West Germany: Homoeopathic déjà vu

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Hong Kong: primary care

Need for

improvement in

A recent visit to report on primary health care services for the World Health Organisation gave me the opportunity to study life, health, and disease in Hong Kong. The population of Hong Kong has more than quintupled in the past 50 years. There has been a proliferation of attractive high-rise buildings of 30-40 floors in central Hong Kong Island and Kowloon, many buildings incorporating private and business accommodation and hotels. Housing is in private blocks or in large Government-built estates of high-rise blocks, each providing homes for 1000-2000

people. Hong Kong,

with its population of 5-7 million, is very much in the business of busyness. Everyone seems to be involved in some occupation, many in two. Unemployment is less than 1 %. The motivation to work hard is to make as much money as possible. The primary health care system reflects Hong Kong’s colonial past, with private health care for ex-patriates (through company schemes) and for those who want to pay, Government services for the less well-off, and some missionary care in the charitable hospitals and clinics. In addition there is a thriving self-care system of traditional medicine with herbs, acupuncture, massage, and the rest. The accident and emergency departments of Government hospitals are used extensively. The measurable health indices of Hong Kong are excellent. The infant mortality rate is only 7 per 1000 births (compared with 10 in the UK), the uptake rate for childhood immunisation (which includes routine BCG and hepatitis B immunisation) is over 95 %, and life expectancy (74 years for men, 80 for women) is higher than in the UK. All this is achieved at a relatively low cost of 4% of gross national product, compared with 6% in the UK and 12% in the USA. Yet not all is well. Care for the elderly is less than effective and is likely to worsen as the numbers of old people grow and extended family care decreases. Care for the mentally ill, the handicapped, and the 55 000 known drug addicts is also

inadequate. practice in Hong Kong is unplanned and no organised training. 95% of work alone or in small units, and their private practitioners standards of care are unobserved and uncertain. Every day they see, without appointment, 50-70 patients, who pay k55 to C 10 for a consultation. There is no provision for home visits or night cover. These doctors probably gross £ 60 000 to 120 000 per year. There are also two groups of 40 and 70 doctors, one with a system of franchised practices-a General

uncontrolled, and there is

"Medical McDonalds"-where doctors receive pay from the group for work done on their own premises. The other has many satellite units, with associates receiving salaries plus a share of the profits. Both groups provide a high standard of care and are paid through contracts with companies and medical insurers, as well as fees from

patients. Doctors in government clinics are paid about £ 25 000 a care is very basic and rushed, because they are expected to see up to 120 patients a day, at 3-4 minutes each. The Department of Health is aware of the deficiencies in primary care and is taking advice on how they may be improved, while accepting that neither the medical year. Their

profession nor the public are keen on change. The Department has set up a committee to report on a possible Primary Health Care Authority on the lines of the Hospital Authority, which has just been set up to plan and administer hospital services. The committee now has before it the report of WHO consultants suggesting setting up some centres

of excellence as models that could be tested.

Beckenham, Kent

West

John

Fry

Germany: Homoeopathic déjà vu

Heidelberg-based medical book publishers, SpringerVerlag, recently took the unusual step of releasing a book about homoeopathy, Jenseits von Milligram (Beyond the Milligram), which resurrects a controversy in the scientific community that centred around the work of the French scientist, Jaques Benveniste. Two years ago Benveniste The

