“Do we need more geezers and VIEWS & REVIEWS fewer geeks?” Des Spence, p 510 The Commonwealth games and “Delhi belly”: what India can learn from Los Angeles PERSONAL VIEW Karunesh Tuli

Waiting to be seated in a restaurant in Delhi, Indian officials, too, are planning to issue patrons are likely to see pictures of Ganesha, grade cards to food vendors in the nation’s Lakshmi, and Mohandas Gandhi and a capital. Their concern for the health of plaque with the phrase “Cleanliness is next athletes and spectators at the Commonwealth to godliness.” Ganesha, the elephant headed games is welcome, but their past record deity, is the remover of obstacles but may owe doesn’t inspire confidence. The Municipal his place in the eatery to his fondness for sweets Corporation of Delhi is severely understaffed. and his great belly. Lakshmi, the goddess of A handful of food hygiene officials struggle wealth, sits next to the cash register. Gandhi, to cover tens of thousands of establishments. who perfected hunger as political protest, is Unable to carry out systematic checks or to the odd one in the bunch; hollow cheeked and counsel food handlers about hygiene, they lean framed, he was better known for his fruit resort to raids, during which teams of officials and goat’s milk diet than for worldly cravings. CHRISTOPHEARCHAMBAULT/AFP/GETTY dash into localities where vendors operate It is his experiments with sanitation, rather Delhi officials dash into localities (often without a licence), confiscate food, than his status as the “father of the nation,” where vendors operate, confiscate and leave within minutes. Vendors move out that justify his presence next to the sign and food . . . Vendors move out temporarily, returning after a few hours. This the gods. Oppressed by the stench at a session temporarily, returning after a few cat and mouse game does little to ensure good of the Indian Congress in Calcutta in 1901, hours. This cat and mouse game does food hygiene. he assigned himself the task of cleaning the little to ensure good food hygiene Indian bureaucrats are eager to improve latrine. the country’s image. Glossy full-page Delhi is getting ready to host the an idea first applied in the 1920s by the advertisements in magazines and billboards Commonwealth games in October. Joining US Public Health Service to the sale of milk at airports proclaim that India is “incredible.” the many concerns that attend major sports bottles, introduced the now familiar letter At the same time, Indians—with their events worldwide—security issues, traffic grades that greet customers as they enter rapidly growing economy, achievements in bottlenecks, and hotel room shortages—is restaurants in the county and increasingly in information and space technology, and a rich one that frequent visitors to the city know cities around the world. cultural tradition—resent comments from well: “Delhi belly” (traveller’s diarrhoea). Each Los Angeles letter grade represents outsiders about the filth and disease that The question is not whether they’ll be struck intense effort by health department billboards cannot hide and spurn advice on down during their visit but when. inspectors, who visit each restaurant at least lowly matters such as hygiene. Offended by Los Angeles has a lesson or two for the three times a year, blessing poor performers Katherine Mayo’s critique of India’s health planners of the Delhi games. Twelve years with an additional “bonus visit.” Inspections conditions in her 1927 book Mother India, ago reporters from the US broadcaster CBS take over an hour and include rigorous Gandhi dismissively called it the report of a carried hidden cameras into restaurant examination of bathrooms, kitchens, and “drain inspector.” kitchens around Los Angeles county. Their food storage. Restaurant owners know they The 1982 Asian games brought colour report, “Behind the Kitchen Door,” and cannot bribe their way out of a low grade; television to India. The Commonwealth games subsequent broadcasts over the next few one owner, who has been in the business offer corporation officials an opportunity to years featured cockroaches, rat droppings, for 30 years, told me he does not offer even make a bigger contribution to the wellbeing “chickens sitting on the floor soaking in their water to the inspectors, for they will accept of Delhi residents. Grade cards by themselves own blood,” and “liquid waste pouring out nothing. Current inspections are much more will not deliver food hygiene; they need to of the ceiling.” Alarmed by the reports, the thorough than the cursory checks of the be backed by methods and human resources county government ramped up its response to pre-grade era. The result: customers can of the kind that have worked so well in Los the problem of poor food handling, shutting step into restaurants without worrying about Angeles. down a number of restaurants for violations food safety; and studies over the years have Karunesh Tuli is an independent consultant in public of health codes, including, for a day, one established improvements in restaurant health, South Pasadena, California owned by the mayor of Los Angeles, Richard hygiene and a reduction in hospitalisations [email protected] Riordan. The health department, borrowing related to foodborne illnesses. Cite this as: BMJ 2010;341:c4507

