- Email: [email protected]
United States Questions about cancer statistics
41 TABLE I-NI’MBER OF WEEKLY SESSIONS WHICH COULD BE FINANCED BY DIFFERENCE IN SALARY BETWEEN RETIRING AND RECENTLY
APPOINTED CONSULTANT WITH THREE SALARY INCREMENTS
appointed
consultant who would be
substantially
whole-
time. In the
acute specialties there has been a swing towards investigation and management on an outpatient basis because of the shortage of beds and expense of hospital admissions and also for the patients’ convenience. Superannuated
consultants would be able to make useful contributions in outpatient clinics and various specialist activities such as daycase surgery, radiology, histopathology, and endoscopy, without requiring additional junior staff. At the same time they would remain in touch with their specialities and their colleagues and so be capable, if required, of retaining teaching, examining, and administrative commitments, to which they would be able to devote adequate time. Such arrangements could generate problems of finance, accommodation, and organisation and could result in clashes of personality. They would entail no great expenditure by the employing authority since many consultants at 60 are in receipt of a distinction award and are advanced on the salary scale. The replacement would start much lower down the scale and the difference in salary would provide for the superannuated consultant to be paid for up to 10’ 5 sessions a week (table I). Such sessions would lapse on full retirement at 65 and the superannuated consultant would of course no longer receive any distinction award. Pensions are not paid by the employing authority but by the Paymaster General’s Department. In most specialties the consultant body would welcome the extra help and expertise which would become available. Superannuated consultants would have to face the fact that they were no longer in charge, which might occasionally cause friction. Those who felt unable to accommodate to such a working relationship might opt either to delay retirement to 65 or to leave the service completely. However, it seems likely that many would wish to lighten their workload, by handing over to younger colleagues, and yet to continue with a few sessions to retain a sense of being useful and in touch. Earlier consultant retirement would certainly help to ease the difficulties of senior registrars. Assuming appointment at 35, the consultant would have a working lifetime of 25 rather TABLE II-ESTIMATED AND EXPECTED ANNUAL CONSULTANT
RETIREMENT RATES
-
i
.
-
-
I
__
I
Senior hospital medical and dental officers with allow, tOn basis of current retirement rates.
than 30 years. On Sept 30, 1982, 13 303 consultants were employed in the NHS;4 earlier retirement would, with an even age distribution, provide an extra 90 retirement vacancies each year, including 7 in general medicine, 6 in general surgery, and 11 in anaesthetics (table II). However, the present age distribution is not even and the expected annual retirement rates between 1983 and 1987, based on current trends, have been calculated to be 30% lower (table II). Nevertheless, retirement at 60 would make a material contribution to the prospects of consultant appointments for time-expired senior registrars and would help to improve their present dismal prospects. REFERENCES 1. Fourth report from the Social Services Committee ofthe House of Commons. London: HM Stationery Office, 1981. 2. Royal College of Physicians’ Committee on Gastroenterology. The need for an increased number of consultant physicians with specialist training in gastroenterology. Gut 1984; 25: 99-102. 3 Holdsworth CD, Atkinson M. Gastroenterological services - a regional review. Br Med J1984; 288: 1245-47. 4. Medical and dental staffing prospects in the NHS in England and Wales 1982-a note from the Medical Manpower Division DHSS. Health Trends 1983; 15: 35-39.
