WORLD MEDICAL ASSOCIATION

621 very flexible thin

branch, is frequently used for the

purpose of

applied to the skin to minimise The more inexperienced and impatient permanent scarring. flogging

and that

a cream

is

omit this. In our filed report on this man it is documented that he has several sequelae of his other forms of torture, such as suspension andfalaka. We are convinced by the nature of his other lesions and by the pattern of his physical complaints that this man has been tortured. The origin of the cluster of scars in the lumbosacral area alone is of less gravity and must be interpreted in the light of this diagnosis. Nevertheless, any clinician who wishes to pursue the matter of clinical interest would be most welcome to visit the Foundation, and we have secured the consent of our patient to further examination if torturer may

required. Medical Foundation for the Care of Victims of Torture, National Temperance Hospital, London NW1 2LT

ELIZABETH GORDON TOM LANDAU BERNARD KNIGHT HELEN BAMBER

We deplore the fact that Switzerland does not provide doctors and patients with the right to present proposals on drug labelling and that the intercantonal authority does not deem itself competent to judge whether or not human insulin packages should contain a specific warning about the possible risks of switching from animal to human insulin. Dr Robert Tattersall, chairman of the British Diabetic Association’s professional advisory committee, has reported that in Britain "pharmaceutical companies have responded to pressure and are now placing the new statements on their human insulin packaging literature".5 How long will it take the European Community to enforce these warnings and how long will it take the World Health Organisation to undertake similar action for the international community? Diabetes Station, Medizinische Universitatsklinik,

A. TEUSCHER P. DIEM

Inselspital, 3010 Bern, Switzerland

A, Berger WG. Hypoglycaemia awareness in diabetics transferred from beef/porcine insulin to human insulin. Lancet 1987; ii: 382-85. 2. Teuscher A, Eggèr M. Human insulin hypoglycaemia unawareness. Lancet 1989; i: 1. Teuscher

TURKS IN BULGARIA

1072.

SIR,-Professor Renda, Dr Sahin, and their colleagues (July 22, p 220), attempting to refute allegations of torture to Turkish Kurds, dismiss the references to publications by Amnesty International on the grounds that that organisation is "well known for its political activity". All Amnesty International publications are carefully researched for accuracy and take pains to avoid any political bias. Both letters ask why the Bulgarian government’s handling of the Turkish population living in Bulgaria is not receiving as much attention as Kurds in Turkey. Amnesty has been active in that area since 1984, when the Bulgarian authorities began a campaign of forced assimilation of the Turkish minority. Amnesty published a detailed report in 1986.1 Since then several prisoners of conscience have been adopted by Amnesty, and the thousands of letters written in their support to the Bulgarian head of state seem to have contributed to the release of some of them. On June 20, 1989, Amnesty International called on Todor Zhikov, chairman of the Bulgarian State Council, for full and impartial investigations into reports of killings and beatings of ethnic Turks by the security forces during demonstrations in May, 1989. Medical Group, British Section,

Amnesty International, 99-119 Rosebery Avenue, London EC1R 4RE 1.

DUNCAN FORREST RUTH HORNE

Amnesty International. Bulgaria: imprisonment of ethnic Turks. London: Amnesty International, 1986.

SWITZERLAND’S DRUG SURVEILLANCE

SIR,-Your July 22 Round the World report describes Switzerland’s inadequate system of private adverse drug reaction (ADR) reporting and concludes that this system does not qualify for the international network of national ADR monitoring centres and that there should be greater participation by IKS (the Swiss intercantonal drug regulatory body) and more financial support of ADR reporting from the federal government. We wish to augment this report by describing a specific problem. Several Swiss diabetologists have accumulated a lot of information on "hypoglycaemia unawareness" experienced by diabetic patients who are switched from animal to human insulin.1-3 Others have noted this possible risk too, and Dr Andrew Herxheimer of Charing Cross Hospital, London, is quoted as saying "Human insulin is not better than conventional insulin treatment and may hold more dangerous side-effects for diabetics".4 When Swiss diabetologists petitioned IKS they were told that the regulatory body would not demand that a warning of this possible danger be added to human insulin packages. We were told that no Swiss physician or patient has the legal right to present such a complaint to IKS; such proposals may only be presented by pharmaceutical companies. The IKS board also declared itself "not competent to answer such a complaint".

3.

Berger W, Keller U, Honegger B, Jaeggi E. Warning symptoms of hypoglycaemia during treatment with human and porcine insulin in diabetes mellitus. Lancet 1989;

i: 1041-44. 4. Erlichman J. Human insulin may hold risks for diabetics. Guardian 1988, March 22. 5. Tattersall R Diabetes deaths and human insulin. Guardian 1989, Aug 10.

