British medical journal

Side effects of lithium are a major factor in confined to second line use in those who do not non-compliance and contribute to its decreased usage respond to lithium, or who have significant and in the United States. Most patients who are prescribed unacceptable side effects due to lithium, and in patients lithium experience some adverse effects, though mainly of a minor nature.6 However, even within the therapeutic range the impact on thyroid function canbe profound. Overt hypothyroidism occurs in 5-10% of Department of Pharmacology and Therapeutics, University CollegeCork, Cork, Ireland (tdinan@indigo.ie) patients and 5% develop a goitre. Such effects arerelated to the dose and duration of therapy. Whether TD has received research donations for acting as a speaker and or not lithium results in memory disturbances is consultant and organising educational events for Eli Lilly and unclear, with a few studies reporting an effect but most failing to find any. Surveys show that many patientsrightly or wrongly associate lithium with deteriorationin their memory.2 Significant gain in weight on lithium Cade JFL Lithium salts in the treatment of psychotic excitement. Med JAust 1949;36:349-52.
is often a source of concern for women. Approximately Goodwin FK, Jamison KR. Manic-depressive illness. Oxford: Oxford one in four patients prescribed lithium put on weight Bowden CL, Calabrese JR, McElroy SL, Gyulai L, Wassef A, Petty F, et al.
of 5 kg or more. However, alternatives to lithium have A randomised, placebo-controlled 12 month trial of divalproex and significant side effects for many patients.
lithium in treatment of outpatients with bipolar I disorder. Arch Gen Psy- Despite declining use, especially in the United Macritchie KA, Geddes JR, Scott J, Haslam DR, Goodwin GM. Valproic States, the evidence base supports the view that lithium acid, valproate and divalproex in the maintenance of bipolar disorder.
should be the first choice prophylactic drug for most Cochrane Database Syst Rev 2001;3:CD003196.
Sachs GS, Printz DJ, Kahn DA, Carpenter D, Docherty JP. The expert patients with bipolar disorder. To date the alternative consensus guidelines series: Medication treatment of bipolar disorder mood stabilisers have not been as extensively 2000. Postgrad Med 2000;Special issue:1-104.
Cookson JC. Lithium: balancing risks and benefits. Br J Psychiat investigated. Valproate or carbamazepine should be Confronting the small arms pandemic
Unrestricted access should be viewed as a public health disaster
Physiciansthroughouttheworldbearwitnessto Datafromthedevelopingworldarelessclear,espe- the terrible consequences of small arms. But do cially in conflict situations. In many post-conflict coun- tries in Central America and Africa only a tiny epidemiology of the small arms pandemic, and can we percentage of guns are registered, estimates of the total devise effective strategies for prevention as we have for in circulation vary widely, and reporting of casualties other major public health issues? The capacity for col- may be affected by fear of the authorities. Nevertheless, lecting consistent, reliable, and relevant data is limited small arms were unarguably the primary cause of by various cultural, economic, infrastructural, and death in wars in the 1990s, accounting for about logistic factors even in developed countries not at war.
300 000 deaths a year.8 Together with the estimated Nevertheless, we have some solid data on the size of the 200 000 people who die each year from firearms in problem and indicators suggestive of possible solu- non-conflict situations these deaths represent about a quarter of the 1.8-2.3 million deaths due to violence in The United States, for instance, has over 28 000 a typical year in the 1990s.9 10 The victims are often the deaths a year from small arms—accidents, suicides, and youngest and healthiest members of society. Male homicides—the highest rate in the developed world.1 In combatants are the major perpetrators and direct that country firearms are the leading cause of death victims of small arms violence, but in many conflicts among 15-24 year olds, slightly ahead of vehicle crashes, and the third leading cause of death in those children—account for a large proportion of direct aged under 15.2 While the US murder rate without casualties and may also suffer the psychological and guns is roughly equivalent to that of Canada (1.3 social burdens of increased domestic violence.
