CORRESPONDENCE
Position papers passed by Canadian Psychiatric Association To the editor: The letter from Dr. A.W. Kushner and the reply from Drs. Harry Prosen and S.E. Greben (Can Med Assoc 1 120: 1499, 1979) prompt me to enter into the discussion. All matters relating to medical ethics are "extremely controversial and emotionally charged"; however, it would be grossly negligent for an association representing a specialty that has the responsibility of treating and supervising patients, many of whom suffer from congenital defects, to accept that such patients are less worthy of treatment than the rest of society. This is the sheet anchor of medical ethics. We are a caring profession, not a disposing one, and we do not make such value judgements. Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
Dr. Kushner chose an unfortunate analogy by citing pediatrics as a specialty that does not interfere with the practice of other specialists. I recall a meeting addressed by a pediatrician who listed a number of conditions that he considered warranted abortion. A gynecologist asked him what proportion of these abortions he reckoned were warranted, and he replied 1 in 20. The gynecologist replied: "Fine. We can deliver the 19 and you can destroy the one you do not want!" Pediatricians are not unique in asking other specialists to do such things. Up to 90% of all abortions are recommended on psychiatric grounds; the psychiatric evidence for such wholesale destruction is very flimsy indeed. Medical ethics, which is based on a respect for human life, cannot be left to the vagaries of pressure groups and to the latest fashions in social behaviour. It is right that professional associations restate the fundamental principles of medical practice. Dr. Kushner's letter illustrates how timely the position paper was, for
The Canadian Medical Aspoclationll'Assoclatlon m6dlcalo canadionne 1867 AIta Vista Dr., Ottawa, Ont. KIG 3Y6; (613) 7314331 President/pr6sldent: Di. Wilson, MD. FRCPfCJ Secretary gen.rai/eecriteire 6ri6rai: R.G. Wilson. MD Director of communtcationsldlr.ct#ijr dee oommunicat1one. D.A. Geekie, BPH., CPH
CMA Journal/Journal do l'AMC Scientific editor/r6dacteur scientiflctue: NJ.S. Wiggin, MD. MSc, PhD News and features editor/r6ciecteur 'des nouvelies at reportages: 4. Garner Associate scientific editor/r6dacteur scienjiftque associ6: P.P. Morgan, MD. DPIi, DEpid Senior assistant editcr/r6dactrice adjointe en chef: A. Bolster, BA Assistant editore/rodactrices adjointes: L.D. MacDougeli. J. Whitney, BSc Contributing editors/coliaboratours: D. Robiliard, PhD; Ci. Jarrett. PhD. MD: MG Lafwjry, BA; D.T. Wigie. MD. PhD, MPH; D. Woods Director et advertising saiss/directeur cia is pubiicit6: N. iiuttoi. Production manager/chef du servlc. de is production: R.M. Birinott
not only he but also society should know that the medical profession does not necessarily reflect - and, indeed, in certain instances must not reflect - the latest trends in society. I would have thought that the support of a substantial number of German doctors for the Nuremberg laws would make further explanation unnecessary. M. SIM, MD (EDIN), FRCP (ED), FRC PSYCH, FRCP[C], DPM Professor of psychiatry
Faculty of health sciences University of Ottawa Ottawa, Ont.
Health problems of developing nations To the editor: Milan Korcok's article on health problems of developing nations (Can Med Assoc I 120: 471, 1979) is to be commended for its focus on the importance of paramedic rural health' care centres as the backbone of health care in the Third World. Our experience in central Nigeria confirms the efficacy of such a system. The Canadian &fedfr*I Association Iour. nel is published twice a month by the Canadian Medical Association. P0 Box 6650, Ottawa, Ont. KIG 008 and is printed by Harpell's Press Cooperative, Gardenvele, P0 l'IOA 150. Subscription rates and information for contributors of manuacripta are published in the first issue of each volume. All reproduction rights are reserved
-II 1PAARj .
Note. All drug advertisements been pre. In the Journal Pharmaceutical by the have cleared Advertising Advisory Board.
