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Press releases Saturday 3 May 2008

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(1) Drug resistant tuberculosis on the increase in the UK
(2) Does it matter that medical graduates don’t get jobs as doctors?
(3) Legalising the production of opium for medical use is neither viable or necessary

(1) Drug resistant tuberculosis on the increase in the UK
(Increasing antituberculosis drug resistance in the UK: analysis of national surveillance data)
www.bmj.com/cgi/content/short/bmj.39546.573067.25v1
(Editorial: Increasing drug resistant tuberculosis in the UK)
www.bmj.com/cgi/content/short/bmj.39560.630613.80

A changing population structure and ongoing migration have increased cases of drug resistant tuberculosis, according to a study published on bmj.com today.

The incidence of tuberculosis in England, Wales and Northern Ireland has been on the increase with more than 8000 cases reported in 2006. In addition, resistance to antituberculosis drugs has been increasing globally.

Of mounting concern is the increasing transmission of drug resistant tuberculosis among difficult to treat, marginalised groups in urban areas such as London, and the problems this could create for tuberculosis control.

Dr Michelle Kruijshaar and colleagues present the latest trends in resistance to antituberculosis drugs between 1998 and 2005 using data from the National Surveillance System, involving 28 620 confirmed cases of tuberculosis.

Overall, the researchers found that the proportion of cases resistant to any first line drug had increased from 5.6% to 7.9%. They report an increasing proportion of isoniazid resistance (6.9%) and small increases in rifampicin resistance (1.2%) and multidrug resistance (0.9%).

Importantly, outside London there was a significant increase in resistance to isoniazid. The authors suggest this reflects the increasing number of patients with tuberculosis who are not born in the UK. Analyses showed an increase in the number of cases in people from Sub-Saharan Africa and the Indian subcontinent that could be related.

In London, the rise in isoniazid resistance has been linked to an ongoing outbreak from 1999 that has involved over 300 cases to date. This outbreak has been associated with imprisonment and drug misuse and includes mainly the UK born population. The authors reinforce the importance of recognising symptoms early in this group.

They also note that the proportion of multidrug resistance showed a small increase (from 0.8% to 0.9%) - with the levels seen in the UK similar to those in other Western European countries - and suggest that most multidrug resistance cases occur due to problems with patient management rather than as a result of transmission within the UK.

These findings highlight the importance of early case detection by clinicians, rapid testing of susceptibility to drugs, additional support services to ensure that patients complete treatment, as well as continuous surveillance, and more help with tuberculosis control in countries with high incidence, conclude the authors.

The rising incidence of tuberculosis in the UK, combined with the rising proportion of resistant cases, increases the potential for onward transmission, warn the authors of an accompanying editorial.

James Lewis and Violet Chihota call for a range of strategies to be implemented including strengthening tuberculosis control and improving research into new diagnostics and drugs for multidrug resistant strains.

"Drug resistant tuberculosis in the UK cannot be controlled solely with local strategies - a global perspective is needed", they conclude.

Contacts:
Health Protection Agency, Centre for Infections, Press Office, London, UK
Telephone: +44 (0)20 8327 6647/ 7098/ 7097
Editorial: James Lewis, London School of Hygiene and Tropical Medicine, London, UK
Email: james.lewis@lshtm.ac.uk

(2) Does it matter that medical graduates don’t get jobs as doctors?
(Head to head: Does it matter that medical graduates don’t get jobs as doctors?)
Yes:
www.bmj.com/cgi/content/short/336/7651/990
No:
www.bmj.com/cgi/content/short/336/7651/990

In 2007, 1300 UK medical graduates were unable to secure training places, and this shortfall looks set to be repeated this year. But is this a betrayal of students' expectations or is this inevitable if patients are to get the best care?

Two experts debate the issue in this week's BMJ.

Thousands of young people compete fiercely for medical school places each year because they want to work as doctors, not to gain an expensive general education, argues Graham Winyard a former postgraduate dean.

There are serious risks to medical education if medical school simply becomes a route to a range of future employment, he warns.

