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COMMENTARY ON THE ECED MEETING IN LONDON ON THE 12TH AND 13TH
SEPTEMBER, 2009
DEBATE AS AN EDUCATIONAL METHOD
When Hubert Lacey invited me to open the meeting on the 12th September I was naturally delighted. I felt privileged to welcome the participants who represented several nations. I also took the opportunity to highlight what has become the key feature of these meetings, namely the occurrence of debates. I anticipated that, as in the past, debates would generate powerful ideas and above all the discussion would be entertaining. I also anticipated that the format of the debates would be of high educational value. It turned out that I was right about the entertainment provided from the close engagement of the participants. But I was mistaken in my prediction of achieving an educational success.
My intention in presenting this mixed picture of the ECED debate is first to admit my limited powers of prediction and secondly to express honestly my disappointment as regards the limited educational success. I can make one safe prediction, and that is that my conclusions will generate disagreements. I am grateful to Gerry Butcher who has offered to have this commentary published on the EDEC website with an invitation to other participants at the meeting to respond. At this stage I wish to stress that no criticism is intended as regards the quality of the presentations, or the discussion. On the contrary, they were of an exceptionally high standard and led to a high level of engagement in the discussions. My criticism is mainly aimed at the format of the debates which on this occasion provided no resolution of polarised views and, even more disappointingly, failed to generate ideas from the available literature or suggestions for future research.
Debate One: “This house believes we should invest much more of our limited resources into preventing eating disorders”.
The protagonists were Runi Børresen and Greta Noordenbos. The opposer was Eric van Furth. (Unusually Eric opposed the motion on his own because the other opposer had met with travel difficulties).
My concern with this debate is that the motion deliberately omitted to define what was meant by “preventing eating disorders”. In particular a standard method of classifying types of prevention was not included. Consequently the proposers and the opposer quite shrewdly (and this is entirely fair) chose to select the type of prevention that suited their arguments. They did not disclose the three conceptual levels of prevention (primary, secondary and tertiary) proposed by Leavell and Clark in the late in1950’s, applicable to almost all medical conditions (quoted by Bertolote, 2009).
By primary prevention is meant preventing the appearance of the disease (or illness). It can be specific in type such as immunisation against an infectious disease, or non-specific such as improving the general health of the population.
By secondary prevention is meant the early detection and treatment of an illness with the preventive goal of avoiding chronicity and irreversible complications.
Tertiary prevention refers largely to rehabilitation whereby damage caused by the illness is reduced as much as possible and intact functions are preserved.
In the case of eating disorders attempts at primary prevention have so far included interventions for the benefit of adolescents in schools. But there has been a notable lack of success with these measures. Secondary prevention includes the early diagnosis of anorexia nervosa and the correction of nutritional abnormalities so as to prevent osteoporosis (for example). This would also apply to patients with bulimia nervosa whose illness would be cut short by an energetic course of cognitive behaviour therapy.
The proposers of the motion said it was very important to avoid severe weight loss and its complications, and recognised this as secondary prevention but ignored the limitations of primary prevention. The opposer to the motion quite rightly said that no one knew an effective way of preventing an eating disorder and evidently he was referring to primary prevention.
My conclusion is that both sides were aware of the obscurity of the wording of the motion and used the ambiguity to suit their own ends. To the audience the debate was like a Rorschach with each side reading what they wished in the ink blots.
Thus, my criticism is that the debate failed to elicit a classification of prevention for eating disorders. The proposers produced a list of references supporting their own arguments but did not summarise the evidence, or lack of it, for primary prevention. No doubt some of the audience saw their way through these obscurities but they would have benefited from a clarification of the taxonomy of prevention. This was an important educational gap in this debate.
Debate Two: “This house believes that information-sharing and carer involvement in the treatment of severe eating disorders should take precedence over confidentiality”.
The proposers of the motion were Fernando Fernandez and Susan Ringwood. The opposers were Erika Toman and Bridget Dolan.
The polarisation of opinion in this debate was very clear with extreme views being adopted. Eloquence was the hallmark of this debate. On the one hand there were dramatic accounts of extremely ill and depressed patients whose life would have been lost if there had been no sharing of information with the carers. On the other hand, the fundamental human right of privacy was presented as enshrined in European law and sacrosanct. The audience became fully engaged in asserting one or other extreme view with little room for compromise. The debate was exciting and even passionate at times.
