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Round the World

From our Correspondents

Singapore, Malaysia, and Burma

FORTY YEARS ON

THE visit last September of the Royal College of Physicians toSingapore and Malaysia gave me the opportunity to revisitSouth-east Asia after 40 years. In 1945, when 47 British GeneralHospital took over the Alexandra Hospital in Singapore from theJapanese, we watched from the ship’s rail the emaciated survivors ofChangi and other prison camps crowding on to the quayside. A fewdays later we treated the more severely ill in hospital. Each patientbrought with him a battered tin or a ragged bundle containing hisfew possessions, carefully hoarded during imprisonment. The mainproblems were beri-beri, pellagra, and undernutrition, often withchronic malaria, amoebiasis, worm infestation, and scabies.

Fortunately a consignment of the unpleasant-tasting aminoacidmixture concocted by scientists in Britain had been stowed at thebottom of a ship’s hold, and we were able to feed our patients ongradually increasing amounts of normal food. No sooner had themajority of prisoners-of-war been evacuated from Singapore thanwe were faced with a new disaster. Between October 4 and 15, 1945,forty-one patients with acute methyl alcohol poisoning wereadmitted to hospital. Cheap wine or coloured water had beenadulterated with commercial methyl alcohol looted from stores leftby the Japanese. Five patients were dead on arrival at the hospitaland five died shortly after admission. The majority of the survivorsrecovered fully but two were completely blind 6 weeks after theepisode, two could see enough to avoid collisions when walking, andthree had field defects.

Singapore was unrecognisable after 40 years. A few streets of oldChinese houses and shops remain, and Raffles Hotel standsuncertainly amid the high-rise blocks. Ever since I attended the firstpost-war orchestral concert by musicians of many races, Singaporehad impressed me as a successful multiracial city. Today, it is athriving commercial and industrial community. English is

compulsory at school and children must also study one other officiallanguage that is not their mother tongue. Surprisingly, theAlexandra Hospital remains largely unchanged, though the mainmedical centre is now the National University Hospital. Thestandard of medicine seemed very high; I taught in their

postgraduate (M Med) course and I also attended two case-conferences on Kawasaki disease and neonatal tetanus. I discoveredthat Graves’ disease is relatively more common in the Chinese thanin the other major ethnic groups in Singapore (thyrotoxicosis inChinese is significantly associated with HLA group BW46, incontrast to B8 in Caucasian patients).

After Singapore, we spent a few days in Malacca, which is still asleepy little town, cherishing its historic buildings which date fromthe Portuguese and Dutch occupations that preceded the arrival ofthe British. Kuala Lumpur, capital of Malaysia, is now a largecommercial centre with a population of one million. The medicalscene had changed greatly since my last visit. Yaws has disappearedand malaria is very rare and occurs only in the indigenous tribes, theOrang Asli, who live in the forests. Ascariasis remains very commonand secondary lactose intolerance is frequent in children. One of themain preoccupations of the paediatric department of the NationalUniversity of Malaysia is non-accidental injury and sexual

abuse, which occur in all ethnic groups and at every level of society.A condition which was new to me was poisoning with margosa oil,which produces a clinical picture similar to Reye’s syndrome.Margosa oil is an extract from the neem tree and is a traditionalpanacea in the Indian subcontinent and South-east Asia. In KualaLumpur there is a movement to replace English with Malay for theteaching of medicine. This step would be a handicap for Malaysiangraduates wishing to study abroad and might discourage visits fromEnglish-speaking specialists. Both in Singapore and Malaysia therewas regret that the fees for overseas students in Britain were so highand condemnation of such a short-sighted policy. Elections were in

progress in Malaysia and it was impossible not to be aware of thefrustration of the large and economically successful Chinese

community at their relative lack of professional and politicaladvancement.We flew, via Bangkok, to Rangoon for an 8-day visit to Burma. In

Rangoon it rained most of the time and was very hot; we dranknumerous bottles of a mineral water optimistically called PH7. Thecity had the same unshaven appearance that I had noticed in 1945and 1946; but the Shwe Dagon Pagoda shone with newly appliedgold leaf when the sun eventually came out. After 2 days in Rangoonwe flew on to Heho in the Shan State. "Now we have fun", said ourThai guide, hopping out of the plane into a ramshackle bus. The sunwas shining, there was a pleasant breeze, and everyone was smiling.We visited the limestone caves of Pindaya, which contain 500statues of Buddha, the markets of Aung Ban (a well-grown calffetches 2000 chats, or C200), Taunggyi, and the Inle Lake famousfor its unique leg-rowers. Our visit to Taunggyi coincided with a natfestival in the neighbouring small town of Toungoo. There are 37nats or spirits in the animistic religion, which predated Buddhism inBurma and which has been absorbed into the fabric of BurmeseBuddhism. At first sight the festival looked like an ordinary fair witha big wheel, food stalls, and fortune tellers. The focal points were thewooden stages for nat dancing, a curious mixture of informality andreligion. The female nats were represented by male dancers, whocome from a small number of families with a long tradition ofproducing these dancers. Members of the audience who wished topropitiate a particular nat brought their gifts on to the stage or couldbe seen praying silently during the dance. From time to time thedancer would slow down or stop for a cigarette or a drink, orsuddenly throw a shower of small denomination notes among theaudience. After Taunggyi we returned to the heat and dust ofMandalay and ended our trip with a visit to Pagan, with itshundreds of 13th and 14th century temples and pagodas.