CMA JOURNAL/NOVEMBER 17, 1979/VOL. 121 4-For prescribing information see page 1384
1335
Our mission hospital has grown slowly over 50 years to its current capacity of 400 inpatients. In addition, we see 150 to 200 individuals a day in the outpatient department. Since its initiation 10 years ago our rural health care program has grown to include almost 100 rural health care centres and first-aid stations scattered over an 80- to 110-km radius; without them we would be even more ridiculously swamped than we are. Incidentally, our medical staff is currently at an all-time high - seven physicians. Without gainsaying for a moment any of the staggering achievements of rural health care programs, it behoves us never to lose sight of the fact that such achievements depend less on the quality of what is provided than on the gaping void that it fills. A therapeutic blunderbuss is enormously successful when it is aimed at such an obvious target as a pediatric death rate of 30% to 40% .. However, when the target is less obvious the success rate is dramatically reduced. Inappropriate medication and misdiagnoses are common among patients of paramedics. Serious errors are fatal or crippling. We hope that the less serious errors occupy patients sufficiently to keep them away from ruinous alternatives while the disease abates on its own. People like Ivan Illich2 could have at least as much of a field day in Nigeria as they do at home. The inability of a decentralized rural health care system to cope with surgical emergencies is not appreciated sufficiently. Without hospital services many people die. Last year 6000 "normal" infants were delivered at our hospital and as many or more were delivered at the rural health care centres. We performed 450 cesarean sections last year, a number that is comparatively insignificant, and there were about the same number of ectopic pregnancies. If such figures are compared with something as gross as infectious disease mortality, then they are insignificant statistically, but only statistically. Rural health care in developing countries is cost-effective because it deals with the bulk of diseases that are cheap to treat and control. Hospitals in developing countries are expensive because conditions 1338
are treated that are inherently more expensive and difficult to treat. Statistically a death is a death and a dollar is a dollar, so it makes sense to concentrate on rural health care and forget about hospitals. However, when this is the case we should never forget that we are playing a numbers game with human lives. If our backs are against the wall we may be forced into that dilemma, but with sufficient determination resources can be stretched to encompass some sort of facility for persons unfortunate enough to have diseases for which treatment is expensive but readily available. Appropriate use of such facilities and of rural health care centres is what comprehensive, rather than exclusively cost-effective, health care is all about in the Third World. Mr. Korcok's article was unreferenced so I must challenge his assertion that Nigerian wells were capped with rims of concrete for $1.40 each. The current price of cement is $11.05 (US currency) per bag. Even when one considers double-digit inflation his cost figure would have been accurate so many years ago that it would have been better not to include it. His article also includes a drawing of an "ingenious Vietnamese latrine". Though blessed with the wealth of almost 20 years of regular use of outdoor facilities I can't fathom what is so ingenious about the device, or how it manages to disinfect and deodorize its contents. An accompanying text or working drawing would not have been amiss as I am sure most less experienced readers would be even more mystified than I. If, in fact, the latrine is as good as its caption says, then it merits an article about it because it has more cost-effective potential for world health care and nutrition than anything else Mr. Korcok has written about. In closing, I cannot resist commenting on the fees charged by Robert MacLellan, a general practitioner in Nova Scotia during World War I (Can Med Assoc 1 120: 494, 1979). He was charging $15 for uncomplicated obstetric procedures at a time when Canada's per capita gross national product (GNP) was $530. According to an article in Newsweek (May 28), Nigeria's per
CMA JOURNAL/NOVEMBER 17, 1979/VOL. 121
capita GNP is currently $500. My wife underwent a routine, midwifeassisted delivery in hospital in February for an official standard fee of $8 (US currency). Perhaps Dr. MacLellan's fees were too high, perhaps ours aI.. too low, or maybe we can simply reflect that cement is very expensive. JOHN VAN DORP, MD
Mkar Christian Hospital Box 261 Jos, Nigeria References 1. MORLEY D: Paediatric Priorities in the Developing World, Butterworths, London, 1973, p 318 2. ILLICH I: Limits of Medicine. Medical Nemesis: the Expropriation of Health,
