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example, the General Medical Council de-recognised in 1975 allundergraduate medical qualifications from Indian universities.Doctors wishing to enter the country for work had to pass a specialexamination for registration. Many foreign graduates believe thatthe standard and the pass rate of that examination are determined bysupply-and-demand factors for doctors in the United Kingdom.These actions by the GMC led the Indian Medical Council toreciprocate and to de-recognise British qualifications. As a resultmemberships and fellowships of the Royal Colleges are no longerregistrable by the IMC, thus deterring some Indian graduates fromcoming to Britain. The decision of the British Government toimpose restrictions on the entry of foreign doctors from April 1,1985, was a final blow to the hopes of graduates wishing to enter thecountry for work. ,

Similar difficulties existed for Indian graduates in the USA.Where they had been welcomed by American hospitals and even hadtheir fares paid at one stage, they found that by the late ’70s thesituation had deteriorated and the welcome had all but disappeared.By 1985 things had reached a crisis, with American medicalstudents graduating at the rate of approximately 17 000 per year.The number of new medical jobs available annually is almost20 000, so only 3000 jobs are available for foreigners. Of these 2000go to those Americans who graduated outside the US, thus leavingonly 1000 posts available for doctors wishing to enter from nearly100 different countries. Several Bills are now before the US

Congress which seek to restrict foreign doctors from residencyprogrammes. One of these stipulates that for any medical institutionto become eligible for Government funds, not more than 25% of itstrainee doctors should be from abroad. These deterrents in the USand the UK, together with a decline in demand for foreign doctors inthe Middle East, have effectively blocked most points of exit forIndian medical graduates.

Privately a number of senior medical politicians in India arepleased with this outcome, although they are reluctant to say so. DrJ. Sood, secretary of the IMA, refused to commit himself on whetheror not this kind of restriction is advantageous or not for India. Hedid state, however, that if some doctors’ "self-respect" allowedthem to go to countries where they would be discriminated againstand where they would find few if any training opportunities, thenthey were free to make that decision.

Standard of Postgraduate EducationAre India’s doctors being deprived of the "respected" post-

graduate education available in the West? A wide consensus amongIndian medical academics is that the standard of postgraduatemedical education in a number of Indian institutions, such as theAIIMS, is comparable to that in the West. Furthermore, accordingto Professor Bhargava, fewer graduates than ten years ago wish to goabroad for training. Nevertheless she had to admit that the standardof postgraduate education varies tremendously throughout thecountry, because of differences in funding and in the quality ofteaching. After the de-recognition of British medical qualificationsin 1976, the National Board of Examination was set up to try tostandardise postgraduate education throughout India. The Boardoffers an examination leading to membership of the Academy ofMedical Sciences in a particular specialty, and it is now not only theGovernment of India’s policy but also the policy of medicalinstitutions to give preference to doctors with Indian postgraduatequalifications rather than those of the Royal Colleges so prized inthe past.In view of this attitude to Western training, it is perhaps not

surprising that the Government has no policy to attract back Indiandoctors working overseas. For one thing, as Dr Bhatla pointed out,doctors residing overseas are "machine oriented", and there is littleneed for their skills in the smaller towns and villages. Furthermorethe big towns and cities are now so saturated with doctors that theassimilation of newcomers is judged likely to cause difficulties.India is now able to train more than enough doctors to meet her

basic needs, and to offer some of them a high standard of post-graduate education. She is determined tcr depend no longer on theWest, either for the return of her doctors working there, or for theprovision of postgraduate education.

PETER KANDELA

United States

MORE RESTRAINTS ON MEDICAL COSTS

THE "reasonable charge" basis of American medicine has beenunder attack. The Government proposed amendments to theMedicare and Medicaid programmes that would, for the first time,apply limits to all items and services that are not provided through ahealth maintenance organisation and that are now reimbursed on anunrestrained "reasonable charge" basis. The affected services anditems are estimated to be worth about$1.15 billion in the fiscal year,1984, and were said to be rising at an annual rate of 15%. Theyinclude: durable medical equipment (eg, oxygen equipment,wheelchairs, hospital beds); ambulance services; prosthetic devices,braces, artificial limbs, and artificial eyes; portable X-ray services;and certain medical supplies used in connection with home dialysisdelivery systems.The proposal tied reimbursements to the economic index

restraint mechanism now in place for physicians’ services. Medicarepayments for clinical diagnostic laboratory tests would be frozen for15 months and thereafter fees would be set. Medicare deductibles

(the portions of medical costs borne by the patients themselves)would be raised annually, tied to the rate of inflation. The mostsignificant change would be the abolition of theMedicare-Medicaid patient’s freedom to choose a physician orother health professional for non-mandatory services and supplies.There is some evidence that medical costs are being controlled. In

California, the rate of increase in hospitalisation cost dropped to lessthan a half of what it was 3 years ago. Hospital costs were climbingby 20% in 1981 and 1982, but the first half of 1985 showed anincrease of only 9.1 % over the previous year. Charges for a hospitalstay of about a week still averages$5948 in California, wherehospital costs have long been the highest in the country. But,starting in 1982, the state has been negotiating rates with hospitalsfor patients on Medi-Cal, the state’s health-care provision for thepoor. Almost 15% of the patients in hospitals are Medi-Calrecipients. Another 40% of the patients in Californian hospitals areon Medicare, the Federal health programme for the aged and thedisabled.

