Thinking the Unthinkable: What Should Commercial Banks or ...
THINKING THE UNTHINKABLE AT EASINGWOLD
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38 We suggest that intravascular sickling in the lungs may account for much of the clinical picture in acute chest syndrome in sickle-cell disease. This view is based on the significant falls in haemoglobin and platelets in the more severe cases, together with the rapid responses to exchange transfusion. A more detailed prospective study including ventilation-perfusion lung scanning and detailed assessment of pulmonary gas exchange is needed to clarify the pathogenesis and to allow a more objective assessment of the response to treatment. Correspondence should be addressed to 1- F. R. REFERENCES 1 Charache S, Scott JC, Charache P. ’Acute chest syndrome’ in adults with sickle cell anaemia Arch Intern Med 1979; 139: 67-69. 2. Young RC Jr, Castro O, Baxter RP, Dunn R, Armstrong EM, Cook FJ, Sampson CC The lung in sickle disease: a clinical overview of common vascular, infectious and other problems. J Natl Med Ass 1981; 73: 19-26 3. Van de Pette JEW, Pearson TC, Slater NGP. Exchange transfusion in life threatening sickling crises. J R Soc Med 1982; 75: 777-80. 4. Petch MC, Serjeant GR Clinical features of pulmonary lesions in sickle cell anaemia. Br Med J 1970; iii: 31. 5. Barrett-Connor E. Acute pulmonary disease in sickle cell anaemia. Am Rev Resp Dis 1971; 104: 159-65. 6. Moser KM, Shea JG. The relationship between pulmonary infarction, cor pulmonale, and the sickle cell state. Am J Med 1957, 22: 561-79. 7. Oppenheimer EH, Esterly JR. Pulmonary changes in sickle cell disease Am Rev Resp Dis 1971; 103: 858-59. Civil Defence THINKING THE UNTHINKABLE AT EASINGWOLD I WILL not be giving away any vital military secrets if I reveal that Easingwold is the site of a Home Office establish- ment largely concerned with preparations for civil defence. Its main function is to run courses of instruction for people from various professions, to prepare them for the possible consequences of war, including nuclear war. Those attending the medically oriented course are doctors, nurses, administrators, pharmacists, blood-bank directors, officials of the Red Cross and St John Ambulance, &c. As a director (designate) of a section of the health service, I agreed with some reluctance to attend a course, it was after all in July, when the Vale of York can look very beautiful, and the name of Easingwold, which seemed to come straight from a novel by Trollope, had a rustic attraction. I must confess I went prepared to scoff but found, as I stayed, quite a lot to applaud. For one thing, the planning of the course and the quality of the instruction were on the whole excellent. Many university lecturers could have learned a lot from the highly professional standards shown in the set lectures, all of which had good illustrations, efficiently projected, and a light but not excessive flavouring of humour. The main part of the course was a well-planned exercise appropriately named Heurisko-we were to teach ourselves-for which we had to split into syndicates of eight or nine persons, each syndicate having to administer the medical services of "Naptonshire" immediately before and during a war. Our circumstances were explained and events were related by bulletins on a television screen, sometimes with films showing military hardware and manoeuvres, and accompanied by questionnaires asking what action we should take. The facts that there was often little time to make critical decisions and that each syndicate was composed of people quite unknown to each other and, therefore, unable to give weight to the arguments and opinions of the others, were perhaps a legitimate reflection of probable reality. As it was, arguments became lively and heated and could easily, one felt, have degenerated to bitter animosity and even violence but for the presence of the instructors and some natural moderators. The musical accompaniment of the bulletins also helped to generate tension. The New World Symphony, for example, whether or not it is politically apposite, sets the pulses racing and, when we approached the climax, Holst’s Mars as background to rocket launching gave one a hollow and sickening sensation of the enormity of it all. Later on, the bulletin that announced 70 000 deaths in one area as a result of fall-out was accompanied by the wailing cry of a peacock in the garden outside; it seemed like the departing souls. Our group survived, having wisely moved our headquarters from an area which proved to be almost the epicentre of an airburst, but long before the end of the short war we had run out of all medical supplies, including analgesics and antiseptics, and as for herbal remedies-I thought with affection of the opium poppies that are common weeds in my garden-they would be difficult to collect and apply. But was it all