- Email: [email protected]
Serbian doctors and ethnic Albanians
CORRESPONDENCE
are damaged goods; this would also explain the high incidence of rape in holocausts. Another corollary is that communist atrocities reflect a contest over the means of reproduction. Carl F Needles 1955 Merrick road, Merrick, NY, 11566, USA 1
Fried I. Syndrome E. Lancet 1997: 350; 1845-47.
Sir—Itzak Fried’s hypothesis1 seems to emphasise a suggested neurophysiological mechanism for the behaviour of those with the syndrome in such as way as to propose this mechanism as the cause rather than the effect. Enticement and encouragement to commit brutal acts by the regime, effectively holding total power, is the common background. In this circumstance, to suggest that there may be benefit from prompt diagnosis and a wide popular recognition of the syndrome’s signs and symptoms, is surely unrealistic. The only effective remedies are, first, on a personal level to instruct young people in the absolute imperatives of humane behaviour, at whatever personal cost; and, second, at the international level, to prevent the emergence of and to isolate authoritarian regimes that exhibit the well known signs of ethnic hatred, intolerance of opposition, and lack of respect for international conventions dealing with the prevention of torture and inhumane treatment, and the covenants relating to civil and political rights. O P Galpin 22 Roumania Crescent, Llandudno, Conwy LL30 1UP, UK 1
Fried I. Syndrome E. Lancet 1997; 350: 1845-47
Author’s reply Sir—John Fabre’s reaction to the photograph of the German soldier taking aim at a Jewish woman and her child expresses eloquently the intuitive horror and denunciation that most people feel at such a sight. But his response also illustrates the difficulty in rational comprehension of such events. The transformation of ordinary individuals into repetitive killers is one of the most radical transitions in human behaviour. Yet to most victims and bystanders, and even to the perpetrators in retrospect, it remains incomprehensible. This transformation cannot be fully characterised by labels such as antisocial or morally degenerate. A medical model based on
830
taxonomy of symptoms and signs and pathophysiology of individuals does not exclude the role of social and political factors proposed by Fabre and your other correspondents. At the same time, social and political explanations should not ignore the psychological aspect. Unfortunately, it is this aspect that has posed the greatest difficulty in interpretation. The Holocaust scholar, Saul Friedlander,1 points out that most historical interpreters try to avoid the difficulty posed by the psychology of total extermination by concentrating on ideology and institutional dynamics. The psychological dimension causes unease and blocking of comprehension, as shown by Fabre’s response. However, it is precisely this dimension that should be rationally investigated to increase the prospects of curbing such behaviour. Frédéric Pochard and colleagues and Fabre are concerned that clinical labelling represents denial of personal responsibility. However, the designation of a medical syndrome does not imply impunity from individual responsibility. Indeed, one of the cardinal signs of syndrome E is an intact intellectual domain, including the capacity for problem solving, planning, memory, and language. The risk to the ethics of responsibility pointed out by Pochard and colleagues may be the price that we have to pay for recognising a psychobiological dimension that offers a framework for systematic inquiry. Carl Needles draws parallels between syndrome E and behaviour in insects and primates. However, with the exception of a few observations in higher primates, the syndrome is unique to man. Contrary to former biological models, the current model regards the events under discussion as manifestations, not of a primitive visceral brain released from cortical inhibition, but of a hyperaroused prefrontal cortex disconnected from the regulatory subcortical centres; hence the notion of cognitive fracture. Thus the prefrontal cortex, the brain region most responsible for the development of human faculties, is also implicated in the most atrocious of human behaviour. Various preventive and punitive measures are proposed by O P Galpin and Pochard and colleagues, such as denunciation and rallying against authoritarian regimes, and the education of the young in the absolute imperatives of humane behaviour. Regrettably, such measures have had little success. Although preventive efforts such as isolation of affected
individuals may seem unrealistic, this is exactly what the Canadian government did when it disbanded the Canadian Airborne Regiment that was involved in the 1993 killing of unarmed Somalian civilians during a UN peacekeeping mission (B Armstrong, personal communication). The response of the medical profession to large-scale atrocities has been limited to sporadic attempts to treat the victims and understand the long-term effects on survivors. But the study of the individuals perpetrating these acts is lacking and largely relegated to non-scientific modes of inquiry. In proposing a medical model, my main goal was to create a framework for debate and systematic inquiry of a behaviour that has constituted a major public health problem worldwide. I hope that this correspondence represents the beginning of such debate. Itzhak Fried Division of Neurosurgery, Brain Research Institute, and Department of Psychiatry and Behavioural Sciences, UCLA School of Medicine, Los Angeles, CA 90095, USA 1
Friedlander S. Memory, history, and the extermination of the Jews of Europe. Bloomington, IN, USA: Indiana University Press, 1993: 104–11.
