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USSR: Doubts about psychiatric reforms
616
work. The majority reported a decline in standards since the introduction of integrated science courses. A plan to end all separate exams in physics, chemistry, and biology at 16 has been stopped at the last moment by the Education
Secretary. There is a grim tale too from the universities. A plan to close or merge 30 small "unviable" physics and chemistry departments was averted only at the end of last year. A special review had suggested that all departments with fewer than 20 full-time staff and 200 full-time students should close or amalgamate. This would have meant the end for 17 out of the country’s 49 university chemistry departments, and 20 out of 47 physics departments. A second battle looms, however. The Advisory Council on Science and Technology, whose meetings have been chaired by the Prime Minister, believes that undergraduate science courses in British universities are too difficult. Instead it wants to spread the first two years over three, with the majority carrying on into a fourth year to pick up an MSc. This runs counter to ideas circulating in the Universities Funding Council, which has been examining financial incentives to encourage universities to devise 2-year rather than 3-year degree courses to increase student numbers. All of which brings us to Sir Claus Moser, the retiring President of the British Association, who captured the front pages with his condemnation of English attitudes to education. England-he exempted Scotland-was in danger of becoming the least adequately educated of all advanced countries. Pointing to young people aged 16-18 in full-time education, Sir Claus noted there were 79% in the US, 77% in Japan, 76% in Sweden, 66% in France, but only 35 % in England. Echoing a theme that has run in this column, he declared it was not tolerable for 2 out of 3 children to abandon school at 16. The Government has introduced a national curriculum which will require schools gradually to place more emphasis on science, but there is still no sign of the Government providing the resources--or the sense of administrative urgency-that are needed to ensure its ambitions are realised. The Royal Society is only the latest academic body to produce a report on the inadequate science facilities in schools. A special report commissioned by the British Association has made some sensible proposals for reformthe need to widen sixth form work so that more students study science through to 18; better teacher recruitment targeting; a review to find why physics is so dominated by men (only 15% of girls compared with 34% of boys in sixth forms concentrate on science and maths). More women scientists would relieve teacher shortages because, although only 16% of science graduates are women, they make up 40% of graduate science teachers. More fundamentally, the English have to change their attitudes towards education. Sir Claus was right. Too many people in the country-from the top down-do not care enough about education. Cleverness is still suspect. No other language uses the familiar English expression "too clever by half. Sir Claus urged the Government to set up a royal commission into education and to declare the 1990s as the Decade for Education. Just two days later this was rejected by the new schools minister in a fatuous speech. To its credit the British Association has not been thwarted. It has decided to set up its own royal commission. A good first step. Malcolm Dean
Round the World USSR: Doubts about psychiatric reforms The Soviet Union’s proposed new law on psychiatry contains a major defect, according to an article in Meditsinskaya Gazeta, the newspaper of the Soviet medical profession. The criticism that the law is not based on the "presumption of mental health" is a serious one, since the readmission of the official Soviet All-Union Society of Psychiatrists and Narcologists to the World Psychiatric Association in Athens last October was conditional on satisfactory reforms and was to be reviewed after five years. The Soviet psychiatrists had assured the WPA that, under Gorbachev, political dissent was no longer considered a form of schizophrenia. Activists were no longer committed to mental hospitals, and those still so confined were being released as soon as their cases could be processed. A new law would shortly be passed which would strengthen patients’ rights and make psychiatrists who abused those rights liable to prosecution. The much-feared "psychiatric register", which imposed major constraints on the civil rights and work prospects of those whose names appeared in it, was being phased out. Penal psychiatric hospitals had been transferred from the jurisdiction of the Ministry of the Interior to the Ministry of Health. In short, the Soviet psychiatric profession was putting its house in order as fast as
possible.
