31 Rapid Responses published for 22 different articles.

Articles			Rapid Responses
	CLINICAL REVIEW: Prehospital management of severe traumatic brain injury Hammell and Henning (19 May 2009) [Full text]		Mannitol: does it accelerate depletion of intracerebral adenine nucleotide pools? Richard G Fiddian-Green   (30 June 2009) Read every Rapid Response to this article
	EDITOR'S CHOICE: Rules of conscience Godlee (14 May 2009) [Full text]		Ranking of the rules of conscience Tjaard U Hoogenraad   (30 June 2009) Read every Rapid Response to this article
	RESEARCH: Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study McCowan et al. (26 March 2009) [Abstract] [Full text] [PDF]		What are the effects of cigarette smoking ? Leslie O Simpson   (30 June 2009) Read every Rapid Response to this article
	RESEARCH: Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study Laméris et al. (26 June 2009) [Abstract] [Full text] [PDF]		An inefficient and costly way of managing an acute abdomen. Richard G Fiddian-Green   (30 June 2009) Read every Rapid Response to this article
	RESEARCH: Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study Thompson et al. (24 June 2009) [Abstract] [Full text] [PDF]		?cost effectiveness Eon H McLaren   (30 June 2009) Read every Rapid Response to this article
	EDITORIALS: Intravenous fluids in adults undergoing surgery Liu and Finfer (24 June 2009) [Full text]		Overly negative? Dilip J DaCruz   (30 June 2009) Read every Rapid Response to this article
	NEWS: Doctors call for head of World Medical Association to quit as "matter of priority" Kmietowicz (23 June 2009) [Full text]		World Medical Association and BMJ Stephanie A Amiel   (30 June 2009) Read every Rapid Response to this article
	LETTERS: Reactive hypoglycaemia in severe mental illness van Winkel and De Hert (23 June 2009) [Full text]		A difficult struggle between case study and statistical construction Zekria Ibrahimi   (30 June 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Blow your own trumpet Dalrymple (23 June 2009) [Full text]		Trumpets on TV, Radio and Magazines Michael Lorenzo Murray   (30 June 2009) Read every Rapid Response to this article
	RESEARCH: Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study Trichopoulou et al. (23 June 2009) [Abstract] [Full text] [PDF]		Glycaemic Index and the Mediterranean Diet William T Neville   (30 June 2009) Read every Rapid Response to this article
	RESEARCH: Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries Butler et al. (23 June 2009) [Abstract] [Full text] [PDF]		Understanding coughs in primary care Rod A Storring   (30 June 2009) Read every Rapid Response to this article
	FEATURE: Vaccine disputes Coombes (24 June 2009) [Full text]		A plea for a balanced discussion on immunisation Richard T Halvorsen   (30 June 2009) The origins of antivaccine activism Isabella Thomas   (30 June 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Women of substance Moore (19 June 2009) [Full text]		Where have all the men gone? john m orchard   (30 June 2009) Read every Rapid Response to this article
	EDITORIALS: Confidentiality and sharing health information Sheather (15 June 2009) [Full text]		Confidentiality and Sharing Health Information Beatrice Amuge   (30 June 2009) Read every Rapid Response to this article
	NEWS: Sharing of patients’ data should not be based on implied consent, say GPs’ representatives Cole (16 June 2009) [Full text]		No enrichment of the summary care record without explicit patient consent Chris Woods   (30 June 2009) Read every Rapid Response to this article
	LETTERS: Choice and equality in health Ali (15 June 2009) [Full text]		Re: Author's (failure to) reply stephen black   (30 June 2009) Read every Rapid Response to this article
	ANALYSIS: Palivizumab and the importance of cost effectiveness Teale et al. (11 June 2009) [Full text]		Long term outcomes following admission for RSV bronchiolitis in children Joanna C Murray, et al.   (30 June 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Sri Lanka: health as a weapon of war? Suntharalingam (8 June 2009) [Full text]		Health as a bridge for Peace-The Sri Lankan experience Indika M Karunathilake, et al.   (30 June 2009) A response from The Sri Lanka College of Paediatricians to “Sri Lanka: health as a weapon of war ?” H.T Wickramasinghe, et al.   (30 June 2009) Conflict in Sri Lanka Gunatungamudalige L Perera   (30 June 2009) A matter of conscience Ken Menon   (30 June 2009) Biased personal views Vasantha de Silva   (30 June 2009) Sri Lanka will never use health as a weapon of war Lilantha Wedisinghe   (30 June 2009) Sri Lanka : Two Sides to Every Story Rasika Wickramasinghe   (30 June 2009) Please give Sri Lanka a chance Dharani K Hapangama   (30 June 2009) Liberation Tigers of Tamil Eelam (LTTE) as terrorist organisation M Perera   (30 June 2009) Read every Rapid Response to this article
	ANALYSIS: Getting the priorities right for stroke care Sudlow and Warlow (4 June 2009) [Full text]		Assisting PCTs in spending wisely and well on stroke services Nigel Dudley   (30 June 2009) Read every Rapid Response to this article
	EDITORIALS: The future of female doctors Winyard (3 June 2009) [Full text]		Women in medicine- the debate must move on Graham P A Winyard   (30 June 2009) Read every Rapid Response to this article
	NEWS: Hanumappa Sudarshan: the quiet reformer Coombes (30 April 2009) [Full text]		We need more such Dr.H.Sudarshans! Vinathe Sharma   (30 June 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: "I want to see the consultant" Crampsey (15 April 2009) [Full text]		Irresponsible Medicine: Disrespect and the Junior Doctor Prof. D.L. Steinberg   (30 June 2009) Read every Rapid Response to this article

CLINICAL REVIEW: Prehospital management of severe traumatic brain injury Hammell and Henning (19 May 2009) [Full text] Prehospital management of severe traumatic brain injury Mannitol: does it accelerate depletion of intracerebral adenine nucleotide pools? 30 June 2009 Richard G Fiddian-Green, FRCs, FACS None Send response to journal: Re: Mannitol: does it accelerate depletion of intracerebral adenine nucleotide pools? If the primary objective in managing head injuries is to limit secondary brain injury, by preventing an intracerebral energy deficit in regions adjacent injured brain and reperfusion injury not only in the injured region but also in the penumbra, then inducing a diuresis with mannitol might be subverting that objective by depleting intracerebral in addition to systemic adenine nucleotide pools(1,2). 1. Fluid volumes and the preservation of adenine nucleotide pools. Richard G Fiddian-Green (1 April 2009) eLetter re: D. R. McIlroy, D. V. Pilcher, and G. I. Snell Does anaesthetic management affect early outcomes after lung transplant? An exploratory analysis Br. J. Anaesth. 2009; 102: 506-514 2. Should permissive oliguria and anuria be added to permissive hypotension? Richard G Fiddian-Green (22 June 2009) eLetter re: E M Dempsey, F Al Hazzani, and K J Barrington. Permissive hypotension in the extremely low birthweight infant with signs of good perfusion Arch. Dis. Child. Fetal Neonatal Ed. 2009; 94: F241-F244 Competing interests: None declared

EDITOR'S CHOICE: Rules of conscience Godlee (14 May 2009) [Full text] Rules of conscience Ranking of the rules of conscience 30 June 2009 Tjaard U Hoogenraad, retired neurologist UMC Utrecht Doorn, 3941VD 20, The Netherlands Send response to journal: Re: Ranking of the rules of conscience Ranking of the rules of conscience At first blink (1) I felt a bit uneasy with the title of the editorial “rules of conscience”. For me conscience is a strict private affair and ruling conscience seems a sort of contradictio in terminis: isn’t conscience intensively related to religion and isn’t ruling of religion in contradiction with the freedom of religion. Liberty of conscience is a great accustomed right and in my opinion this should stay so: therefore, at first blink, for me, no ruling but freedom of conscience. At a later look I saw that BMJ-editor Fiona Godlee wants to make it clear in her editorial that doctors do better to follow their conscience than to obey to rules and national laws. She seems to have the opinion that “rules of conscience” make part of the rules of the Helsinki Declaration on Ethical Principles for Medical Research that contains the crucial statement that a doctor’s conscience must transcend national laws. She also reminds us that the World Medical Association (WMA) has formulated a code that tells that it is a doctor’s duty to accept their ethical rules. It looks like the WMA is trying to rule the conscience of doctor’s globally and that the WMA thinks that doctors should do better to obey the WMA rules of conscience than to obey their own conscience. Analysing a bit more the meaning of the expression “rules of conscience” in health care I found that there are those who adhere the ruling of doctor’s conscience and those who object to it. In the U.S., the Catholic Medical Association supports the regulation of conscience and in late 2008 the Bush administration announced a “conscience protection rule”. The Obama administration seems to object to such protective ruling of conscience and is moving to overturn this controversial abortion related policy that allows health care workers to decline to participate in any service that violates their conscience. Although I feel uneasy by being ruled in my conscience I respect fully the important endeavours of those who try to regulate the ethical principles of behaviour of doctors. For myself there is a sort of ethical ladder of ranking in obeying of rules: national laws, Hippocratic guidelines, Helsinki declaration, WMA ethical rules, ethical protocol guidelines, personal evidence based patient centered problem solving. Therefore, on second thoughts I stick to my first blink and continue to feel very uneasy if my private conscience would be ruled by someone else. I am responsible for what I do and I realize that I have to accept full personal accountability for my actions. Ref.: 1. Richard G FiddianGreen: Tjaard Hoogenraad’s blink. Re:Re: Rapid Response 11 May 2009 Competing interests: None declared