Serbian doctors and ethnic Albanians Sir—With all due respect, we must express our deep disagreement with Theresa Agovino’s Dec 13 news item.1 We are nephrologists working in Belgrade, and the fact is that every month at least five Albanians from Kosovo are provided with medical care in our institute. Every citizen of our country has free medical care even though that care is very poor at the moment (but equal for all our citizens). From Agovino’s report one might get the impression that we have drugs and equipment to take care of our patients, but that we are using them selectively and discriminatorily. The truth is that even though we are affiliated with Belgrade University, we look after our patients 24 hours a day in conditions that you cannot even imagine (eg, there are no doublelumen catheters for haemodialysis, no Tenckhoff catheters, not many essential drugs, such that patients have to provide them themselves; there are even not enough clean bed sheets or soap, &c). It is important that your readers understand that the little that we have we distribute equally. Therefore, we do not understand what
THE LANCET • Vol 351 • March 14, 1998
CORRESPONDENCE
it is that we have that we are not giving to the Albanians. Everything we mention can be checked in the institute files. As far as transfusion is concerned, to give a somewhat more accurate picture we describe one of our patients, who was referred from Pristina (she has been our patient several times). She had thrombosis of her vascular prosthesis and needed haemodialysis. She was anaemic and also needed blood transfusion. However, she refused treatment because of her religious beliefs. There are two questions about the Mother Theresa Birth Centre: why do they give transfusions if it is not sanctioned by law, and how do they test blood taken from relatives without the essential means? Agovino states that there is no appropriate laboratory nor radiographic equipment, but there are two computers—which we find a little strange. If that institution was receiving donations, perhaps they should first buy the medical equipment they need and then computers. Is Agovino’s report an illustration of documented wrongdoing to ill Albanians or merely her interpretation of poor hospital conditions in this country? We are convinced that such reports do not belong in a journal such as The Lancet. Therefore we feel a moral obligation to put the record straight. We believe that other Yugoslav medical institutions have had similar experiences. *Zoran Paunic, Neven Vavic, Nada Dimkovic Dialysis Unit, Belgrade Medical School, Institute for Kidney Diseases, “Zvezdara” Hospital, Belgrade, Yugoslavia 1
Agovino T. Serbia continues to fail ethnic Albanians. Lancet 1997; 350: 1757.