In contrast, I thought that with the extreme polarisation of views there was a failure to explore a practical balance that should be reached in a clinical dilemma which is frequently encountered when treating eating disorders. On voting the motion was defeated, which means that in some instances the potential help from carers would be excluded. The dilemma is well recognised by family therapists treating adolescent anorexic patients. They become skilled at squaring this circle. It seems arbitrary, and wasteful, that after the legal cut-off age of 16 an adolescent patient could cut herself off from the help of an effective carer.
My one personal contribution was to admit that I did not know of any systematic research in the field of eating disorders to try to resolve the conflicts which are commonly experienced. In contrast there is a growing literature on how the participation of carers can be facilitated in the case of psychotic patients who do not consent to sharing information with carers (Slade et al, 2007). This research group at the Institute of Psychiatry recognised that carers require access to relevant information to support them in their role. Moreover, a “culture shift” is probably required to train professionals to work with carers. The article also points out that legal rights to confidentiality are not absolute. A useful practical recommendation is the distinction between general information about the patient, which can always be shared without consent, and personal information which is new to the carer where consent generally needs to be obtained. It is also important to record what the carer already knows, and keep an audit of the consent already given by the patient. Such practical advice can be valuable when clinical obstacles are met, such as an adolescent anorexic patient demanding that the clinician should not communicate with her parents or carers. Slade and his colleagues recognised that the sharing of information is a complex process, best balanced by clinical judgement.
My grouse about the second debate is that it was extremely strong in the expression of personal opinion but weak in recognising that in the field of eating disorders we need to emulate research that has already been achieved in other branches of psychiatry.
CONCLUSIONS
The two debates that took place at the Athenaeum were highly successful in engaging the audience, arousing interest and calling forth eloquent outpourings of opinion. They were both entertaining. On the other hand, they were both flawed in that there was insufficient recourse to established knowledge and no recognition of the need to inform opinion through research.
Gerald Russell
References
Bertolote, J.M. (2009). Primary prevention of eating disorders. In New Oxford Textbook of Psychiatry. Eds. M.G. Gelder, Nancy C. Andreasen, J.J. López-Ibor and J.A.R. Geddes. 2nd edition, vol II, chapter 7.4, pp 1447-1451. Oxford University Press, Oxford.
Slade, M., Pinfold, V., Rapaport, J., Bellringer, S., Banarjee, S., Kuipers, E. and Huxley, P. (2007). Best practice when service users do not consent to sharing information with carers. National Multi-method study. Vol. 190, pp 148-155. |
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Kofi Annan, the UN-Arab League joint special envoy for Syria, addresses the UN General Assembly on the latest situation in Syria at the UN headquarters in New York, June 7, 2012. (/Shen Hong)UNITED NATIONS, June 7 () -- Kofi Annan, the UN-Arab League joint special envoy for Syria, said here on Thursday that his six-point peace plan to end the Middle East country's 16-month crisis had not been implemented.Annan was speaking at the UN General Assembly on the latest situation in Syria.The peace plan, widely backed by the international community and officially accepted by the Syrian government, had failed to halt violence in Syria, Annan said, stressing that violence could not be allowed to become part of ordinary life in the country.Both the Syrian government and the armed opposition had failed to carry out the six-point plan, he said."Today, despite the acceptance of the six-point plan and the deployment of a courageous mission of United Nations observers to Syria, I must be frank and confirm that the plan is not being implemented," Annan said.The former UN secretary-general met with Syrian President Bashar al-Assad late in May in the Syrian capital Damascus to discuss the situation in the country.Annan said he told Assad during the meeting that "the six-point plan is not being implemented as it must," and strongly urged the Syrian leader to "take bold and visible steps to now radically change his military posture and honor his commitments to the six- point plan.""I also made clear that his government must work with my mediation effort on behalf of both organizations that I represent, " said Annan, who has been on a good offices mission on Syria for nearly two months.Annan's peace plan calls for the withdrawal of heavy weapons and troops from population centers, a daily halt in fighting for the delivery of humanitarian aid and treatment for the wounded, as well as talks between the government and the opposition."If things do not change, the future is likely to be one of the brutal repression, massacres, sectarian violence, and even all-out civil war," Annan warned. "All Syrians will lose.""Clearly, the time has come to determine what more can be done to secure implementation of the plan -- and/or what other options exist to address the crisis," he said."It is your shared interest -- and our collective responsibility -- to act quickly," he told the General Assembly. " The process cannot be open-ended.""The longer we wait, the more radicalized and polarized the situation will become, and the harder it will be to forge a political settlement," he added."The international community has united, but it now must take that unity to a new level," Annan said. "We must find the will and the common ground to act -- and act as one. Individual actions or interventions will not solve the crisis.""As we demand compliance with international law and the six- point plan, it must be made clear that there will be consequences if compliance is not forthcoming," he said. "We must also chart a clear course for a peaceful transition, if we are to help the government and opposition, as well as Syrian society, to help resolve the crisis."