RESEARCH: Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study McCowan et al. (26 March 2009) [Abstract] [Full text] [PDF] Spontaneous preterm birth and small for gestational age infants in women who stop... What are the effects of cigarette smoking ? 30 June 2009 Leslie O Simpson, retired medical research worker Dunedin, New Zealand 9077 Send response to journal: Re: What are the effects of cigarette smoking ? A strange feature of both the original article and the comments by the many respondents is the failure to address this question. From a pathophysiological viewpoint, the most significant feature is the effect on blood viscosity with an adverse effect on capillary blood flow. A significant literature confirms such effects, as well as showing that the adverse effects are reversed when smoking stops. Competing interests: None declared

RESEARCH: Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study Laméris et al. (26 June 2009) [Abstract] [Full text] [PDF] Imaging strategies for detection of urgent conditions in patients with acute abdominal... An inefficient and costly way of managing an acute abdomen. 30 June 2009 Richard G Fiddian-Green, FRCS, FACS None Send response to journal: Re: An inefficient and costly way of managing an acute abdomen. In this study, "Surgical residents evaluated 74% (n=757) of patients, and emergency medicine residents evaluated the other 26% (264). The mean clinical experience of the residents was 25 months (range 2 months to 8.7 years). The ultrasonography was done by a radiological resident in 57% (582) of patients and by a staff radiologist in 43% (439). Fifty two per cent (300/582) of the ultrasonography examinations by residents were done during office hours under the supervision of a staff radiologist, and 48% (282) were done after office hours without supervision. The experience of the ultrasonography and CT readers ranged from one year’s residency to more than 30 years’ experience as a radiologist" (1). No mention was made of the time passed between admission to the ER and definitive intervention. In my experience in academic medical centers in the US this could be many hours and even longer than 24 hours. That all patients had blood work done prior to imaging it but one factor contributing to the delay. When my young daughter developed appendicitis whilst we were out watching the Wolverines plat a football game I made the diagnosis within minutes of returing, having been informed by my eldest daughter that she was not well, and took her to the ER having called the consultant surgeon/attending of my choice in informing him that my daughter had an acute abdomen. I then called the consultant anaesthetist of my choice telling her of my diagnosis so she could prepare the OR. The surgeon, who was waiting for me when I arrived at the ER, confirmed my diagnosis within 30 minutes without blood tests or imaging and took her to the OR. All was done in hours and she came home in under 24 hours, and that was prior to the advent of laparoscopic surgery. Running the gauntlet of inexperienced clinicians in training and being subjected to unnecessary investigations is, sadly, the rule in many medical centers today including those in this Dutch study. How much more efficient and cost-effective it could be if patients with an acute abdomen had were first seen by a consultant surgeon/attending. This is not difficult to do. In the medical center in US in which I worked consltant surgeons/attendings would be on call for emergencies for 24 hours about once a month but the patients were still evaluated by residents before they were called. It would not take much more to have them evaluate all patients presenting with acute abdominal pain. Furthermore residents could learn much by assisting in the process. Ultrasound might be a helpful addition to a consultant surgeon especially if he/she were to perform it him/herself. By the time imaging reveals anything the pathology is, however, usually fairly far advanced. More helpful might be the support of a computer progran such as that poineered decades ago by de Dombel (2). 1. Wytze Laméris, Adrienne van Randen, H Wouter van Es, Johannes P M van Heesewijk, Bert van Ramshorst, Wim H Bouma, Wim ten Hove, Maarten S van Leeuwen, Esteban M van Keulen, Marcel G W Dijkgraaf, Patrick M M Bossuyt, Marja A Boermeester, Jaap Stoker on behalf of the OPTIMA study group Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study BMJ 2009; 338: b2431 2. de Dombel, F. T., Dallos, V., & McAdam, W. A. (1991). Can computer aided teaching packages improve clinical care in patients with acute abdominal pain. BMJ (Clinical Research Ed.), 302(6791), 1495-1497. Competing interests: None declared

RESEARCH: Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study Thompson et al. (24 June 2009) [Abstract] [Full text] [PDF] Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness... ?cost effectiveness 30 June 2009 Eon H McLaren, Retired Consultant Physician Prev Stobhill Hospital Glasgow G21 3UW Send response to journal: Re: ?cost effectiveness Clearly the cost effectivness of an intervention (especially in the 65+ age group who are subject to the multiple effects of ageing on survival) should be determined by its effect on the overall survival of the intervention group compared with that of the control group and not on the difference in survival of those suffering from the condition under study. Some statistical sleight of hand which is said to correct for other co- morbidities appears to have gone on but is incomprehensible to the non- statistician. However, in spite of this, I find it inconceviable that an intervention should be declared cost effective when the deaths from all causes were 10481 (average age at death 75.0 years) in the intervention group and 10274 (average age at death 75.4 years) in the control group. Presumeably the groups were well matched for age and co-morbidity but no mention is made of this in the paper. Unless this discrepancy can be satisfactorily explained to the non- statistician one is forced to conclude that the whole intervention merely changes the cause of death without affecting survival and, as such, screening for AA is basically a waste of time and money. Competing interests: None declared

EDITORIALS: Intravenous fluids in adults undergoing surgery Liu and Finfer (24 June 2009) [Full text] Intravenous fluids in adults undergoing surgery Overly negative? 30 June 2009 Dilip J DaCruz, Consultant in Emergency Medicine Dubai UAE Send response to journal: Re: Overly negative? If everything one did was evidence-based, one would have little to do. So let's be grateful that these people have taken it upon themslves to produce this work. Of course, the recommendations are imperfect but those that perceive such imperfection do so through their own biases and opinions. As an Emergency Physician I could, for instance, rant about the fact that shock- ultrasound is overlooked. I also find the administeration of 200ml boluses in a shocked adult overly cautious, especially when a CVP line is in place. But I rise above such negativity when I encounter boldness and effort. These guidelines are a great start and a laudable attempt to wrap-up the current state of play. It is from work like this that trainees will identify areas for further focused research. And that's where the revised guidleines will come from. Competing interests: None declared

NEWS: Doctors call for head of World Medical Association to quit as "matter of priority" Kmietowicz (23 June 2009) [Full text] Doctors call for head of World Medical Association to quit as "matter of priority" World Medical Association and BMJ 30 June 2009 Stephanie A Amiel, Professor of Diabetic Medicine King's College London SE5 9NU Send response to journal: Re: World Medical Association and BMJ Dear Editor, With reference to BMJ 2009: 338:b2556 May we hope that the fact that nearly 3000 people have signed a petition in support of Dr Blachar's Presidency of the World Medical Association will receive as prominent coverage of your article saying that more than 700 doctors opposed it, or does that run counter to BMJ editorial policy? Yours faithfully, Stephanie A Amiel, BSc, MD, FRCP Professor of Diabetic Medicine, King’s College London School of Medicine Competing interests: None declared

LETTERS: Reactive hypoglycaemia in severe mental illness van Winkel and De Hert (23 June 2009) [Full text] Reactive hypoglycaemia in severe mental illness A difficult struggle between case study and statistical construction 30 June 2009 Zekria Ibrahimi, psychiatric patient Coombs Library UB1 3EU Send response to journal: Re: A difficult struggle between case study and statistical construction The letter from van Winkel and De Hert provides a statistical fog through which it is not altogether easy to find the medical core. They apply multivariate regression to patients on antipscyhotics in the context of an oral glucose test. They conclude that in a 'control' population of military draftees, hypoglycaemia is found in a minority and would appear asymptomatic(1). They are implying that hypoglycaemia can be a 'normal' state, and that the three cases cited by Suzuki et al are mere irrelevant 'outliers' (2). Under a 'normal' distribution, we would expect an oral glucose test to give figures for a population that would conform to the tediously ubiquitous and dreadfully mathematically complicated 'bell curve'- that is, most at the average, and some at the two extremes. Thus, the 'results' of van Winkel and De Hert are to a degree merely reflecting the normal distribution. Statistics is confined to generalities and abstractions; it is rather similar to a vague haze where we cannot register individuals as individuals. Medicine will not advance without the statistical insight of a van Winkel or De Hert- or without the bright focus on individuals of a Suzuki. The difficult medical problem is that second generation antipsychotics are usually linked to hyperglycaemia. In the three Suzuki cases, some psychiatric drugs were actually causing the reverse, hypoglycaemia. Here was a medical rather than a statistical point. Medicine has traditionally not progressed in the absence of serendipity. To dismiss the Suzuki results because they are unusual would be wrong. Statistical tools are just tools, and cumbersome ones too. So, there is no medical illumination if we do not have both methods- the case study of a Suzuki, or the statistical perspective of a van Winkel and De Hert. REFERENCES: (1) Hypoglycamia in mental illness. Ruud Van Winkel. Marc De Hert. BMJ 2009;338:b2536 (2)Hypoglycaemia induced by second generation antipsychotic agents in schizophrenic non- diabetic patients. Yutaro Suzuki, Junzo Watanabe, Naoki Fukui, Vural Ozdemir, Toshiyuki Someya. BMJ 2009;337:a1792. Competing interests: None declared

