CORRESPONDENCE
Not covered by CIRS 1–5 6–10 11–15 16–25
2
3
4
5
Department of Health. Planning for major incidents: the NHS guidance. London: Department of Health, 1998. Horby P, Murray V, Cummins A, MackwayJones K, Euripidou R. The capability of accident and emergency departments to safely decontaminate victims of chemical incidents. J Accid Emerg Med 2000; 17: 344–47. Crawford IWF, Mackway-Jones K, eds. The structured approach to chemical casualties, 2nd edn. Manchester: Advanced Life Support Group, 2002. The Public Health Laboratory Service. Deliberate release: guidance for health professionals. http://www.phls.org.uk/ topics_az/deliberate_release/menu.htm (accessed Mar 13, 2003).
The neglect of child neglect The rate of chemical incidents reported to the CIRS per million population by strategic health authority (July to December, 2002)
A nationally funded training standard, the “structured approach to chemical casualties”,4 has been cascaded down to all ambulance services and emergency departments. The aims of this half-day individual skills course are to ensure staff understand the use and limitations of the NHS-specified chemical personal protective equipment, understand the method and limitations of individual casualty decontamination, and understand the initial and further treatment of chemical casualties. The treatment component focuses on those chemicals identified as likely to be used in a deliberate release scenario. Information on these chemicals is publicly available from the UK Department of Health public health laboratory service.5 There has been a great deal of progress nationally in chemical incident preparedness, particularly in ambulance services and emergency departments. The results reported by Connor and White might not be truly representative because of the small numbers of participants in their study. Furthermore, the positions held by those surveyed is not given. Since chemical contaminants will be removed before advanced life support we would question the need for specific training of anaesthetists or intensivists in the initial management of a chemical incident. *Ian Crawford, Kevin Mackway-Jones, Virginia Murray *Department of Emergency Medicine, Manchester Royal Infirmary, Manchester M13 9WL, UK (IC, KM-J); and Chemical Incident Response Service, Guy’s and St Thomas’ Hospital, London, UK (VM) (e-mail:
[email protected]) 1
Connor DJ, White SM. Preparedness of London hospitals for a chemical weapons attack. Lancet 2003; 361: 786–87.
Sir—In your Feb 8 Editorial (p 443),1 you question the commitment of paediatricians to child protection and its research. If the scale of the problem is as great as implied, it would indeed be a shameful indictment on the profession. The reality is somewhat different. Cases of serious child abuse are relatively rare and account for only a fraction of the workload of a general paediatrician in the UK. In our location, no more than one in 1000 cases is seen. Many more children die of other treatable diseases such as meningococcal sepsis. Less severe cases of child abuse are more common but still only account for around 1·5% of our contacts with patients. However, the work generated by all cases of child abuse is disproportionately high and extremely stressful. By contrast with the positive response achieved by treating general illness, paediatricians working in the field of child protection are subject to frequent criticism and even campaigns of vilification. For example, the hounding of David Southall because of his research into child abuse2 and other high-profile cases. Is it any wonder that so few paediatricians choose to work in the field of child protection? It is not just health professionals that need to get their house in order. The judiciary in particular, where an adversarial system rarely works in the interests of the child, and the process of justice discourages child protection. A root and branch reform geared to the interests of the child is desperately needed. A good example to start with would be the Swedish Government report on Child Protection published in August, 2001. Sweden has the lowest recorded rate of child death by abuse in the world. In the UK, we have a society where an adult’s right to hit a child is granted greater
THE LANCET • Vol 361 • April 26, 2003 • www.thelancet.com
importance than a child’s right to protection, and a popular press seeking sensation before facts. We have a long way to go before the blaming of paediatricians is likely to make a difference. William H Lamb The General Hospital, Bishop Auckland, County Durham DL14 6AD, UK (e-mail:
[email protected]) 1 2
Editorial. The neglect of child neglect. Lancet 2003; 361: 443. Boseley S. Parents’ campaign ‘success’. Guardian Unlimited Dec 10, 1999. http://www.guardian.co.uk/uk_news/story/0, 3604,245700,00.html (accessed Feb 27, 2003).
Sir—I challenge the view expressed in your Editorial of Feb 81 that child maltreatment research is neglected by the medical profession because it does not attract drug-company funding. We need also to look at attitudes within the medical profession. More than 100 years ago, doctors failed to recognise child sexual abuse as important in the transmission of gonorrhoea in children. As new evidence was introduced about the fastidious nature of the gonococcus, theories remained unchanged.2 In the textbooks held at Melbourne University Library from this era, 50% of those that mention child sexual abuse deny it as a cause of gonococcal vulvovaginitis in children. No mention is made in any of the texts of incest or male family member abuse, but 18% blame female household members for transmission. Professional statements were openly hostile: “Very rarely indeed is [vulvitis or vaginitis] the result of attempted rape, and such charges are often brought against innocent persons simply because mothers conclude that all discharges from the genital organs in children must be venereal; and it should be remembered that some children are led to invent stories or to confirm suggestions made by ignorant or dishonest mothers”.3 The same textbooks acknowledge sexual transmission in adults and deny contact transmission, but maintain the opposite for children.4 Doctors in primary care today describe difficulty dealing with the disclosure of abuse in women and children. Reasons include lack of education and training, a perception that it is not “real medicine”, victim blaming, time, fear of or identification with perpetrator, and identification with the victim.5 Child abuse remains an uncomfortable area for much of the profession. Is our present inability to see child abuse as real medicine a reflection of
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