Author’s reply Sir—I am glad to hear that Zoran Paunic and colleagues do not discriminate against Albanians. And in fairness to them, perhaps my report should have highlighted that the sanctions against Yugoslavia and the country’s poor economy does adversely affect medical care for all people irrespective of their background. However, I stand by my reporting. I have talked to numerous Albanian doctors, who had all been fired from their jobs at the Pristina Hospital. I talked to many, many Albanian patients who were afraid to go to the main hospitals in Pristina because they feared the Serbian doctors. Many Albanians recounted horror stories of how they were treated by them. I believe the figures in my story
THE LANCET • Vol 351 • March 14, 1998
confirm that healthcare in Kosovo has really suffered since 1989, and that the Kosovars are suffering more than the Serbs in Yugoslavia. The cuts in the healthcare system have not been distributed equally. As far as the blood transfusions are concerned, I certainly cannot comment on one of their patients who did not want such a procedure. But with respect to blood transfusions in the Mother Theresa Hospital, the doctors do the transfusions when necessary with whatever equipment is available. The doctors are not happy that they are doing procedures that are against the law. Nor are they happy that they are conducting such procedures in less than ideal circumstances. But if the life of the mother is at stake, they do the transfusions with what they have. The computers were donated, not purchased. Theresa Agovino Flat 2, Benczur U12, 1068 Budapest, Hungary
Absence of Bartonella-like inclusions in microangiopathy after transplantation Sir—Stefano Tarantolo and colleagues (Nov 29, p 1602)1 report the presence of rod-shaped structures in the erythrocytes of five women with thrombotic thrombocytopenic purpura (TTP), 1 and subsequently found similar inclusions in the red blood cells of 13 patients with post-marrow-transplant thromboangiopathy (TM).2 These inclusions were seen on Wright’s-stained blood films in 0·1–2% of red cells and were fluorescent with acridine orange, indicating a nucleic-acid composition. The investigators note the resemblance of these structures to Bartonella, a species of gram-negative bacilli whose pathogenic spectrum is still emerging; associations include serious systemic infections and bacillary angiomatosis in immunocompromised patients, cat scratch fever, and blood culturenegative endocarditis.3 Some Bartonella subtypes are haemotropic (B bacilliformis), are associated with an acute haemolytic syndrome, and stimulate endothelial cells in culture.3 The organisms are fastidious and infections difficult to diagnose. Aerobic and anaerobic cultures were negative in all 17 patients, and serology and PCR for Bartonella were negative in all TTP and TM patients tested.1,2 Tarantolo and co-workers cite
clinical response to therapy with doxycycline alone in two of five patients with TTP and in two of 13 TM patients and disappearance of rods from red blood cells in three of five TTP patients as evidence of an infectious aetiology of these syndromes.1,2 However, the number of these patients who had possible precipitating factors such as withdrawal of cyclosporin A therapy, which can lead to resolution of TM in some cases, is not clear.4 We reviewed blood smears from nine consecutive episodes of TM in seven patients after allogeneic bonemarrow transplantation; four transplants were from HLA identical siblings, two from unrelated donors with single HLA class I mismatches, and one from a fully matched unrelated donor. Transplantation was done for the following diagnoses: acute myeloid leukaemia in three patients, chronic myeloid leukaemia in two, acute lymphoblastic leukaemia in one, and non-Hodgkin’s lymphoma in one. Five patients were conditioned with high-dose cyclophosphamide plus single fraction total-body irradiation, one had busulphan plus cyclophosphamide, and one had both therapies. 39 days (20–334) after transplantation, haemolysis was indicated by anaemia, fragmented erythrocytes, and raised concentrations of bilirubin and lactate dehydrogenase. Peak lactate dehydrogenase values ranged from 852–2966 U/L (median 1588 [230–460] U/L). The patients were receiving cyclosporin A at the time of onset in eight of nine episodes of TM. A mean of five (SD 1·25) blood films were examined for each episode of TM starting 2 days before the onset of haemolysis and including the day of peak lactate dehydrogenase concentration. A minimum of 4000 red blood cells were examined in each May-Grunwald-Giemsa-stained film by two independent observers. No rodlike red-blood-cell inclusions were seen in any of the nine episodes of TM, and blood cultures were negative in the eight episodes examined. Our observations in seven patients do not confirm an association between TM and Bartonella-like organisms. The aetiology of TM is likely to be multifactorial, and large prospective studies including improved culture techniques, serology, and PCR, are required before such an infectious aetiology can be excluded. *Rachel Pawson, Andres Virchis, Mike Potter, H Grant Prentice Department of Haematology, Royal Free Hospital, London NW3 2QG, UK
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are damaged goods; this would also explain the high incidence of rape in holocausts. Another corollary is that communist atrocities reflect a contest over the means of reproduction. Carl F Needles 1955 Merrick road, Merrick, NY, 11566, USA 1
Fried I. Syndrome E. Lancet 1997: 350; 1845-47.
