Press releases Monday 21 June to Friday 25 June 2010

Please remember to credit the BMJas source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Only local doctors should provide out of hours primary care, say experts
(2) No link between early child cancers and living near mobile phone masts
(3) Do spending cuts cost lives?
(4) Polarised arguments about breast screening are not helping women, warns expert
(5) Rape in war “a deliberate military strategy” argue researchers

(1) Only local doctors should provide out of hours primary care, say experts
(Analysis: Safer out of hours primary care)
http://www.bmj.com/cgi/content/extract/340/jun22_1/c3194

Only doctors familiar with local health services should provide out of hours primary care, argue two experts, following the death of a patient given an overdose of diamorphine by an out of hours doctor.

This is just one of several wide ranging changes needed to ensure the quality and safety of out of hours care, say Dr Paul Cosford and Dr Justyn Thomas from NHS East of England in a paper published on bmj.com today.

David Gray died after he was wrongly injected with 100 mg diamorphine by Daniel Ubani, a doctor based in Germany and providing out of hours primary care in Cambridgeshire. Dr Ubani had never worked in the United Kingdom, did not practise primary care in Germany, and was not familiar with local health care or with diamorphine. Yet he could fly in on Friday evening and work unsupervised on Saturday without routine access to patient notes.

Dr Ubani made a critical and fatal error, say the authors, but they believe that solely to blame him is to miss several key facts and that a wider examination of the system that allowed him to practise in these circumstances is needed.

They point out that many areas do have high quality out of hours care, but point to other contributing factors in this case and recommend areas for change.

These include a review of laws governing registration of doctors from the European Economic Area. “This is not to prevent the free movement of well qualified doctors,” they explain, “but to recognise that healthcare systems differ across the EU, and that doctors’ competence is at least partly specific to the system in which they work.”

Secondly, they strongly advocate changes to the PCT performers list system. Currently a doctor on one list can practice anywhere in England, but this system should require GPs to be on the list of the PCT where they work, with the extra provision that GPs should be able to enter more than one list if they have good reason.

They also argue that arrangements for out of hours primary care should be reviewed locally to ensure that doctors operate within structured teams providing high quality, safe care.

“As a profession, we should not accept a system that allows incidents such as this in any part of the NHS,” they conclude. “Clinical leaders throughout the NHS must advocate and lead the necessary changes."

Contact:
Paul Cosford, Director of Public Health, NHS East of England, Cambridge, UK
Email: paul.cosford@eoe.nhs.uk

(2) No link between early child cancers and living near mobile phone masts
(Research: Mobile phone base stations and early childhood cancers: case-control study)
http://www.bmj.com/cgi/content/abstract/340/jun22_1/c3077
(Editorial: Childhood cancer and proximity to mobile phone masts)
http://www.bmj.com/cgi/doi/10.1136/bmj.c3015

There is no association between risk of early childhood cancers and a mother’s exposure to a mobile phone base station during pregnancy, concludes a new study published on bmj.com today.

This is the first study to look at phone masts in Britain as a whole and is the largest of its kind.

Use of mobile (cellular) phones has increased markedly in recent years and questions have been raised about possible health effects, including brain and other cancers, especially after prolonged use. Surveys also indicate high levels of public concern about the potential risks of living near mobile phone masts.

Previous reports of apparent cancer clusters near mobile phone base stations are difficult to interpret due to small numbers and possible biases that could have affected the results. Also, any radiobiological explanation for such cancer excesses is lacking.

So researchers at Imperial College London set out to investigate the risk of early childhood cancers, such as brain tumours and leukaemia, and proximity to a mobile phone base station during pregnancy.

They identified 1,397 British children aged 0-4 years registered with leukaemia or a tumour in the brain or central nervous system between 1999 and 2001. Each case was matched to four controls from the national birth register. Data on all mobile phone base station antennas across Britain from 1996-2001 were also obtained.

Birth address was then used to estimate distance (in metres) from the nearest mobile phone base station, total power output for base stations within 700m of birth address and power density for base stations within 1400m of birth address.