VIEWS & REVIEWS: Blow your own trumpet Dalrymple (23 June 2009) [Full text] Blow your own trumpet Trumpets on TV, Radio and Magazines 30 June 2009 Michael Lorenzo Murray, GP Annandale Q.4814 Queensland Australia Send response to journal: Re: Trumpets on TV, Radio and Magazines I doubt if the UK is any different than Australia. On any one day here, one can via the Media have, ones impotence cured with nasal sprays, ones wrinkles abolished by low level laser, and ones obesity curtailed by the knife. And all by experts, at least they must be if they are on TV, Radio or in magazines at the supermarket checkout. By careful attention to these advertisements, a fecund, slim, ageless existence is available to all without boring recourse to a Family Physician, and one doesn't get a lecture. Dr.Williams would need an agent and marketing manager were he alive today in this crowded marketplace. Michael Murray Competing interests: None declared

RESEARCH: Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study Trichopoulou et al. (23 June 2009) [Abstract] [Full text] [PDF] Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study Glycaemic Index and the Mediterranean Diet 30 June 2009 William T Neville, General Practitioner Abbey Road Surgery, 63 Abbey Road, Waltham Cross, Hertfordshire, EN8 7LJ Send response to journal: Re: Glycaemic Index and the Mediterranean Diet This article and the Mediterranean Diet Score unfortunately do not consider one of the major benefits of a Mediterranean diet which is its low Glycaemic Index (GI). The resulting scores and conclusions therefore give an incomplete picture. If the GI were considered, a better explanation of the benefits of a Mediterranean diet would be apparent. GI is a measure of how rapidly carbohydrates are digested. High GI food causes a high, sharp rise in blood glucose and insulin which is harmful. Low GI food causes a low, sustained rise in blood glucose. A low GI diet may prevent or control a variety of conditions including diabetes, cardio-vascular disease, obesity, hyperlipidaemia, Alzheimer’s disease and breast cancer. Due to the high content of fruit, vegetables and legumes the Mediterranean diet has a low GI. Pasta has a low GI which is relevant to the Italian diet. The GI is therefore important for people who wish to improve their health by switching to a Mediterranean diet. If they continue to eat the high GI food typical of a Western European diet they will not benefit. Such high GI food includes potatoes, most rice and most breakfast cereals. White bread, brown bread and even wholemeal bread have a high GI because they are made from finely milled flower. This high GI food needs to be replaced by low GI alternatives for example porridge, muesli, stone-ground bread, granary bread (made with malted or sprouted wheat) or bread containing soya and linseed. Eating fish, unsaturated fat, nuts, legumes, fruit and vegetables are important. But for a Mediterranean diet to benefit a wider population the consumption of high GI food needs to be decreased and replaced with low GI food. References: 1. Kelly SAM, Frost G, Whittaker V, Summerbell CD. Low glycaemic index diets for coronary heart disease. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004467. DOI: 10.1002/14651858.CD004467.pub2. 2. Thomas DE, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005105. DOI: 10.1002/14651858.CD005105.pub2. 3. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006296. DOI: 10.1002/14651858.CD006296.pub2. 4. Jenkins DJ, Wolever TM, Taylor RH, et al. (1981) Glycemic index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr 34:362–6 Competing interests: None declared

RESEARCH: Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries Butler et al. (23 June 2009) [Abstract] [Full text] [PDF] Variation in antibiotic prescribing and its impact on recovery in patients with... Understanding coughs in primary care 30 June 2009 Rod A Storring, Consultant community chest physician Barking and Dagenham PCT, IG11 8EY Send response to journal: Re: Understanding coughs in primary care I am not suprised at these findings of the GRACE group (The Genomics to combat Resistance against Antibiotics in Community-acquired lower respiratory tract infections in Europe).That antibiotic presribing was not associated with clinically important differences in recovery in patients with acute cough in primary care is consistent with an understanding of the causative mechanisms involved and that antibiotics are only infrequently needed in the usually healthy.That this latter number is very small is demonstrated by the fact that in the 3402 patients recruited, benefits from antibiotics were not demonstrated. Coughs in primary care can be very troublesome and prolonged. My understandig of the mechanisms involved is as follows. Approximately 30% of the population tend to get chest symptoms with viral infections (personal findings). It has been demonstrated that viral infections cause an inflammatory reaction in the respiratory tract and it is this that causes the symptoms, usually only a cough, though there may also be chest tightness, wheeze, dyspnoea, phlegm etc. If sufficiently troublesome, these symptoms will settle with anti-asthma treatment. Antibiotics in the otherwise healthy are only needed if the patient feels unwell or has purulent phlegm. As pointed out above, this number is very small. Competing interests: none

FEATURE: Vaccine disputes Coombes (24 June 2009) [Full text] Vaccine disputes A plea for a balanced discussion on immunisation 30 June 2009 Richard T Halvorsen, GP WC1N 3NA Send response to journal: Re: A plea for a balanced discussion on immunisation Any hope for a rational discussion on the benefits and risks of vaccination was not helped by Rebecca Coombes' less than objective critique of what she refers to as the "anti-vaccination lobby".[1] I, too, deplore personal attacks that are made on Paul Offit, David Salisbury or any other enthusiastic proponent of vaccines. But I am also concerned when I hear that those who simply question the value of vaccines, like many of the parents I meet every week in my immunisation clinic, have been patronized and bullied into vaccinating their children by my fellow health professionals. Any discussion about vaccines is liable to get heated - on both sides of the debate; and that's a great shame because it prevents us from having the open, honest discussion that this important subject demands. Those who speak determinedly in favour of vaccines are just as much to blame as the "anti-vaccination lobby". In the same edition of the BMJ, Iona Heath challenges the benefits of breast screening and the one-sided propaganda that is put out to encourage women to have their mammograms.[2] Many of Dr Health's arguments could equally apply to vaccination. In particular, she quotes David Sackett's description of the arrogance of preventive medicine, of which immunisation must be the pre-eminent example. "Preventive medicine displays all 3 elements of arrogance. First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy . . . Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them. Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations." All 3 elements apply to immunisation. There is an arrogance amongst some doctors that doubters simply need to be told "the facts" to be persuaded of the clear and overwhelming benefits of immunisation. I have spent much time studying "the facts" in the form of published peer-reviewed research papers. These, in general, do demonstrate the benefits of vaccines, but these benefits are usually less than widely claimed, the risks greater than admitted, and the diseases that vaccines aim to prevent often less serious than portrayed. The disease Ms. Coombes mentions most in her feature is measles, a disease that can be serious and fatal. However, when I was a child, in the 1960s, we all caught measles and certainly did not live in fear of it. A BMJ editorial of 1963, prior to the introduction of the single measles vaccine, whilst asserting the need for the vaccine in underdeveloped countries, stated, "But the need or desire for a vaccine for the general population of Great Britain is much les certain. Measles is now a mild disease, and many parents and doctors may feel that no protection against it is required."[3] It is true that during that period between 50 and 150 people died every year from measles (many of these suffered form chronic health problems, for whom the case for immunisation was stronger), but these figures must be balanced against the evidence that catching measles prevents allergic disease - including asthma, which kills over 1,000 people every year in the UK.[4] The case for vaccination needs to be put in perspective. And why are we immunising the whole population against mumps when a 10-year survey of 2,482 of the most serious cases of mumps (those admitted to hospital), found just five cases of long-term complications - of deafness due to involvement of the eighth cranial nerve? The authors concluded, "It seems clear from the results of this survey that there is little need for general vaccination against mumps."[5] Just as with breast screening, the current public health message is unequivocally in favour of vaccination and never puts the counter argument. Ms Coombes' assertion that JABS is "anti-vaccine" is incorrect. Indeed the JABS web site clearly states this. And yes, the JABS web site does still maintain - correctly - that "some children have and will continue to be damaged by combined and single dose vaccines." If this were not the case, the UK Vaccine Damage Payments Unit would not have paid out 1367 vaccine damage awards between 1978 and 2005. It is an unspoken truth that mass vaccination programmes necessitate sacrificing the few to protect the majority. Those who question the benefit of mass immunisation are not all irrational non-believers. Most support vaccination but are concerned at - and question the necessity for - the large number of vaccines and the early ages at which these are given. Many have studied the research, only to find - as I have - contradiction and uncertainty. They deserve to be treated with respect and given the opportunity for an open and honest debate. [1] Coombes R. Vaccine Disputes. BMJ 2009;338:1528-31. [2] Heath I. It is not wrong to say no. BMJ 2009;338:1534. [3] Anonymous. Vaccination against measles. BMJ 1963;5360-1. [4] Rosenlund H et al. Allergic Disease and Atopic Sensitization in Children in Relation to Measles Vaccnation and Measles Infection. Pediatrics 2009;123:771-778. [5] Anonymous. A retrospective survey of the complications of mumps. Journal of the Royal College of General Practitioners 1974; 24:552-6. Competing interests: Author of The Truth about Vaccines. Medical Director of BabyJabs children's immunisation service. Vaccine disputes The origins of antivaccine activism 30 June 2009 Isabella Thomas, Parent Somerset BA3 4TE Send response to journal: Re: The origins of antivaccine activism Could Dr. Flegg give evidence on his quote 'Andrew Wakefield’s now discredited paper was published? How was it discredited? That paper was about bowel problems in Autistic children and still stands unless Dr. Flegg knows better. Dr. Flegg should listen to parents who are on the front line of vaccine damage when it happens. The 'high pitch screaming' within hours of MMR vaccine etc. It is so very easy to call parents of vaccine damage children as 'anti- vaccine' when we DID give our children their vaccines. We are responsible parents. Who is responsible for the children when they are sick? Who is responsible when children become 'brain damaged'? Who is responsible when something goes wrong with a vaccine? Doctors like you talk the talk but do NOT know anything about our children or are bothered to find out the 'hell' our children are going through. All you are fixed on it that any talk of vaccine damage and there is a panic that all parents would stop vaccinating their children. We all believe is 'safe' vaccines but our children should NOT be the 'sacrifice' of the many. What would you do if it was one of yours? Competing interests: Two vaccine damaged children