I knew that Burma had cut itself off from outside influences since

independence in 1947; this was understandable after 61 years underBritish rule (tactlessly, from Delhi), and 3 years under the Japanese.Nevertheless, I was unprepared for so little change in the traditionalway of life. Certainly people were better fed and better clothed thanafter 3 years of war, and there was an abundance of produce in themarkets and goods in the shops. Medical services are free in thissocialist state and medical aid was easily available. Why is it that thereturning visitor’s highest praise is "It hasn’t changed a bit?"Allowing for some sentimentality about the past, I am sure that theBurmese have made the right choice and that their gentle way of life,inextricably bound up with Buddhism, could not survive theinvasion of the bankers and the multinationals.

JOHN BLACK

United States

AN ABUNDANCE OF PHYSICIANS?

THE number of medical students who have graduated or will doso in the next few years has aroused alarm in the profession andamongst politicians and economists. The latter have emphasisedthat more physicians do not produce the competition that mightreduce the costs of medical care. So medical schools cut down onadmissions. The evidence of an over-production of physiciansseemed dubious, considering the situation in many small towns andrural areas, the ages of those who practise there, and the number ofphysicians suspended or forced to limit their practice in rural areasbecause of the ease of looking after patients in small hospitals.

In some of the larger medical centres, however, there has beenconcern over inexperienced interns and residents treating patientsat night and weekends without supervision. Traditionally, juniorstaff work very long shifts with little or no sleep or time off. Thisordeal, advocated by senior physicians, was designed to enablejunior staff to cope with fatigue, stress, and emergencies but newdrugs and diagnostic and monitoring systems have added to theburden. In a New York City hospital, a young woman, seen only by

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an intern and an inexperienced resident, was admitted with highfever, given the wrong medication, and tied to the bed because of heragitation. She died of undiagnosed meningitis. No steps were takento control her fever. Inquiries revealed a most unsatisfactoryabsence of supervision.As a result, the State Health Commissioner has recommended,

endorsed by a committee from the major medical centres, that theshifts of interns and residents be reduced to 12 hours with 8 hoursoff duty and that a full-time fully trained physician be placed inevery busy emergency room. Some hospitals believe they can copeby rescheduling hours on duty; others say they must employ extrastaff. It seems likely that more junior staff will be needed, especiallyif other states make similar changes. This confusion is compoundedby the mounting numbers of patients with AIDS. Perhaps there isno abundance of physicians after all.

Occasional Book

JOBLING’S BITING FLIES

FROM the very beginning of scientific entomology shapes,colours, and structures of insects had for the naturalists anextraordinary fascination. The iconography of the insectworld is immensely rich, and the range of entomologicalillustrations extends from the naive but evocative woodcutsin Hortus Sanitatis published in 1491 in Mainz, throughMaria Merian’s famous plates in Metamorphosis InsectorumSurinamensium of 1719 or John Curtis’s engravings forBritish Entomology (1834) to the refined and poeticalmodern water-colours of Vere Temple.No one who looks at the work of a dedicated scientific

artist like Signor Terzi, the illustrator of many of Sir PatrickManson’s studies on the role of insects as vectors of tropicaldiseases, can fail to be impressed and enchanted by theirscientific accuracy and elegance. But there are few scientistswho are masters of the knowledge involved and have theartistic talent needed to make the subject alive by its sheervisual impact.One of them was Dr Boris Jobling, a former staff member

of the Wellcome organisation, whose posthumous atlas ofdrawings of medically important insects has just beenpublished, thanks to the generosity of the British Museumof Natural History and of the Wellcome Trust. Jobling’slife had a touch of romance and adventure. Born in Russia of

an English father, an engineer employed on the railways, andof a Russian mother, he studied entomology and proto-zoology at the University of Moscow and worked at theFreshwater Biological Station on the Oka river. Imprisonedduring the revolution he was eventually repatriated toEngland and worked at the Wellcome Bureau of ScientificResearch in Wisley and London.He published a number of papers on biting flies, ticks, and

laboratory technique. He contributed illustrations forseveral books by Wenyon, James, Buxton, and Hoare; thesebooks have now become classics in parasitology andentomology. He died in 1985 and left the numerous

drawings that now form the Jobling Collection. The presentvolume contains 356 drawings of various sizes and types;they include the sandfly (Phlebotomus papatasi), the yellowfever mosquito (Aedes aegypti), the blackfly (Simulium),the deerfly (Chrysops caecutiens), and the stable fly(Stomoxys calcitrans); they depict their external andinternal anatomy as well as details of their sensory, feeding,and copulating structures.The drawing technique is remarkably varied, ranging

from clear and precise line to the incredibly fine shading bytiny dots. The effect is startling, almost 3-dimensional andvery impressive, as shown in the accompanying figure.The book is introduced by the late Dr David Lewis of the

department of entomology, British Museum National

History, who also wrote a brief biography of the artist andincluded his photograph. A note on the Jobling Collection ofother drawings, a list of 300 abbreviations of anatomicaldetails, and a bibliography numbering 90 items complete thehandsome volume.The editing, printing, and binding of this book are

impeccable and of rare distinction. The sponsors, editors,and publishers deserve our thanks for paying a memorabletribute to Boris Jobling’s scientific contribution, for savingthis set of entomological drawings from oblivion, and forallowing us to admire their scientific perfection and intrinsicbeauty.Wellcome Tropical Institute,London NW1 2BQ L. J. BRUCE-CHWATT

1. Joblmg B. Anatomical drawings of biting flies. Edited by David J. Lewis London.British Museum Natural History m association with the Wellcome Trust. 1987.Pp 119. ISBN 0-565010042. £9.95

Longitudinal section through body of a female Aedes aegypti.