly to the public, as described by your Round the World correspondent Sandra Coney (May 20, p 1128), is not a practice limited to New Zealand. Montreal and Toronto public relations firms have been reported to hound media medical reporters with telephone calls, heavy information packages about company products, and notices of important conferences on new drugs and talks to be given by doctors on a company’s payroll. Dr Charles Godfrey of the Toronto Wellesley Hospital attended the 1982 Pan-American League Against Rheumatism conference and wrote about the "massive drug promotion program" there for a new anti-arthritic medication.2 A spacious suite was thrown open to the press complete with the usual liquid refreshments and a free lunch. Videotapes showing a bottle of the medication along with deformed arthritic hands and X-rays were given away to television reporters. As a result of the claims made for the medication in question at this conference and in other news releases thousands of patients demanded the drug from their physicians. Recently, in Canada, Upjohn has been promoting ’Rogaine’ (minoxidil) to the public with techniques similar to those described from New Zealand. When these advertising tactics were criticised, Douglas Squires, president and general manager of Upjohn in Canada, defended the company’s actions with the rhetoric of providing the consumer with "factual, objective, scientific information". The informational and educational component in this form of pharmaceutical advertising is only a secondary motive well behind the desire to increase sales. The late Pierre Garai, an advertising executive and a staunch supporter of the pharmaceutical industry, decisively dismissed educational claims for pharmaceutical
SiR,—We join Dr Seaman and Dr Rivers (March 27, p 1204) in expressing concern about nutritional deficiency diseases, including vitamin A deficiency, scurvy, and anaemia, among refugees. The commodities commonly distributed to refugees include cereals, legumes, skim milk powder, and oil, all of which are poor sources of vitamins A and C. It is said to be logistically impossible to provide fresh foods to large refugee populations. To satisfy nutritional requirements, either refugees must produce or purchase fresh food their food should be fortified. Food fortification may be the only solution in the many situations where large numbers of refugees are finding it impossible to obtain fresh food. Food fortification is not novel; experience in several countries has shown that it can alleviate specific nutritional deficiencies.1,2 Food fortification should be seriously considered by the international agencies responsible for feeding refugees. It would be easy to introduce, presenting minimal technological problems, would secure acceptance, and could easily be monitored. Skim milk powder and edible oils may be suitable vehicles for fortification. Most skim milk powder is already fortified with vitamins A and D and could also be fortified with a vitamin C derivative, ascorbyl palmitate. Edible oil is highly suitable as a vehicle for ascorbyl palmitate and retinol palmitate, as they are both fat soluble. Ascorbyl palmitate together with tocopherol are already used by the food industry as antioxidants. Where virtually the entire food-aid package provided to refugees is derived from existing long-term surpluses in the west, fortification at source may be feasible. Packaging practices introduce logistical problems for food fortification for specific populations. These problems would not be insurmountable with sufficient forward planning and organisation. Given the extent of nutritional deprivation by refugee populations world wide, immediate responses are required. or
Refugee Studies Programme, University of Oxford, 21 St Giles, Oxford OX1 3LA; and Department of Biological and Molecular Sciences, Oxford Polytechnic
patients.2 The costs of medical care have not come under control, and the number of individuals denied care, or whose care is reduced, continues to rise. If the recommendations of the UK Government’s white-paper Working for Patients are introduced damage to the doctor-patient relationship is inevitable and the effect would be even more drastic than it has been in the US. The ability of physicians to ration care would be reduced, and certainly they would be in a poorer position to decided in a diminished doctor-patient relationship a patient would be less accepting of a doctor’s decision, and the doctor would be less willing to undertake the responsibility of decision making. The British Government, spurred on by its success in privatising industry and in stimulating competition in business, is unlikely to be so successful with the delivery of medical care because, no matter what, rationing will be needed. Moreover, if rationing is to be just, it must be done by doctors-and doctors must be guided by their professional ethics. Introducing more competition erodes the ethical standard of its providers. In the US this is apparent most vividly in hospitals: originally created for a charitable purpose, they now must compete in the marketplace to survive, and their services to patients have become a secondary issue. Not long ago the Economist stated: "Some kinds of public spending-most defense budgets for example-seem to involve great waste; others-like health-seem to achieve better value for money than their public counterparts". Is it not probable that the vital element in this difference between the value to the British Government of its expenditures on defence and health is the difference beween British physicians and their ethics and the business ethos of munitions-makers? Thus medical ethics have an economic value, which is unlikely to be taken into account in the calculations of economists. Quadrangle, Elm 3101, 3300 Darby Road, HENRY A. SHENKIN
Haverford, Pennsylvania 19041, USA 1. Evans RW. Health
B. E. HARRELL-BOND C. J. K. HENRY KEN WILSON
1. Hetzel BS. Iodine deficiency disorders (IDD) and their eradication. Lancet 1983; ii: 1126-29. 2. Arroyave G, Mejia LA, Aguilar JR. The effect of vitamin A fortification of sugar on the serum vitamin A levels of preschool Guatemalan children: a longtitudinal evaluation. Am J Clin Nutr 1981; 34: 41-49.