Sir—Itzak Fried’s hypothesis1 seems to emphasise a suggested neurophysiological mechanism for the behaviour of those with the syndrome in such as way as to propose this mechanism as the cause rather than the effect. Enticement and encouragement to commit brutal acts by the regime, effectively holding total power, is the common background. In this circumstance, to suggest that there may be benefit from prompt diagnosis and a wide popular recognition of the syndrome’s signs and symptoms, is surely unrealistic. The only effective remedies are, first, on a personal level to instruct young people in the absolute imperatives of humane behaviour, at whatever personal cost; and, second, at the international level, to prevent the emergence of and to isolate authoritarian regimes that exhibit the well known signs of ethnic hatred, intolerance of opposition, and lack of respect for international conventions dealing with the prevention of torture and inhumane treatment, and the covenants relating to civil and political rights. O P Galpin 22 Roumania Crescent, Llandudno, Conwy LL30 1UP, UK 1
Fried I. Syndrome E. Lancet 1997; 350: 1845-47
Author’s reply Sir—John Fabre’s reaction to the photograph of the German soldier taking aim at a Jewish woman and her child expresses eloquently the intuitive horror and denunciation that most people feel at such a sight. But his response also illustrates the difficulty in rational comprehension of such events. The transformation of ordinary individuals into repetitive killers is one of the most radical transitions in human behaviour. Yet to most victims and bystanders, and even to the perpetrators in retrospect, it remains incomprehensible. This transformation cannot be fully characterised by labels such as antisocial or morally degenerate. A medical model based on
830
taxonomy of symptoms and signs and pathophysiology of individuals does not exclude the role of social and political factors proposed by Fabre and your other correspondents. At the same time, social and political explanations should not ignore the psychological aspect. Unfortunately, it is this aspect that has posed the greatest difficulty in interpretation. The Holocaust scholar, Saul Friedlander,1 points out that most historical interpreters try to avoid the difficulty posed by the psychology of total extermination by concentrating on ideology and institutional dynamics. The psychological dimension causes unease and blocking of comprehension, as shown by Fabre’s response. However, it is precisely this dimension that should be rationally investigated to increase the prospects of curbing such behaviour. Frédéric Pochard and colleagues and Fabre are concerned that clinical labelling represents denial of personal responsibility. However, the designation of a medical syndrome does not imply impunity from individual responsibility. Indeed, one of the cardinal signs of syndrome E is an intact intellectual domain, including the capacity for problem solving, planning, memory, and language. The risk to the ethics of responsibility pointed out by Pochard and colleagues may be the price that we have to pay for recognising a psychobiological dimension that offers a framework for systematic inquiry. Carl Needles draws parallels between syndrome E and behaviour in insects and primates. However, with the exception of a few observations in higher primates, the syndrome is unique to man. Contrary to former biological models, the current model regards the events under discussion as manifestations, not of a primitive visceral brain released from cortical inhibition, but of a hyperaroused prefrontal cortex disconnected from the regulatory subcortical centres; hence the notion of cognitive fracture. Thus the prefrontal cortex, the brain region most responsible for the development of human faculties, is also implicated in the most atrocious of human behaviour. Various preventive and punitive measures are proposed by O P Galpin and Pochard and colleagues, such as denunciation and rallying against authoritarian regimes, and the education of the young in the absolute imperatives of humane behaviour. Regrettably, such measures have had little success. Although preventive efforts such as isolation of affected
individuals may seem unrealistic, this is exactly what the Canadian government did when it disbanded the Canadian Airborne Regiment that was involved in the 1993 killing of unarmed Somalian civilians during a UN peacekeeping mission (B Armstrong, personal communication). The response of the medical profession to large-scale atrocities has been limited to sporadic attempts to treat the victims and understand the long-term effects on survivors. But the study of the individuals perpetrating these acts is lacking and largely relegated to non-scientific modes of inquiry. In proposing a medical model, my main goal was to create a framework for debate and systematic inquiry of a behaviour that has constituted a major public health problem worldwide. I hope that this correspondence represents the beginning of such debate. Itzhak Fried Division of Neurosurgery, Brain Research Institute, and Department of Psychiatry and Behavioural Sciences, UCLA School of Medicine, Los Angeles, CA 90095, USA 1
Friedlander S. Memory, history, and the extermination of the Jews of Europe. Bloomington, IN, USA: Indiana University Press, 1993: 104–11.
