West Germany

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Round the World From

our

Correspondents

Armenia MEDICAL RELIEF AFTER THE EARTHQUAKE

AT 1120 on Dec 7 a violent earthquake measuring 10 on the Richter scale struck the Armenian Republic of the Soviet Union. The epicentre was at Nalban, a town of about 3500 inhabitants in central Armenia; 2800 were killed. Also devastated were Spidak, a regional centre of 40 000 persons about 20 km away and Leninakan, the second largest city in Armenia with a population of about 250 000. About 80% of Spidak was destroyed as was about 30% of Leninakan. An international relief effort was launched almost immediately. Earthquakes require three types of aid--search and rescue, medical support, and disaster relief. Search and rescue teams consisting of dogs, their handlers, support personnel, and trauma experts arrived from France, Italy, Switzerland, and the United Kingdom. An official American team, of which I was a member, arrived early on Sunday morning. Confusion reigned at the airport and we circled for almost an hour while aircraft were removed from the runway. As an official delegation we expected’ formal directions from the Ministries of Foreign Affairs and Health; but no one met us-no immigration, no customs. These things can be expected in a disaster of this magnitude. For example, an official from the Ministry of Health was off arranging to fly the most severely injured to Moscow, Kiev, Tibilisi, and elsewhere. From the airport we drove to Yerevan, the capital. It was 0900 on Sunday but we found the Prime Minister, Mr Sarkasian, who suggested we depart immediately for Leninakan. It took us 4 hours to arrive. The scene was shocking: 10-storey buildings were reduced to a heap no more than 10m high. After some negotiations we set up headquarters in the KGB office and secured a tent for the

dog teams. it was learned we had arrived, people congregated at Frantic parents pleaded with the dog teams to go immediately to one site or another where their child or spouse was buried. They claimed to hear voices, tapping, other signs of life. Such requests were impossible to refuse. However, it is dangerous to let the team explore unsafe structures. Also, an organised plan is likely to save more lives. A compromise was struck; some dog teams handled local requests and others organised a critical review of collapsed structures which might contain live victims. We could see that the need for physicians was greatest in Yerevan; three of the four hospitals in Leninakan were destroyed and the injured were being flown to the capital by helicopter; so we left the search and rescue teams with two trauma physicians and returned to Yerevan. The next few days were a logistical nightmare. Communication with Leninakan was poor or nonexistent. Our team and others continued to pull survivors from the wreckage. The salvage rate decreased with time and the cold weather, but even a week after the accident a few persons were found-some might survive. By about 10 days it seemed as if the risk to the rescuers might exceed the likelihood of finding persons alive. The teams were exhausted. We decided to terminate the search and rescue effort. Meanwhile we visited the twelve hospitals of Yerevan which have 10-12 000 beds. With us we had Armenian-American physicians who had been in touch with Armenian colleagues for several years before the accident. This helped enormously in our fact-finding efforts. We also had persons well connected with the Armenian Church and Cultural Ministry. These contacts produced vehicles, helicopters, and warehouses at a moment’s notice when official channels failed. The major medical problems of this disaster were trauma, open and closed fractures, secondary infections, and "crush" syndrome (in which destruction of muscle mass leads to myoglobinuria and renal failure). Numerous amputations were performed. The As

soon as

our tent.

haemodialysis capability of Yerevan, which was never great, was rapidly exceeded. The West Germans arrived with 21 units; all went to one hospital which could only support 10. Through our contacts we arranged for the others to be sent to two large hospitals without any machines. There was a critical shortage of facilities for rapid automated biochemistry and blood gas analysis; we were less successful in correcting this. By five days most of the critically injured were being treated, generally in Yerevan, others at major Soviet trauma centres after a massive airlift. Tragically, two plane crashes and one helicopter crash in the first three days resulted in than 90 deaths. The foreign relief effort was impressive, if uncoordinated. There were more than enough antibiotics and medical supplies. It took a few days to get these into the hospitals but this is understandable. Next, medical equipment, such as dialysis machines, began to arrive-almost everyone who needed dialysis received it. We were less successful in getting equipment for rapid X-ray diagnosis onto more

the

scene.