Calder & Boyers, London, 1975 To the editor: Dr. Van Dorp appears to be saying that rural health care centres, on the basis of a paramedic approach to services, have a critical, albeit limited, function in maintaining health care standards in the Third World. That too is the point of my articles. The fact that such a paramedic brand of medicine cannot always measure up to the needs of all the people, especially those requiring the services of a higher technology, is a pity. But, as my articles point out, the greatest need in emerging countries is for a preventive approach to health care, one dedicated to raising the overall health status of the people. In effect, the preventive rather than the curative elements of health care are emphasized, and in this respect the Western styles of medicine do not appear to be the most appropriate models. My reference to Nigerian wells being capped with rims at $1.40 each is from the Mahler-Labouisse report to the international conference on primary health care at Alma Ata in the Soviet Union in September 1978. A lot of concrete rims can be made from one bag of cement, especially if the concrete is diluted and contains a lot of sand. They don't have to last as long as the sphinx and the builders know it. Even at a higher price the cost-effectiveness of this kind of prevention goes unquestioned. With regard to the drawing of the Vietnamese latrine, it is true
Position papers passed by Canadian Psychiatric Association To the editor: The letter from Dr. A.W. Kushner and the reply from Drs. Harry Prosen and S.E. Greben (Can Med Assoc 1 120: 1499, 1979) prompt me to enter into the discussion. All matters relating to medical ethics are "extremely controversial and emotionally charged"; however, it would be grossly negligent for an association representing a specialty that has the responsibility of treating and supervising patients, many of whom suffer from congenital defects, to accept that such patients are less worthy of treatment than the rest of society. This is the sheet anchor of medical ethics. We are a caring profession, not a disposing one, and we do not make such value judgements. Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
Dr. Kushner chose an unfortunate analogy by citing pediatrics as a specialty that does not interfere with the practice of other specialists. I recall a meeting addressed by a pediatrician who listed a number of conditions that he considered warranted abortion. A gynecologist asked him what proportion of these abortions he reckoned were warranted, and he replied 1 in 20. The gynecologist replied: "Fine. We can deliver the 19 and you can destroy the one you do not want!" Pediatricians are not unique in asking other specialists to do such things. Up to 90% of all abortions are recommended on psychiatric grounds; the psychiatric evidence for such wholesale destruction is very flimsy indeed. Medical ethics, which is based on a respect for human life, cannot be left to the vagaries of pressure groups and to the latest fashions in social behaviour. It is right that professional associations restate the fundamental principles of medical practice. Dr. Kushner's letter illustrates how timely the position paper was, for
The Canadian Medical Aspoclationll'Assoclatlon m6dlcalo canadionne 1867 AIta Vista Dr., Ottawa, Ont. KIG 3Y6; (613) 7314331 President/pr6sldent: Di. Wilson, MD. FRCPfCJ Secretary gen.rai/eecriteire 6ri6rai: R.G. Wilson. MD Director of communtcationsldlr.ct#ijr dee oommunicat1one. D.A. Geekie, BPH., CPH
CMA Journal/Journal do l'AMC Scientific editor/r6dacteur scientiflctue: NJ.S. Wiggin, MD. MSc, PhD News and features editor/r6ciecteur 'des nouvelies at reportages: 4. Garner Associate scientific editor/r6dacteur scienjiftque associ6: P.P. Morgan, MD. DPIi, DEpid Senior assistant editcr/r6dactrice adjointe en chef: A. Bolster, BA Assistant editore/rodactrices adjointes: L.D. MacDougeli. J. Whitney, BSc Contributing editors/coliaboratours: D. Robiliard, PhD; Ci. Jarrett. PhD. MD: MG Lafwjry, BA; D.T. Wigie. MD. PhD, MPH; D. Woods Director et advertising saiss/directeur cia is pubiicit6: N. iiuttoi. Production manager/chef du servlc. de is production: R.M. Birinott
not only he but also society should know that the medical profession does not necessarily reflect - and, indeed, in certain instances must not reflect - the latest trends in society. I would have thought that the support of a substantial number of German doctors for the Nuremberg laws would make further explanation unnecessary. M. SIM, MD (EDIN), FRCP (ED), FRC PSYCH, FRCP[C], DPM Professor of psychiatry
Faculty of health sciences University of Ottawa Ottawa, Ont.
Health problems of developing nations To the editor: Milan Korcok's article on health problems of developing nations (Can Med Assoc I 120: 471, 1979) is to be commended for its focus on the importance of paramedic rural health' care centres as the backbone of health care in the Third World. Our experience in central Nigeria confirms the efficacy of such a system. The Canadian &fedfr*I Association Iour. nel is published twice a month by the Canadian Medical Association. P0 Box 6650, Ottawa, Ont. KIG 008 and is printed by Harpell's Press Cooperative, Gardenvele, P0 l'IOA 150. Subscription rates and information for contributors of manuacripta are published in the first issue of each volume. All reproduction rights are reserved
-II 1PAARj .
Note. All drug advertisements been pre. In the Journal Pharmaceutical by the have cleared Advertising Advisory Board.