Even at the Athens meeting, many delegates feared that this official picture was overoptimistic, although they were willing to give the All-Union Society the benefit of the doubt. Also present at the meeting (and, after some heated argument, also admitted to the WPA) was an alternative organisation, the Independent Psychiatric Association of the Soviet Union, established in the spring of 1989 by a small group of psychiatrists who believed that the ethics of their profession were ill-served by the Soviet psychiatric establishment. These psychiatrists warned that many of the reforms were merely cosmetic. The same people, they said, were running the penal mental hospitals: "they have just changed their police jackets for white coats". Moreover, they emphasised, keeping dissidents in hospital was only a symptom of the basic fault of the Soviet psychiatric system-the wide powers of compulsory confinement at the
psychiatrists’ disposal. The authors of the Meditsinskaya Gazeta article, Dr Yury Savenko, President of the Independent Psychiatric Association, and A. Rudakov, head of the juridical consultation unit attached to the office of the chief psychiatrist of Moscow province, say that the draft of the new law, at present being circulated for discussion among the medical profession, makes no provision for the assistance of a lawyer in the case of "emergency or first-aid" admissions. Even when patients have the right to legal protection, there is no obligation on the legal profession to assist them, and "in practice, lawyers often refuse to handle such cases". The clauses on compulsory treatment, and the compulsory admission to hospital of persons who in a state of psychological illness have committed "especially dangerous crimes" are, the authors say, insufficiently precise and could therefore provide a loophole for unacceptably repressive practices. Finally, they note, the law is difficult even for psychiatrists and jurists to understand and apply. How much more so will it be for patients and their relatives.
617
The thrust of the criticism is not, therefore, how the new law could be "bent" by a future, hard-line regime to "neutralise" dissidents (the main concern of many Western campaigners), but what it will mean to the average Soviet citizen who happens to fall ill. Mental illness still carries a considerable social stigma in the Soviet Union-hence Rudakov and Savenko’s insistence that the patient should be presumed mentally healthy until proven sick. For decades, Soviet psychiatry has been, even at its best, paternalistic. But it is not only psychiatrists and lawyers, concerned with the integrity of their profession, who feel that the new law is inadequate. The poet Yevgeny Yevtushenko has called for a special commission to review the professional status of psychiatrists who for years gave "expert opinions" on cases of "enemies of the people" and dissidents. Many of these psychiatrists still hold influential posts. The political monthly Kommunist would go even further. Last month, it called for the setting up of a new psychiatric service, independent of the health ministry (since the existing system "did not withstand the test of democracy and glasnost"), and the establishment of an independent organisation of psychiatrists to defend patients’ rights in court. The practice of committing politically sensitive cases to the hands of psychiatrists still continues. The Moscow evening paper Vechernyaya Moskva reported on Aug 23 that a homeless unemployed man, Gennady Smirnoff, had been sent for psychiatric tests after strolling through the streets of Moscow with a satirical portrait of Mikhail Gorbachev which "insulted the president’s personality". Smirnoff will be the first person to be tried under new legislation prohibiting public insults to the president, the paper said.
Vera Rich
USA: Agent orange Congressional investigators are calling for an independent study to determine whether spraying of the defoliant, agent orange, from aircraft during the Vietnam war caused cancers and other illnesses in ground troops below. Such research has already been attempted by the Centers for Disease Control in Atlanta, but the Reagan administration cancelled it in 1987 on the grounds that a scientifically valid study based on military records was not possible. That was a political, not a scientific, decision, says a subcommittee in the House of Representatives headed by Ted Weiss of New York in a report published last month. The White House, says the report, manipulated the research, fearing lawsuits against the Government from cancer victims. A separate investigation by Representative C. V. (Sonny) Montgomery of Mississippi, a leading Congressional spokesman for veterans, found the CDC study to be sound. The CDC investigators spent$43 million in five years but did not get as far as trying to determine whether agent orange had caused cancer. The first stage of the study was to find veterans who had been in areas sprayed, but the CDC found the task of matching troop movements to this spraying impossible. The military records, Dr Vernon Houk of CDC told a Weiss hearing, showed that troops on the ground could be dispersed as much as 20 km, and many sprayings had not been recorded. In addition, he said, except for veterans known to have been exposed during the 1970 defoliation strategy, Operation Ranch Hand, former troops did not show raised blood levels of agent orange’s main carcinogenic contaminant, dioxin (TCDD).