Round the World From
our
Correspondents
Sudan REFUGEES FROM ETHIOPIA
EACH day 3000 refugees are reported to be walking out of the desert into Kassala, a city in Eastern Sudan which is experiencing a second year of severe drought. These sick and hungry families have trekked over mountainous terrain for up to three weeks from the Ethiopian provinces of Tigre and Eritrea, it seems to no avail. "Instead of dying in Ethiopia they will die in Sudan. They will walk to face their deaths in Sudan." This statement from the Sudanese Commissioner for Refugees conveys the desperation of a country which has already accepted well over I million refugees fleeing from famine and civil war in Uganda, Chad, and Ethiopia. In the face of the current overwhelming influx and a failed harvest in Sudan, the continuing ability of the Sudanese to express their charity and the lives of millions depend on an enormous increase in international aid. Britain is to give a further f1 million. Several voluntary agencies, including Save the Children Fund, the’Red Cross, and Oxfam, are active in Sudan; and War on Want and Christian Aid are working directly with relief associations in Eritrea and Tigre. A Sudan appeal is being organised and inquiries may be directed to Dr A. M. Salih, 12 Colosseum Terrace, Albany Street, London NW11
(01-388 0682). United States QUESTIONS ABOUT CANCER STATISTICS
SOME clinicians are beginning to raise doubts about the optimistic from the National Cancer Institute on progress in the treatment of cancer. One prominent sceptic is Dr Haydn Bush, who directs the London Regional Cancer Centre in Ontario, Canada. As he sees it, contrary to NCI press releases about increasing survival rates, little progress has been achieved in treating the big killers such as cancers of the breast, colon, and prostate over the past 25 years. Death rates from lung cancer, he adds, have actually risen. His argument was set out in the September issue of the magazine Science 84. Asked by Mr Philip M. Boffey of the New York Times to comment on the criticism, the NCI director, Dr Vincent De Vita, Jr, replied: "I think it’s a bunch of nonsense. We’re saving thousands of lives today that weren’t saved 20 years ago." Just a few months ago, NCI handed out publicity to the press calling cancer the most curable of all chronic diseases. NCI set its goal as the reduction of cancer deaths by half between now and the year 2000.
publicity
42 Dr Bush believes that public misunderstanding stems from the way survival rates are calculated. As an example, he examines the NCI figure that in the ’50s about 57% of women with breast cancer survived for five years. By the ’70s this figure had risen to 66%, and the rate is presumably even higher now. This improvement, as Bush sees it, may be largely a statistical illusion. When screening was not in general use, tumours were often discovered at a late stage. With more widespread screening, tumours are diagnosed earlier. Even if these latter patients received no treatment at all and their disease followed its natural course, they would be more likely to survive the five years.
John Cairns, a cancer analyst at the Harvard School of Public Health, likens the cheerful statistics from such organisations as NCI and the American Cancer Society to the excessive body counts American generals handed out to the news media during the war in Vietnam. John Bailar, a Harvard biostatistician and former NCI official, called survival rates "rubber numbers" that mislead people. The critics all emphasise they are not questioning the integrity of Government officials-only their figures.
ABORTION AND INCITEMENT TO VIOLENCE
DURING the Presidential election campaign anti-abortionists clamoured for the election of a candidate who had openly expressed opposition to abortion. Great efforts were made to oppose the election of Congressional and local candidates who had not openly avowed their intention to oppose abortion politically. Both Catholic and Fundamentalists leaders joined in this endeavour. While these attempts were not seen to influence the election results, they have been accompanied by increasingly violent language and escalating pressure. There have been frequent attempts to intimidate women (especially teenagers), clinics and family planning centres have been picketed, and clinic staff have been attacked. In one incident, the house of a counsellor was broken into and vandalised, and a pet cat decapitated—a strange way of showing reverence for life. Even worse, over twenty incidents of bombing and arson have been reported from various parts of the country.
Loss of life and serious injuries are bound to happen if these tactics continue. In Maryland, a clinic which had been repeatedly picketed was eventually the site of a sit-in, .leading to numerous arrests. The same night it was totally destroyed by a bomb, together with a neighbouring clinic. No reasonable doubt exists that these incidents were connected, despite denials by some of the picketers, .including a minister. Some anti-abortionists claim that the incidents were staged by pro-abortionists to discredit them. There is little doubt in the minds of clinic staff and other observers that the arson and bombings, like the intimidation and picketing, are orchestrated; this is strongly denied by the anti-abortionists. Yet such domestic terrorism has evoked no denunciation from the White House, or from those prominent in the Administration, who are so loud in their condemnation of terrorism elsewhere. It is time that the abusive language and other tactics were toned down before someone is killed or injured, and retaliation starts. After all, churches, and the homes of those using such intolerant language, can be burnt or bombed as easily as clinics.