worth it? Would we have done better to stay at our jobs signing certificates, treating ingrowing toe-nails, gallstones, the menopause, or anxiety states? Despite a thorough perusal of the British Medical Association’s excellent book, The Medical Effects of Nuclear War, I I am still uncertain. One could ask, first of all, whether preparing for the consequences of a disaster makes that disaster more likely to occur. In this case, surely the credibility of nuclear weapons as a deterrent must be enforced by preparations for defence? The knowledge that some of us are determined to do what we can to stay alive must make an enemy believe more strongly that our fellow countrymen have an equal determination to counter-attack. Thus the very act of holding courses in civil defence, however inappropriate their content might appear to be, reinforces the attitude of non-submission that constitutes the real deterrence to an aggressor. I was reminded of a debate held at my school in 1939 on the motion "this house approves of ARP" (air raid precautions). I cannot remember whether the motion was lost or won but in retrospect it seems pretty silly to have disapproved; while that attitude was foolish but not particularly harmful, the debate at the Oxford Union on "this house declines to fight for King and country" was certainly one of the factors that precipitated the last war. But, one must ask, are there any circumstances for which planning is actually relevant? The authors of the BMA book think there are none; "it became clear that the probable scale and pattern of attack cannot be gauged with any precision. This being the case, the corollary must be that no effective planning against the consequences is possible." That is, in the first place, a non sequitur and in the second place it underestimates, as does also the parallel document from the Royal College of Nursing, the importance of submaximum attacks (for criticism of this attitude, see reference 2). The authors of the BMA book specifically rejected the single-shot- across-the-bows type of attack and did not consider the single weapon launched accidentally or by a group of fanatics, nor the chance of a nuclear attack on military targets only. Furthermore, even with an attack of the order of 500 megatons there would be, depending on all sorts of assumptions, anything between 10 and 45 million survivors, and the individual doctor probably has about a 50/50 chance
Transcript of THINKING THE UNTHINKABLE AT EASINGWOLD
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We suggest that intravascular sickling in the lungs mayaccount for much of the clinical picture in acute chest
syndrome in sickle-cell disease. This view is based on thesignificant falls in haemoglobin and platelets in the moresevere cases, together with the rapid responses to exchangetransfusion. A more detailed prospective study includingventilation-perfusion lung scanning and detailed assessmentof pulmonary gas exchange is needed to clarify the
pathogenesis and to allow a more objective assessment of theresponse to treatment.
Correspondence should be addressed to 1- F. R.
REFERENCES
1 Charache S, Scott JC, Charache P. ’Acute chest syndrome’ in adults with sickle cellanaemia Arch Intern Med 1979; 139: 67-69.
2. Young RC Jr, Castro O, Baxter RP, Dunn R, Armstrong EM, Cook FJ, Sampson CCThe lung in sickle disease: a clinical overview of common vascular, infectious andother problems. J Natl Med Ass 1981; 73: 19-26
3. Van de Pette JEW, Pearson TC, Slater NGP. Exchange transfusion in life threateningsickling crises. J R Soc Med 1982; 75: 777-80.
4. Petch MC, Serjeant GR Clinical features of pulmonary lesions in sickle cell anaemia.Br Med J 1970; iii: 31.
5. Barrett-Connor E. Acute pulmonary disease in sickle cell anaemia. Am Rev Resp Dis1971; 104: 159-65.
6. Moser KM, Shea JG. The relationship between pulmonary infarction, cor pulmonale,and the sickle cell state. Am J Med 1957, 22: 561-79.
7. Oppenheimer EH, Esterly JR. Pulmonary changes in sickle cell disease Am Rev RespDis 1971; 103: 858-59.
Civil Defence
THINKING THE UNTHINKABLE ATEASINGWOLD
I WILL not be giving away any vital military secrets if Ireveal that Easingwold is the site of a Home Office establish-ment largely concerned with preparations for civil defence.Its main function is to run courses of instruction for peoplefrom various professions, to prepare them for the possibleconsequences of war, including nuclear war. Those attendingthe medically oriented course are doctors, nurses,
administrators, pharmacists, blood-bank directors, officialsof the Red Cross and St John Ambulance, &c. As a director
(designate) of a section of the health service, I agreed withsome reluctance to attend a course, it was after all in July,when the Vale of York can look very beautiful, and the nameof Easingwold, which seemed to come straight from a novelby Trollope, had a rustic attraction.