times), its murder rate with handguns is 15 times the Impacts have also been evaluated in economic Canadian rate.3 Countries with similar cultural, terms. Small arms purchases account for perhaps economic, and ethnic make up but with different gun US$10bn (£6.9bn; €11bn) each year, a relatively small possession rates also have widely differing firearm proportion of the roughly $850bn spent on military death rates, roughly correlating with the percentage of forces annually worldwide.11 Yet the economic conse- households with guns.4 For example, Britain’s firearm quences can be far greater. In Colombia violence death rate is about 0.3 in 100 000 while the US rate is primarily related to small arms has been calculated as 10.6.5 Households with firearms are three times more costing up to 25% of the country’s gross domestic likely to have murders and five times more likely to product (OV Vieira, Workshop on International Small have suicides (due to all causes) than similar Arms/Firearms Injury Surveillance and Research, households without firearms.6 7 These data suggest that firearm deaths may be preventable by controlling the Unless weapons are removed when hostilities end, casualties may not be substantially reduced. In the BMJ VOLUME 324 27 APRIL 2002 bmj.com
mid-1990s in Afghanistan, for example, Meddings national Physicians for the Prevention of Nuclear War found a decline in the rate of weapons related injury, (IPPNW) has used the public health paradigm to call before and after a particular region came under for the abolition of nuclear weapons and to support uncontested control, of only 20-40% when weapons the global ban on landmines. With the convening of an international medical conference on small arms last Supply side strategies such as buyback and amnesty autumn in Helsinki, IPPNW announced its intent to schemes have been tried in countries such as the campaign for policies that can reduce firearms related United Kingdom and Australia. In response to massa- injuries. The conference drew more than 200 cres at Dunblane and Port Arthur, those countries participants—physicians, researchers, social scientists, tightened regulations, the former banning handguns peace activists, representatives of governments and and the latter semiautomatic rifles. British citizens vol- international agencies, and students—from six conti- untarily turned in 250 000 weapons, while the Austral- nents to address gaps in our knowledge, propose areas ian buyout programme netted 750 000. Law enforce- for research, and ponder educational and advocacy ment officials in both countries affirm the effectiveness of these measures in reducing damage by these The next steps will be to determine data on which to base recommendations for policy change and com- Many argue that a supply side approach alone is munity action; standardise databases and collection inadequate, and various demand side measures have methods across the world; heighten awareness about been proposed. Awareness building and educational the public health and social consequences of small programmes to promote cultures of peace; inter- arms among local, national, and international policy national norms that stigmatise the possession of guns; makers; and inform professional colleagues, students, and programmes to reintegrate former combatants and the public about the multiple causes and the dev- into society and to provide real economic opportuni- astating consequences of small arms violence.
ties have all been postulated to reduce harm fromsmall arms, but are more difficult subjects of study. In Neil Arya family doctor and president of Physicians for Mozambique a unique project, Tools for Arms, combines supply and demand side approaches. The 99 Northfield Drive, Waterloo, Ontario, Canada N2K 3P9 buyback of weapons, the metal of which is turned into art, provides compensation for gun owners, givingthem new economic opportunities.
International humanitarian law may be applied to Centers for Disease Control Atlanta. www.cdc.gov/nchs/data/nvsr/ restrict weapons that cause damage disproportionate nvsr49/nvsr49_12.pdf. Accessed 10 April 2002.
to war aims. Whole classes of weapons could be Centers for Disease Control and Prevention. Rates of homicide, suicideand firearm related death among children—26 industrialized countries.
banned from civilian possession, just as landmines and MM Weekly Report 1997;46:101-5.
other indiscriminately harmful weapons have been Cukier W. Firearms regulation: Canada in the international context.
Chronic Diseases in Canada 1998;19;25-33.
banned from military and civilian use. Although it Goldring N. Bridging the gap: light and major conventional weapons in recent seems clear that restrictions on the possession of conflicts. Toronto: International Studies Association, 1997.
weapons are necessary to prevent harm due to small arms, such restrictions are fiercely opposed by highly Kellermann AL, Rivara FP, Somes G, Reay DT, Francisco J, Banton JG, et organised, wealthy, and influential groups such as al. Suicide in the home in relation to gun ownership. New Engl J Med1992;327:467-72.
America’s National Rifle Association. The failure to Kellermann AL, Rivara FP, Rushforth NB. Gun ownership as a risk factor reach meaningful agreement to control illegal manu- for homicide in the home. N Engl J Med 1993;329:1084-91.
Project ploughshares: armed conflicts report. Waterloo, Ontario: Institute of facture and trafficking in small arms at the recent United Nations conference on the illicit trade in small Cukier W. Firearms/small arms; finding common ground. Canadian For-eign Policy 1998;6:73-87.
arms and light weapons was partly the result of the 10 Reza A, Mercy JA, Krug E. Epidemiology of violent deaths in the world.
Injury Prevention 2001;7:104-11.
Public health models could be used to evaluate the 11 Boutwell J, Klare MT. A scourge of small arms. Sci Am 2000; June:48-53.
12 Meddings D. Weapons injuries during and after periods of conflict: retro- effectiveness of each preventive approach. Inter- spective analysis. BMJ 1997;315:1417-20.
Health care and the European Union
Profound but uncertain consequences for national health systems
Slowly,inhealthandsocialaffairsministriesacross Yetthescopeforactionisoftenuncertain.Afailure Europe, the realisation is dawning that European to address health care explicitly at a European level Union law has profound consequences for the means that the evolving legal situation is based largely organisation of national healthcare systems. Even in the on policies designed to address broad principles, in United Kingdom, which for many years was in a state of particular the free movement of goods, services, active denial about the influence of Europe, ministers people, and capital. These are then applied to the are looking at how to exploit the opportunities offered health sector in rulings on specific cases brought by provisions on free movement of patients (to France) before the European Court of Justice, but leaving and professionals (bringing teams of German surgeons uncertainty as to how they should be interpreted in to operate at weekends in NHS hospitals).
similar but slightly different circumstances. The BMJ VOLUME 324 27 APRIL 2002 bmj.com

Source: http://www.ippnw.org/pdf/BMJAryaSmallArms.pdf