Serbian doctors and ethnic Albanians Sir—With all due respect, we must express our deep disagreement with Theresa Agovino’s Dec 13 news item.1 We are nephrologists working in Belgrade, and the fact is that every month at least five Albanians from Kosovo are provided with medical care in our institute. Every citizen of our country has free medical care even though that care is very poor at the moment (but equal for all our citizens). From Agovino’s report one might get the impression that we have drugs and equipment to take care of our patients, but that we are using them selectively and discriminatorily. The truth is that even though we are affiliated with Belgrade University, we look after our patients 24 hours a day in conditions that you cannot even imagine (eg, there are no doublelumen catheters for haemodialysis, no Tenckhoff catheters, not many essential drugs, such that patients have to provide them themselves; there are even not enough clean bed sheets or soap, &c). It is important that your readers understand that the little that we have we distribute equally. Therefore, we do not understand what
THE LANCET • Vol 351 • March 14, 1998
CORRESPONDENCE
it is that we have that we are not giving to the Albanians. Everything we mention can be checked in the institute files. As far as transfusion is concerned, to give a somewhat more accurate picture we describe one of our patients, who was referred from Pristina (she has been our patient several times). She had thrombosis of her vascular prosthesis and needed haemodialysis. She was anaemic and also needed blood transfusion. However, she refused treatment because of her religious beliefs. There are two questions about the Mother Theresa Birth Centre: why do they give transfusions if it is not sanctioned by law, and how do they test blood taken from relatives without the essential means? Agovino states that there is no appropriate laboratory nor radiographic equipment, but there are two computers—which we find a little strange. If that institution was receiving donations, perhaps they should first buy the medical equipment they need and then computers. Is Agovino’s report an illustration of documented wrongdoing to ill Albanians or merely her interpretation of poor hospital conditions in this country? We are convinced that such reports do not belong in a journal such as The Lancet. Therefore we feel a moral obligation to put the record straight. We believe that other Yugoslav medical institutions have had similar experiences. *Zoran Paunic, Neven Vavic, Nada Dimkovic Dialysis Unit, Belgrade Medical School, Institute for Kidney Diseases, “Zvezdara” Hospital, Belgrade, Yugoslavia 1
Agovino T. Serbia continues to fail ethnic Albanians. Lancet 1997; 350: 1757.