CMA JOURNAL/NOVEMBER 17, 1979/VOL. 121 4-For prescribing information see page 1384
1335
Our mission hospital has grown slowly over 50 years to its current capacity of 400 inpatients. In addition, we see 150 to 200 individuals a day in the outpatient department. Since its initiation 10 years ago our rural health care program has grown to include almost 100 rural health care centres and first-aid stations scattered over an 80- to 110-km radius; without them we would be even more ridiculously swamped than we are. Incidentally, our medical staff is currently at an all-time high - seven physicians. Without gainsaying for a moment any of the staggering achievements of rural health care programs, it behoves us never to lose sight of the fact that such achievements depend less on the quality of what is provided than on the gaping void that it fills. A therapeutic blunderbuss is enormously successful when it is aimed at such an obvious target as a pediatric death rate of 30% to 40% .. However, when the target is less obvious the success rate is dramatically reduced. Inappropriate medication and misdiagnoses are common among patients of paramedics. Serious errors are fatal or crippling. We hope that the less serious errors occupy patients sufficiently to keep them away from ruinous alternatives while the disease abates on its own. People like Ivan Illich2 could have at least as much of a field day in Nigeria as they do at home. The inability of a decentralized rural health care system to cope with surgical emergencies is not appreciated sufficiently. Without hospital services many people die. Last year 6000 "normal" infants were delivered at our hospital and as many or more were delivered at the rural health care centres. We performed 450 cesarean sections last year, a number that is comparatively insignificant, and there were about the same number of ectopic pregnancies. If such figures are compared with something as gross as infectious disease mortality, then they are insignificant statistically, but only statistically. Rural health care in developing countries is cost-effective because it deals with the bulk of diseases that are cheap to treat and control. Hospitals in developing countries are expensive because conditions 1338
are treated that are inherently more expensive and difficult to treat. Statistically a death is a death and a dollar is a dollar, so it makes sense to concentrate on rural health care and forget about hospitals. However, when this is the case we should never forget that we are playing a numbers game with human lives. If our backs are against the wall we may be forced into that dilemma, but with sufficient determination resources can be stretched to encompass some sort of facility for persons unfortunate enough to have diseases for which treatment is expensive but readily available. Appropriate use of such facilities and of rural health care centres is what comprehensive, rather than exclusively cost-effective, health care is all about in the Third World. Mr. Korcok's article was unreferenced so I must challenge his assertion that Nigerian wells were capped with rims of concrete for $1.40 each. The current price of cement is $11.05 (US currency) per bag. Even when one considers double-digit inflation his cost figure would have been accurate so many years ago that it would have been better not to include it. His article also includes a drawing of an "ingenious Vietnamese latrine". Though blessed with the wealth of almost 20 years of regular use of outdoor facilities I can't fathom what is so ingenious about the device, or how it manages to disinfect and deodorize its contents. An accompanying text or working drawing would not have been amiss as I am sure most less experienced readers would be even more mystified than I. If, in fact, the latrine is as good as its caption says, then it merits an article about it because it has more cost-effective potential for world health care and nutrition than anything else Mr. Korcok has written about. In closing, I cannot resist commenting on the fees charged by Robert MacLellan, a general practitioner in Nova Scotia during World War I (Can Med Assoc 1 120: 494, 1979). He was charging $15 for uncomplicated obstetric procedures at a time when Canada's per capita gross national product (GNP) was $530. According to an article in Newsweek (May 28), Nigeria's per
CMA JOURNAL/NOVEMBER 17, 1979/VOL. 121
capita GNP is currently $500. My wife underwent a routine, midwifeassisted delivery in hospital in February for an official standard fee of $8 (US currency). Perhaps Dr. MacLellan's fees were too high, perhaps ours aI.. too low, or maybe we can simply reflect that cement is very expensive. JOHN VAN DORP, MD
Mkar Christian Hospital Box 261 Jos, Nigeria References 1. MORLEY D: Paediatric Priorities in the Developing World, Butterworths, London, 1973, p 318 2. ILLICH I: Limits of Medicine. Medical Nemesis: the Expropriation of Health,
Calder & Boyers, London, 1975 To the editor: Dr. Van Dorp appears to be saying that rural health care centres, on the basis of a paramedic approach to services, have a critical, albeit limited, function in maintaining health care standards in the Third World. That too is the point of my articles. The fact that such a paramedic brand of medicine cannot always measure up to the needs of all the people, especially those requiring the services of a higher technology, is a pity. But, as my articles point out, the greatest need in emerging countries is for a preventive approach to health care, one dedicated to raising the overall health status of the people. In effect, the preventive rather than the curative elements of health care are emphasized, and in this respect the Western styles of medicine do not appear to be the most appropriate models. My reference to Nigerian wells being capped with rims at $1.40 each is from the Mahler-Labouisse report to the international conference on primary health care at Alma Ata in the Soviet Union in September 1978. A lot of concrete rims can be made from one bag of cement, especially if the concrete is diluted and contains a lot of sand. They don't have to last as long as the sphinx and the builders know it. Even at a higher price the cost-effectiveness of this kind of prevention goes unquestioned. With regard to the drawing of the Vietnamese latrine, it is true