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REVIEW OF THE WEEK The danger of do-gooders The intervention of humanitarian groups may actually exacerbate conflict, Jonathan Kaplan finds

The Swiss humanitarian Jean-Henri Dunant looked in with the competing logos of different organisations— despair upon the carnage of the 1859 battle of Solferino. Médecins Sans Frontières (MSF) had theirs printed on Forty thousand French and Austrian soldiers lay dead; every sticking plaster—like an “aid agency supermarket.” a similar number were left to die from their wounds. This public relations arena required NGOs to gloss over With army medical services lacking, local villagers took certain awkwardnesses: that these “victims” were the per- the casualties to stables and churches. Dunant gathered petrators of genocide, or its supporters; that the camps together volunteers to care for the wounded of both sides were controlled by the Hutu government in exile, which without favour, mobilising a corps of society women to diverted aid, food, and medical care to its power base; give of their time and compassion. Far from a reluctance and that the death toll arose partly from people mur- to be involved, the biggest problem Dunant had was that dered by Hutu militia for insufficient loyalty. Local nurses of “enthusiasts” turning up with inappropriate help: appointed by NGOs to run their health centres were Hutu “most of those who brought their own goodwill to the government staff (most of Rwanda’s health service had task lacked the necessary knowledge and experience, so settled in the camps, from the minister of health down- that their efforts were inadequate and often ineffective.” wards), and Western doctors performing their rounds in War Games: The Story of Aid and War in Modern In his native country he lobbied for the creation of a the tent hospitals found patients disappearing, replaced Times donor supported, professional, international voluntary by family members of the Hutu leadership. Linda Polman organisation that would bring medical care to all victims The 2001 invasion of Afghanistan placed humanitar- Viking, £12.99, pp 218 of war while, “by reducing the number of cripples, a sav- ian intervention under new ethical pressures. “NGOs are ISBN 978-0670918966 ing would be effected in the expenses of a Government such a force multiplier for us,” announced the US sec- Rating: which has to provide pensions for disabled soldiers.” retary of state, Colin Powell, “such an important part of **** Among the celebrities to whom Dunant turned for backing our combat team.” And by May 2003 some of the NGOs was Florence Nightingale, heroine of the recent war in the flooding into Baghdad in the wake of the US invasion of Crimea. To his astonishment her response was negative: Iraq were requesting permission from the occupying coa- voluntary medical intervention removed from govern- lition provisional authority to bear arms in furtherance of ments the obligation and cost of caring for the wounded, their aid missions. The harm suffered to the principle of she objected, allowing them to wage war for longer. humanitarian neutrality became explicit when the Bagh- But in 1863 Dunant’s dream was realised. The Inter- dad headquarters of first the International Red Cross and national Committee of the Red Cross was established in then the UN were demolished by bombs. Western aid Geneva, on principles of neutrality: help whenever, wher- groups withdrew their expatriate staff from Iraq. ever, and to whomever it was needed. In Dunant’s time The scenario wished for by Henri Dunant and warned 90% of war casualties were soldiers, and it was for them of by Florence Nightingale has come to pass. The global that the Geneva Conventions were forged. As the propor- army of humanitarian volunteer groups, all vying for tion of affected civilians rose—around 50% in the sec- publicity, prominence, and funding, is growing expo- ond world war, at least 90% now—the conventions have nentially: a web search for NGOs working in Darfur changed, to extend impartial protection and humanitar- generates some 300 000 referrals. The aid that NGOs dis- ian aid to non-combatants. This remains the ethical goal tribute can allow armed groups to wage war for longer, of all humanitarian non-governmental organisations not just by feeding combatants but in providing money (NGOs): to help those afflicted. But, as Linda Polman illus- and resources to sustain the conflicts. Funds are embez- trates so effectively, they also need to be seen to be help- zled by officials and warlords, militias demand dollars ing, for publicity is the key to gaining donors’ attention. to guard clinics and aid distribution points, a tax may be When in 1994 two million Rwandan Hutus fled into extracted for the “use” of children for vaccination and The global army the Democratic Republic of the Congo after the slaugh- injured people for rehabilitation. of humanitarian ter of around 800 000 Tutsis, the global NGO corps, who Yet the lure of doing good remains. “The humane desire volunteer groups, all (alongside the United Nations and nearly all the world’s to lighten a little the torments of all these poor wretches vying for publicity, governments) had failed to raise much outcry at mass . . . creates a kind of energy which gives one a positive prominence, and murder, now saw their opportunity. A cholera epidemic craving to relieve as many as one can,” observed Dun- funding, is growing among the refugees became “the second genocide”; and ant. And a UK medical school is offering the country’s exponentially: a web at the UN high commissioner for refugees’ daily press first intercalated BSc degree in disaster medicine, to begin search for NGOs briefings NGO spokespeople would step forward with ever in September. It should be hoped that the syllabus will working in Darfur bigger death estimates. “The man with the highest death include such insightful texts as Polman’s War Games. toll,” recorded a watchful journalist, “got on the 9 o’clock Jonathan Kaplan is a war zone surgeon and writer, based in London generates some news.” The refugee camps became a sea of flags, T shirts, [email protected] 300 000 referrals tents, vehicles, water pumps, and latrines all decorated Cite this as: BMJ 2010;341:c4585