RADIATION LIMITS
ONE of the persistent criticisms of the present Administration its attitude to the Environmental Protection Agency (EPA); it is even claimed that every attempt has been made to limit the actions of the EPA in protecting our environment. In the hubbub which preceded the Presidential election this has not been a matter of much debate. In fact, the only health problems which surfaced at all during the campaign were the rising costs of Medicare and the abortion issue. concerns
.
Amid this relative quietness on health matters, it is all the more curious that the EPA should suddenly provoke the environmentalists by stating that it would not control airborne radioactive materials because they are not menaces to health; control costs
would be high, and benefits, in their view, slight. It is agreed that there is no safe limit of exposure to radioactive materials, and at least there is a clear statement from official sources to this extent. But there is too much evidence that airborne material can cause severe ecologieal damage and human harm for the effects of airborne radiation to be underestimated. The decision is seen both as an attack on the Clean Air Act and as a typical example of the Administration’s indifference to environmental hazards.
The EPA admits the dangers of uranium mining, but does not intend to do anything about other sources of exposure to airborne radioactive materials. Naturally this decision is going to be tested in the courts where, it is to be hoped, some solid scientific information will be given in evidence, free of the emotionalism that constantly surrounds the issue. Considerable emphasis has been placed on the dangers of radioactive exposure, many people have been frightened, and atomic energy generating plants have been closed, making balanced judgment here and elsewhere difficult to achieve. The attitude of the EPA has hardly helped. It has been heavily involved in recent controversies, seemingly lax about clearing toxic waste dumps, apparently influenced by the polluters themselves, and, in general, very unsatisfactory in protecting us. Failure to protect the environment from what the public perceives as a serious hazard from which they cannot protect themselves is a grave failure, in both political and social terms.
BRAIN DEATH IN NEW YORK
SOMETIMES the courts give a real prod to the legislature; this happened recently in the State of New York which, unlike other States, did not have legal criteria for the diagnosis of brain death.
This omission was exploited by defence lawyers in two homicide cases. In each case the victim, shot in the head, quickly lapsed into coma and was placed on a respirator where he remained unresponsive with a flat electroencephalogram. The medical assessment was brain death, and, with agreement of the families, organs were removed for transplantation and the respirator disconnected. On behalf of the defendants, it was argued that death did not result from the wounds but from the actions of those who disconnected the life support machine. The State’s Court of Appeals would have none of this, and upheld the convictions. In Judge Cooke’s opinion, failure of the legislature to enact a brain death statute did not preclude the court from stepping in, it being the duty of the court to "instill certainty and uniformity" in these
important
areas.
The decision is warmly welcomed by hospitals and physicians, who now know where they stand; uncertainties in the past undoubtedly led to serious difficulties in procuring organs for transplantation. Although the court did not recommend detailed scientific standards for the diagnosis of brain death, or the part that families should play, it mentioned favourably the Harvard Medical School criteria for brain death, and determined that a comatose patient unable to breathe on his own, and thus with brainstem dysfunction, should be considered dead. Some critics, who would like to see the criteria and methods of establishing brain death, as well as the role of the family and others, more clearly defined, object to the courts defining brain death, contending that this is the job of the legislature. But the legislature has been toying with the matter for years and no legislation has ever been enacted. If the legislators will not take action then we must be grateful for judicial decisions. In New York there are bound to be attempts at further legislative delay by referring the whole question to the Governor’s newly proposed task force on life and the law. This task force, which has a varied membership, has been established to investigate matters which arouse conflicting views on life and law, especially in the fields of science and medicine where clashes between medical technology and medieval outlook are becoming severe. At least the law has given a clear lead; the onus is now on the legislature.