Clearly a long-term commitment to this disaster is needed since much work remains to be done. Amputations will need revisions and there will be a substantial need for artificial limbs and rehabilitation. The psychological needs of the population require attention. Physicians are called on for every sort of task in such a disaster. We did what we could-it could never be enough. Perhaps one of the most important was helping an Armenian peasant bury his wife and son in a family grave site in Nalban. After all, our major responsibility is to the living. University of California, Los Angeles, USA

ROBERT PETER GALE

Gaza DEATH IN A CELL

A SECOND Israeli doctor has been charged with causing death through negligence. This follows an Israeli Army investigation into

the death of Hani Deeb Al-Shami, who died in his cell at the Israel Defence Force (IDF) post in Jabaliyah, Gaza, on Aug 22,1988. Itis alleged that AI-Shami was beaten by four soldiers who entered his home on-the day of his death. When taken to the IDF post at Jabaliyah he asked for medical help. Dr David Nussam examined him and instructed an orderly to clean the blood from his face but apparently decided that no further action was necessary. Hours later AI-Shami was found dead in his cell. Necropsy revealed, besides bleeding from the mouth and ears, fractured ribs and internal haemorrhage. The soldiers, who are still in detention accused of causing Al-Shami’s death, are denying responsibility. Their defence is that Dr Nussam examined the man and could find no injury at the time of his arrival at the IDF post. This is the second case within six weeks in which a doctor has been charged by the IDF with neglecting his duties. International pressure, especially from medical groups, had led the authorities in Israel to open 170 files relating to the deaths of civilians in the occupied territories during the uprising.

West Germany PROPRIETARY VERSUS GENERIC

Daimler invented the automobile around the time Hoffmann discovered the analgesic effect of aspirin. Nobody would think of buying a Daimler car just to help the inventor’s company. But this argument may still be heard in the Federal Republic of Germany in defence of the prescribing of proprietary instead of generic drugs. In 1986 generic drugs paid for by the Sick Funds of the FRG amounted to DM0million or 83% of the total medicines bill. This is much less than the proportion prescribed in the United States. There a substantial portion of the cost of medicines has to be paid by the patient himself or by benevolent organisations, and both have to economise. Until recently most patients in the FRG did not even know how much their medicines cost. The Sick Funds merely determined the patient’s monthly contribution as a percentage of the wage or salary. With premiums exceeding one-tenth of the

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political pressure rose to contain costs. One of the "cost dampening" measures was to have pharmacists put the price on the pack. Not surprisingly, the insured vied to get expensive drugs in wage,

for their high contribution, thus undoing the Government’s The Government then tried to enforce the intentions. good decades-old regulation that the Sick Fund doctor should choose among equivalent drugs those fulfilling the "order of economy". To return

help him with this task the Price Comparison List was issued. The message took time to get through to the prescriber, but the leading German generics manufacturer now ranks among the first ten pharmaceutical houses in domestic sales. The share of generics for some frequently prescribed compounds-eg, allopurinol, amoxicillin, co-trimoxazole, dihydroergotoxin, doxycycline, erythromycin, ibuprofen, levothyroxine, metoclopramide, and penicillin had already exceeded 50% by 1985.

In

England Now

I SUPPOSE most people who read In England Now just enjoy each piece or not-and leave it at that. But there is another legitimate plane of interest: have you ever wondered how it came to be written? Having now achieved my hundredth contribution, I feel quite an authority on how some of it arrives (all right, I confess that it’s taken me thirty-six years to score the century). The first angle to consider is humour. This column is commonly seen as being humorous. But when you come to examine it, that’s only a partial truth. It’s really much more appropriate to talk about tone. What is required is a consistent lightness of tone. Pomposity is out; self-deprecation is more in order.