I must confess I went prepared to scoff but found, as I
stayed, quite a lot to applaud. For one thing, the planning ofthe course and the quality of the instruction were on thewhole excellent. Many university lecturers could havelearned a lot from the highly professional standards shown inthe set lectures, all of which had good illustrations, efficientlyprojected, and a light but not excessive flavouring of humour.The main part of the course was a well-planned exercise
appropriately named Heurisko-we were to teachourselves-for which we had to split into syndicates of eightor nine persons, each syndicate having to administer themedical services of "Naptonshire" immediately before andduring a war. Our circumstances were explained and eventswere related by bulletins on a television screen, sometimeswith films showing military hardware and manoeuvres, andaccompanied by questionnaires asking what action we shouldtake. The facts that there was often little time to make criticaldecisions and that each syndicate was composed of peoplequite unknown to each other and, therefore, unable to giveweight to the arguments and opinions of the others, wereperhaps a legitimate reflection of probable reality. As it was,arguments became lively and heated and could easily, onefelt, have degenerated to bitter animosity and even violencebut for the presence of the instructors and some naturalmoderators. The musical accompaniment of the bulletinsalso helped to generate tension. The New World Symphony,for example, whether or not it is politically apposite, sets thepulses racing and, when we approached the climax, Holst’sMars as background to rocket launching gave one a hollowand sickening sensation of the enormity of it all. Later on, thebulletin that announced 70 000 deaths in one area as a result
of fall-out was accompanied by the wailing cry of a peacock inthe garden outside; it seemed like the departing souls.Our group survived, having wisely moved our
headquarters from an area which proved to be almost theepicentre of an airburst, but long before the end of the shortwar we had run out of all medical supplies, includinganalgesics and antiseptics, and as for herbal remedies-Ithought with affection of the opium poppies that are commonweeds in my garden-they would be difficult to collect andapply.But was it all worth it? Would we have done better to stay at
our jobs signing certificates, treating ingrowing toe-nails,gallstones, the menopause, or anxiety states? Despite a
thorough perusal of the British Medical Association’sexcellent book, The Medical Effects of Nuclear War, I I am stilluncertain. One could ask, first of all, whether preparing forthe consequences of a disaster makes that disaster more likelyto occur. In this case, surely the credibility of nuclearweapons as a deterrent must be enforced by preparations fordefence? The knowledge that some of us are determined to dowhat we can to stay alive must make an enemy believe more
strongly that our fellow countrymen have an equaldetermination to counter-attack. Thus the very act of holdingcourses in civil defence, however inappropriate their contentmight appear to be, reinforces the attitude of non-submissionthat constitutes the real deterrence to an aggressor. I wasreminded of a debate held at my school in 1939 on the motion"this house approves of ARP" (air raid precautions). I cannotremember whether the motion was lost or won but in
retrospect it seems pretty silly to have disapproved; while thatattitude was foolish but not particularly harmful, the debateat the Oxford Union on "this house declines to fight for Kingand country" was certainly one of the factors that precipitatedthe last war.
But, one must ask, are there any circumstances for whichplanning is actually relevant? The authors of the BMA bookthink there are none; "it became clear that the probable scaleand pattern of attack cannot be gauged with any precision.This being the case, the corollary must be that no effectiveplanning against the consequences is possible." That is, inthe first place, a non sequitur and in the second place it
underestimates, as does also the parallel document from theRoyal College of Nursing, the importance of submaximumattacks (for criticism of this attitude, see reference 2). Theauthors of the BMA book specifically rejected the single-shot-across-the-bows type of attack and did not consider the singleweapon launched accidentally or by a group of fanatics, northe chance of a nuclear attack on military targets only.Furthermore, even with an attack of the order of 500
megatons there would be, depending on all sorts ofassumptions, anything between 10 and 45 million survivors,and the individual doctor probably has about a 50/50 chance
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of surviving the onslaught. Most of the survivors wouldprobably die of starvation, disease, and civil strife in theensuing few months and, in those circumstances, givensupplies of analgesics and antiseptics, many of us, if
psychologically prepared for such an event, could perhapsrelieve more pain and suffering in a few short weeks than ispossible in many years of an ordinary career. But, of course,there would soon be no supplies, since much would have beendestroyed and reserves would not have been stockpiled.That brings us to a critical decision over the use of
resources. Let us assume it is reasonable to plan healthservices to meet the demands of a conventional war or of alimited nuclear attack; let us increase the knowledge of self-protection and first aid which are useful for all sorts ofsubmaximum disasters. Such planning is not expensive, butare we prepared to spend money in building up a stockpile ofanalgesics, antiseptics, and perhaps antibiotics? It would costabout ;C50 million to store say 100 mg of morphine for everyman, woman, and child and it should not be impossible todevise safe methods of storage, usage, and replacement.(Perhaps some of the illegal heroin recovered by the policecould be diverted to store.) £ 50 million would be an
unpleasant dent in the health service budget but if theintention is to deter by showing a determination not to yieldto threats, it could be a cheap price compared with thethousands of millions which the next round of submarinesand their missiles would cost. It is not, of course, an
alternative to the deterrence of nuclear weapons, whoever
possesses them, but because it combines a legitimate medicalobjective with a possible effect in actually preventing a futurewar it should be attractive to all in the health service, indeedto all of peaceful intent, multilateralists and unilateralistsalike.