WORLD MEDICAL ASSOCIATION

SIR,-Dr Beck’s article on apartheid, South Africa, and the World Medical Association (WMA) (June 24, p 1441) is politically biased. It is the latest chapter in an attack on Hans-Joachim Sewering, of Munich. Beck maintains that Professor Sewering had to resign as president of the West German Medical Association in 1978 because of "financial irregularities". This statement is incorrect and Beck knows it yet your contributor used the word that will defame Sewering all over the world. He has been treasurer of the WMA for many years; and WMA as an international organisation, it is implied, could not afford to have as treasurer someone who had lost his post in a national medical organisation because of alleged financial irregularities. He resigned as president of the West German Medical Association after disagreements with the Landesverband der Ortkrankenkassen in Bayern (the Bavarian association of local sick funds) over problems of accounting, and these were not kept secret. Kassenarztliche Veremigung Hessen, 2

Vorsitzender,

6000 Frankfurt

am

Main 97, West

Germany

J. BAUSCH

SIR,-Dr Beck’s article on The World Medical Association and South Africa contains inaccuracies and misconceptions. There are not three medical associations in South Africa. The South African Medical and Dental Council is a statutory body which registers doctors and licences them to practise; it is the equivalent of the General Medical Council in the UK. The Medical Association of South Africa (MASA) is an independent professional organisation which represents only medical doctors. It is not government-run, and has never been. Membership, which is voluntary, is open to every registered medical practitioner in South Africa irrespective of race, creed, or political persuasion, and MASA has no affiliation with political groups. MASA attaches no significance to the skin colour of its members, and does not make inquiries or keep records about this. MASA is well aware of the medical profession’s collective responsibility for the wellbeing and health of the people of this country. Its involvement and activities speak for itself. I direct your readers’ attention to MASA’s policy on discrimination and apartheid, insofar as it affects the health of the population. MASA subscribes to the World Medical Association’s Declaration of Geneva, which states that "the health of his/her patients will be the doctor’s first consideration and that he/she will not permit considerations of religion, nationality, race, party politics or social standing to intervene between his/her duty and his/her patient".

622

Recognising that the health of a population is primarily influenced by hygiene, sanitation, nutrition, housing, lifestyle, education, and primary health care "MASA seeks the abolition of all discriminatory measures in South Africa to ensure the disappearance of the practice of apartheid, so that the human dignity of all people be acknowledged, affording them equal and just opportunities". Medical Association of South Africa, 428 King’s Highway,

B. B. MANDELL

Lynnwood, Pretoria 0081, South Africa

Chairman, Federal Council, MASA

COMPUTER SOFTWARE IN GENERAL PRACTICE

SIR,-Your July 22 editorial on databases did not mention care. Here, too, there is a remarkable epidemiological opportunity, if suitable software is provided to manage the drug

primary

budget in the practice and at the family practitioner committee. The white-paper and accompanying working paper suggest a choice between PACT (prescription analysis and costing), derived from data held by the Prescription Pricing Authority, and special software and PACT as a temporary expedient, software being provided later. It seems that the choice has fallen on PACT: the Government is not asking for software to be written. PACT tells us how many prescriptions were dispensed and how much they cost. It does not relate to individual patient morbidity. It is a blunt instrument to control the drug bill. The doctor, unless he has voluminous records

or a

computer with effective software,

adequately a charge of overprescribing-but if he can relate prescribing, day after day, to patient and to morbidity his choice of drug can be defended as a clinical judgment. With information on morbidity and prescriptions, as well as cost, data can be analysed in several ways-by patient according to prescription over time, by prescriptions related to episode of illness, by drug or therapeutic group related to morbidity, and all these by cost-a far better way of controlling cost and improving quality. The doctor would learn from his evaluated experience and we would begin to understand the thinking behind his prescribing and choice of drugs. We would be on the way to assessing the comparative efficacy of drugs by learning about treatment outcome. In other areas software can expand epidemiological opportunity--outpatient referrals, laboratory investigation, audit of hospital care as seen in the practice, and post-marketing cannot meet

surveillance. It is not too late to introduce the modest changes that would make possible all these studies. The software envisaged in the white-paper for drug budget and practice budget should be written as a matter of policy. Morbidity should be an essential element of data collection under that software so that the triad, morbidity/item/cost (where "item" is drug, prescription, investigation, outpatient referral, or

operation), becomes the essential quota of information on a patient’s computer record. In this way the epidemiological opportunity to transform the NHS will not be lost. Update Computers Ltd, 19-30 Alfred Place,

