Government health studies and the CMA During the past 15 years numerous national and provincial government commissions, task forces and committee studies on health services in Canada* have produced reports containing hun¬ dreds of recommendations. Most phy¬ sicians are aware of some of these studies, but few have read even one report in its entirety. I know of no one who has studied all of them. The proliferation of government studies raises many questions. Why are they conducted and at the governmental levels concerned? Should the profes¬ sion welcome or oppose them? Should individual physicians, the Canadian Medical Association and other levels of organized medicine work with
government agencies by attempting to be a partner in the studies, by nominating or otherwise providing experts in
the
concerned? Should they pub¬ or otherwise publicize the study reports or should they avoid any contact whatsoever? Most important of all, what impact or effect do these studies have on health and medical care in Canada? Have the studies been positive and constructive or are they a waste of time, effort and energy, not to mention money? The various study groups fail into area
lish,
comment on,
three
categories: 1. A group brought together to study a particular problem or subject, whose members represent one or more levels of government, segments of organized medicine or other professional groups or health agencies, or both. ?Examples are the Hall "Royal Commission on Health Services", "A New Perspective on the Health of Canadians", The Quebec Nepveu Cas¬ tonguay report, "Task Force Reports on the Cost of Health Services in Canada", the Hastings community health centre report, "Health Security for British Columbians" (the Foulkes report), the "Ontario Report of the Committee on the Heal¬ ing Arts", health care in Nova Scotia "A New Direction for the Seventies", the Manitoba "White Paper on Health Policy", the Mustard report and Department of National Health and Welfare advisory committees on standards and guidelines in medical practice, human reproduc¬ tion physiology, prescription drug bioavailability and immunization.
appointed by one or professional groups con¬ cerned. 3. A group appointed by government with the professional groups nominating expert candidates as committee members. Sometimes the subject is the clear responsibility of the level of govern¬ ment appointing the study group. At other times there appears to be no jurisdictional justification for their in¬ volvement. Indeed, the lines of respon¬ sibility for health have become so blurred that government has frequently appointed these bodies through intergovernmental agencies such as the min¬ isters or deputy ministers of health 2. A group
more levels of erence to the
government without ref¬
conferences. While "ultraconservative" is not an appropriate label for the medical pro¬ fession in 1976, the profession is still as are other guardians of public conservative by nature. well-being Therefore it is not surprising that the profession has rejected, sometimes emo¬ tionally, recommendations for radical change in the health care delivery sys¬ tem contained in these reports. The .
reaction, amounting almost to paranoia,
anything related to or emanating from the government, shown by some physicians, appears to be decreasing in frequency and severity, but it still exists and sometimes with justification. Occasionally it is obvious that political expediency or economic factors have unduly influenced the selection of re¬ port recommendations to be implemented, although we are convinced that many of these bodies are formed in an honest attempt to bring expert opinion to bear on perceived problems. The responsibilities, authority and privileges of the medical profession are to
unquestionably granted or delegated by course, will always be, To what degree can, and should, government delegate
government. The major question, of
such responsibility and authority, and to what extent must government exer¬ cise its ultimate authority directly? I believe that it is in the best interests of all Canadians that government dele¬ gate as much responsibility as possible to those most capable of fulfilling it the medical profession. But government must ensure that delegated responsibil¬ ities are accepted and it is mandatory that the profession meet these respon¬ sibilities as completely as possible. When it fails, the profession must acknowledge its failure and assist govern¬ ment to ensure that the responsibility is fulfilled. On the other hand, if govern¬ ment proceeds in an inappropriate or arbitrary manner, the profession has a .