On the basis of evidence from other scientists, the Weiss subcommittee disputes both of these explanations. With respect to the records, the report says, CDC eliminated from consideration thousands of veterans who were most likely to have been exposed. The protocol, it says, kept changing, ending with the elimination of all military forces except the Army (and all but one of the Army’s seven Combat Corps units), all officers, and all personnel who had had more than one tour of duty. However, a team from the National Academy of Sciences, says the Weiss report, found available military records "important and useable and was critical of CDC’s performance". As for the blood tests, the NAS team said that negative samples alone could not justify cancellation of the CDC study. "Little can be said with certainty about the TCDD levels in men 20 years ago", the team wrote. "Moreover, background levels discovered some years later do not provide assurance that no health effects will ultimately surface". It is rare for a Congressional committee to question the integrity of CDC, a health agency renowned for its epidemiological investigations. Dr James Mason, the head of CDC at the time of the agent orange study and now assistant secretary for health at the Department of Health and Human Services, says the Weiss subcommittee’s report is "for the most part incorrect". As for White House manipulation, he says officials there "were not privy to the scientific results of any of these studies until shortly before (public) release". Whatever is found in any future agent orange study, the reality is that for the first time the Government’s Veterans Affairs Department started making disability payments this year to Vietnam war veterans with soft-tissue sarcomas and non-Hodgkin lymphoma. The scientific rationale was the finding, in another CDC study, of an abnormally high incidence of these rare cancers among the veterans. Veterans organisations have claimed for a decade that agent orange caused these cancers, but CDC was careful to say that it found no causal association.
J. B. Sibbison
Conference Pharmacoepidemiology for developing countries In 1982 the International Clinical Epidemiology Network (INCLEN) was set up to promote clinical epidemiology in the developing world. Last April, a conference was held in Bellagio, Italy, to explore ways of developing training programmes and to identify career opportunities for those among the 200 or so INCLEN fellows and new trainees, located in 27 medical schools in 16 developing countries, who might be interested in pharmacoepidemiology. The conference, sponsored by the Rockefeller Foundation and the Carnegie Corporation of New York, was an outgrowth of efforts of many groups to improve the availability and rational use of essential drugs and vaccines in developing countries. Avoidence of paternalism, sensitivity to cultural differences in concepts of health and disease, and recognition of the diverse political and economic constraints in developing countries were accepted by the delegates as basic requirements for the successful implementation of pharmacoepidemiology programmes in the third world.
work. The majority reported a decline in standards since the introduction of integrated science courses. A plan to end all separate exams in physics, chemistry, and biology at 16 has been stopped at the last moment by the Education
Secretary. There is a grim tale too from the universities. A plan to close or merge 30 small "unviable" physics and chemistry departments was averted only at the end of last year. A special review had suggested that all departments with fewer than 20 full-time staff and 200 full-time students should close or amalgamate. This would have meant the end for 17 out of the country’s 49 university chemistry departments, and 20 out of 47 physics departments. A second battle looms, however. The Advisory Council on Science and Technology, whose meetings have been chaired by the Prime Minister, believes that undergraduate science courses in British universities are too difficult. Instead it wants to spread the first two years over three, with the majority carrying on into a fourth year to pick up an MSc. This runs counter to ideas circulating in the Universities Funding Council, which has been examining financial incentives to encourage universities to devise 2-year rather than 3-year degree courses to increase student numbers. All of which brings us to Sir Claus Moser, the retiring President of the British Association, who captured the front pages with his condemnation of English attitudes to education. England-he exempted Scotland-was in danger of becoming the least adequately educated of all advanced countries. Pointing to young people aged 16-18 in full-time education, Sir Claus noted there were 79% in the US, 77% in Japan, 76% in Sweden, 66% in France, but only 35 % in England. Echoing a theme that has run in this column, he declared it was not tolerable for 2 out of 3 children to abandon school at 16. The Government has introduced a national curriculum which will require schools gradually to place more emphasis on science, but there is still no sign of the Government providing the resources--or the sense of administrative urgency-that are needed to ensure its ambitions are realised. The Royal Society is only the latest academic body to produce a report on the inadequate science facilities in schools. A special report commissioned by the British Association has made some sensible proposals for reformthe need to widen sixth form work so that more students study science through to 18; better teacher recruitment targeting; a review to find why physics is so dominated by men (only 15% of girls compared with 34% of boys in sixth forms concentrate on science and maths). More women scientists would relieve teacher shortages because, although only 16% of science graduates are women, they make up 40% of graduate science teachers. More fundamentally, the English have to change their attitudes towards education. Sir Claus was right. Too many people in the country-from the top down-do not care enough about education. Cleverness is still suspect. No other language uses the familiar English expression "too clever by half. Sir Claus urged the Government to set up a royal commission into education and to declare the 1990s as the Decade for Education. Just two days later this was rejected by the new schools minister in a fatuous speech. To its credit the British Association has not been thwarted. It has decided to set up its own royal commission. A good first step. Malcolm Dean