SEOUL, March 30 () -- South Korean shares ended lower on Friday, the three straight day of decline, as investors took to the sidelines amid lingering concerns over the global economic recovery, but the fall was limited due to hopes for the possible rebound in undervalued stocks, analysts said.The benchmark Korea Composite Stock Price Index (KOSPI) inched down 0.37 points, or 0.02 percent, to close at 2,014.04. Trading volume stood at 445.2 million shares worth 5.25 trillion won (4.64 billion U.S. dollars).After fluctuating in and out of negative terrain, the KOSPI closed slightly down as investors still worried about the outlook for global economy.The U.S. economy grew at an annual rate of 3 percent in the fourth quarter of last year, unrevised from the previous estimate, but still lower than market consensus of 3.2 percent. The U.S. jobless claims fell 5,000 to a seasonally adjusted 359,000 last week, but investors seemed not so sure about the recovery due to the latest string of data on hosing and consumer sentiment.Adding to the concerns, the news on Spain refreshed the worries about Europe's debt crisis. In Madrid, people took to the street to protest against the government's austerity plan and clashed with police.Market watchers, however, noted that the KOSPI's decline was limited due to outperformance in undervalued stocks, forecasting that the future correction of the KOSPI may not big as expected before. "Tech and financial shares that led this month's rally took correction, but undervalued shares such as chemical stocks rebounded. This is an opposite picture against the recent movement of stocks," Park So-yeon, an analyst at Korea Investment & Securities in Seoul, told .Park warned that if tech shares take correction, the overall market conditions would not be good as those shares account for around 17 percent of KOSPI's total market capitalization, but analyst said that the correction would not be as bad as worried about because undervalued stocks may rebound as seen in Friday's market movement.Tech shares led the market retreat. Market bellwether Samsung Electronics fell 0.39 percent to 1,275,000 won, and memory chip giant SK Hynix sank 4.1 percent to 29,250 won on news that the chipmaker would participate in the acquisition bid for the Japanese chipmaker Elpida Memory.Transportation shares lost ground amid market decline. Leading shipyard Samsung Heavy Industries dropped 3.58 percent to 37,750 won, and its rival Daewoo Shipbuilding & Marine Engineering dipped 3.04 percent to 30,300 won. Top automaker Hyundai Motor fell 1.48 percent to 233,000 won and its affiliate Kia Motors slid 1.2 percent to 74,100 won.In contrast, undervalued chemical shares gained ground. Leading chemical firm LG Chem gained 2.21 percent to 370,000 won, and top crude oil refiner SK Innovation rose 1.85 percent to 165,500 won. Crude oil refiner Honam Petrochemical jumped 4.18 percent to 336, 500 won.The local currency finished at 1,132.4 won against the greenback, up 4.5 won from Thursday's close. Special Report: Global Financial Crisis
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GAZA, Jan. 13 () -- Two Palestinians were wounded early on Friday in an Israeli artillery fire east of al-Buriej refugee camp in central Gaza Strip, medics and security officials said.Adham Abu Selmeya, spokesman of Gaza emergency services said that the two Palestinians were moderately injured and were immediately sent to hospital.An Israeli Army spokesman said that unknown Palestinian militants fired from Gaza a homemade rocket toward a southern Israeli area. No injuries were reported and no one claimed responsibility for the attack.Violence goes up and down between the Israeli army and Gaza militants despite ceasefire deals, mediated by Egypt, have been set in place several times between the Israeli government and Islamic Hamas movement.Hamas, which controls Gaza, has been urging militant groups to refrain from firing rockets to Israel to avoid another large-scale Israeli military operation.However, Israel denies any ceasefire with Gaza militants and vows to respond to every rocket attack from the coastal enclave. Radical militants also refuse to abide by the restraint that Hamas called for. Special Report: Palestine-Israel Conflicts
LONDON, April 5 () -- The 2011 International Paralympic Day will be held on 8 September in Trafalgar Square, announced the London Organising Committee of the Olympic Games and Paralympic Games (LOCOG) on Tuesday.International Paralympic Day is held every two years in Germany by the International Paralympic Committee. But with the London 2012 Paralympic Games happening in just over 500 days to go, it was decided that London was an ideal place to hold the event.LOCOG chairman Sebastian Coe said, "I'm thrilled and honoured that we'll be hosting International Paralympic Day here in London in September. It's fantastic way for the public to learn more about Paralympic sports and get a taster of the excitement that they will witness during the Paralympic Games in just over 500 days time."Tickets applications for the Paralympic Games will open the next day on 9 September 2011.