responsibility
not
only
to refuse to
submit but openly to oppose its efforts. That philosophy has served as the basis for CMA activity regarding gov¬ ernment projects of this type. The as¬ sociation has contributed actively as a participating cosponsoring agency to studies such as the medical manpower committee studies. We have participated in, or nominated experts to serve on, task forces that studied the costs of health services, amphetamine and methadone controls, the require¬ ments and value of regular medical examinations and many others. We have published task force reports, such as the task force report on cervical cancer screening programs in the June 5 issue of this journal, that were con¬ sidered to have scientific merit, so as to disseminate the information con¬ tained and thereby expose it to scientific review and knowledgeable comment. The publication of such re¬ ports should not be misinterpreted as CMA endorsement of the project, the report or its recommendations. We have been openly critical of such re¬ ports as the Hastings committee report on community health centres and have refused to play any part on Govern¬ ment of Canada task forces to create
CMA JOURNAL/JUNE 19, 1976/VOL. 114 1081
guidelines for such areas as the medical management of hypertension, criteria for elective surgical procedures, and criteria for admission to hospital or length of stay. On the surface the association's policy may appear inconsistent. But we believe there is merit in the association's decision to participate in projects on an individual basis. Sometimes there is merit in the association being a signatory member of such bodies. At other times it may not be desirable that the association play such an integral role, but rather that it support the efforts of government by ensuring access to expertise from the profession. There will be occasions when the profession or the public, or both, are best served
by publication of the results of such studies - as was the case with the Hastings committee report on community health centres and the report on cervical cancer screening programs. There will also be occasions when we should oppose such government projects. To date these government studies have made few major changes in the delivery of health care, though they have forced many to consider the subjects and problems, they have altered some attitudes and they have influenced gradual shifts and changes of emphasis. To varying degrees they warrant the participation, assistance, study and, on occasion, the opposition of the profession. Certainly such studies must be
recognized because in future, government and the public will have more input relative to the organization and provision of medical services. In my view the Canadian Medical Association should adhere to the view first proposed by Junius, that "the subject who is truly loyal to the chief magistrate will neither advise nor submit to arbitrary measures". That said, I believe that we must also recognize the authority vested in the government by our democratic processes and work to achieve our patients' well-being within the context of governmental authority. The alternative to this is unacceptable anarchy. L.C. GRISDALE, MD, FRCP[CJ
President The Canadian Medical Association
Cystic fibrosis: physiology gone wrong Cystic fibrosis (CF), like syphilis, could accurately be described as "the great imitator". Many organ systems are involved, and a clear understanding of the disease and its many complications is a useful exercise in understanding human physiology. CF could be called thick-secretion disease, because all exocrine fluids, like pancreatic juice, are thick, or it could be called multimystery disease, because there are so many unanswered questions about it. Many manifestations of CF are understandable complications of malabsorption, malnutrition and the physical and chemical effects of abnormal exocrine secretion; others, including the susceptibility to recurrent nasal polyps, the hypersalinized sweat, low female fertility and male sterility,1 given present knowledge, do not make physiologic sense. CF may present for the first time in any age group up to early adulthood.2 Anderson3 drew the attention of North Americans to this disease and established it as an entity separate from celiac disease. Pulmonary involvement remains the main determinant of longevity in most cases of CE, and vigorous treatment of respiratory tract infections therefore remains the cornerstone of treatment. Specially interesting and frequently forgotten, however, are the extrapulmonary manifestations of the disease. CF patients sweat a great deal4 and their sweat contains large amounts of sodium and chloride ion; salt crystals may precipitate and become visible on the forehead. Patients who play the guitar may, because of the excessive
salt in the hand sweat, have problems with rusty strings, Shwachman and Antonowicz5 considered these children similar to the "rusters" in industry, who were known to cause corrosion or spoilage of certain materials they handled because of the high salt content of their moist fingers. It is the measurement of the salt concentration of sweat that forms the basis of the Gibson6 iontophoresis sweat test for CF. In warm weather and when febrile, CF children sweat excessively; they may lose enough to become severely dehydrated and salt-depleted. This occurred in a 6-month-old male infant who was admitted to hospital near death from profound shock. He had a history of cough and excessive sweating but no fever, and was found to be severely dehydrated (blood urea nitrogen concentration, 70 mg/dl) with very low serum concentrations of sodium (Na.) (127 mmol/l) and chloride (79 mmol/b. His condition improved rapidly with fluid and salt replacement. Later a sweat test (Na., 130 mmol/l) confirmed the diagnosis of CF. The gastrointestinal manifestations of CF are also of special interest. These are in themselves the "meat" of a text on physiology "gone wrong". The clinical aspects of the gastrointestinal complications have been reviewed well by Kopel7 and Berk and Lee.8 CF may first present in the neonatal period with intestinal obstruction (meconium ileus) when plugs of thick, abnormally constituted meconium block the terminal ileum.9'10 Meconium ileus may be associated with small-intestinal atresia, volvulus and perforation, with
1082 CMA JOURNAL/JUNE 19, 1976/VOL. 114
resulting meconium peritonitis. The mucus-secreting goblet cells of the small intestine and appendix are greatly distended in CF and the presence of such cells on histologic slides has, on occasion, allowed the pathologist to anticipate the clinician in establishing a diagnosis.11 As CF patients grow older many have less need for artificial pancreatic enzymes and some can maintain an adequate nutritional status without this therapy. Shwachman and Kulczycki11 stated that 10 to 15% of CF patients have normal pancreatic function. In fact, paradoxical constipation does occur in patients receiving too much pancreatic replacement enzyme and too little dietary fat. It is curious that pancreatitis and duodenal ulcer are rare in CF. Fatty change in the liver is common and cannot be correlated with the general health or the nutritional status of the patients involved; however, focal biliary cirrhosis is present frequently and up to 25% of CF patients at autopsy have multinodular biliary cirrhosis.13 In some this has clinical significance: the liver becomes hard and nodular, the spleen enlarges and portal hypertension develops. Hematemesis from esophageal varices secondary to portal hypertension is a common cause of death in older CF patients. Intussusception is most commonly seen in children under 1 year of age but may be seen in older children. In a recent review of the latter group14 the diagnosis of CF was not mentioned, and it is generally not known that, in the older CF child, intussusception is
government agencies by attempting to be a partner in the studies, by nominating or otherwise providing experts in
the
concerned? Should they pub¬ or otherwise publicize the study reports or should they avoid any contact whatsoever? Most important of all, what impact or effect do these studies have on health and medical care in Canada? Have the studies been positive and constructive or are they a waste of time, effort and energy, not to mention money? The various study groups fail into area
lish,
comment on,
three
categories: 1. A group brought together to study a particular problem or subject, whose members represent one or more levels of government, segments of organized medicine or other professional groups or health agencies, or both. ?Examples are the Hall "Royal Commission on Health Services", "A New Perspective on the Health of Canadians", The Quebec Nepveu Cas¬ tonguay report, "Task Force Reports on the Cost of Health Services in Canada", the Hastings community health centre report, "Health Security for British Columbians" (the Foulkes report), the "Ontario Report of the Committee on the Heal¬ ing Arts", health care in Nova Scotia "A New Direction for the Seventies", the Manitoba "White Paper on Health Policy", the Mustard report and Department of National Health and Welfare advisory committees on standards and guidelines in medical practice, human reproduc¬ tion physiology, prescription drug bioavailability and immunization.
