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HEAT ILLNESS AND THE ARMED FORCES

SiR,—I read with great sadness your editorial on heat illness andthe armed forces (Sept 30, p 782). Dr Linsell, in his letter in thesame issue (p 803), asks: "Has nobody learned anything since1948?" Regrettably, the answer is no. I "retired" as a medical officerin the Royal Army Medical Corps (RAMC) 5 years ago. During myservice I took a keen interest in heat illness. As a result of myexperiences I can categorically state that the figure of 400 cases ofheat illness, admitted by the Ministry of Defence between 1978 and1986, is a gross underestimate. During the late summer of 1979 theincidence of heat illness induced by the training methods of theParachute Regiment in particular reached epidemic proportions. Iwas at that time working as a casualty officer at the CambridgeMilitary Hospital, Aldershot, and hardly a day passed without atleast one case of heat illness.

During my two years service in the British Military Hospital,Hong Kong, in 1980 and 1981 I received further unwanted

experience of heat illness, and the associated rhabdomyolysis andmyoglobinuria. I saw one officer die with renal and hepatic failuresecondary to heat illness (despite the best efforts of the superb RoyalAir Force renal team flown out from the UK). Within a couple ofmonths we had to recall the team to save the life of a Gurkha withrenal failure secondary to heat illness; he survived. While working asa medical officer at the Royal Military Academy, Sandhurst, Ireceived further cases of heat illness (at least 40 cases during thespring, summer, and autumn).One of the main features of severe heat illness is hypovolaemia

and shock. As a result the patient feels cold: to a layman it seems thatthe patient is too cold, not too hot, which often leads to

inappropriate action. Many of these patients also act in an almostpsychotic/psychopathic fashion. They are aggressive and rude (ifstill conscious) and this, in a military setting, also leads to

misdiagnosis by the layman.I do not think that the average officer or instructor has the

slightest idea that heat illness is potentially fatal. Nor do I think thatmost instructors are even interested. But for prompt intravenous

rehydration and cooling by medical officers of the RAMC, theMinistry of Defence would be facing a far higher case fatality rate. Ido not see an end to this problem while the ignorance and disinterestof those who train soldiers and officers persists.

The Surgery,Swallowfield,Reading, Berks RG7 1QY N.J. RIDDELL

IMPROVING THIRD WORLD HEALTH

SIR,-Unfortunately the situation that Dr Summerfield hasresearched so carefully (Sept 2, p 551) is not that simple. Thedisparate statements from the World Bank and the UN Children’sFund-one suggesting improvement, the other disaster-do forceone to judge the issue, but it is facile to cast the World Bank andInternational Monetary Fund (IMF) as the bad boys who need toloosen their pursestrings.

Yes, the IMF has specified the abolition of government subsidiesfor basic foodstuffs, but poor farmers see that as the lifting of unfaircompetition. The "very poorest on earth" must live in Africa assubsistence farmers. They grow all they eat, and their standard ofliving can only rise as the price of foodstuffs rise. One cannot bothdecry the fall in food prices and object to the raising of subsidies, asSummerfield does. For the poorest it would be great if the price ofbasic foodstuffs were to rocket.One West African country lives off rice imports which are sold at

such a subsidised price that local farmers have no incentive to growany. However, the subsidised rice is being sold by rich businessmento neighbouring countries for twice the subsidised price, creatingshortages within the country.The IMF has not been happy with fixed exchange rates. These

may benefit government officials who have access to hard currencyat official rates to buy their expensive cars. The local people have nosuch access to the official rate and are in a dilemma, being forced tosell their basic foodstuffs to the government at a fixed price andforced to live off the black market rate for anything that is importedby local traders.

Ghana went through an economic collapse from 1980 to 1984,when shops were as good as empty. Since the IMF plan was put intopractice in 1986 the country now gives the external appearance ofopulence, even though prices are high. Therefore to quote anincrease in malnutrition during 1980-84 undermines

Summerfield’s case against the IMF.The United States has reduced its contributions to many overseas

health ministries and choose to give their aid to non-governmentalorganisations. They understand even if Summerfield does not thatmassive financial assistance will help only the elite, unless it is givenimaginatively.Some of the fmancial policies of the IMF and USA can thus be

defended but it remains morally indefensible and scandalous thatthe Western world is demanding such staggering amounts ofinterest from Africa. How can the very rich demand so much fromthe very poor? Not even the most corrupt country in the worldwould tax its poorest citizens like that.There are more enlightened countries, such as Canada which has

been aiming for the past 10 years to give away 4% of FederalGovernment revenues. Unfortunately the date for implementingthis policy is constantly being postponed for short-term political,military, and other self-interest reasons.

Is it too much to expect politicians to become morallyresponsible? Can we hope that with lessening worldwideconfrontation and conflicts a small part of the vast sums spent on

weapons might trickle down to those who need the money most?The best that I or Summerfield can do is to keep the issue in thepublic eye, but let us not oversimplify a complex problem and let usnot blindly push our own particular political persuasions.ELWA Hospital,1000 Monrovia 10,Liberia PHILIP B. WOOD

BODY PARTS FOR MEDICAL RESEARCH

SIR,-Your Round the World correspondent (Aug 5, p 323)criticises a request by the New York State Health Department thatthe State’s attorney general take civil or criminal legal action againstanyone who secures or provides body parts, without consent, formedical research. Your correspondent neglects to mention twofacts. The State Health Department found that the research hadnothing to do with the necropsy and New York State law includes aprocedure for the use of body parts in research with consent of thenext of kin. If the State legislature believes that a research-workershould be allowed to use body parts without consent, it can amendthe strict constraints on such use now in the law.

Department of Health,State of New York,Albany, NY 12237, USA

PETER J. MILLOCK,General counsel

LIVE DONORS AND HEPATIC TRANSPLANTATION

IR,—i-Totessor Kaia and colleagues (Aug Lb, p 4y ) report liver

transplantations from two living donors.The use of living related donors goes back to the early 1950s in

kidney grafting. Kidneys are paired organs and it was assumed thatdonors were subjected to little immediate harm and no long-termharm. Although living related kidney grafting is still widelypractised in the United States and results in outstandingrehabilitation for the recipient, it is not without some morbidity forthe donor1 and doubts about the long-term function of the residualkidney persist.2 The liver is a non-paired organ and, althoughsegments can be safely excised, the removal of liver segments II andIII, so that the vascular pedicle is suitable for reimplantation,requires a more extensive dissection. Even in experienced handsthis surgery may not be as free of risk as standard liver dissection

techniques can be.In one of the cases reported from Brazil the donor was not a

member of the child’s family. Recent experience in the UK remindsus that non-related donor volunteers may sometimes be motivated

by factors other than altruism. Concern about the danger ofunacceptable "traffic in donor organs" has resulted in legislationprohibiting financial and other inducements to living donors in theUK.