APPOINTED CONSULTANT WITH THREE SALARY INCREMENTS
appointed
consultant who would be
substantially
whole-
time. In the
acute specialties there has been a swing towards investigation and management on an outpatient basis because of the shortage of beds and expense of hospital admissions and also for the patients’ convenience. Superannuated
consultants would be able to make useful contributions in outpatient clinics and various specialist activities such as daycase surgery, radiology, histopathology, and endoscopy, without requiring additional junior staff. At the same time they would remain in touch with their specialities and their colleagues and so be capable, if required, of retaining teaching, examining, and administrative commitments, to which they would be able to devote adequate time. Such arrangements could generate problems of finance, accommodation, and organisation and could result in clashes of personality. They would entail no great expenditure by the employing authority since many consultants at 60 are in receipt of a distinction award and are advanced on the salary scale. The replacement would start much lower down the scale and the difference in salary would provide for the superannuated consultant to be paid for up to 10’ 5 sessions a week (table I). Such sessions would lapse on full retirement at 65 and the superannuated consultant would of course no longer receive any distinction award. Pensions are not paid by the employing authority but by the Paymaster General’s Department. In most specialties the consultant body would welcome the extra help and expertise which would become available. Superannuated consultants would have to face the fact that they were no longer in charge, which might occasionally cause friction. Those who felt unable to accommodate to such a working relationship might opt either to delay retirement to 65 or to leave the service completely. However, it seems likely that many would wish to lighten their workload, by handing over to younger colleagues, and yet to continue with a few sessions to retain a sense of being useful and in touch. Earlier consultant retirement would certainly help to ease the difficulties of senior registrars. Assuming appointment at 35, the consultant would have a working lifetime of 25 rather TABLE II-ESTIMATED AND EXPECTED ANNUAL CONSULTANT
RETIREMENT RATES
-
i
.
-
-
I
__
I
Senior hospital medical and dental officers with allow, tOn basis of current retirement rates.
than 30 years. On Sept 30, 1982, 13 303 consultants were employed in the NHS;4 earlier retirement would, with an even age distribution, provide an extra 90 retirement vacancies each year, including 7 in general medicine, 6 in general surgery, and 11 in anaesthetics (table II). However, the present age distribution is not even and the expected annual retirement rates between 1983 and 1987, based on current trends, have been calculated to be 30% lower (table II). Nevertheless, retirement at 60 would make a material contribution to the prospects of consultant appointments for time-expired senior registrars and would help to improve their present dismal prospects. REFERENCES 1. Fourth report from the Social Services Committee ofthe House of Commons. London: HM Stationery Office, 1981. 2. Royal College of Physicians’ Committee on Gastroenterology. The need for an increased number of consultant physicians with specialist training in gastroenterology. Gut 1984; 25: 99-102. 3 Holdsworth CD, Atkinson M. Gastroenterological services - a regional review. Br Med J1984; 288: 1245-47. 4. Medical and dental staffing prospects in the NHS in England and Wales 1982-a note from the Medical Manpower Division DHSS. Health Trends 1983; 15: 35-39.
