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THIRD WORLD DEBT CRISIS

SIR,-Dr Summerfield’s essay (Sept 2, p 551) is a stunninglynaive exercise in neo-marxist economic illiteracy. If Summerfieldhad prescribed leeches to treat gout you would have dismissed hisarticle out of hand, yet you printed a commentary that recommendsequally outdated, discredited, and harmful therapy for the maladiesof underdeveloped economies.

Summerfield’s only accurate assertions are that the debt burdenis blocking development and, in so doing, hurts the poorest peoplein the countries the most, and that this crisis was created byirresponsible western bankers and corrupt domestic elites. Hisstatistical substantiation is impressive, but this insight is neitheroriginal nor any longer a topic of debate. The question facing us nowis what to do-and it is here that Summerfield’s piece collapses.He criticises International Monetary Fund austerity packages

because they "specify the abolition of government subsidies forbasic foodstuffs, medicines, school books, and so on". In otherwords, he is recommending that third world nations borrow moremoney and dig themselves deeper into debt to prolong a period ofartificial prosperity and so make the eventual reckoning even morepainful. Subsidies cannot be maintained indefmitely; costs spiralout of control, as in any government exercise which attempts torepeal the free market, until the government is forced to default onits debt or end subsidies. Summerfield also defends "the publicwage bill", a code phrase for fat salaries to the unproductive elites(now ensconced in debt-financed air-conditioned high-riseaccommodation) who conspired to create this mess at the expense ofthe poor people in the fields. The solution is not to repeal the freemarket but to straighten out kinks in the economy so that the nationcan develop and the people can raise their income enough to buyfood at real world prices-and the first step in that process is toeliminate the web of government subsidies and distortions which

discourage food production by farmers.In a classic exposition of the intellectually flaccid "dependency

theory", Summerfield goes on to tie this all to the supposed500-year-old continuous conspiracy by the western world,somehow dating all the way back to slavery, to keep the third worldnations impoverished. Every study that has attempted to measure"dependency" has discovered (to its great disappointment) that themore dependent nations (such as Mexico) develop faster than theless dependent ones.

Summerfield proposes that debt-ridden nations "turn away fromthe dominant development paradigms, to direct economic activityaway from the international markets and towards the real needs oftheir peoples". This is known as the "Albanian model" of

development (see also Cuba and North Korea): isolation, distortion,stagnation, and perpetual poverty. Summerfield has done for debtwhat Marx did for capitalism, brilliantly enumerating its problemsand proposing a vague, poisonous "cure".

2125 Lynwood,Champaign, Illinois 61821, USA ERIC KROCK

INFORMING PATIENTS

SIR,-Dr Tattersall (July 29, p 280) and Dr Pelosi (Sept 2, p 564)report that they send to patients copies of their letters to generalpractitioners. I too believe that parents (or patients)—except inexceptional circumstances-have the right to know my assessmentof their problem.

I have completed a pilot study of parents’ (patients’) reaction andresponse to my sending them copies of all correspondence (mostlyto the family doctor) relating to their care. Along with my letter ofexplanation and a copy of the outpatient letter, I asked parents byquestionnaire whether they found the practice helpful or unhelpful,whether it made them worried or less worried, and whether theywished the practice to be repeated on future occasions. They werealso requested to discuss any concerns or misunderstandings withmyself, or their family doctor, by telephone.

Of 253 families questioned, 225 responded. Of these, 222 repliedthat the practice was helpful, made them less worried, and wished itto be repeated. 2 found it helpful and wished it to be repeated, butthey had been worried by a letter with a hospital franking mark until

they knew the content. 1 family found the letter helpful and causedless worry, but they did not wish it to be repeated. I have receivedtwenty-seven telephone calls, mainly expressing interest and

requesting further information. Three general practitioners wereunhappy with the practice, mainly because they felt that theconsultant’s opinion should be exclusive to them.With this practice, I have not needed to change the letter I would

have written in other circumstances. I have not excluded anypatient. Occasional discrepancies between what familiesunderstood at the consultation and what was written in the lettershave been easily resolved. The hospital administration had concernsin respect of the medicolegal implications. I consider the practicewill improve doctor/patient relationships and reduce the need toresort to the law courts.

I accept that patients might find medical terms difficult tounderstand and that doctors might have to modify their letters.Nevertheless, I believe that the benefits of this practice greatlyexceed the disadvantages and problems. After all, parents have theright to know what we are doing to them and for them; and why notin writing?Children’s Hospital,Birmingham B16 8ET GEORGE RYLANCE

MATURE ENTRANTS TO MEDICINE

SiR,—I was interested to read the details of the survey done byMr Wakeford (Sept 16, p 679). Presumably the reply to thetelephone inquiry that his research assistant received from ourmedical school was included in the "equivocal" group. In view ofthis he is correct in his conclusion that would-be applicants shouldwrite for formal information.Three years ago Leeds Medical School decided to increase the

number of mature students (aged 21-30) to about 10% of the intakeand our number of entrants in this category has been 11 in 1987,12in 1988, and 18 in 1989.We conduct a considerable correspondence with potential

mature applicants, giving full details of our policy and offeringadvice and encouragement to many excellent candidates. I wouldwish to support Wakeford’s suggestion that medical schools shouldconsider increasing the number of mature entrants. My mainconcern is related to the fees they will have to pay in the future. Mostmature applicants do not qualify for a mandatory local educationauthority grant and are therefore self-funding. Increased"economic" fees, as proposed by the Government, will do morethan any admissions policy to curtail the entry of these students tomedical school.

Medical School,Leeds LS2 9JT PETER D. HOWDLE

LOCAL APPLICATION OF HYPEROSMOLARGLUCOSE SOLUTION IN TUBAL PREGNANCY

SiR,—Conservative management of tubal pregnancy by localinstillation of prostaglandinsl can cause severe systemiccomplications and methotrexate can produce uncontrolled localnecrosis. We have attempted to induce local necrobiosis and thusspontaneous healing in unruptured tubal pregnancies by injecting ahyperosmolar glucose solution through a laparoscope.The project was approved by the university ethical committee

and all patients gave informed consent. 18 patients with an

unruptured tubal pregnancy and a human chorionic gonadotropin(HCG) urinary concentration of 5000 IU/1 or under were randomlyassigned to treatment with either prostaglandin (n = 9) or glucose(n = 9). Prostaglandin was applied as described by Egarter andRusslein.2 In the patients treated with glucose, about 15 ml (range,10-20 ml) of a 50% solution was instilled. Prostaglandin treatmentwas successful in 8 of 9 patients. HCG excretion ceased after 17 (6)days. 1 patient with persistent HCG excretion and imminent tubalrupture underwent relaparoscopy and salpingotomy. Glucosetreatment was successful in all 9 patients. HCG excretion ceasedafter 19 (9) days. Patients treated with glucose were subjectively wellafter the procedure, while 6 of 9 treated with prostaglandin reported