ABRAHAM MARCUS

London WC1E 7EA

TIME LIMIT FOR ANTI-SNAKE VENOM

ADMINISTRATION

SiR,—The accepted treatment for snake-bite poisoning is prompt administration of anti-snake venom. But how long after envenomation is antivenom therapy still effective? Antivenom is said to be useful if given within 4 h, of less value if delayed for 8 h, and of doubtful value after 24 h.l Therefore, should antivenom therapy be withheld if a patient with snake bite seeks medical advice after a delay of more than 24 h? We report a patient with a severely bleeding snake bite, admitted 8 days after the bite. A 19-year-old man was admitted with a history of snake bite 8 days previously. He had bleeding from multiple sites (ecchymosis, melaena, and frank haematuria). The patient was apprehensive and restless with pronounced pallor, swelling around the site of bite on the left foot, and multiple ecchymotic patches all over his body. His pulse was 120/min and feeble. Blood pressure was 120/80 mm Hg.

tachycardia and functional haemic murmur all over the precordium. There was diffuse tenderness all over the abdomen, but no mass was palpable. Chest and neurological examinations He had

were

normal. The fundus did not show any evidence of

haemorrhage. Haemoglobin was 5-8 g/dl, total and differential leucocyte counts were normal, and platelets numbered 168 000 cells/J..ll. Erythrocyte sedimentation rate was 150 mm/h. Bleeding time was 4-5 min and clotting time was more than 30 min. Prothrombin time was 23 s. Urine showed macroscopic and microscopic haematuria. Renal indices including blood urea and creatinine were normal. At this stage, 40 ml of polyvalent antivenom diluted in 500 ml of isotonic saline was given by intravenous infusion over 4 h, after which bleeding stopped completely, the urine became clear, clotting time 6 h after admission was normal (8 min), and prothrombin time was 15/10 s. The coagulation profile after 3 days continued to be normal. Even though our patient presented after a delay of 8 days and had haemorrhagic manifestations, his response to antivenom administration was striking. The prolonged bleeding could be attributed to persistence of the venom in the blood. Reid et al2 gave antivenom up to 72 h after Malayan viper bites and found it to be effective. A report from the Jammu region of India showed 1 patient in a series of 232 consecutive snake-bite cases had prolonged bleeding for up to 18 days. The anti-snake venom was started on the 4th day and continued till the cessation of bleeding.3 Antivenom therapy has proved effective in patients still defibrinated weeks after bites by Viperidae.4 These observations indicate that antivenom

therapy has a useful role even after 24 h of snake-bite poisoning. S. DWIVEDI

Department of Medicine, SHUBHA SHESHADRI Kasturba Medical College, C. D’SOUZA India 576119, Manipal 1. Russell FE, Carison RW, Wainschel J, Osbome AH. Snake venom poisoning in the United States. JAMA 1975; 233: 341-44. HA, Chan KE, Thean PC. Prolonged coagulation defect (defibrination syndrome) in Malayan viper bite. Lancet 1963; i: 621-26. 3. Virmani SK, Dutt OP. A profile of a snake bite poisoning in Jammu region. J Indian Med Ass 1987; 85: 132-35. 4. Warrel DA. In: Weatherall DJ, Ledingham JGG, Warrel DA, eds. Oxford text book of medicine, vol 1. 2nd ed. Oxford: Oxford University Press, 1987: 6.75. 2. Reid

INSULIN AUTOANTIBODIES—WHICH METHOD?

SIR,-Dr Betterle and colleagues (July 22, p 223) present four patients in whom insulin autoantibodies (IAA) were retrospectively demonstrated before the onset of insulin dependent diabetes mellitus (IDDM). As organisers of the next International IAA Standardisation Workshop we believe that their conclusion that IAA are markers of potential diabetes (as are islet cell antibodies, ICA) is misleading. An earlier IAA Workshopl has demonstrated that the two IAA detection methods generally used-fluid-phase radiobinding and solid-phase enzyme-linked assay-measure distinct and only partly overlapping populations of IAA. This means that there is no defined IAA entity. Which of the various IAA-assays detects an antibody population most predictive of potential IDDM is the topic of the present IAA-Workshop. Betterle and co-workers used an enzyme-linked immunosorbent assay (ELISA) to measure IAA. Previous experience for a large number of subjects raises serious questions about the predictive value of the positive IAA signal as a marker of potential IDDM:2 IgG-IAA was found in 6 (29%) of 21 ICA-positive first-degree relatives of patients with IDDM and in 25 (22%) of 114 ICA-negative relatives (IgM-IAA 10% and 9%, respectively). Among non-diabetic relatives of IDDM patients IDDM develops mainly in those who are ICA positive; and the risk in ICA-negative relatives is very low.3 Thus, the similarly high percentage of (ELISA-negative) IAA in ICA-positive and ICA-negative relatives suggests a lack of specificity of their IAA results for predicting subsequent IDDM. In our IAA-ELISA assay (B. K. and H. K.) the prevalence of IgG-IAA among 1266 first-degree relatives is 94%. After a mean observation period of 2-4 years, 8 IAA-positive individuals had IDDM (6 of them were ICA positive). Thus, we confirm the occasional presence of IAA in the absence of ICA in prediabetics. Additionally, like Dr Betterle et al, we did not find a significant association of IgG-IAA and ICA."