The content does not have to be medical, but a medical ambience is preferable. Otherwise-and here we’re getting to the heart of it, to the essential character and joy of this section of The Lancet-the subject can be anything. Well, anything that’s not improper. A 400 word contribution cannot aspire to an 0. Henry punch-line. But each piece needs to be rounded off, to stand square on its own feet, to be an entity. Not so much a punch as a twist. *

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WILL the Government soon extend its plans for privatisation to the emergency services? The prospect has already caused a flurry of activity, and a hastily formed consortium of private services, especially in the health sector, has produced draft plans. Callers to the 999 services would be asked at once for their credit card number. The planning group admits that this would allow immediate access to the extent of the callers’ credit worthiness but insists that the purpose would be principally to deter hoaxers. Many members of the public might want to subscribe to 999, and graded subscriptions would ensure greater benefits. No-claims bonuses would accrue. Others would be charged for the call plus a fee per item of service. Calls for the Fire Service would be handled much as now, but those asking for the Police would be offered a choice between a private security firm and the ordinary free public constabulary service. Requests for an ambulance would be channelled towards the private hospital service of the caller’s choice. Most people envisage that the public ambulance service, which now ferries patients to accident and emergency departments that are increasingly closed, would rapidly decline, with consequent great savings to the NHS. Competition would keep down the costs of using the service, and both 888 and 777 have been reserved for possible use should rival services emerge. To offset expenses, the services would sell details of calls to firms of solicitors specialising in insurance claims. Speed of answering calls would obviously be an important factor with the public, and companies would be expected to guarantee an answer within four minutes except at peak accident times and at weekends. It is likely that some companies would expand into providing for other emergencies-plumbers, dentists,

Price comparison is indivisible from quality comparison, and the West German drugs licensure requests that manufacturers disclose how they ensure satisfactory pharmaceutical quality. Different symbols in the drugs list showed the doctor how close the product came to the ideal. But that convention was temporarily banned by court injunction. Another court forbade generic manufacturers to name the standard by which they compared the bioequivalence of their own drugs. In a laudable action contrary to their own commercial interests, German pharmacists now provide physicians with data on the quality of most prescribed proprietary and generic drugs. The leading generics manufacturer distributes a handbook with comparative bioequivalence data on all of his products. This should enable German physicians to prescribe more economically in the best interest of their patients.

vets, meals on wheels, the Samaritans, and both types of AA, together with specialists in rescuing pets from trees and small children from railings, would be expected to register. The result would be a greatly expanded service at competitive

prices which would deliver, as a byproduct, financial relief to the hard-pressed public services. Everyone would benefit-at a cost that would be advertised as a considerable saving on what it might have been. For the basic call, a figure of 75 is being suggested. *

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THE road to Innsbruck by Ehrwald takes course around the limestone crags of the Zugspitze, small by Austrian standards at 9500 feet, but still the highest peak in Germany and worthy of conquest, especially because a cable car goes to the top. Our only guide-book was the cable car timetable, which did not explain why some 400 people had by 9 am ascended the cable car to go through a tunnel to a church on the plateau. The ascent was by two cable cars, the first taking two huge leaps of some 2000 feet each. The second, shorter, journey took us to the restaurant on the Austrian side of the summit and to a passport control to be negotiated before reaching Germany’s highest point, left bare for the adventurous to set foot on the true summit. We descended to the penultimate station, where we passed an Austrian passport control and entered a tunnel just large enough to take a pedestrian. This descended some 500 feet in half a mile; initially the going got colder, with ice crystals on the walls and slippy slush on the floor, until a pair of swing doors (the frontier?) marked the end of the ice and the halfway stage. The now warm tunnel finally ending at a German passport control. We emerged, as if in a fairy tale, on the 5th floor of a thickly carpeted hotel staircase, which led us down to a restaurant, where an unperturbed waiter directed us past the bar to the outside world again. Outside was a vast triangular plateau flanked on two sides by the back of the crags we had seen from the main road. We descended to plant level, first campanulas and gentians, and then prostrate pines and junipers-no doubt a skiers’ paradise in season. We became aware of the sound of Beethoven’s Creation Hymn echoing around the corrie, and then Luther’s Redemption Hymn could be heard, coming, as we could eventually see, from a large congregation about an hour’s walk away across the base of the plateau and the scree. As we approached, the congregation broke up and began to make its way along the narrow cliff path, looking for all the world like corpuscles in a capillary. We soon became part of the column which was making its way to a col, and to a plaque that had been erected there. A German traveller revealed all. He was a traffic policeman, and the crowd was attending an annual mass to commemorate five German policemen who had died in a mountain rescue operation in 1952, together with those who have died in similar operations since. Quite a day. Don’t expect to find a vacant bed in Ehrwald on the second Sunday in September.