Round the World USSR: Doubts about psychiatric reforms The Soviet Union’s proposed new law on psychiatry contains a major defect, according to an article in Meditsinskaya Gazeta, the newspaper of the Soviet medical profession. The criticism that the law is not based on the "presumption of mental health" is a serious one, since the readmission of the official Soviet All-Union Society of Psychiatrists and Narcologists to the World Psychiatric Association in Athens last October was conditional on satisfactory reforms and was to be reviewed after five years. The Soviet psychiatrists had assured the WPA that, under Gorbachev, political dissent was no longer considered a form of schizophrenia. Activists were no longer committed to mental hospitals, and those still so confined were being released as soon as their cases could be processed. A new law would shortly be passed which would strengthen patients’ rights and make psychiatrists who abused those rights liable to prosecution. The much-feared "psychiatric register", which imposed major constraints on the civil rights and work prospects of those whose names appeared in it, was being phased out. Penal psychiatric hospitals had been transferred from the jurisdiction of the Ministry of the Interior to the Ministry of Health. In short, the Soviet psychiatric profession was putting its house in order as fast as
possible.
Even at the Athens meeting, many delegates feared that this official picture was overoptimistic, although they were willing to give the All-Union Society the benefit of the doubt. Also present at the meeting (and, after some heated argument, also admitted to the WPA) was an alternative organisation, the Independent Psychiatric Association of the Soviet Union, established in the spring of 1989 by a small group of psychiatrists who believed that the ethics of their profession were ill-served by the Soviet psychiatric establishment. These psychiatrists warned that many of the reforms were merely cosmetic. The same people, they said, were running the penal mental hospitals: "they have just changed their police jackets for white coats". Moreover, they emphasised, keeping dissidents in hospital was only a symptom of the basic fault of the Soviet psychiatric system-the wide powers of compulsory confinement at the
psychiatrists’ disposal. The authors of the Meditsinskaya Gazeta article, Dr Yury Savenko, President of the Independent Psychiatric Association, and A. Rudakov, head of the juridical consultation unit attached to the office of the chief psychiatrist of Moscow province, say that the draft of the new law, at present being circulated for discussion among the medical profession, makes no provision for the assistance of a lawyer in the case of "emergency or first-aid" admissions. Even when patients have the right to legal protection, there is no obligation on the legal profession to assist them, and "in practice, lawyers often refuse to handle such cases". The clauses on compulsory treatment, and the compulsory admission to hospital of persons who in a state of psychological illness have committed "especially dangerous crimes" are, the authors say, insufficiently precise and could therefore provide a loophole for unacceptably repressive practices. Finally, they note, the law is difficult even for psychiatrists and jurists to understand and apply. How much more so will it be for patients and their relatives.
617
The thrust of the criticism is not, therefore, how the new law could be "bent" by a future, hard-line regime to "neutralise" dissidents (the main concern of many Western campaigners), but what it will mean to the average Soviet citizen who happens to fall ill. Mental illness still carries a considerable social stigma in the Soviet Union-hence Rudakov and Savenko’s insistence that the patient should be presumed mentally healthy until proven sick. For decades, Soviet psychiatry has been, even at its best, paternalistic. But it is not only psychiatrists and lawyers, concerned with the integrity of their profession, who feel that the new law is inadequate. The poet Yevgeny Yevtushenko has called for a special commission to review the professional status of psychiatrists who for years gave "expert opinions" on cases of "enemies of the people" and dissidents. Many of these psychiatrists still hold influential posts. The political monthly Kommunist would go even further. Last month, it called for the setting up of a new psychiatric service, independent of the health ministry (since the existing system "did not withstand the test of democracy and glasnost"), and the establishment of an independent organisation of psychiatrists to defend patients’ rights in court. The practice of committing politically sensitive cases to the hands of psychiatrists still continues. The Moscow evening paper Vechernyaya Moskva reported on Aug 23 that a homeless unemployed man, Gennady Smirnoff, had been sent for psychiatric tests after strolling through the streets of Moscow with a satirical portrait of Mikhail Gorbachev which "insulted the president’s personality". Smirnoff will be the first person to be tried under new legislation prohibiting public insults to the president, the paper said.