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MEDICAL CLASSICS A question of euthanasia Zalma By Thomas Mullett Ellis First published 1895 Richard Hughes BETWEEN the rabbit and her (1900-76) is now brother. There is, The use of biological agents in warfare and terrorism is often mainly remembered THE LINES for example, no evi- regarded as an idea that emerged in the 20th century. The for his novel A High Theodore Dalrymple dence that Owen is anthrax mail attacks of September 2001, directed towards Wind in Jamaica, actually suffering, two Democratic senators and several news media offices in published in 1929, whereas the rabbit the United States, are well remembered by many. Others may recall the British experimentation with anthrax and for having been was screaming after spores on Gruinard Island, off the west coast of Scotland, in the friend of Dylan the cat attacked it. 1942. Few, however, will be acquainted with the 1895 novel Thomas. Kingsley But Lowrie decides in which Thomas Mullett Ellis wrote what is one of the first Amis and Philip that it would be accounts of the use of anthrax as a weapon. Larkin made slight- better for all con- In this tale Zalma, the beautiful, intellectual, and seductive ing reference to him cerned if Owen daughter of an anarchist count, was rejected by her husband in their correspond- were dead: not to be, the Duke of Umbria, and fled to England in great ence, but that is only better for Owen distress. There she married a young Englishman, using her charm and cunning to put in motion what the Glasgow no evidence of any himself but for her Herald of 12 December 1895 described as a “magnificently bad qualities on his sister Charlotte, who murderous project.” part. would then be free to Zalma planned—in her resentment and hatred towards Initially, however, There surely cannot be marry her fiancé. humankind—to destroy all of humanity by sending tubs Hughes wanted many plays in which a There surely can- of anthrax germs to various international centres and by to be a dramatist, 13 year old is portrayed not be many plays in releasing the organisms from strategically placed balloons. and it was as such which a 13 year old As The Standard noted in its somewhat scathing review (15 trying to strangle her February 1896), the novel was also scattered with “excited that he first came is portrayed trying to severely disabled brother Anti-vivisectionist females . . . [and] scenes of horror in to prominence. strangle her severely the dissecting-room of a savant,” all of which served as George Bernard disabled brother. background to Zalma’s “diabolical Shaw called Hughes’s first work, The Despite Lowrie’s opinion that Owen and quite impossible scheme for the Sisters’ Tragedy, which he wrote aged 22 would be better off dead, he fights back extermination of the human race in 1922, the finest one act play ever writ- and makes it clear that he does not want by the sudden dissemination of ten. It was produced at the Royal Court to be strangled. Incapable of speech, anthrax microbes.” Theatre. Hughes went on two years later though, he makes only what the family In that same year H G Wells wrote his short story “The Stolen to write the first play in the world specifi- calls “Owen’s noise.” Bacillus”—relating another