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KUALA LUMPUR, Jan. 10 () -- Malaysian opposition leader Anwar Ibrahim's acquittal of sodomy grabbed Malaysian headlines on Tuesday, with analysts interviewed by major newspapers suggesting the ruling coalition, National Front to be the biggest gainer.Sixty-four-year-old Anwar was acquitted by the Kuala Lumpur high court on Monday of sodomy after an almost two-year long trial proceedings.The judge presiding over the case said evidence has been compromised and ruled that Anwar can't be convicted without corroborated evidence.Anwar, a former deputy prime minister, was charged with sodomising his 26-year-old former assistant, Mohd Saiful Bukhari Azlan at a condominium unit in Kuala Lumpur in June 2008.Sodomy, consensual or not, is a crime punishable by 20 years behind bars in Muslim-majority Malaysia.The verdict was deemed crucial to both sides of the political divide as the national election looms. Prime Minister Najib Razak is expected to call for a snap poll before the parliamentary term ends in 2013.The verdict, analysts said, is seen as a move in line with Prime Minister Najib's reform image.The prime minister has been portraying himself as an advocate for democracy in the country.He suggested amendments to draconian legislations that existed for over several decades, with the most significant one in September when he announced the abolishment of the Internal Security Act, a law that allowed for indefinite detention.An editorial in the New Straits Times said the opposition, the People's Alliance are seen to be eating crow after the judiciary that they claimed to be flawed decided in their favor.But political observers interviewed by Chinese newspapers, Nanyang and Oriental Daily believed Anwar's acquittal was a win-win for both sides of the political divide.While it absolves the government of claims that it interfered in the judiciary, Anwar's acquittal also emboldens the opposition, allowing them to focus on promoting policies that appeal to the electorates.The opposition are no longer bogged down by his indictment and who to replace him if he was to be imprisoned.Nonetheless most believed the verdict, albeit a shocker, came as a sense of relief not only to Anwar, but also the people and the ruling government who were "dragged into the overhyped and aggrandized dramatics."As the Star daily argued, it puts the coming election on a level-playing field to be a race over economic policies, political and civil reforms by the Najib administration, without the sodomy trial latching on Anwar.Anwar will face a leaner and more realistic opponent.The opposition will have to get on with the job instead of figuring what else to whine about, online news portal the Malaysian Insider wrote."Or else the BN (National Front) will always seem the better bet at running the country," the news portal said.
ISLAMABAD, May 23 () -- Pakistani Foreign Minister Hina Rabbani Khar will visit Japan from May 23 to May 26 at the invitation of the Government of Japan, the foreign ministry said Wednesday.This will be her first official visit to Japan as foreign minister, said the foreign ministry in a statement.The minister will hold bilateral talks with her Japanese counterpart Mr. Koichiro Gemba on bilateral relations and regional and global issues of mutual interest, the statement said.The foreign minister will also apprise the Japanese side of the active role being played by Pakistan against extremism and terrorism."The foreign minister's visit will further strengthen and deepen the existing relationship between Pakistan and Japan including development cooperation," said the statement.According to the statement, the Pakistani foreign minister will also participate in the 18th Annual Conference on "Future of Asia", sponsored by Japan's Nikkei Group.
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