The researchers found no association between cancer risk in young children and mobile phone base station exposures during pregnancy.

The authors acknowledge that their focus was early childhood cancers and therefore did not include longer term or other potential health effects that have been associated with mobile phone use. However, they conclude: “The results of our study should help to place any future reports of cancer clusters near mobile phone base stations in a wider public health context.”

In an accompanying editorial, John Bithell from the Childhood Cancer Research Group at the University of Oxford, says that clinicians should reassure patients not to worry about proximity to mobile phone masts. “Moving away from a mast, with all its stresses and costs, cannot be justified on health grounds in the light of current evidence,” he writes.

Contacts:
Research: Paul Elliott, Professor of Epidemiology and Public Health Medicine, Imperial College, London, UK
Email: l.gallagher@imperial.ac.uk
Editorial: John Bithell, Honorary Research Fellow, Childhood Cancer Research Group, University of Oxford, UK
Email: john.bithell@spc.ox.ac.uk

(3) Do spending cuts cost lives?
(Analysis: Budget crises, health, and social welfare programmes)
http://www.bmj.com/cgi/content/extract/340/jun24_1/c3311

Radical cuts to social welfare spending to reduce budget deficits could cause not just economic pain but cost lives, warn experts in a study published on bmj.com today.

While there is a major debate under way about the potential economic impacts of radical budget cuts in Europe, David Stuckler from the University of Oxford and his colleagues dissect the effect of public spending on people’s health.

Their analysis shows that levels of social spending in Europe are “strongly associated” with risks of death, especially from diseases relating to social circumstances, such as heart attacks and alcohol-induced illness. As such, they argue that, although governments may feel they are protecting health by safeguarding healthcare budgets, social welfare spending is as important, if not moreso, for population health.

The team evaluated data on social welfare spending collected by the Organisation for Economic Cooperation and Development (OECD) from 15 European countries in the years 1980 to 2005. This includes programmes to provide support to families and children, help the unemployed obtain jobs, and support for people with disabilities, all of which could plausibly affect health.

They analysed the relationship between trends in these data and social spending. They found that when social spending was high, mortality rates fell, but when they were low, mortality rates rose substantially.

Based on their mathematical models, the researchers estimated that each £70 reduction in social welfare spending per person would increase alcohol-related deaths by about 2.8% and cardiovascular mortality by 1.2%, so that even modest budget cuts could have a significant impact on public health.

The researchers found spending on social welfare to promote health, and not simply healthcare, had the greatest impact on public health. However, they also found that reducing spending on non-welfare sources, such as military or prisons, had no such negative impact on the public’s health.

“This result indicates that some aspects of population health are sensitive to spending on social support,” say the authors. “Nevertheless, health and social welfare programmes appears to be a key determinant of future population health that should be taken into account in ongoing economic debates.”

They add: “This report reveals that ordinary people may be paying the ultimate price for budget cuts - potentially costing them their lives. If we want to promote a sustainable recovery in Britain, we must first ensure that we have taken care of people’s most basic health needs.”

Contact:
David Stuckler, Researcher, Department of Sociology, University of Oxford, UK
Email: david.stuckler@chch.ox.ac.uk

(4) Polarised arguments about breast screening are not helping women, warns expert
(Analysis: Screening for breast cancer - balancing the debate)
http://www.bmj.com/cgi/content/extract/340/jun24_1/c3106

Polarised arguments about the benefits and harms of breast screening are not helping women to make an informed decision, argues a senior doctor on bmj.com today.

Klim McPherson, Professor of Public Health Epidemiology at the University of Oxford looks at the evidence and calls for dispassionate analysis of all available data.

The burden of breast cancer is unremitting and we must do anything we can to contain it, he says. But screening for a progressive disease is justified only if earlier diagnosis and treatment improve disease progression.