cally for radio, called Danger. Lowrie does not take the hint, how- anarchist’s attempt to steal cholera The Sisters’ Tragedy deals with the ever, but rather concludes that her bacilli from a bacteriological question of euthanasia. (Young men method of euthanasia was a foolish laboratory and poison the London write surprisingly often about death, one. She tries another method, this water supply—and thus Zalma perhaps because it is for them of purely time successfully: she sends the blind received significant contemporary abstract interest and of no application Owen out for a walk, straight into the attention. to themselves.) Two sisters, Philippa, pond—which rather implausibly seems The book was reviewed in several newspapers, and aged 28, and Charlotte, 19, devote to abut immediately on to the French the medical and scientific themselves to looking after Owen, their windows—knowing that he will drown community also provided comment on 24 year old brother, who has a form of in it, as he does. the content of Ellis’s novel through the columns of the BMJ subacute sclerosing panencephalitis Owen’s death does not have the lib- (1897;1(1896):1101). The BMJ considered that the book after measles, leaving him deaf, mute, erating effect on family life that Lowrie presented a “bald misrepresentation of biological objects and blind. Charlotte is engaged to marry hoped for. After she has confessed that and methods,” and yet it was sufficiently popular that a but does not want to leave Philippa to she virtually killed Owen, Charlotte’s special, gilt edged edition was published in 1897. look after Owen on her own. fiancé decides that he does not want to On 1 December 1895, the year after Zalma’s initial publication, the Glasgow Herald reported that a gentleman There is a younger sister, too, called marry into a murderous family; instead had appeared in New York who held “Zalma’s tenets, though Lowrie, who is 13. She is at the stage he threatens to go to the police. As he has adopted slightly different methods of promoting of questioning everything, and the play for Lowrie, she begins to hallucinate them.” He had apparently taken to leaving phials of disease begins after a pet rabbit has been sav- Owen, in a psychotic attempt to restore causing agents in street cars, which he “thoughtfully aged by the family cat and left alive the status quo ante. label[led] ‘diphtheria,’ ‘cholera,’ ‘pneumonia’ . . . in order but seriously injured and in terrible The play, incidentally, was written that each victim may choose his own disease.” pain. Charlotte kills the rabbit; and of 11 years before J R Dawson proposed We should recognise, therefore, that “Zalma’s followers” course Lowrie starts to ask questions as measles virus as the cause of subacute came into being in the century when the microbial cause of anthrax and many other diseases had first been recognised. to whether it is sometimes right to kill. sclerosing panencephalitis. She is told that it is. Theodore Dalrymple is a writer and retired James F Stark, doctoral student in history of medicine, Department Lowrie draws the rather obvious but doctor of Philosophy, University of Leeds [email protected] Cite this as: BMJ 2010;341:c4570 not quite accurate analogy between Cite this as: BMJ 2010;341:c4567