VIEWS & REVIEWS: Women of substance Moore (19 June 2009) [Full text] Women of substance Where have all the men gone? 30 June 2009 john m orchard, general practitioner limes medical centre, limes avenue ,alfreton derbyshireDE55 7DW Send response to journal: Re: Where have all the men gone? Wendy Moore states the future is female. I understood the aim of increasing the number of female medical students was equality not domination. The central tennet was that half our patients are female, so our clinicians should match. How can I expect the exclusively female workforce to understand my impending prostatism, to provide friendly reassurance about the anxieties of my dotage. It has always been argued that as a mere man I can't possibly understand a woman - does not the reverse apply? My future is bleak - just when I need a consistent sympathetic ear as I contemplate retirement, I am faced with a bevvy of endless changing female family physicians who rotate part-time general practice with part - time motherhood whilst asserting their rights - full time. Come on, chaps, grasp the nettle and insist on equal numbers of traing places for men. Once there was only one medical school for women - soon there wont be any men in medical school. We too want equality and we must not let it slip away! Competing interests: None declared

EDITORIALS: Confidentiality and sharing health information Sheather (15 June 2009) [Full text] Confidentiality and sharing health information Confidentiality and Sharing Health Information 30 June 2009 Beatrice Amuge, Assistant Commissioner Health Services, Nursing Jinja Hospital, Uganda Send response to journal: Re: Confidentiality and Sharing Health Information The Issue of confidentiality is quite complex. I do agree with most of the authors comments on confidentiality. In most cases patients release information not even knowing that it is going to be shared among the health personnel directly involved in providing care, and yet this is what usually happens. This affects patents confidentiality though it is beneficial for providing care to the patient. In reference to releasing data required for ancillary use such as audit, research, care planning or accountability, this actually poses a problem in confidentiality because the information is being used or at times even published without the consent of the source (patient). Some of the patients are aware of the above scenarios and do not disclose sensitive information leading to fragmentation and bias. Sharing information among health personnel who are directly involved in care and also the use information for ancillary processes are very important for patients’ care and planning. I do accept that there is need to balance rights to health care with duties to share information, without conflicting the issues of confidentiality in future, by explaining to the patient the future prospective of releasing health information. Beatrice Amuge Competing interests: None declared

NEWS: Sharing of patients’ data should not be based on implied consent, say GPs’ representatives Cole (16 June 2009) [Full text] Sharing of patients’ data should not be based on implied consent, say GPs’ representatives No enrichment of the summary care record without explicit patient consent 30 June 2009 Chris Woods, general practitioner Bolton BL1 3RG Send response to journal: Re: No enrichment of the summary care record without explicit patient consent I am a Bolton GP and spoke at the recent LMC Conference. The Bolton motion was "that a patient must give explicit consent before their information is uploaded to create an 'enriched' summary care record." An enriched record contains additional significant information such as a disease summary as well as drugs and allergies. The BMJ kindly reported on the speech(1). The report mentions that "only 13 out of 55 practices in the area have so far agreed to go ahead because of concerns about confidentiality." There are a number of reasons why Bolton GPs are not uploading patient data. Bolton PCT was the first to pilot the summary care record and after careful consideration at that time, ie in 2007, the LMC opposed it on grounds of consent, confidentiality, cost and data security. The RCGP now appears to support the summary care record(2). As a College member I am concerned that the process of 'enrichment' may not have been dealt with comprehensively by the College. Bolton LMC opposes the enrichment of the summary care record without explicit patient consent. The Government has a poor record on the handling of personal information. Less than a third of patients are aware of their summary care record(3). It is not clear which groups will have access to the record. There may well be merit to the summary care record but patients need to know what is happening to their data. Let patients decide. No enrichment without explicit patient consent. Chris Woods general practitioner, Bolton, BL1 3RG (1) Cole A. Sharing patient data should not be based on implied consent. BMJ 2009;338:b2441 (2) Gerada C, Field S. RCGP supports use of summary care records. BMJ 2009;338:b2516 (3) Greenhalgh et al. Summary Care Record Early Adopter Programme. An independent evaluation by University College London. May 2008 Competing interests: None declared

LETTERS: Choice and equality in health Ali (15 June 2009) [Full text] Choice and equality in health Re: Author's (failure to) reply 30 June 2009 stephen black, management consultant london sw1w 9sr Send response to journal: Re: Re: Author's (failure to) reply It is not really a reply if the author just restates his original point which appears to be an assumption that healthcare is completely unique and therefore totally immune to any benefits of competition, choice or markets. While I'm sure many medics in the NHS would like to believe this, it isn't true. The reply repeats the error of focussing exclusively on "technical quality" of care and compounds the mistake by claiming that most aspects of quality cannot be assessed by patients. But technical quality isn't the only thing patients care about: they also have a range of preferences for speed of treatment, how far they have to travel and whether the hospital overcharges their visitors for car parking. Additionally, quality is not as opaque to them as many medics would like to believe: patients are perfectly capable of judging relative infection rates, success rates, death rates and so on. The assumption that healthcare is completely unlike other markets is also wildly wrong. Many other markets also function despite imperfect access to apparently critical information. Consumers are rarely able to assess the long term reliability of the cars they buy, yet the market forces up quality and lowers cost over time. They can't directly assess the safety of airlines, yet they still travel. They don't know (perhaps nobody knows) which toothpaste is best for their long term oral health, but they still manage to choose which one to buy. Allowing the market to eliminate poor hospitals does not fail because of the problems with patients making the wrong choices, it fails because of a lack of political will. There are plenty of parts of England oversupplied with hospitals and letting some shut would not leave the population lacking in accessible care. But SHAs, the Department of Health and politicians have shown a distinct lack of the cojones required to allow this to happen. The idea that choice breeds inequality is also false. North American evidence sufferers from too many confounding factors to be useful in judging the NHS: when care is free to all, choice is highly empowering for the poor. The biggest barriers to the benefits of choice are the lack of availability and accessibility of performance and quality information plus the deeply held belief that doctors know better than patients what is best for patients. There is substantial evidence (eg from the Dartmouth Atlas Project) that giving patients accessible information leads them to make different choices of treatment: there is no reason why it shouldn't lead them to make different choices about where they are treated as well. Competing interests: None declared

ANALYSIS: Palivizumab and the importance of cost effectiveness Teale et al. (11 June 2009) [Full text] Palivizumab and the importance of cost effectiveness Long term outcomes following admission for RSV bronchiolitis in children 30 June 2009 Joanna C Murray, Research Assistant Department of Primary Care and Social Medicine, Imperial College London, Charing Cross Campus W6 8RP, Sonia Saxena, Mike Sharland, Alex Bottle and Azeem Majeed Send response to journal: Re: Long term outcomes following admission for RSV bronchiolitis in children Respiratory syncitial virus (RSV) bronchiolitis remains the most common cause of serious lower respiratory tract infection in infants worldwide.(1) Teale et al. describe the cost effectiveness of Palivizumab prophylaxis following acute infection, currently only recommended in high risk infants.(2) Emerging evidence from the United States (US) suggests there is considerable long-term respiratory burden following an episode of RSV bronchiolitis and most affected infants are previously healthy.(3) With a RSV vaccine currently recruiting in global trials, the impact of RSV infection on the long term health of children and future healthcare utilisation needs to be considered, to establish whether vaccination would be best targeted at high risk infants or given wider population coverage. We estimated the five year healthcare burden following hospital admission for bronchiolitis in England. We used the Hospital Episode Statistics database to follow up all children admitted to English hospitals where the primary diagnosis (main reason for admission) was bronchiolitis or RSV bronchiolitis (ICD-10 codes J21 and J210 respectively), during the index year 2000/01. We examined subsequent significant health outcomes over the following 5 years, including readmissions to hospital (by primary cause), outpatient consultations, length of stay and mortality. In 2000/01, 11463 children aged between 4 weeks and 6 months were admitted with bronchiolitis (2% of all infants aged <1), 4207 of these with confirmed RSV-associated bronchiolitis. Over the next five years, 42.4% of the overall cohort had one or more further admissions, 25% had one or more outpatient attendances and 68 children died (6 per 1000 children admitted). Almost half of all further hospital admissions were for respiratory conditions (48.1%), 15.9% of the overall cohort were readmitted with bronchiolitis, 7% with asthma and 6% with wheezing. Further admissions for bronchiolitis had longer hospital stays than further admissions for other causes (median = 2 days) compared with the median length of stay for all other which was 1 day (p<0.001). Our observational study supports the findings of Hall et al., which showed long-term illness burden and subsequent healthcare utilisation costs following childhood bronchiolitis are considerably greater than previously reported(3,4) and not limited to high risk infants.(3) The next step in the UK is to undertake a full health economic review of the population burden of RSV disease in children. Development of a live attenuated vaccine against RSV is progressing rapidly and an improved prophylactic drug Motavizumab has completed phase III trials.(5) To assess the clinical and cost effectiveness of these interventions, we now need to utilise a broad range of data including paediatric intensive care units, to enhance our understanding of the long-term cost and disease burden of RSV infection. References (1) Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson LJ. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA 1999; 282(15):1440-1446. (2) Teale A, Deshpande S, Burls A. Palivizumab and the importance of cost effectiveness. BMJ 2009; 338(jun11_1):b1935. (3) Hall CB, Weinberg GA, Iwane MK, Blumkin AK, Edwards KM, Staat MA et al. The Burden of Respiratory Syncytial Virus Infection in Young Children. N Engl J Med 2009; 360(6):588-598. (4) Greenough A, Alexander J, Burgess S, Bytham J, Chetcuti PA, Hagan J et al. Health care utilisation of prematurely born, preschool children related to hospitalisation for RSV infection. Arch Dis Child 2004; 89(7):673-678. (5) Handforth J, Friedland JS, Sharland M. Inhaled corticosteroids after respiratory syncytial virus infection. BMJ 2009; 338(mar31_2):b164. Competing interests: Abbott Laboratories provided funding for this study.

