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team sees other settings as equally appropriate-community’ centresand general-practice premises, for example. Size of membershipshould be limited according to the nature and structure of theneighbourhood, the type and quantity of facilities available, and thenumber of people the staff can hope to know by name. That thesuccess of any Peckham-type venture depends essentially on theenthusiasm, commitment, and authority of the team leader wasdemonstrated recently by the failure of a planned project in theScottish new town of Glenrothes after the death of a key member ofthe team.

1. Total participation, total health. Reinventing the Peckham Health Centre for the1990s. Edited by Alex Scott-Samuel. Edinburgh: Scottish Academic Press, 1990.£3.50 (plus 50p postage). ISBN 0-707306302.

Britain-Nepal Medical Trust

It is said that the valley traversing Nepal was once the bed of ahuge lake and that the god Vishnu-the second god of the Hindutriad-cut a passage through the hills with his sword to release thewater. The longitudinal river basins and watersheds that Vishnu leftnow provide fertile land for temperate and subtropical crops. TheBritain-Nepal Medical Trust (BNMT) has also reached a

watershed of sorts with the death of Dr John Cunningham, one ofits founders, in June, 1990. Nepal has recently passed through aperiod of unprecedented political upheaval. Last year KingBirendra lifted a 30-year ban on political parties and allowed aninterim coalition government to be formed. The death penalty formurder and subversive activities was lifted, laws restricting politicalactivity and press freedom were repealed, and a multipartycommission completed a draft of a new constitution. All this

instability led a Dutch charity to withdraw its funding of BNMTafter eight years of support, leaving the trust to raise over c250 000in 1991.Out of this uncertainty, the BNMT has redefined its goals and

offered an optimistic and constructive outlook for the comingyears.! Existing programmes directed towards tuberculosis (TB)and other drug schemes have continued to expand. A trial of sixmonths of short-course oral chemotherapy for TB began in May,1990, and will run for two years. The purpose of the trial is toimprove on the 12-month injectable drug regimen now in place.BNMT recognises that such vertical schemes run against the tide ofhorizontal development programmes currently emphasised byother aid agencies. To overcome criticisms of vertical intervention,street theatre has been introduced to convey simple health messagesto a wider audience in a culturally acceptable way; a women’sliteracy programme has enabled 718 women to read and write;Nepalese staff have been incorporated into community healthschemes; district public-health officers are to receive specialsupport; and a training unit has been established. These newprojects will begin to empower the Nepalese to set and implementtheir own health-care agenda.Whatever the BNMT achieves through its imaginative

programme for the new decade, little headway will be made unlessthe fledgling democracy of Nepal makes an equal commitment tohealth. The signs have not been good. The health developmentbudget has contracted because of the prevailing economicdifficulties: average annual expenditure on health is now US$1-6per person. However, the announcement of multiparty elections tobe held on May 12, 1991, for 205 seats in the House of

Representatives offers hope for those concerned with health inNepal.

1 Britain-Nepal Medical Trust. 22nd annual report, 1990. Pp 50. Copies available freefrom Stafford House, East Street, Tonbndge, Kent TN9 1HG, UK.

Guy’s Hospital Rugby Football ClubIn 1993 Guy’s Hospital Rugby Football Club, the oldest in the

world, will be celebrating its 150th anniversary. Graduates of Guy’swho want to learn more about plans to celebrate this event shouldcontact Dr T. Gibson, Guy’s Hospital, St Thomas Street, LondonSE19RT (071-955 4310).

In England Now

I have just returned from my first international meeting of theyear. It was held in Italy, already warmed by the early Spring sun. Ienjoy meetings like these because they involve a certain amount oftheatre. The presentations are really only to give some sort of formalstructure to the event. What matters most are the personalexchanges that take place before, during, and after the sessions,especially if they involve drink. In fact, there are a number of peopleI am unable to recognise, even after years of friendship, if they arenot holding a glass in their hand.

Several years ago I formulated the following model forinternational meetings that goes like this: (a) no matter the size of theaudience, at any one moment only half are listening; (b) of those whoare listening only half understand the language; and (c) of those thatdo understand the language only half understand the content. Ichristened this my Conference Reducing Audience Paradigm,which shrinks an apparent audience of say 2000 to only 250, and Ilike to use it to boost the confidence of first-time speakers.There is, of course, a certain amount on one-upmanship about

conferences. I arrived at the beginning and remained to the end,identifying myself as someone of little importance. Opinion leadersnever arrive on the first day and leave before the last, preferably byhelicopter. Entering and leaving the conference hall as often aspossible is vital; if there are any simultaneous sessions, this canoccupy the entire day. Walking out while a Nobel prizewinner isspeaking gets maximum points, especially if you contrive to shakeyour head in disagreement.

This time I attended my first press conference, a wonderful pieceof theatre: drinks were provided before and after, the presentationswere at a comfortably elementary level, and the questionsrefreshingly different and intelligent compared with those asked atthe professional sessions. One thing I especially enjoyed were theglossy photographs of the distinguished speakers, most taken whenthey were twenty years younger. Next day newspapers carriedaccounts of the session-incredible to those of us used to waitingthree months for proofs and another three months to see ourmasterpiece in print.

* * *

She was a very old lady with terminal left heart failure, and I was avery young doctor with only a failure in the membership to myname. Because she was so agitated I sat with her, holding her hand.It did not help her dyspnoea, but it seemed to allay her distress. Myboss, coming into the ward for a last look round before home,instantly grasped the situation. He took my other hand. "Look", hetold me, "the doctors who do most for their patients aren’t the onesthat sit holding their hands. They are the ones who go away and readup what they can do for the patient." We left the ward together. Iwent to the library and a little while later the patient died peacefully.

I am not sure why I recount these events. I am not sure whetherthey are related, nor whether they had anything to do with myeventually passing the membership. But I know that those foolishenough to contrast the scientific doctor with the caring doctor havesomething very important still to learn.

International Diary

48th annual meeting of the American Society of HospitalPharmacists is to take place in San Diego, California, USA on June 2-6:ASHP, 4630 Montgomery Avenue, Bethesda, Maryland 20814, USA.

7th international symposium entitled Endoscopic Ultrasonographywill take place in Munich on June 14-15: Dr Thomas Rosch, CongressSecretary, II Medizinische Klinik und Poliklinik der Technischen,Universitat Munchen, Ismaninger Strasse 22, 8000 Munchen 80, Germany(089 41401).

7th international conference on Low Level Radiation and Health willtake place in Bristol on June 22-23: Jill Sutcliffe, Conference OrganisingGroup, 7th Conference, Bristol City Council, Brunel House, St George’sRoad, Bristol BS1 5UY, UK (0243-603705).