claimed to have observed the release of histamine from white blood cells caused by "solutions" of IgE antibodies so dilute that they did not contain any antibody molecule. Nature decided to publish the results without believing in them but sent out a committee, consisting of the editor, a magician, and a "policeman for scientific fraud" from the American National Institutes of Health, to investigate Benveniste’s work. This team reported that the claimed homoeopathic effect was the result of self-deception and sloppy laboratory practice rather than the principles of Samuel Hahnemann, the founder of homoeopathy. But Benveniste never retracted his findings. Jenseits von Milligram is just as provocative as the Benveniste affair. The book describes animal experiments with several homoeopathic dosages, some of which seem to have an effect despite dilutions which progressively exceed the Avogadro number. These experiments were conducted by a biochemist at the Veterinary University of Hannover, Prof Gunther Harisch. His interest in the subject was stimulated by the apparent effect of homoeopathic drugs he and his family had tried out on themselves. As in other countries, scientists in the Federal Republic wishing to research on the effect of homoeopathic medicines usually have to rely on the medicines’ manufacturers for financial support. However, a few years ago the former West German Bundesprasident Karl Carstens and his wife Veronica, a practising doctor, founded a society, Natur und Medizin, with the express aim of introducing natural medicine into university curricula. Nowadays Natur und Medizen has about 50 000 members, whose support was instrumental in the founding of a chair for natural medicine in Berlin and in the financing of research projects to investigate natural cures with scientific methods. The West German population has a high regard for natural curessome 70% are said to have used unproven methods at some stage in their life. Professor Harisch’s work is one of those projects supported by Natur und Medizin. He used well-established animal models in the experiments, feeding sugar tablets containing different homoeopathic doses to rats, and measuring either histamine release by mast cells or activity of lysosomal enzymes. A placebo group and an untreated control group were always included for comparison. The cells were acquired by the aspiration of fluid injected into the peritoneal cavity. Simple substances such as calcium carbonate, phosphorus, arsenic, or zinc were used as

homoeopathic drugs.

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Jenseits von Milligram reads like a very tidy laboratory protocol, restricting itself to a description of the experiments and the results. Some of the findings are truly astonishing. In some (but not all) experiments, drugs with dilutions beyond the Avogadro number still had a significant effect. In some cases an effect that had been lost at intermediate dilutions was recovered at higher ones. How does Harisch explain his results? He does not try. "This is a task for physicists" is his answer. His book does not contain any interpretation of the results. In this respect Harisch is very unlike Benveniste, who publicised his results before any scientific discussion was possible. Harisch is reticent about his work, not liking to be compared with the French scientist, and he does not reference Benveniste in his book. He now hopes that other scientists will reproduce his work and start a truly scientific debate about homoeopathy.

Annette Tuffs

Medicine and the Law Coroners and allegations of lack of care, UK and Hong Kong The Divisional Court held on July 26,1990, that Dr W. I. H. Shedden, assistant coroner for the Inner London North District, on June 30,1989, had erred when he refused to call a doctor as witness at an inquest. In a Hong Kong case the High Court concluded that a coroner had been too liberal when faced with an allegation of lack of care. Death in police custody, London On Oct 7,1988, a man had been sentenced in a magistrates’ court to 10 weeks’ imprisonment for theft and for breaches of probation and conditional discharge. Because of difficulties within the Prison Service at that time he had been taken to a police cell. During Oct 8 his physical and mental condition deteriorated and he was taken to University College Hospital, London, where he died the following

night. post mortems, one for the coroner and one for the revealed the cause of death as acute myocarditis. The family, coroner proposed an inquest without a jury but the dead man’s father applied for judicial review and the Divisional Court directed that a jury should be summoned (1989 1 WLR 395; Times, Jan 21, 1989). At the inquest, on June 29,1989, the verdict was death from natural causes. However, before the inquest, the deceased’s father had consulted Dr Gordon Jackson, because he felt that his son’s medical condition had been aggravated by lack of care by the police and the doctors who had attended him at the police cell. That allegation was supported by Dr Jackson’s report, which was sent to the coroner with a request that the doctor be called. The coroner took no action; when the request was repeated at the inquest he refused to call the witness and withdrew the issue of lack of care from the jury on the ground that there was no evidence to support it. The applicant contended before the Divisional Court that a new inquest should be ordered under the 1988 Coroners Act because there had been rejection of evidence and insufficiency of inquiry on the part of the coroner. Lord Justice Farquharson said that the coroner had refused the application to call Dr Jackson because he considered it inappropriate to rely on a witness selected by someone other than himself and because the coroner, having regard to his own experience in infectious diseases, felt he did not need to rely on the professional knowledge of another doctor. His lordship said that it was for the coroner to decide which witnesses he should summon to an inquest, but the applicant submitted that the coroner’s reasons were bad in law. That criticism was justified. The witness could not be called by the family, but there was no reason why the evidence should not be admitted for the coroner’s consideration. The The