appointed by one or professional groups con¬ cerned. 3. A group appointed by government with the professional groups nominating expert candidates as committee members. Sometimes the subject is the clear responsibility of the level of govern¬ ment appointing the study group. At other times there appears to be no jurisdictional justification for their in¬ volvement. Indeed, the lines of respon¬ sibility for health have become so blurred that government has frequently appointed these bodies through intergovernmental agencies such as the min¬ isters or deputy ministers of health 2. A group
more levels of erence to the
government without ref¬
conferences. While "ultraconservative" is not an appropriate label for the medical pro¬ fession in 1976, the profession is still as are other guardians of public conservative by nature. well-being Therefore it is not surprising that the profession has rejected, sometimes emo¬ tionally, recommendations for radical change in the health care delivery sys¬ tem contained in these reports. The .
reaction, amounting almost to paranoia,
anything related to or emanating from the government, shown by some physicians, appears to be decreasing in frequency and severity, but it still exists and sometimes with justification. Occasionally it is obvious that political expediency or economic factors have unduly influenced the selection of re¬ port recommendations to be implemented, although we are convinced that many of these bodies are formed in an honest attempt to bring expert opinion to bear on perceived problems. The responsibilities, authority and privileges of the medical profession are to
unquestionably granted or delegated by course, will always be, To what degree can, and should, government delegate
government. The major question, of
such responsibility and authority, and to what extent must government exer¬ cise its ultimate authority directly? I believe that it is in the best interests of all Canadians that government dele¬ gate as much responsibility as possible to those most capable of fulfilling it the medical profession. But government must ensure that delegated responsibil¬ ities are accepted and it is mandatory that the profession meet these respon¬ sibilities as completely as possible. When it fails, the profession must acknowledge its failure and assist govern¬ ment to ensure that the responsibility is fulfilled. On the other hand, if govern¬ ment proceeds in an inappropriate or arbitrary manner, the profession has a .
responsibility
not
only
to refuse to
submit but openly to oppose its efforts. That philosophy has served as the basis for CMA activity regarding gov¬ ernment projects of this type. The as¬ sociation has contributed actively as a participating cosponsoring agency to studies such as the medical manpower committee studies. We have participated in, or nominated experts to serve on, task forces that studied the costs of health services, amphetamine and methadone controls, the require¬ ments and value of regular medical examinations and many others. We have published task force reports, such as the task force report on cervical cancer screening programs in the June 5 issue of this journal, that were con¬ sidered to have scientific merit, so as to disseminate the information con¬ tained and thereby expose it to scientific review and knowledgeable comment. The publication of such re¬ ports should not be misinterpreted as CMA endorsement of the project, the report or its recommendations. We have been openly critical of such re¬ ports as the Hastings committee report on community health centres and have refused to play any part on Govern¬ ment of Canada task forces to create
CMA JOURNAL/JUNE 19, 1976/VOL. 114 1081
guidelines for such areas as the medical management of hypertension, criteria for elective surgical procedures, and criteria for admission to hospital or length of stay. On the surface the association's policy may appear inconsistent. But we believe there is merit in the association's decision to participate in projects on an individual basis. Sometimes there is merit in the association being a signatory member of such bodies. At other times it may not be desirable that the association play such an integral role, but rather that it support the efforts of government by ensuring access to expertise from the profession. There will be occasions when the profession or the public, or both, are best served
by publication of the results of such studies - as was the case with the Hastings committee report on community health centres and the report on cervical cancer screening programs. There will also be occasions when we should oppose such government projects. To date these government studies have made few major changes in the delivery of health care, though they have forced many to consider the subjects and problems, they have altered some attitudes and they have influenced gradual shifts and changes of emphasis. To varying degrees they warrant the participation, assistance, study and, on occasion, the opposition of the profession. Certainly such studies must be
