There is a trend for pharmaceutical companies to contract third parties to conduct the clinical trials that are needed to test their drugs. This trend is referred to as outsourcing, and the companies that carry out the work are called contract research organisations. In addition, clinical trials are increasingly conducted in non-traditional trial regions, which are mainly low-and middle-income countries. This trend is called offshoring. The combination of outsourcing and offshoring poses serious risks for the ethical treatment of participants in clinical trials.

Studies worldwide have reported alarming rates of alcohol misuse among medical students (Webb et al, 1996; Kuo et al, 2002; Akvadar et al, 2004). These reports are surprising as well as of extreme concern, as medical professionals are supposedly more educated on the harmful effects of excessive alcohol consumption. The majority of studies exploring the knowledge and attitudes of medical students regarding alcohol have been from the USA and the UK, with only few from lower-income countries and the Islamic world (Kumar & Basu, 2000; Akvadar et al, 2004).

Some 7000 years ago Egyptians believed in one God, the after-world and that our worldly deeds would be balanced in the day of judgement. This led James Breasted to consider that the emergence of Egyptian culture marked the dawn of conscience (Breasted, 1934; Okasha & Okasha, 2000).

The World Association for Psychosocial Rehabilitation (WAPR) could be considered as a newcomer among scientific societies in the mental health field, because it was established in 1986 in France, when about 100 professionals from 35 countries met at its founding congress. That congress was preceded by an extensive international planning process, which began with the First World Congress on Rehabilitation for the Mentally Ill in Helsinki, in 1970. Subsequent meetings of key professionals and agency representatives from various countries, mainly supported by the World Health Organization (WHO) and the International Labour Office, resulted in the formation, in 1980, of a promoting group which planned, through its international secretariat, the foundation of the WAPR. Therefore, close links with the mental health programme of the WHO have been maintained by the WAPR since its beginnings.

As the median age of populations around the world increases, due to the provision of better diets and better medical care, the number of elderly persons vulnerable to mental illness will inevitably increase too. We are not good at providing high-quality geriatric care, even in high-income countries. For example, Age Concern (a UK-based charity) states on its website: ‘Health and social care services have made some progress in tackling age discrimination, but older people still report feeling that they have had second class treatment and care simply because of their age’ (www.ageconcern.org.uk/AgeConcern/ageism-in-healthcare.asp). How much worse these matters are in low- and middle-income countries is the subject of our theme in this issue. We have drawn articles from three distinct geographic regions: India, Africa and South-East Asia. We often assume that cultural factors in lower-income areas lead to greater respect for, and better care of, the elderly than we experience in many parts of the Western hemisphere. This appears to be a misapprehension, and attitudes towards the elderly are changing as the impact of industrialisation increases.

Bermuda comprises a group of small islands in the Atlantic Ocean, situated approximately 1000 km east of the USA. It is a self-governing crown dependency of the UK. It is the third richest country in the world, with average wages per head of US$41 495 in 2000. Its economy is based on a flourishing offshore insurance industry and tourism.

All psychiatrists would acknowledge that communication between individuals is fundamental to their speciality, but it is perhaps less obvious that the increasing ease and speed of communication worldwide are also having a profound effect on psychiatric practice. With this improved communication comes an awareness of the commonality of many mental health issues and recognition that there is much to learn from others working in very diverse environments. It is also true that many mental health problems have an international dimension, particularly when large numbers of people are displaced by war or other disasters. Increasingly we need to have a better understanding of other cultures and the relationship between culture, mental health and psychiatric disorder.

Regular appraisal and revalidation are now a routine part of professional life for doctors in the UK. For British-trained psychiatrists working abroad (in either development/humanitarian or academic fields) this is a cause of insecurity, as most of the processes of revalidation are tailored to those working in the standard structures of the National Health Service. This article explores the degree to which a peer group for psychiatrists working abroad has achieved its aim of helping its members to fulfil their revalidation requirements. It gives recommendations for how those considering work abroad can maximise their chances of remaining recognised under the revalidation system.

I visited Chile for the first time in 2003. Over the course of the 12 months during which the country became my home, I realised there was a secret side to the capital city, Santiago. Never was this clearer than when I witnessed a demonstration to mark the 30th anniversary of the 11 September 1973 coup, when General Pinochet took power. I watched tears stream down the cheeks of men and women as they sang along with the revolutionary Cuban folk singer Silvio Rodriguez, raising their fists in the air. I felt the distrust of and anger towards the police who lined rooftops with snipers and the military units which filled side streets with water cannons. It was a visceral experience, made more so by the contrast with day-to-day life on the city's streets. This was a boom town, proud of its malls and economic growth, and the residents of Santiago made every effort to remark upon their high standards of living.

Region Jönköping County (RJC) in Sweden is a healthcare system that is characterised by sustainable work with quality in healthcare and long-term system-wide improvement. This article describes important factors behind the improvement work in RJC, and how the improvement methods and initiatives have been adopted also in mental healthcare. For example, patients otherwise eligible for admission to a psychiatric department were treated at home after introduction of home treatment teams. Patient satisfaction was high and the number of visits to the emergency department, hospital admissions and hospital stay decreased.

This paper is a British psychiatrist's personal reflection of the treatment of homeless people in American societies. Drawing upon theories of social distance, exclusion, discrimination and internalised stigma, this reflective piece suggests that homelessness is one price that certain societies pay to invest in the notion of individualised success and self-sufficiency. In reflecting on his own dissonance, the author argues that these societal processes exert a powerful influence on us as individuals, even if we as psychiatrists might think that our understanding confers on us a certain level of understanding.

The Netherlands borders the North Sea and is located between Belgium and Germany. Its total area is about 41 500 km2, nearly 34 000 km2 of which is land area. The country consists mostly of coastal lowland and land reclaimed from the sea (polders). An extensive system of dykes and dams protects nearly one-half of the total area from being flooded.