VIEWS & REVIEWS: Sri Lanka: health as a weapon of war? Suntharalingam (8 June 2009) [Full text] Sri Lanka: health as a weapon of war? Health as a bridge for Peace-The Sri Lankan experience 30 June 2009 Indika M Karunathilake, Senior Lecturer Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 08, Sri Lanka, Lalitha N Mendis, Shashimali Wickramasinghe Send response to journal: Re: Health as a bridge for Peace-The Sri Lankan experience The mind perceives what it agrees with. It filters reality according to its values, prejudices, feelings, attitudes, interests, goals and agendas and producers a perception. Dr Shiamala Sunderalingam in her letter to the BMJ perceives the Government of Sri Lanka as using health as a weapon of war. We who have worked in the IDP camps in Northern Sri Lanka perceive the efforts that are being made as a road to achieving Peace through Health. Yes, these Tamil people are physically and psychologically traumatized, but so are numerous Sinhalese in border villages who faced ruthless attacks by the LTTE, and the families of those who lost loved ones in train bombs, bus bombs, attacks on public buildings and other LTTE atrocities – the list is long. The IDPs are in such a sorry state because they were being held hostage by the LTTE. The food that was meant for these people was hijacked by the LTTE, they including children were used as fire fodder and slaves to build earth bunds etc. They did not surrender to the government forces, they were rescued by them. True those camps are overcrowded, but every person has a roof above their head which is more than the situation among the IDPs of the SWAT valley in Pakistan. It is not the ideal way for traumatized persons to live, but the Sri Lankan government and the people in the South are doing their very best. E.g. no foreign media has ever commented on the tons of food, items of clothing, other necessities and funds that have been collected in the South for the IDPs. There is no ban on Tamil doctors working among the IDPs. Quite contrary to Dr. Sunderalingam’s claim, there are many examples of health professionals from different ethnic communities working together. The Sri Lankan situation can actually be considered as a golden opportunity to promote the more positive concept of “health as a bridge for peace” as opposed to Dr. Sunderalingam’s destructive and biased concept of “health as a weapon of war”. Dr. Indika Karunathilake Director, Medical Education Development And Research Centre, Faculty of Medicine, University of Colombo, Sri Lanka (This writer was the team leader of a medical team that recently worked among the IDPs. at the Ramanthan relief village, Chettikulam. This team comprised of academic staff, junior doctors and medical students. There were four Muslim doctors and five Tamil doctors in the team) Competing interests: None declared Sri Lanka: health as a weapon of war? A response from The Sri Lanka College of Paediatricians to “Sri Lanka: health as a weapon of war ?” 30 June 2009 H.T Wickramasinghe, President. Sri Lanka College of Paediatricians SLMA House. No:6 Wijerama Mawatha. Colombo 7, On behalf of the Council of Sri Lanka College of Paediatricians Send response to journal: Re: A response from The Sri Lanka College of Paediatricians to “Sri Lanka: health as a weapon of war ?” VIEWS & REVIEWS A response from The Sri Lanka College of Paediatricians to “Sri Lanka: health as a weapon of war ?” The Sri Lanka College of Paediatricians (http://www.srilankacollegeofpaediatricians.com/index.php) wishes to respond to the above named article, which appeared in the BMJ of 13th June 2009. Unfortunately the author of the article has provided ‘misinformation as a weapon of war’ to the readership which often happens in conflict situations as adverse false propaganda is a weapon used by most terrorist organizations. The said article makes various unfounded allegations against the democratically elected government of The Democratic Socialist Republic of Sri Lanka. The carnage created and carried out by the world famous and utterly ruthless terrorist organisation known as The Liberation Tigers of Tamil Eelam (LTTE) over a three decade long armed conflict in Sri Lanka is only too well known to the international world. This organisation is currently banned in most Western Countries including US, UK, EU and Canada http://www.tamilcanadian.com/page.php?cat=70&id;=4137 , http://timesofindia.indiatimes.com/India/LTTE_ban_extended_by_two_more_yrs/articleshow/3044780.cms . These so-called “freedom fighters” not only killed and maimed tens of thousands of Sri Lankans in the South of the country but also perpetrated numerous atrocities against the Tamil people in the North and East of the country http://canadiancoalition.com/LTTE/Massacres.html . During their last days, they even shot, killed and maimed, not only their so-called “own people” but children as well, who attempted to escape from the human shield and seek refuge in the safety of the government authorities. http://www.nowpublic.com/world/5100-civilians-ltte-human-shield , http://www.groundviews.org/2006/12/17/human-shields-in-the-battle-of-sri- lanka/ The author states that the Sri Lankan government and its armed forces have systematically blocked the provision of clean water, shelter, food, and medicines. There is no truth whatsoever in the statement that the government of Sri Lanka ever used health as a weapon of war at any time against the unfortunate people of the North and the East of the country. For the last 30 years of the conflict, the people in the affected areas including the terrorists were fed by the government and the UN/WFP and medicines supplied by the government of Sri Lanka through the ICRC. http://www.expressbuzz.com/edition/story.aspx?Title=%E2%80%98LTTE+stealing+medical+supplies+for+own+purpose%E2%80%99&artid;=lOUfoiMsHhc=&SectionID;=W2qvuypEr4I=&MainSectionID;=aZcEE40zV1s=&SectionName;=pebaNw/XyPtYiO1Vye55fA==&SEO;=. It is on record how the LTTE plundered these supplies to their own advantage on numerous occasions and deprived the populace of the region the benefits of health care. http://www.uthr.org/Reports/Report5/chapter4.htm The Hospitals were supplied and managed by government doctors who were paid by government. The ICRC also was also involved in the process. http://www.icrc.org/web/eng/siteeng0.nsf/html/sri-lanka-update-170309. It was the LTTE that restarted the war in 2006 during the ceasefire when the main Mavil Aru annicut sluice gates were forcibly closed by the LTTE. This activity deprived about 60,000 people and 30,000 ripe paddy land for irrigation. Col R Hariharan (retd.), South Asia Analysis Group SRI LANKA: MAVIL ARU OPERATION & AFTER - An Analysis. http://www.saag.org/common/uploaded_files/paper1908.html. Wikipedia: http://en.wikipedia.org/wiki/Mavil_Aru The author also states “the Sri Lankan authorities denied access to the north east for long term relief and rehabilitation projects” during the Tsunami, which is also untrue, since the then Sri Lankan President Chandrika Kumaratunga's bold decision to push through a deal to share international tsunami aid has restored hopes of a negotiated settlement to the island's ethnic conflict”. Instead the LTTE robbed the Tamil people who received funds after the Tsunami. Asia Tribune: http://74.125.153.132/search?q=cache:yYtRxYalHMIJ:www.asiantribune.com/oldsite/show_news.php%3Fid%3D13789+Tsunami+aid+LTTE&cd;=4&hl;=en&ct;=clnk≷=lk&client;=firefox -a The statement in the article that the government prevented foreign donors from meeting the LTTE is also false since “The LTTE chief, V. Prabhakaran raised the issue of direct aid with the Norwegian Foreign Minister, Jan Peterson, who called on him in his Killinochchi headquarters on January 28.” India News Online: http://news.indiamart.com/newsanalysis/sri-lanka-govt-ltte--8775.html. Even the LTTE terrorists website mentions “Mr Akashi (the Japanese special envoy) met the LTTE delegation at the Kilinochchi LTTE Peace Secretariat..” which contradicts the author’s statement. http://www.tamilnet.com/art.html?catid=13&artid;=14895 The author mentions several statements that are hearsay undocumented statements that amount to propaganda such as “According to local NGOs, the sick are allowed to seek limited medical help...” and “I have heard from colleagues in the area that Tamil doctors from other regions of Sri Lanka who came forward to serve these people have been refused access. The readers of a prestigious Journal would expect evidence based information. The Sri Lanka College of Paediatricians has arranged for a roster of specialists to work in these areas including Tamil doctors. Of course, we asked all members of the College and some Tamil doctors responded while some refused for personal reasons. So far, many Tamil doctors have and are still working in the IDP camps. It is on record, quite contrary to the impressions generated by the article in the BMJ, how countless numbers of Tamil doctors refused to serve in these areas over the last three decades. In those circumstances, many Sri Lankan doctors from the South did go and work selflessly in those areas, leaving their families and relatives behind in the South of the country. The Sri Lanka College of Paediatricians is proud to record that many young and even experienced paediatricians did go and work in these areas over the last three decades. They did their best even under those appalling conditions created by the LTTE. Admittedly, there are quite significant problems in the camps of the Internally Displaced Persons (IDPs) at the present time. The government of Sri Lanka in general and The Sri Lanka College of Paediatricians in particular, have taken steps to provide medical assistance and from our point of view, paediatric care, to these, our very own people, of our own country. As befits a renowned academic organisation, The Sri Lanka College of Paediatricians, looks at these children just as children and quite unlike the LTTE, not as Tamils or children of any other community. For us, children are the same, wherever they come from. Teams of paediatricians and other doctors have been visiting these camps, for days on end, at great personal sacrifice, to try and provide the best possible care for these children. Some of the more recently trained paediatricians have even elected to serve on a long-term basis in the hospitals of these areas. We are doing our best to try to cope with a situation that was originally created by the LTTE itself. The government of Sri Lanka is determined to sort out the problems of these IDPs as fast as is humanly possible and re- settle them back in their own homes within a period of six months or so. It is most unfortunate that, such biased and adverse articles as the one referred to, do create a completely erroneous impression of the goings -on in our country. Many of the professionals of Tamil origin, who have elected to desert their motherland in its gravest hour of need, under the guise of “asylum seekers” and “refugees”, to secure a beneficial haven in the Western world, have now started a campaign of misinformation and journalistic terror to discredit the government and professional organisations of Sri Lanka. It is worthy of note that even the Tamil doctors, listed by name in the article, have now explained to the authorities how they were forced and coerced by the LTTE to provide erroneous and damaging information to the international media. They had no alternative but to accede to these coercions as they literally had several guns pointed at their heads during those intensely stressful encounters. We are sure that the government is quite cognizant of the facts of these cases and will be sympathetic to their plight. There is no reason whatsoever to doubt their safety. Hopefully, the terrible war of the last three decades is over in Sri Lanka. It had taken a dreadful toll of the people of our country. We need to regroup and rise like the proverbial phoenix, from the ashes. The need of the hour in Sri Lanka is not to mull over the past, shed crocodile tears about the plight of some sections of Sri Lankans, but to take steps to help all Sri Lankans to live in peace and harmony right throughout our beautiful country. As our own President of the country eloquently extolled recently, we should not think of our own people by any sort of segregation of ethnicity, culture, creed or religion. He said categorically that there are only two types of Sri Lankans, one which loves and feels for the country and the other, quite the opposite. It is blatantly obvious to which of these groups, the members of the Tamil diaspora that disseminate misinformation belong to. Dr. H.T Wickramasinghe President On behalf of the Council of Sri Lanka College of Paediatricians. Competing interests: This article seems to be written to mislead readers by providing misinformation and unfounded allegations against a democratically elected government of a country. Sri Lanka: health as a weapon of war? Conflict in Sri Lanka 30 June 2009 Gunatungamudalige L Perera, Associate Specialist St Marys Hospital, Kettering NN15 7PW Send response to journal: Re: Conflict in Sri Lanka Dr Sunthralingam describes the Sri Lankan conflict through tinted glasses. As a result it is a distorted and tinted account of the event. She says that successive governments used access to medicines as a weapon of war against the Tamils living outside the government controlled areas. The fact is that the government had no access to the areas controlled by the Tamil Tiger terrorists. The same applies to the tsunami relief. The government did not disallow access to the NGOs but could not guarantee their safety in the terrorist controlled areas. Still the NGOs worked from near by areas. However the terrorists used the food aid to feed its conscripts and construction materials to fortify their bunkers. Her account is full of apparent 'facts' but are really distorsions. It is totally wrong to say that the government and the armed forces systematically blocked the provision of clean water and sanitation to the terrorist held areas - clean water in most areas of Sri Lanka comes from wells and local supplies. Dr Sunthralingam is entitled to have a tinted view but I am concerned that the BMJ published such an one sided distorted article which looks more like propaganda than a genuine analysis of the events. Competing interests: I am a Sinhalese of Sri Lankan origin. Sri Lanka: health as a weapon of war? A matter of conscience 30 June 2009 Ken Menon, GP CM5 9AA Send response to journal: Re: A matter of conscience When a section of the population, for whatever reason, is denied equitable access to medical care, it is a cause for concern. That collective punishment or deprivation may be inflicted on a group of people is unpardonable. The silence, if it so, of the medical profession to the incarceration of its colleagues shall be an indelible stain on the conscience of the profession in that land. Competing interests: None declared Sri Lanka: health as a weapon of war? Biased personal views 30 June 2009 Vasantha de Silva, Consultant Medway Maritime Hospital, Gillingham, Kent, ME7 5NY Send response to journal: Re: Biased personal views This is an extremely biased and one sided article published to discredit the SriLankan government. BMJ is a reputed journal and should not have published this article which involved nothing but internal politics of another country. BMJ would lose its reputation if similar papers are published. There is hardly any evidence to justify what the author is trying to prove. It is extremely sad that BMJ has converted itself to a political journal by publishing this article Competing interests: none Sri Lanka: health as a weapon of war? Sri Lanka will never use health as a weapon of war 30 June 2009 Lilantha Wedisinghe, Specialty Registrar in Obstetrics & Gynaecology Glasgow Royal Infirmary, Glasgow, G4 0SF Send response to journal: Re: Sri Lanka will never use health as a weapon of war I was surprised to see such a one-sided personal view by Shiamala Suntharalingam criticising Sri Lankan in the BMJ1. The main aim of the article becomes evident in latter paragraphs: there are some Tamil doctors who have been detained by the Sri Lankan armed forces with the suspicion of supporting terrorists, she wants them free. There are many incorrect facts. In the fifth paragraph she states that these internally displaced persons will be kept under these conditions for another three years. However, the government’s 180-day resettlement and re-conciliation plan is already underway. In the fourth paragraph she refers to the Channel 4 News on this matter, which has been proven wrong. The Liberation Tigers of Tamil Elam (LTTE) abused all the facilities provided through NGOs for Tsunami victims for their terrorist activities. Therefore, all aids will be directly supervised and tightly controlled by the Sri Lankan authorities in order to prevent terrorism in the future which has been the cause of these issues. Furthermore, the ministry of health of Sri Lanka has launched a rapid program to provide much needed care for Sri Lankans living in these camps. Dr Suntharalingam blames the government that it uses health as a weapon of war. However, the war has come to a complete end on 19 May 2009 leaving the country with no