RATIONING OF MEDICAL CARE
SIR,-Nations which finance access to medical care for their citizens can never afford all that could be consumed so rationing becomes inevitable.1 In the United States, which devoted 11-5% of its 1988 gross national product (GNP) to a medical care system organised to respond to consumer demand, rationing is accomplished by the marketplace method of denying access. 37 million people have no health insurance, and many more are underinsured. The UK utilises only 6% of GNP for a system that provides universal access and responds to professionally defined needs, with rationing left to doctors. The government funds the National Health Service (NHS), turning the money over to doctors to spend. Rationing is also achieved by waiting-lists for nonemergency care. Nevertheless the British system is more just and more humane than the US one. It was the dissatisfaction created by patients needing to queue that led the UK government to change from administering the NHS to managing it, in an effort to improve efficiency. Now the Government, rather than increase funding of the NHS (even if to a level still below that of other advanced nations), proposes to increase efficiency by introducing more competition among medical care providers. Some of the planned measures would also reduce the autonomy of clinicians, a factor generally recognised as essential to the maintenance of doctors’ ethical code. Experience in the US has shown that competition in the delivery of medical care has been damaging to the doctor-patient relationship and has reduced the responsibility doctors feel for
care technology and the inevitability of resource allocation and rationing decisions I. JAMA 1983; 249: 2047-53. 2. Shenkin HA Clinical practice and cost containment. New York: Praeger Scientific,
1986. 3. Schwartz WB, Aaron HJ. Rationing hospital 1984; 310: 52-56.
care:
lessons from Britain. N
Engl J Med
ADVERTISING DRUGS TO THE PUBLIC
SIR,-Pharmaceutical promotion directly to the public, as described by your Round the World correspondent Sandra Coney (May 20, p 1128), is not a practice limited to New Zealand. Montreal and Toronto public relations firms have been reported to hound media medical reporters with telephone calls, heavy information packages about company products, and notices of important conferences on new drugs and talks to be given by doctors on a company’s payroll. Dr Charles Godfrey of the Toronto Wellesley Hospital attended the 1982 Pan-American League Against Rheumatism conference and wrote about the "massive drug promotion program" there for a new anti-arthritic medication.2 A spacious suite was thrown open to the press complete with the usual liquid refreshments and a free lunch. Videotapes showing a bottle of the medication along with deformed arthritic hands and X-rays were given away to television reporters. As a result of the claims made for the medication in question at this conference and in other news releases thousands of patients demanded the drug from their physicians. Recently, in Canada, Upjohn has been promoting ’Rogaine’ (minoxidil) to the public with techniques similar to those described from New Zealand. When these advertising tactics were criticised, Douglas Squires, president and general manager of Upjohn in Canada, defended the company’s actions with the rhetoric of providing the consumer with "factual, objective, scientific information". The informational and educational component in this form of pharmaceutical advertising is only a secondary motive well behind the desire to increase sales. The late Pierre Garai, an advertising executive and a staunch supporter of the pharmaceutical industry, decisively dismissed educational claims for pharmaceutical