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The memory class

FROM THE Sunday night, and the exams were still two weeks away. It memory, however, because an 8 year old with a smart FRONTLINE was Songs of Praise on the television or a Dickens period phone can access millenniums of medical knowledge in drama in 50 nail grating episodes. Bored, we played an instant. Knowledge is losing its premium. And pure aca- Des Spence cards. We had no money; playing for matchsticks being demic ability is often a proxy for the concrete, inflexible pointless, the only option was playing for forfeits. So thinker, a dangerous characteristic in a rapidly changing pouring cooking oil, salt, and curry powder into our five world. And as in all disciplines medicine needs attributes chipped mugs we salivated and sweated in fear of failure. other than total recall, such as problem solving, integrity, We, the academic elite, all had great minds of memory; caring, kindness, coping, and, above all, creativity. Some indeed one of my flatmates could visualise any word and universities are tackling such concerns by using the UK read it backwards in his head. But he wasn’t any good at Clinical Aptitude Test, which seeks to test for aptitude cards. I heard him retching in the toilet throughout the rather than knowledge. The reality, however, is that this night. is becoming yet another exam for the already advantaged The regurgitation of knowledge is the key to power. to be tutored. Knowledge is the stock and trade of the professional Surely it is important and desirable that the profession classes. We might not be able to peel a potato, but we can be diverse and representative. But the lowest social class remember facts, and we sell them for a high premium. remains hugely under-represented and we, the memory Even now during selection for medical school we still class, hugely over-represented. Do we need to rethink our choose the academic “brightest” with a minimum three biased obsession with factual ability? Do we need more As at A level. Today’s profession may look more diverse, geezers and fewer geeks? In defence of traditional exams, but in many ways it is unchanged—we are all memory however, they are at least a measure of hard work, a medi- machines. But testing memory through examination is cal fundamental. There is no perfect medical selection deeply confounded by education, home life, opportunity, process, and it seems that change is forever unlikely. Per- and class. It is little wonder then that the profession has haps we should try something different—a game of cards remained stubbornly middle class, because we are select- with forfeits might be the answer. ing our own, with the exam system geared in our favour. Des Spence is a general practitioner, Glasgow [email protected] Today there seems little need to have an encyclopaedic Cite this as: BMJ 2010;341:c4761

Why many patients shouldn’t be in hospital

STARTING OUT Rules are drummed into us from care, such as waiting for a place friendly wave from the end of the Kinesh Patel the earliest moments we are taught in a care home or even waiting for bed, and the ward round moves on clinical inpatient medicine. We must their house to be cleaned, become to the next patient. Some doctors see patients daily. We must check medically unwell by virtue of being intermittently try to stamp their feet the observations chart. We must there, which in turn means they in protest but soon give up when document findings in the notes. All cannot leave. they realise their impotence when these seem pretty sensible. There is an inexorable pressure to dealing with social services. Paradoxically it is completely reduce the time that people spend Commands such as “Start them acceptable for inpatients not to in hospital. Entire departments are on intravenous antibiotics” are see a doctor at weekends. And woe judged on how effective they are at usually followed swiftly and without betide any patients in hospital discharging patients—and how often question. Orders along the lines of when Christmas or Easter extends they come back. But for a third of the “Get this patient to a nursing home” the weekend to four days, unless week nothing happens. tend to be ignored, because they are of course the team has decided in What keeps people in hospital outside our sphere of influence. advance that the patient is unwell. Is for weeks is rarely medical and Perhaps what is needed is to this negligent? Surely patients who more often social. We have become remove the NHS’s responsibility for are deemed ill enough to need acute adept at managing patients outside looking after people without acute hospital care shouldn’t go for 72 hospital—a prime example is medical problems, but this would hours without seeing a doctor? intravenous antibiotic treatment at reveal the huge hidden demand People who are ill enough to need home—as long as they don’t have for social care in the community, a care in hospital should be seen daily. social care needs. But this is at the demand that may be impossible to But the reality is that many patients price of neglecting our long stayers. meet. in hospital do not need to be there “They’re still waiting for their Kinesh Patel is a junior doctor, London at all. The irony is that people in social package,” chirps the house [email protected] hospital for reasons to do with social officer. Usually that leads to a Cite this as: BMJ 2010;341:c4710

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