Private insurance companies are also allowed now to negotiaterates with hospitals. Before this triple assault by the state, Federal,and private insurers on hospital expenses, hospitals were paidsimply for their cost, which were rising almost uncontrolled. Inrecent years, however, fewer patients have been entering hospitalsand their stays have become shorter. Competitive pressure hasforced hospitals to cut staff and equipment.

It is not known whether these changes are detrimental to patients;and research on the effects of cost-cutting on health is hard toachieve. Some critics complain that the changes forced the earlyrelease of patients who would benefit from a longer stay in hospital.It would take only one well-publicised incident attributed to theaction of a cost-cutting bureaucrat to rekindle the flames of thecontroversy over cost and poor patients’ health.

ORGAN TRANSPLANTS: PREFERENCE FOR THE WEALTHY ?

CONGRESSIONAL hearings in Washington showed that largenumbers of foreign nationals are travelling to this country forkidney transplants at a time when 8000 Americans are awaitingkidneys. The Government of Saudi Arabia told Senator Gore(Tennessee) that 114 of its citizens had received transplants here inthe past three years. In some cases there is a strong suggestion ofpreferential treatment. Reportedly, some US surgical services

charge a higher fee for kidney transplants, as much as five timeshigher, when the patient is a wealthy alien.A representative of the End-Stage Renal Disease Network related

an incident where a dialysis patient was told to stand by because twokidneys have become available. The patient was considered a goodmatch. Later, it was discovered that both kidneys had gone to non-immigrant aliens. It is impossible to determine whether the personin question was the best match or whether he was passed over forfinancial reasons. Washington Hospital Center data show that theforeign recipients have approximately one-third the waiting time ofAmerican recipients before a transplant takes place. Almost 50% ofthe kidney transplants in this Centre were received by foreign

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nationals in 1983 and a similar ratio was found at New York’sDownstate Medical Center.Another finding was that hundreds of donated kidneys are wasted

every year in this country-or sent overseas when matches cannot befound here. Abroad, they fetch$8000-$12 000 in procurementcosts. For example, 575 kidneys obtained by the SoutheasternOrgan Procurement Foundation from 1982 to 1984 were sentoverseas or were "wasted" because of lack of match with US

recipients.A financial issue that surfaced at the hearings was that the number

of patients that could receive transplants may be kept artificiallylow. Dr Paul Terasaki, director of the Southern California OrganProcurement Agency, estimated that 30% of the patients on dialysiscould benefit from a transplant, but only 10% are awaiting one. Hesaid that doctors now taking care of the dialysed patients arereluctant to transfer control of the patient to a specialty that is moreoriented toward transplantation. Some nephrologists own dialysiscentres in the US.

Further developments were the appearance of a company thatcoordinated kidney transplants for foreign nationals and advertisedbroadly in the foreign press to induce foreigners to have their organstransplanted at particular US hospitals and the emergence of abrokerage for organ donors, inviting donors to put up their organsfor auction to the highest bidder. Some of these activities relating tokidneys were suppressed by 1983 but threats remain of similarenterprises coming on the scene in relation to hearts. To preventfinances ruling medicine-at least in this area-the Task Force onOrgan Transplantation will recommend to Congress the use of UScitizenship as a criterion for receiving donated organs. One possibleoption is to place a limited number of foreign nationals on organtransplant waiting lists through the use of a quota system. Once onthe list, foreigners would be treated as equal to US citizens. ManyTask Force members view organs as scarce national resource.

Recommendations in the report will serve as voluntary guidelinesfor organ distribution in hospitals.