terrorists, which in other words, means that the Sri Lanka is using the health as a weapon of war against its own civilians. This does not make any sense. Although it is not difficult to understand Shiamala Suntharalingam’s frustration, her arguments are incomprehensible. Reference: 1. Suntharalingam S. Sri Lanka: health as a weapon of war? BMJ 2009; 338: b2304. Competing interests: None declared Sri Lanka: health as a weapon of war? Sri Lanka : Two Sides to Every Story 30 June 2009 Rasika Wickramasinghe, Physician Baltimore, Maryland, United States Send response to journal: Re: Sri Lanka : Two Sides to Every Story Every story has two sides, and in Dr. Suntharalingam’s article entitled “ Sri Lanka: Health as a Weapon of War” this aphorism is conveniently forgotten. As a Sri Lankan physician, I too have witnessed the horrors of war in Sri Lanka’s north and east. And, like Dr Suntharalingam, I too have volunteered for months in Sri Lanka’s war ravaged regions. As Sri Lankans living in the west, we both share significant similarities in the time and effort we have spent working to improve the lives of our countrymen. Still, our similarities end right there. Each of our perceptions and prejudices are colored by our own experience, and perhaps owing to this, my analysis of blame is starkly different to hers. While she insists that fault for the predicament of over 300,000 Sri Lankans rests with their elected government, allow me to provide an alternate viewpoint. That the Liberation Tigers of Tamil Eelam (LTTE), an internationally recognized terrorist organization banned in 31 countries, was far more responsible for the condition of Sri Lanka’s Tamil civilians today. If nothing else, I feel a moral compulsion to remind the readership of the BMJ that there are two sides to every story. In her piece, Dr Suntharalingam, flatly accuses successive Sri Lankan governments of blocking access to medicine as a weapon of war against the Tamil people living outside the military controlled areas in Sri Lanka. In order to bolster her assertion, she continues to provide facts that underwrite her own preconceived convictions. Not only is this accusation completely baseless, but nothing could be further from the truth. In fact, even as the Liberation Tigers of Tamil Eelam (LTTE) continued to declare a de-facto state against the Sri Lankan government, continued to assassinate democratically elected politicians – both Sinhalese and Tamil, bombed civilian targets such as commuter buses, temples, public squares, and airports, it was the Sri Lankan ministry of health that provided LTTE- controlled regions with physicians, paid their salaries and sent supplies of medicines to civilians under rebel control (all at the Sri Lankan tax- payers expense). Even the physicians who worked in LTTE-controlled areas (some of whom were murdered by the LTTE) were appointed to those regions by the ministry of health. These very provisions by the Sri Lankan government sustained the continued pseudo-statehood of the LTTE’s Tamil Eelam enabling them to hold civilians under their control, and allowing them to disregard the laws of the land from which they were extricating resources. If the government did indeed fail to provide medicines to civilians under LTTE control, it was more often than not due to embargoes placed by the LTTE against the very people it claims to represent. For example, a few months ago, the UN strongly reprimanded the LTTE for hoarding BP-100 high-energy food for use as snacks by rebel fighters, when these foods were distributed by the government intended for malnourished civilians . Similarly, the entire world witnessed the use of child soldiers and civilians as human shields by the LTTE in the last phase of its military struggle . Despite these obvious transgressions, I wonder why Dr Suntharalingam’s entire article is devoid of any blame to an internationally renowned terrorist organization. Is her purpose to seek attention to a humanitarian crisis that has arisen due to a civil war, or is she implicitly exculpating the LTTE of any wrongdoing by blaming the Sri Lankan government? In fact, in December 2004, I had the displeasure of a personal encounter with the LTTE. I was a volunteer health worker in Sri Lanka right in the aftermath of the Tsunami. I led a contingent of medical supplies that were donated from various charities in the United States to the war-torn eastern province of Sri Lanka. Right as we were about to enter the LTTE-controlled area, these supplies and the trucks carrying them were confiscated at gunpoint by the LTTE and we were told that any aid to their territory should be handed over to the Tamils Rehabilitation Organization (TRO), the organization at the time that was spearheading the LTTE-sponsored aid distribution. Now with the benefit of hindsight and with the confessions of leading LTTE members who recently plead guilty in New York for LTTE-fundraising, we know that the TRO was nothing short of a front organization for the LTTE’s military campaign, and that the donations earmarked for tsunami victims were largely used for weapons procurement . Civilians in the tsunami-devastated regions were left to suffer, and Sri Lankans were accused of ignoring their brethren in war-torn regions. This is only one of the examples among many that explain why the Sri Lankan government "appeared" to have placed embargoes on the public under LTTE-control, blame that is conveniently misplaced by Dr Suntharalingam. Dr Suntharalingam also asserts that the Sri Lankan government prohibited international political observers from visiting conflict areas. To this, I ask whether any other government would have done differently. If the government discouraged President Bill Clinton from visiting areas outside of government control, it was out of genuine security concerns because those areas were by definition “out of government control”. The LTTE had a notorious taste for political assassinations, especially of leaders who were unsympathetic to their methods (The assassination of Indian Prime Minister, Rajiv Gandhi is a case in point). Given that the LTTE was banned in the United States under President Bill Clinton’s watch in 1997, why is it surprising that Sri Lanka did not want to give LTTE another opportunity? As a matter of fact, on March 5, 2007, the LTTE opened fired at the Ambassadors from Germany, Italy, France, Japan and the United States, while they were making a goodwill trip to visit displaced civilians . I will concede to Dr. Suntharalingam, that the conditions in the camps for Internally Displaced People (IDPs), requires significant attention. These camps were built out of necessity, as the rate of influx of civilians out of the clutches of the LTTE during the last phase of the war significantly outstripped government resources to provide rehabilitation and resettlement services. Moreover, the speed at which people were escaping rebel control created an easy escape route for LTTE- leaders intermixed with the civilian exodus. Several suicide bombings that occurred at security checkpoints in IDP camps exemplify just how successfully the LTTE has disguised themselves as IDPs. These matters create concurrent security concerns interspersed with the humanitarian situation unfolding in Sri Lanka, and perhaps explain why the government has been reluctant to release many IDPs. Nevertheless, I do agree that the majority of people in these camps live under squalid conditions with limited medical access, and under constant security and supervision. Indeed, the government of Sri Lanka must do more to improve conditions in these camps, must accelerate the process by which people are screened and released from these camps, and must provide a systematic process for these civilians to be re-integrated into society. I also recognize the need for the Sri Lankan government to allow international aid agencies, particularly the UN, to provide access to civilians in these camps to assist with resources that the government lacks. Despite these issues, I completely reject Dr Suntharalingam’s accusation that the Sri Lankan government used the health of its citizens as a bargaining chip, or the notion that it used medicine embargoes as a weapon of war. Let us not forget that the majority of the Tamil community in Sri Lanka lives outside of these IDP camps. Roughly half of the Tamil populace in Sri Lanka lives outside of the Northern Province largely assimilated with other ethnic groups in the rest of the country. The impression that the democratically elected government of Sri Lanka is systematically endangering the health of a minority community, and using “health as a weapon of war” espoused in her article, is both misleading and irresponsible. While I wholeheartedly agree that a lot needs to be done to help all Sri Lankans trying to rebuild a nation in the aftermath of a three-decade civil war, I would like to remind Dr Suntharalingam to be more careful in assigning blame to a single party in this conflict. There are two sides to every story. SOURCES/REFERENCES : 1 . “Confirming details from Vanni and Mullaitivu Hospitals”, North East Secretariat on Human Rights, Report, Jan 6-13, 2009. http://tamilinsight.org/mydesk/blog/nesohr-confirming-details-on-victims- from-kilinochchi-and-mullaithivu-hospitals/ 2. “UN Denounces Miuse of Food Destined for Children”, IRIN News Agency of the UN Office of Coordination of Humanitarian Affairs. March 12, 2009. http://www.irinnews.org/Report.aspx?ReportId=83430 3. “Amnesty International Slams LTTE human shield”, BBC News Sinhala Service. http://www.bbc.co.uk/sinhala/news/story/2008/08/080815_ai_civilians.shtml 4. “Four plead guilty to conspiring to provide material support to the LTTE, a foreign-terrorist organization: Defendants include the leader of the LTTE in the United States, and one of the LTTE’s senior arms procurement agents”, June 9, 2009. U.S. Attorney General’s Office, New York. http://newyork.fbi.gov/dojpressrel/pressrel09/nyfo060909.htm 5. “Three Ambassadors hurt in LTTE attack” India New Online, March 5, 2007. http://news.indiamart.com/news-analysis/three-ambassadors-hu- 14964.html Competing interests: None declared Sri Lanka: health as a weapon of war? Please give Sri Lanka a chance 30 June 2009 Dharani K Hapangama, Clinical lecturer Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS Send response to journal: Re: Please give Sri Lanka a chance Dear Editor, As a long standing member of the BMA, it brings me immense sorrow to see articles such as Suntharalingam et al 2009 published in the BMJ (1). My impression of BMJ until then was as a premier medical journal publishing articles which are evidenced based, professionally responsible and reviewed by experts in the field (Medical science). Alas, how wrong have I been? This particular so-called “personal view” of Dr Suntharalingam is full of inaccurate, evidence-less, biased account of a civil-war and supports one of the most brutal terrorist organisations the world has encountered. It further suggests that BMA sympathizes with this terrorist outfit which is banned by many countries in the world including the UK. The Liberation Tigers of Tamil Eelam (LTTE) repeatedly used suicide bombings in public places killing many civilians (2, 3). They have also attacked Sinhalese villages in areas they regard as their own and murdered unarmed civilians (4). They murdered anyone opposing their views including many Tamil politicians / Human Right Activists (5). Few examples are Mr Lakshman Kadiragama SL foreign Minister, and Dr Thiruchelvam (Human Right Activists) (6, 7). We did not see BMJ publishing an article condemning the murder of Dr Rajini Thiranagama (a Tamil medical doctor and human right activist) by the LTTE (8). They also murdered many international political leaders (Indian prime minister Rajiv Gandhi, Sri Lankan premier Mr Premadasa) (9, 10) and they have destroyed a generation of Sri Lankan Tamils by recruiting them as child soldiers (11), held over 300,000 civilians as human shields and killed many fleeing civilians in the recent conflict (12). The UN recently reported that the Sri Lanka government has improved the access of the foreign humanitarian organizations to the internally displaced and Secretary-General Ban Ki-moon has said that the Government has addressed some concerns he raised during his recent visit to Sri Lanka over humanitarian access to the camps (12). Dr. Indika Karunathilake, Director, Medical Education Development and Research Centre, Faculty of Medicine, University of Colombo, Sri Lanka, who recently co-ordinated a medical camp (consisting 27 doctors from Colombo) at Ramanathan transitional relief village at Manik Farm, Northern Sri Lanka has provided me with the following information on the current medical service provision to the Internally Displaced Persons (IDP) in well-fare camps. According to him, there are a total of 16 hospitals situated near the IDP welfare camps, and over 6741 IDPs are being treated at these hospitals. The most recently established camp is said to have 60 doctors, 57 qualified nurses and 30 pharmacists working. Furthermore, 3 secondary hospitals has been set up to operate near the camps with 25 doctors, 40 nurses, 100 Red Cross volunteers, 15 public health workers and 15 family planning representatives. 232 doctors have been newly assigned to treat the patients in the IDP welfare camps to conduct daily clinics and to stop epidemics spreading. Sri Lanka is a 3rd world country with limited resources, and one has to be aware of difficulties faced by such government trying to make the best conditions possible for 300,000 persons until it is safe for the IDPs to return to their home (e.g. clearing of the landmines, booby-traps set by the LTTE during the war). According to the US Congress delegation led by Congressman Heath Shuler (Democrat – North Carolina), the said conditions in New Orleans refugee camps (not been able to provide safe drinking-water and no facilities to prevent the spread of epidemics) after Hurricane Katrina in USA seems to have been much worse than the conditions in the IDP camps in northern Sri Lanka (13). If one equate what Sri Lanka is doing for her IDPs to what USA, with all her might did for their New Orleans counterparts, we should commend rather than criticise the efforts of all Sri Lankans (with the help of many NGOs that are working in partnership with the government) in rebuilding their nation. Finally after 30 years Sri Lanka is in a position to reestablish as a nation in harmony, respecting all races included. Please do not attempt to disrupt their endeavors by publishing such irresponsible and bias views. Obviously as medics we cannot claim to be the experts of international politics. For this reason and for the credibility of BMJ, I urge you to post an apology to Sri Lankan people and refrain from publishing such damaging articles where you have no expertise in. D Hapangama, Liverpool, UK References: 1. BMJ 2009;338:b2304 2. http://www.guardian.co.uk/theguardian/2009/apr/22/1987-colombo-bus- station-bomb 3. http://news.bbc.co.uk/onthisday/hi/dates/stories/january/31/newsid_4083000/4083095.stm 4. http://en.wikipedia.org/wiki/Aranthalawa_Massacre 5. (Dr Nadesan is a Tamil journalist) http://www.srilankaguardian.org/2009/05/no-more-tears-for-tamils.html 6. http://news.bbc.co.uk/1/hi/world/south_asia/4147482.stm 7. http://news.bbc.co.uk/1/hi/world/south_asia/406644.stm 8. http://news.bbc.co.uk/1/hi/world/south_asia/4835142.stm 9. http://en.wikipedia.org/wiki/List_of_attacks_attributed_to_the_LTTE 10. http://news.bbc.co.uk/onthisday/hi/dates/stories/may/21/newsid_2504000/2504739.stm 11. www.who.int/disasters/repo/15210.pdf 11. http://www.un.org/apps/news/story.asp?NewsID=30785&Cr;=sri+lanka&Cr1;= 12. http://www.un.org/apps/news/story.asp?NewsID=31129&Cr;=sri+lanka&Cr1;= 13. http://www.nowpublic.com/world/conditions-idp-centres-are-standard-and -impressive-us Competing interests: None declared Sri Lanka: health as a weapon of war? Liberation Tigers of Tamil Eelam (LTTE) as terrorist organisation 30 June 2009 M Perera, Consultant Glasgow, G4 8SJ Send response to journal: Re: Liberation Tigers of Tamil Eelam (LTTE) as terrorist organisation Dear Editor, It is a shame that the BMJ decided to publish a biased & inaccurate article on Sri Lanka. As a longstanding member of the British Medical Association I strongly feel that the association & its Journal should not go into areas it has no expertise in such as international politics without a proper understanding of all aspects of a conflict. The article gave the impression that the British Medical Association sympathises with one of the most brutal terrorist organisations the world has known. The Liberation Tigers of Tamil Eelam (LTTE) have killed & maimed thousands of innocent civilians by using suicide bombers in public transport & public places, They had child soldiers as young as 9 years, Used civilians as human shields, Killed fleeing civilians during the recent battles & murdered anyone opposing their views including many Tamil politicians. For the first time in 30 years Sri Lanka has got a chance to rebuild the country in unity & respect for all irrespective of race, gender or creed. Give the government of Sri Lanka & her people a chance. M Perera Scotland Competing interests: None declared