Round the World From
our
Correspondents
Sudan REFUGEES FROM ETHIOPIA
EACH day 3000 refugees are reported to be walking out of the desert into Kassala, a city in Eastern Sudan which is experiencing a second year of severe drought. These sick and hungry families have trekked over mountainous terrain for up to three weeks from the Ethiopian provinces of Tigre and Eritrea, it seems to no avail. "Instead of dying in Ethiopia they will die in Sudan. They will walk to face their deaths in Sudan." This statement from the Sudanese Commissioner for Refugees conveys the desperation of a country which has already accepted well over I million refugees fleeing from famine and civil war in Uganda, Chad, and Ethiopia. In the face of the current overwhelming influx and a failed harvest in Sudan, the continuing ability of the Sudanese to express their charity and the lives of millions depend on an enormous increase in international aid. Britain is to give a further f1 million. Several voluntary agencies, including Save the Children Fund, the’Red Cross, and Oxfam, are active in Sudan; and War on Want and Christian Aid are working directly with relief associations in Eritrea and Tigre. A Sudan appeal is being organised and inquiries may be directed to Dr A. M. Salih, 12 Colosseum Terrace, Albany Street, London NW11
(01-388 0682). United States QUESTIONS ABOUT CANCER STATISTICS
SOME clinicians are beginning to raise doubts about the optimistic from the National Cancer Institute on progress in the treatment of cancer. One prominent sceptic is Dr Haydn Bush, who directs the London Regional Cancer Centre in Ontario, Canada. As he sees it, contrary to NCI press releases about increasing survival rates, little progress has been achieved in treating the big killers such as cancers of the breast, colon, and prostate over the past 25 years. Death rates from lung cancer, he adds, have actually risen. His argument was set out in the September issue of the magazine Science 84. Asked by Mr Philip M. Boffey of the New York Times to comment on the criticism, the NCI director, Dr Vincent De Vita, Jr, replied: "I think it’s a bunch of nonsense. We’re saving thousands of lives today that weren’t saved 20 years ago." Just a few months ago, NCI handed out publicity to the press calling cancer the most curable of all chronic diseases. NCI set its goal as the reduction of cancer deaths by half between now and the year 2000.
publicity
42 Dr Bush believes that public misunderstanding stems from the way survival rates are calculated. As an example, he examines the NCI figure that in the ’50s about 57% of women with breast cancer survived for five years. By the ’70s this figure had risen to 66%, and the rate is presumably even higher now. This improvement, as Bush sees it, may be largely a statistical illusion. When screening was not in general use, tumours were often discovered at a late stage. With more widespread screening, tumours are diagnosed earlier. Even if these latter patients received no treatment at all and their disease followed its natural course, they would be more likely to survive the five years.
John Cairns, a cancer analyst at the Harvard School of Public Health, likens the cheerful statistics from such organisations as NCI and the American Cancer Society to the excessive body counts American generals handed out to the news media during the war in Vietnam. John Bailar, a Harvard biostatistician and former NCI official, called survival rates "rubber numbers" that mislead people. The critics all emphasise they are not questioning the integrity of Government officials-only their figures.
ABORTION AND INCITEMENT TO VIOLENCE
DURING the Presidential election campaign anti-abortionists clamoured for the election of a candidate who had openly expressed opposition to abortion. Great efforts were made to oppose the election of Congressional and local candidates who had not openly avowed their intention to oppose abortion politically. Both Catholic and Fundamentalists leaders joined in this endeavour. While these attempts were not seen to influence the election results, they have been accompanied by increasingly violent language and escalating pressure. There have been frequent attempts to intimidate women (especially teenagers), clinics and family planning centres have been picketed, and clinic staff have been attacked. In one incident, the house of a counsellor was broken into and vandalised, and a pet cat decapitated—a strange way of showing reverence for life. Even worse, over twenty incidents of bombing and arson have been reported from various parts of the country.
Loss of life and serious injuries are bound to happen if these tactics continue. In Maryland, a clinic which had been repeatedly picketed was eventually the site of a sit-in, .leading to numerous arrests. The same night it was totally destroyed by a bomb, together with a neighbouring clinic. No reasonable doubt exists that these incidents were connected, despite denials by some of the picketers, .including a minister. Some anti-abortionists claim that the incidents were staged by pro-abortionists to discredit them. There is little doubt in the minds of clinic staff and other observers that the arson and bombings, like the intimidation and picketing, are orchestrated; this is strongly denied by the anti-abortionists. Yet such domestic terrorism has evoked no denunciation from the White House, or from those prominent in the Administration, who are so loud in their condemnation of terrorism elsewhere. It is time that the abusive language and other tactics were toned down before someone is killed or injured, and retaliation starts. After all, churches, and the homes of those using such intolerant language, can be burnt or bombed as easily as clinics.