Vera Rich
USA: Agent orange Congressional investigators are calling for an independent study to determine whether spraying of the defoliant, agent orange, from aircraft during the Vietnam war caused cancers and other illnesses in ground troops below. Such research has already been attempted by the Centers for Disease Control in Atlanta, but the Reagan administration cancelled it in 1987 on the grounds that a scientifically valid study based on military records was not possible. That was a political, not a scientific, decision, says a subcommittee in the House of Representatives headed by Ted Weiss of New York in a report published last month. The White House, says the report, manipulated the research, fearing lawsuits against the Government from cancer victims. A separate investigation by Representative C. V. (Sonny) Montgomery of Mississippi, a leading Congressional spokesman for veterans, found the CDC study to be sound. The CDC investigators spent$43 million in five years but did not get as far as trying to determine whether agent orange had caused cancer. The first stage of the study was to find veterans who had been in areas sprayed, but the CDC found the task of matching troop movements to this spraying impossible. The military records, Dr Vernon Houk of CDC told a Weiss hearing, showed that troops on the ground could be dispersed as much as 20 km, and many sprayings had not been recorded. In addition, he said, except for veterans known to have been exposed during the 1970 defoliation strategy, Operation Ranch Hand, former troops did not show raised blood levels of agent orange’s main carcinogenic contaminant, dioxin (TCDD).
On the basis of evidence from other scientists, the Weiss subcommittee disputes both of these explanations. With respect to the records, the report says, CDC eliminated from consideration thousands of veterans who were most likely to have been exposed. The protocol, it says, kept changing, ending with the elimination of all military forces except the Army (and all but one of the Army’s seven Combat Corps units), all officers, and all personnel who had had more than one tour of duty. However, a team from the National Academy of Sciences, says the Weiss report, found available military records "important and useable and was critical of CDC’s performance". As for the blood tests, the NAS team said that negative samples alone could not justify cancellation of the CDC study. "Little can be said with certainty about the TCDD levels in men 20 years ago", the team wrote. "Moreover, background levels discovered some years later do not provide assurance that no health effects will ultimately surface". It is rare for a Congressional committee to question the integrity of CDC, a health agency renowned for its epidemiological investigations. Dr James Mason, the head of CDC at the time of the agent orange study and now assistant secretary for health at the Department of Health and Human Services, says the Weiss subcommittee’s report is "for the most part incorrect". As for White House manipulation, he says officials there "were not privy to the scientific results of any of these studies until shortly before (public) release". Whatever is found in any future agent orange study, the reality is that for the first time the Government’s Veterans Affairs Department started making disability payments this year to Vietnam war veterans with soft-tissue sarcomas and non-Hodgkin lymphoma. The scientific rationale was the finding, in another CDC study, of an abnormally high incidence of these rare cancers among the veterans. Veterans organisations have claimed for a decade that agent orange caused these cancers, but CDC was careful to say that it found no causal association.
J. B. Sibbison
Conference Pharmacoepidemiology for developing countries In 1982 the International Clinical Epidemiology Network (INCLEN) was set up to promote clinical epidemiology in the developing world. Last April, a conference was held in Bellagio, Italy, to explore ways of developing training programmes and to identify career opportunities for those among the 200 or so INCLEN fellows and new trainees, located in 27 medical schools in 16 developing countries, who might be interested in pharmacoepidemiology. The conference, sponsored by the Rockefeller Foundation and the Carnegie Corporation of New York, was an outgrowth of efforts of many groups to improve the availability and rational use of essential drugs and vaccines in developing countries. Avoidence of paternalism, sensitivity to cultural differences in concepts of health and disease, and recognition of the diverse political and economic constraints in developing countries were accepted by the delegates as basic requirements for the successful implementation of pharmacoepidemiology programmes in the third world.