ANALYSIS: Getting the priorities right for stroke care Sudlow and Warlow (4 June 2009) [Full text] Getting the priorities right for stroke care Assisting PCTs in spending wisely and well on stroke services 30 June 2009 Nigel Dudley, Consultant in Elderly / Stroke Medicine St James's University Hospital LEEDS LS9 7TF Send response to journal: Re: Assisting PCTs in spending wisely and well on stroke services The fact that Cathie Sudlow and Charles Warlow show that there are problems with the NAO’s arithmetic - that interestingly have not been challenged after two weeks - should be of concern.[1] The NAO’s 2005 stroke report outcomes and savings figures were republished in the Committee of Public Accounts own July 2006 report; that report was made “to the House” so if concerns were suspected about the figures the Committee should have been warned so as to avoid the possibility of making misleading claims in the report. Those reports have been driving stroke service funding decisions and the focus of the National Stroke Strategy on acute care. It is hard to believe that with known NNTs for the effects of thrombolysis and stroke units of the variety pointed out in the tables in Sudlow and Warlow’s paper that it cannot have struck anyone in either the Department of Health or the NAO before July 2006 when the Committee reported to the House that those NAO report outcome and savings figures were inaccurate as demonstrated by Sudlow and Warlow. The two tables in Sudlow and Warlow’s paper should now aid all PCTs in England in making far better choices around how to spend the taxpayers’ money wisely and well rather than relying on either the NAO or Committee stroke reports’ figures and recommendations. The focus of time, energy and resources over recent years on access to acute imaging and thrombolysis has been detrimental to rehabilitation developments as shown by the 2008 Royal College of Physicians audit findings in relation to Early Supported Discharge and Community rehabilitation teams. NHS London’s decision to spend £21 million of taxpayer’s money “for the acute hospital costs” and just “£1 million for rehabilitation and community care costs as a result of changes in the acute system” [1] looks rather odd when the Department of Health’s own excellent 2007 Impact Assessment work shows that net benefits of the National Stroke Strategy are delivered by Early Supported Discharge and community rehabilitation. At present NHS London would not appear to be commissioning a comprehensive stroke service for the capital. It is possible that there is yet more funding to come for stroke services in London that will soon be announced in July when decisions are made about the location of the eight hyperacute units. The longer term rehabilitation requirements of the local 7.2 million NHS London population do need to be addressed as clearly shown by Sudlow and Warlow’s paper. [1] Sudlow C, Warlow C. Getting the priorities right for stroke care. BMJ 2009;338:b2083 Competing interests: None declared