t

two

question of the coroner’s own special knowledge did not arise; it was for the jury to give the verdict on the evidence called before it and since the coroner himself could not give expert evidence another doctor would have to do so. The coroner withdrew the issue of want of care, in effect directing the jury (though nominally leaving the possibility of an open verdict) to return a verdict of natural causes. It was open to a jury to return a verdict of death through natural causes aggravated by lack of care. The coroner’s difficulty was caused by rule 42 of the Coroner’s Rules (1984) which provide that no verdict should be framed in such a way as to determine any question of civil liability. A coroner would always be anxious to prevent an inquest from being used as a platform for allegations of negligence. However, lack of care could be raised so long as nobody was identified as being responsible for it. Farquharson L_7 said that the issue of whether the death from acute myocarditis was aggravated by lack of care should have been left to the jury. If the jury accepted the evidence of the applicant, the doctor’s evidence could have been relevant. There was evidence that if the deceased had been taken to hospital at the time the applicant had requested his transfer, the man’s life might have been saved, and the applicant submitted that it was in the public interest that the issue of lack of care should have been resolved. However, 21 months had elapsed since the death. Dr Jackson had made no criticism of the police, and there was very little evidence to show want of care on their part as causative of the death. Accordingly, the court did not order a new inquest. Mr Justice Nolan agreed.

Anaesthetic death,

Hong Kong

A too liberal approach towards evidence on lack of care was taken by a Hong Kong coroner, who allowed a five-week inquest into the death of a patient during anaesthesia for a reduction of an ankle fracture, at the Canossa Hospital, Hong Kong, on Jan 14, 1989. More than a week was spent examining the medical and anaesthetic aspects of the case; the anaesthetist, Dr M. J. Bascombe, was questioned persistently and expert witnesses were asked how a reasonable anaesthetist would have reacted when the emergency occurred. Counsel for Dr Bascombe, before the inquest and at its conclusion, submitted that a lack of care verdict would not be appropriate but the coroner ruled that, subject to the evidence, such a verdict was open to the jury. However, he then directed that, on the medical evidence that he had heard, the jury could not consider lack of care when they came to their verdict. The jury held that death was "due to the wrong supply of gas to the hospital". Unbeknown to the anaesthetist and other staff the hospital oxygen supply contained nitrogen and the patient died of cerebral anoxia. Even so the family was alleging that the emergency should have been responded to more effectively. On a matter of principle the Medical Defence Union (and Dr Bascombe) applied for judicial review and for a declaration that the coroner had erred. The doctor had been subjected to a "harrowing and unnecessary experience" and did not wish that experience on colleagues in the future. Mr Justice Bamett held that the coroner had exceeded his jurisdiction. The judge argued that the legislature could not have intended coroners to have carte blanche to examine all aspects of a death. A "lack of care" verdict entailed something far short of a legal evaluation of conduct; it meant conduct, by a person with some responsibility for the deceased, which had contributed to the medical cause of death. That conduct should be judged according to the standards of the reasonable man (ie, the jury) rather than those of experts, whose views often conflict. The coroner was charged with finding the cause of death-what was done and what was not done and why-but he must not go on to evaluate conduct. Nonetheless the judge rejected the declaration sought by the MDU and Dr Bascombe because the doctor had been vindicated in his approach at the coroner’s inquest. The judge did not, however, rule out the evaluation of conduct entirely. "Clearly it is of crucial importance in relation to the possibility of criminal charges. It may also be crucial in determining whether some intervening factor was the effective cause." For example, if the patient had died during surgery from a cause other than the one found, evaluation of the surgeon’s or the anaesthetist’s conduct might have been appropriate.