Author’s reply Sir—I am glad to hear that Zoran Paunic and colleagues do not discriminate against Albanians. And in fairness to them, perhaps my report should have highlighted that the sanctions against Yugoslavia and the country’s poor economy does adversely affect medical care for all people irrespective of their background. However, I stand by my reporting. I have talked to numerous Albanian doctors, who had all been fired from their jobs at the Pristina Hospital. I talked to many, many Albanian patients who were afraid to go to the main hospitals in Pristina because they feared the Serbian doctors. Many Albanians recounted horror stories of how they were treated by them. I believe the figures in my story
THE LANCET • Vol 351 • March 14, 1998
confirm that healthcare in Kosovo has really suffered since 1989, and that the Kosovars are suffering more than the Serbs in Yugoslavia. The cuts in the healthcare system have not been distributed equally. As far as the blood transfusions are concerned, I certainly cannot comment on one of their patients who did not want such a procedure. But with respect to blood transfusions in the Mother Theresa Hospital, the doctors do the transfusions when necessary with whatever equipment is available. The doctors are not happy that they are doing procedures that are against the law. Nor are they happy that they are conducting such procedures in less than ideal circumstances. But if the life of the mother is at stake, they do the transfusions with what they have. The computers were donated, not purchased. Theresa Agovino Flat 2, Benczur U12, 1068 Budapest, Hungary
Absence of Bartonella-like inclusions in microangiopathy after transplantation Sir—Stefano Tarantolo and colleagues (Nov 29, p 1602)1 report the presence of rod-shaped structures in the erythrocytes of five women with thrombotic thrombocytopenic purpura (TTP), 1 and subsequently found similar inclusions in the red blood cells of 13 patients with post-marrow-transplant thromboangiopathy (TM).2 These inclusions were seen on Wright’s-stained blood films in 0·1–2% of red cells and were fluorescent with acridine orange, indicating a nucleic-acid composition. The investigators note the resemblance of these structures to Bartonella, a species of gram-negative bacilli whose pathogenic spectrum is still emerging; associations include serious systemic infections and bacillary angiomatosis in immunocompromised patients, cat scratch fever, and blood culturenegative endocarditis.3 Some Bartonella subtypes are haemotropic (B bacilliformis), are associated with an acute haemolytic syndrome, and stimulate endothelial cells in culture.3 The organisms are fastidious and infections difficult to diagnose. Aerobic and anaerobic cultures were negative in all 17 patients, and serology and PCR for Bartonella were negative in all TTP and TM patients tested.1,2 Tarantolo and co-workers cite
clinical response to therapy with doxycycline alone in two of five patients with TTP and in two of 13 TM patients and disappearance of rods from red blood cells in three of five TTP patients as evidence of an infectious aetiology of these syndromes.1,2 However, the number of these patients who had possible precipitating factors such as withdrawal of cyclosporin A therapy, which can lead to resolution of TM in some cases, is not clear.4 We reviewed blood smears from nine consecutive episodes of TM in seven patients after allogeneic bonemarrow transplantation; four transplants were from HLA identical siblings, two from unrelated donors with single HLA class I mismatches, and one from a fully matched unrelated donor. Transplantation was done for the following diagnoses: acute myeloid leukaemia in three patients, chronic myeloid leukaemia in two, acute lymphoblastic leukaemia in one, and non-Hodgkin’s lymphoma in one. Five patients were conditioned with high-dose cyclophosphamide plus single fraction total-body irradiation, one had busulphan plus cyclophosphamide, and one had both therapies. 39 days (20–334) after transplantation, haemolysis was indicated by anaemia, fragmented erythrocytes, and raised concentrations of bilirubin and lactate dehydrogenase. Peak lactate dehydrogenase values ranged from 852–2966 U/L (median 1588 [230–460] U/L). The patients were receiving cyclosporin A at the time of onset in eight of nine episodes of TM. A mean of five (SD 1·25) blood films were examined for each episode of TM starting 2 days before the onset of haemolysis and including the day of peak lactate dehydrogenase concentration. A minimum of 4000 red blood cells were examined in each May-Grunwald-Giemsa-stained film by two independent observers. No rodlike red-blood-cell inclusions were seen in any of the nine episodes of TM, and blood cultures were negative in the eight episodes examined. Our observations in seven patients do not confirm an association between TM and Bartonella-like organisms. The aetiology of TM is likely to be multifactorial, and large prospective studies including improved culture techniques, serology, and PCR, are required before such an infectious aetiology can be excluded. *Rachel Pawson, Andres Virchis, Mike Potter, H Grant Prentice Department of Haematology, Royal Free Hospital, London NW3 2QG, UK
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