EDITORIALS: The future of female doctors Winyard (3 June 2009) [Full text] The future of female doctors Women in medicine- the debate must move on 30 June 2009 Graham P A Winyard, Retired PG Dean SO239TE Send response to journal: Re: Women in medicine- the debate must move on None of the responses to my editorial address a key point in the RCP report, namely the tension between the needs of doctors in training for work/life balance and the needs of patients for continuity of care. Calls for "the NHS" or "employers" to adapt sound utterly reasonable, but often have significant cost and quality implications that must be weighed against other priorities. Specifically funded part time training was critical when medical working hours were so much longer than for other staff. As a 48 hour week is achieved, many other professional and managerial groups in the NHS may challenge such special arrangements. These will have to be justified in terms of benefits to patients, not to doctors. The two are not synonymous as your correspondents imply. Competing interests: None declared

NEWS: Hanumappa Sudarshan: the quiet reformer Coombes (30 April 2009) [Full text] Hanumappa Sudarshan: the quiet reformer We need more such Dr.H.Sudarshans! 30 June 2009 Vinathe Sharma, Academic Researcher India & Australia Send response to journal: Re: We need more such Dr.H.Sudarshans! I had a good opportunity of visiting Karuna Trust project area at Biligirirangana Betta in Karnataka in 1993 and also interviewing Dr.Sudarshan personally. My article appeared in ANDOLANA daily newspaper published from Mysore city in Karnataka in May 1993. The conservation of medicinal plants including Ayurveda clinic, the primary health, elementary education and life skills enhancement programmes that were run at the project were making a tremendous positive change in the lives of hundreds of Soligas who were caught up in modern development. It is a shame that despite the presence and work of Dr.Sudarshan and others corruption and political vandalism is still rampant in Karnataka state. We need more such Dr.Sudarshans!! Competing interests: None declared

VIEWS & REVIEWS: "I want to see the consultant" Crampsey (15 April 2009) [Full text] "I want to see the consultant" Irresponsible Medicine: Disrespect and the Junior Doctor 30 June 2009 Prof. D.L. Steinberg, Professor Warwick University CV47AL Send response to journal: Re: Irresponsible Medicine: Disrespect and the Junior Doctor The position advocated by Dr Crampsey in his article 'I want to see the consultant' is arrogant and self serving. The clinical encounter is not an occasion for a junior doctor to serve his sense of self-importance, entitlement or authority. It is not an occasion to engage in point scoring with patients or to indulge oneself in dismissive, distainful and crude judgements that malign the character and motivations of patients. It is an occasion for responsible, respectful and skilled engagement with patients over the subject of their welfare and health. To suggest otherwise is to demonstrate a serious deficit in the author's own clinical competence and suitability to see patients. It might behoove Dr Crampsey to consider how extraordinarily distressing it can be for patients to be forced to grapple with the kinds of medical problems that require a consultant to be involved at all. A desire for continuity of care, for an experienced clinician, and for a baseline of respectful interaction with whomever the patient consults are not unreasonable. Self advocacy by patients on behalf of their own medical welfare, as they see it, is not a form of discrimination. Indeed, there is a considerable literature that has noted that patients who are prepared and able to take assertive responsibility for their own welfare fare better than those who are passive, silenced and compliant. It is the health service that must find a way to responsibly grapple with question of how to ensure training opportunities for junior doctors without compromising patient health and safety. It is the health service that is responsible for seeking fairness across services for patients. These are unquestionably difficult questions for medical and nursing personnel. However, neither of these obligations is the personal responsibility of individual patients. Nor is the clinical encounter a place to legitimately rehearse this debate. Patients may not have a 'right' to see the consultant. But they explicitly have the right to make such a request and to have their wishes and their self care taken seriously. It is a gross abuse of the clinical encounter for a junior doctor to take offense at such a request from a patient or to treat it as a 'challenge' (to his own authority). To categorically dismiss such request, as Dr David P Crampsey advocates, intrinsically violates 'politeness' and profoundly compromises patient care. Competing interests: None declared