A recent US report on screening for breast cancer estimated that the mortality reductions attributable to breast screening are 15% for women aged 39-49, 14% for those aged 50-59, and 32% for those aged 60-69. Worse still, estimated numbers of women needed to be invited to a US screening programme in order to save one life are high. For the younger group it is nearly 2,000 while in those aged 60-69 it is still nearly 400. In the UK, the figure is 1,610 for women aged 40-55.

A recent analysis from the Nordic Cochrane Centre also claimed that one in three breast cancers detected in screening programmes is overdiagnosed, although others argue that the lives saved by screening greatly outnumber overdiagnosed cases.

So are women more likely to be overdiagnosed than to have their life saved by screening mammography, asks McPherson?

Whatever we believe about the science, there is no doubt that screening for breast cancer has limited benefit and some possibility of harm for an individual women and marginal cost effectiveness for a community, he says. So, has the time come for a serious scientific rethink of the benefits of the NHS screening programme in the context of cost effective care?

Arguments that polarise are unhelpful and render women, many with strong preferences, more helpless, he argues. For too long they have been misled and confused by too much agenda driven analyses of these data. What is required now is a full examination of all the data by dispassionate epidemiologists to get the best estimates in the UK screening setting.

Meanwhile, he believes that the NHS screening programme needs to be really clear about these uncertainties when communicating with women, and organisers of current trials need to be clear about how much of this uncertainty will be addressed, with what precision, and by when. “More importantly, we all need to understand better how a national programme of such importance could exist for so long with so many unanswered questions,” he concludes.

Contact:
Klim McPherson, Visiting Professor of Public Health Epidemiology, University of Oxford, UK
Email: klim.mcpherson@obs-gyn.ox.ac.uk

(5) Rape in war “a deliberate military strategy” argue researchers
(Editorial: Rape as a weapon of war in modern conflicts)
http://www.bmj.com/cgi/content/extract/340/jun24_1/c3270

Since the second world war, the use of rape as a weapon of war has assumed strategic importance, and is now a deliberate military strategy, argue researchers in an editorial published on bmj.com today.

The effects of rape and sexual violence during war also extend beyond individual victims and are economically, physically, psychologically, and culturally devastating for families and communities, say authors Coleen Kivlahan, volunteer forensic physician for HealthRight International, and Nate Ewigman from the University of Florida.

For example, in recent conflicts, rape has been used as a reward for victory in battle, a boost to troop morale, as punishment and humiliation for both men and women, to incite revenge in opposing troops, to eliminate or “cleanse” religious or political groups, and to destabilise entire communities by creating terror.

A study in the Democratic Republic of the Congo found that 16,000 rapes occurred in 2008 alone, and in South Kivu province, health centres estimate that 40 women were raped in the region daily. In the United Kingdom, 50-70% of female asylum applicants were raped, witnessed rape, or have a credible fear of rape.

Geographical, cultural, religious, political, legal, and behavioural conditions affect the likelihood of the systematic use of rape, explain the authors. For instance, geographically remote locations allow perpetrators to rape with impunity, while the likelihood that women will be raped, shamed, and isolated is increased in cultures with strong traditions regarding virginity, marital fidelity, and genital cleanliness.

Religions with strong beliefs about appropriate female clothing and behaviour also increase the risk that women will be falsely accused of adultery and raped as humiliation and punishment, they add.

The effects of rape and sexual torture on survivors are economically, physically, psychologically, and culturally devastating. They also extend to the family and community.

The international community has mounted a considerable response to the use of rape as a weapon of war, but the authors argue that rape during armed conflict is not simply about military personnel, police, or terrorists.

For example, before 2004, rape assailants in the Democratic Republic of the Congo were primarily affiliated with the military; however, after 2004, civilian rapes increased 17-fold while rapes by armed combatants decreased by 77%.

“This pattern suggests a disturbing acceptance of rape among civilians,” they conclude. “Rape is the result of the lack of dedicated societal attention to the safety, respect, and prosperity of women in peace time, as well as in war.”

Contact:
Coleen Kivlahan, Volunteer Forensic Physician, HealthRight International, Phoenix, AZ, USA
Email: ckivlahan@hotmail.com

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