However, evidence is growing that several thousand UK medical graduates may not be able to pursue a career in medicine. This is due to a "catastrophic failure in government policy on medical migration" that has resulted in a huge surplus of applicants for specialist training, writes Winyard.

Attempts by the Department to Health to give priority to local medical graduates were thwarted by the Home Office's highly skilled migrants programme that gave skilled people the right to enter the UK job market, he says. Although the entry rules have now been amended, an estimated 10 000-20 000 overseas graduates have already been accepted on to the programme to compete with local graduates.

"Much has been made by the British Medical Association and others of the importance of abiding by the undertakings made to overseas doctors. It is surely just as important that we keep faith with our own medical students and graduates, whose recruitment and training has been on the explicit understanding that they are needed to work as doctors", he concludes.

But Alan Maynard, from the University of York, argues that the purpose of the National Health Service (NHS) is to deliver patient care that is compassionate and efficient and not to guarantee the employment of medical graduates.

Medical graduates, like all graduates should only be given jobs if they have the suitable knowledge and personal skills appropriate to their employers' and customers' needs, and within the finite resource constraints of the NHS, he states.

He points out that the inefficiency of health care delivery worldwide means that the market for medical graduates is uncertain. Recent changes in skill mix have added to this uncertainty, he says. For example, the emergence of nurse prescribers, nurse practitioners, and the training of nurses to carry out minor surgery, coupled with tighter NHS resource constraints, have the potential to reduce employment opportunities for medical graduates.

In addition, the recent success of negotiations for increasing pay and making medical graduates more expensive to employ, means that employers will gradually look for economy and changed skill mix, Maynard writes.

He concludes that the government's failure to plan the medical workforce efficiently should not include a responsibility or need to guarantee medical graduates employment.

Contacts:
Graham Winyard, Winchester, Hampshire, UK
Email: gwinyard@doctors.org.uk
Alan Maynard, Department of Health Services, University of York, York, UK
Email: akm3@york.ac.uk

(3) Legalising the production of opium for medical use is neither viable or necessary
(Editorial: Opium production in Afghanistan)
www.bmj.com/cgi/content/short/336/7651/972

Proposals to legalise the production of opium in Afghanistan for medical use are unworkable and unnecessary, says the Minister of State for Africa, Asia, and the United Nations in an editorial in this week's BMJ.

Writing in response to an article* in the BMJ that called for legal cultivation of poppies to combat the shortage of opiate medicines, Mark Malloch-Brown argues that a sustainable solution to the problem of illegal opium production requires attractive, economically viable legal livelihoods, security and good governance in Afghanistan, as well as a determined effort to reduce demand around the world.

Around 90% of the world's opium comes from Afghanistan, most of it intended for the illegal market. Opium offers farmers a quick turnover and high returns, but production continues to drive instability and insurgency.

The Afghanistan government lacks the resources, institutional capacity, and control mechanisms to ensure that opium grown would be purchased legally, he says. In addition, those cultivating opium for legal medical usage would be in direct competition with illegal traffickers, which in turn could drive up the price of opium and encourage increased cultivation.

He suggests that the demand for legal opium is better met by established sources of production from countries like Turkey and Australia, where there are fewer problems with security and stability and where production costs are up to six times cheaper.

He also points out that a greater supply of medical opiates is not needed because the global demand for medical and scientific purposes is already fully met.

According to Malloch-Brown, the essential challenge is to create development initiatives and economic incentives that provide attractive legal alternatives for farmers. This can be done by improving the infrastructure and local government capacity, giving farmers improved access to markets, land, water, credit, food security, and employment, he argues.

The question of demand is the key, he says. The arguments regarding opium production are global and cannot be controlled with local strategies.

"Only by reducing demand [for heroin] on the streets everywhere will the producers and traffickers on the streets of Afghanistan be given the best reason to follow their alternative livelihoods", he concludes.

Notes to Editors: *Afghan farmers should be licensed to grow poppies for morphine, Senlis Council says. BMJ, Jun 2007; 334: 1343.

Contact:
Steve Bird, Press Office, Foreign and Commonwealth Office, London, UK
Email: steve.bird@fco.gov.uk

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