recognized because in future, government and the public will have more input relative to the organization and provision of medical services. In my view the Canadian Medical Association should adhere to the view first proposed by Junius, that "the subject who is truly loyal to the chief magistrate will neither advise nor submit to arbitrary measures". That said, I believe that we must also recognize the authority vested in the government by our democratic processes and work to achieve our patients' well-being within the context of governmental authority. The alternative to this is unacceptable anarchy. L.C. GRISDALE, MD, FRCP[CJ
President The Canadian Medical Association
Cystic fibrosis: physiology gone wrong Cystic fibrosis (CF), like syphilis, could accurately be described as "the great imitator". Many organ systems are involved, and a clear understanding of the disease and its many complications is a useful exercise in understanding human physiology. CF could be called thick-secretion disease, because all exocrine fluids, like pancreatic juice, are thick, or it could be called multimystery disease, because there are so many unanswered questions about it. Many manifestations of CF are understandable complications of malabsorption, malnutrition and the physical and chemical effects of abnormal exocrine secretion; others, including the susceptibility to recurrent nasal polyps, the hypersalinized sweat, low female fertility and male sterility,1 given present knowledge, do not make physiologic sense. CF may present for the first time in any age group up to early adulthood.2 Anderson3 drew the attention of North Americans to this disease and established it as an entity separate from celiac disease. Pulmonary involvement remains the main determinant of longevity in most cases of CE, and vigorous treatment of respiratory tract infections therefore remains the cornerstone of treatment. Specially interesting and frequently forgotten, however, are the extrapulmonary manifestations of the disease. CF patients sweat a great deal4 and their sweat contains large amounts of sodium and chloride ion; salt crystals may precipitate and become visible on the forehead. Patients who play the guitar may, because of the excessive
salt in the hand sweat, have problems with rusty strings, Shwachman and Antonowicz5 considered these children similar to the "rusters" in industry, who were known to cause corrosion or spoilage of certain materials they handled because of the high salt content of their moist fingers. It is the measurement of the salt concentration of sweat that forms the basis of the Gibson6 iontophoresis sweat test for CF. In warm weather and when febrile, CF children sweat excessively; they may lose enough to become severely dehydrated and salt-depleted. This occurred in a 6-month-old male infant who was admitted to hospital near death from profound shock. He had a history of cough and excessive sweating but no fever, and was found to be severely dehydrated (blood urea nitrogen concentration, 70 mg/dl) with very low serum concentrations of sodium (Na.) (127 mmol/l) and chloride (79 mmol/b. His condition improved rapidly with fluid and salt replacement. Later a sweat test (Na., 130 mmol/l) confirmed the diagnosis of CF. The gastrointestinal manifestations of CF are also of special interest. These are in themselves the "meat" of a text on physiology "gone wrong". The clinical aspects of the gastrointestinal complications have been reviewed well by Kopel7 and Berk and Lee.8 CF may first present in the neonatal period with intestinal obstruction (meconium ileus) when plugs of thick, abnormally constituted meconium block the terminal ileum.9'10 Meconium ileus may be associated with small-intestinal atresia, volvulus and perforation, with
1082 CMA JOURNAL/JUNE 19, 1976/VOL. 114
resulting meconium peritonitis. The mucus-secreting goblet cells of the small intestine and appendix are greatly distended in CF and the presence of such cells on histologic slides has, on occasion, allowed the pathologist to anticipate the clinician in establishing a diagnosis.11 As CF patients grow older many have less need for artificial pancreatic enzymes and some can maintain an adequate nutritional status without this therapy. Shwachman and Kulczycki11 stated that 10 to 15% of CF patients have normal pancreatic function. In fact, paradoxical constipation does occur in patients receiving too much pancreatic replacement enzyme and too little dietary fat. It is curious that pancreatitis and duodenal ulcer are rare in CF. Fatty change in the liver is common and cannot be correlated with the general health or the nutritional status of the patients involved; however, focal biliary cirrhosis is present frequently and up to 25% of CF patients at autopsy have multinodular biliary cirrhosis.13 In some this has clinical significance: the liver becomes hard and nodular, the spleen enlarges and portal hypertension develops. Hematemesis from esophageal varices secondary to portal hypertension is a common cause of death in older CF patients. Intussusception is most commonly seen in children under 1 year of age but may be seen in older children. In a recent review of the latter group14 the diagnosis of CF was not mentioned, and it is generally not known that, in the older CF child, intussusception is