RADIATION LIMITS
ONE of the persistent criticisms of the present Administration its attitude to the Environmental Protection Agency (EPA); it is even claimed that every attempt has been made to limit the actions of the EPA in protecting our environment. In the hubbub which preceded the Presidential election this has not been a matter of much debate. In fact, the only health problems which surfaced at all during the campaign were the rising costs of Medicare and the abortion issue. concerns
.
Amid this relative quietness on health matters, it is all the more curious that the EPA should suddenly provoke the environmentalists by stating that it would not control airborne radioactive materials because they are not menaces to health; control costs
would be high, and benefits, in their view, slight. It is agreed that there is no safe limit of exposure to radioactive materials, and at least there is a clear statement from official sources to this extent. But there is too much evidence that airborne material can cause severe ecologieal damage and human harm for the effects of airborne radiation to be underestimated. The decision is seen both as an attack on the Clean Air Act and as a typical example of the Administration’s indifference to environmental hazards.
The EPA admits the dangers of uranium mining, but does not intend to do anything about other sources of exposure to airborne radioactive materials. Naturally this decision is going to be tested in the courts where, it is to be hoped, some solid scientific information will be given in evidence, free of the emotionalism that constantly surrounds the issue. Considerable emphasis has been placed on the dangers of radioactive exposure, many people have been frightened, and atomic energy generating plants have been closed, making balanced judgment here and elsewhere difficult to achieve. The attitude of the EPA has hardly helped. It has been heavily involved in recent controversies, seemingly lax about clearing toxic waste dumps, apparently influenced by the polluters themselves, and, in general, very unsatisfactory in protecting us. Failure to protect the environment from what the public perceives as a serious hazard from which they cannot protect themselves is a grave failure, in both political and social terms.
BRAIN DEATH IN NEW YORK
SOMETIMES the courts give a real prod to the legislature; this happened recently in the State of New York which, unlike other States, did not have legal criteria for the diagnosis of brain death.
This omission was exploited by defence lawyers in two homicide cases. In each case the victim, shot in the head, quickly lapsed into coma and was placed on a respirator where he remained unresponsive with a flat electroencephalogram. The medical assessment was brain death, and, with agreement of the families, organs were removed for transplantation and the respirator disconnected. On behalf of the defendants, it was argued that death did not result from the wounds but from the actions of those who disconnected the life support machine. The State’s Court of Appeals would have none of this, and upheld the convictions. In Judge Cooke’s opinion, failure of the legislature to enact a brain death statute did not preclude the court from stepping in, it being the duty of the court to "instill certainty and uniformity" in these
important
areas.
The decision is warmly welcomed by hospitals and physicians, who now know where they stand; uncertainties in the past undoubtedly led to serious difficulties in procuring organs for transplantation. Although the court did not recommend detailed scientific standards for the diagnosis of brain death, or the part that families should play, it mentioned favourably the Harvard Medical School criteria for brain death, and determined that a comatose patient unable to breathe on his own, and thus with brainstem dysfunction, should be considered dead. Some critics, who would like to see the criteria and methods of establishing brain death, as well as the role of the family and others, more clearly defined, object to the courts defining brain death, contending that this is the job of the legislature. But the legislature has been toying with the matter for years and no legislation has ever been enacted. If the legislators will not take action then we must be grateful for judicial decisions. In New York there are bound to be attempts at further legislative delay by referring the whole question to the Governor’s newly proposed task force on life and the law. This task force, which has a varied membership, has been established to investigate matters which arouse conflicting views on life and law, especially in the fields of science and medicine where clashes between medical technology and medieval outlook are becoming severe. At least the law has given a clear lead; the onus is now on the legislature.