In England Now

FOR a short time Giles was known by a nickname which recentlyhas become quite common. His sobriquet was earned some years agowhen he moved into the modern development which has nowbecome part of our village. The houses were new and every familyhad the unenviable task of creating gardens out of clay and builders’rubble. Top priority was given to making a front lawn. Thisrequired the ground to be cleared of bricks and stones and, afterlevelling, the admixture of copious amounts of sand. It became thehabit of many to wheel a barrow in the evening down towards thesite where further houses were being built. And when the watchmanwas off for his unofficial but regular visit to the local tavern, to loadthe aforesaid barrows with sand. In fairness, I suspect the contractorknew of the practice but in the interests of good communityrelations and the economics of having adjacent dwellings withattractive gardens, turned a blind eye to the situation.When Giles’ new neighbour arrived he surveyed his frontage

mournfully. "Not to worry," said my friend, "I know where there issand aplenty. Come along with me." And so saying they made theirway to the site where together they hid behind a hut until thecaretaker disappeared. Quickly Giles loaded up his barrow and,united in crime, they returned to their respective gardens whereGiles demonstrated the art of mixing earth and sand to form thebasis of a green sward. "Now," he said. "It’s your turn. I think thereis just about time for another load." His new-found friend hesitated."Don’t worry," said Giles. "We all do it. This is how we make upour lawns." His comrade still demurred. "Well," said Giles,"Tomorrow then. But bring your own barrow and make sure thewheel is well oiled."Next morning Giles chanced to glance out of the front window

while dressing. He was just in time to see his new neighbour, in thefull uniform of an assistant chief constable, step irto a police car tobe driven to work. For some months, thereafter, Giles was known inthe village as "supergrass".

* * *

THIS week’s visit to that circular chamber in north-east Londonwherein the official inquiry into Mrs Wendy Savage’s obstetricpractice is taking place was prompted by the warning issued by SirJohn Walton, President of the General Medical Council, whodeclared earlier in the week that the public nature of the proceedingscompromised patient confidentiality. Mr Christopher Beaumont,QC, chairman of the inquiry, had, however, already ruled that thecases under investigation were to be referred to by the patients’initials only. So I found the same small number of the public inattendance. Luckily, I also found the same case (see Lancet, Feb 15,p 376) under scrutiny. Prof Jurgis Grudzinskas, Mrs Savage’s headof department at the London Hospital, who had set in motion thetrain of events culminating in Mrs Savage’s suspension, had

declined last week to condemn outright her management of MrsA. U.’s delivery. Mrs Savage had agreed, in response to a familyplea, that Mrs A. U. should attempt vaginal delivery, even thoughshe had had a previous caesarean section, the infant was presentingin the breech position, and her pelvis was small. The infant died 8days after delivery by caesarean section. The case was described thisweek as an "obstetrician’s nightmare", by Prof John Dennis, of theUniversity of Southampton, who had been asked to give an expertopinion. Professor Dennis criticised Mrs Savage’s handling of thecase, on the grounds that a trial of labour exposed Mrs A. U. tounacceptable risk. He argued that he would not have expected anyinfant to emerge undamaged as a result of her management and healso suggested that a trial of labour in such unpromisingcircumstances was unkind.

* * *

I HAVE related before in this column the censoriousness of the

young towards the pecadilloes of the elderly. This spoil-sportattitude extends to legal liaisons.Not so long ago I was summoned to a local authority old people’s

home by a highly-agitated matron. I was told, in a voice filled withhorror, that Alec had proposed marriage to Ivy, and had beenaccepted. This seemed to be a perfectly reasonable, indeed laudable,state of affairs. I could think of no reason for matron’s

agitation-other than my private knowledge that she herself hadcarelessly omitted to involve either a minister of religion or a

registrar before cleaving unto the man who shared her flat. So Ienquired why the business of Alec and Ivy was so terrible.

It was explained to me, patiently, that Alec was very fit, had beenmarried previously, and, what was more, was an ex-naval man. Thushe would, it was felt, wish to exercise his conjugal rights to thefullest extent. Ivy was a spinster, and could not, the staff felt sure,have any idea of what was coming to her.Ignoring the implied slur on the Senior Service, I asked what I was

supposed to do. It was my duty as a psychiatrist, I was told, to certifythis man and, by incarcerating him in hospital, prevent him havinghis evil way with this inoffensive and innocent maiden. This, ofcourse, I refused. However, I found myself manoeuvred into theposition of having to find out whether Ivy knew the facts of life, andof enlightening her if she did not.

I chatted to her for a while about Alec, and then cautiously-afterall, she was old enough to be my mother-asked her if she realisedthat there was something Alec would definitely want from herbeyond mere companionship and platonic friendship. Her eyessparkled with pleasure and excitement as she answered, "Ohyes!"At this point I gave my blessing to the union and withdrew.

Alas, it was not to be. Officialdom would not tolerate the situation,especially when chivvied by Ivy’s family, which saw its long-awaited, if modest inheritance slipping from its grasp. Alec wasmoved to another home, twenty miles away, and no contact, noteven letters, was allowed between the two sweethearts.A few weeks later, Ivy died, still a virgin.