Royal Marsden Hospital,Fulham Road,London SW3 6JJ H. E. M. KAY
REFERENCES
1. The medical effects of nuclear war. Report of the British Medical Association’s Boardof Science & Education. London: BMA, 1983.
2. Editorial. Double-talk on civil defence. Nature 1983; 305: 459.3. Nuclear war, civil defence planning-the implications for nursing. Report by the Royal
College of Nursing. London: RCN, 1983.
Round the World
Ethiopia MEASLES EPIDEMIC
In 1981 a severe epidemic of measles occurred in south-westEthiopia. 20% of the 220 000 people living in the Gardulla districtare children aged under five. The fact that this epidemic affectedteenagers and adults too probably reflects the lack of measlesimmunity in this community. The epidemic started in the Konsosubdistrict, which has a population of 100000-110000. Thevillages are densely populated and there is little contact betweenvillages except on market days. Cases of severe measles were firstseen at the church-run clinic in Konso in August and September,1981. The Ministry of Health started a vaccination campaign inNovember, 1981, around the epidemic centre. This continued toJanuary, 1982, and over 3500 children were vaccinated.
Officially 750 deaths were reported. But since the mortality ratewas estimated to be about 20%, at least 4000 are likely to have died inthe Gardulla area. A survey by the Ethiopian Red Cross Societyreported that families of the Konso tribe lost 2-4 children each. Inone village of nine families with 42 children, 30 children died. All 12children in another family died from severe measles or its
complications.Gidole which is 65 km from Konso has a small church-run
hospital. The population of 10 000 live in small villages on themountain slopes. The villages are less densely populated than thosein Konso. Some are very isolated and probably have not had ameasles epidemic for many years.Recognising that the Konso epidemic was likely to spread, the
staff at the Gidole hospital did a serological survey of children agednine months to three years. 70% had no immunity against measles.At the time of the survey children with severe measles started to beadmitted to Gidole hospital and a vaccination programme wasstarted in January, 1982, in the villages not affected by the disease.874 children were vaccinated. The epidemic reached its peak inMarch to April, 1982. At times 40-45% of the hospital inpatientswere children with severe measles and/or its complications (tables iand i!). At the height of the epidemic attendance at the Konso clinicfell, probably because parents were unwilling to have their childrenvaccinated. All injections were regarded as harmful. Other localbeliefs prejudiced preventive measures and treatment. Measlespatients were not allowed to drink water or to eat meat.The severity of this epidemic and the failure to contain it are
attributable to several factors apart from these cultural practices.
TABLE I-MEASLES MORBIDITY AND MORTALITY IN - PATIENTS
BY AGE-GROUP
*57/901 (6 33%) dIed, t34/341 (10%) died.
TABLE II-COMPLICATIONS OF MEASLES SEEN IN GIDOLE HOSPITAL
Natural measles immunity was low. Living conditions and
sanitation were poor and food and drinking-water were in shortsupply. Vaccination, surveillance, and other preventive measureswere not started as quickly as they might have been. Duringtransport of the vaccine from Addis Ababa the cold chain wasbroken and some vaccine became ineffective.
In Konso a third of measles patients attending the clinic were aged5-14, whereas in Gidole most (80%) were less than 5 years old.During the epidemic nurses reported an increase in stillbirths andspontaneous abortions and two cases of hydrocephalus.80-85% of the children who still require vaccination do not have
access to health care. There are not sufficient trained staff for aneffective vaccination campaign to be mounted.
Lmnankoskenkatu 23 A2,Helsinki 25,Finland LEENA KAARTINEN
