Living next to an elephant T n he life of a community family physician in Ottawa is not easy. At times it can be likened to being a mosquito on the side of an elephant. Clearly illustrating this is the article by Anne Gilmore on the Heart Check Centre, a project at the University of Ottawa Heart Institute ("With new Ottawa centre, acute care and health promotion share same address" [Can Med Assoc J 1991; 144: 229, 231-232]). The heart institute has made a major initiative into primary preventive medicine and health promotion with the Heart Check Centre. It is interesting that "the centre was established with advice from an expert committee of physicians from the family medicine, pediatrics and public health fields." The concerns of Dr. Reg Perkin, executive director of the College of Family Physicians of Canada, as stated in the article, are very appropriate. What is truly debatable and is not mentioned in Gilmore's article is the following policy, as stated in the Ottawa Citizen Feb. 28, 1990 (Cl). The centre doesn't duplicate services by doctors because the current system of remuneration does not provide incentives for physicians to practise preventive medicine.
There is considerable research in the literature refuting this position. A major component of the Heart Check Centre's underlying philosophy is clearly false. Patients who come to the office are now confused as to the role played by community family physicians, who have always been doing primary preventive medicine and health promotion - to varying extents, depending on their interest and knowledge. Yet we have the heart institute clearly stating that physicians have not 954
CAN MED ASSOC J 1991; 144 (8)
been doing this important aspect of medicine. The public deserves an explanation. Living next to an elephant is not always easy. One would hope that as the heart institute moves forward, on sound philosophic grounds, it will somehow find a place for the conscientious community family physician without squashing him or her along the way. Howard R. Cohen, MD, CCFP 5-2286 Carling Ave. Ottawa, Ont.
[The directors of the Heart Check Centre respond:] Dr. Cohen's major concern relates to a comment that, as he notes, appeared not in the article by
vice and advice provided by voluntary health associations, professional organizations and others regarding heart-healthy behaviour. It has been and will remain our intention to ensure that a spirit of close cooperation exists between the Heart Check Centre and family practitioners. William A. Dafoe, MD, FRCPC Andrew L. Pipe, MD Medical directors Robert Reid, MSc, MBA Program director
HIV infection among Quebec women giving birth to live infants
Anne Gilmore but in the Ottawa Citizen. That comment misrepresented remarks made by Heart Check Centre staff. We have not been aware of any confusion on the part of people who have attended the Heart Check Centre regarding the role of their family physician. Cohen will no doubt realize that it is an expectation of many in the community (and within the heart institute) that a facility such as ours should be as active in the prevention of heart disease as in its treatment. The Heart Check Centre is one response to those expressed needs. It permits a comprehensive, relatively rapid assessment of an individual's personal risk. Such an approach is particularly relevant for the family members of those who have recently experienced heart disease, those who have a high degree of curiosity about their personal risks and those who have no family physician. It is also relatively portable, which makes it ideal for worksite and other health promotion activities. We feel that the presentation of personalized information relat-
D_ r. Catherine A. Hankins' response (Can Med Assoc J 1991; 144: 280) to my letter (ibid: 277, 280) requires further debate. Epidemiology is the handmaiden of public health, not vice versa, and the health of the individual is the ultimate concern. In the second paragraph of her response Hankins considers two principles: prevalence of disease and timing of screening. I would like to address these issues. In Guthrie testing we screen for phenylketonuria (incidence 1 in 104), hypothyroidism (incidence 1 in 4 x 103) and galactosemia (incidence 1 in 6 x 104). The prevalence of HIV antibodies among pregnant women in British Columbia screened in anonymous testing is reported to be 1 in 1300 (1.3 x 103).' How high is high? As to the timing of testing, I conclude from the second principle enunciated that testing could be better later rather than sooner! I have difficulty applying this principle to infectious disease. Hankins mentions that 70% of the seropositive infants may be uninfected. These are the very ing to individual risk comple- infants in whom HIV infection ments the family physician's ad- might be prevented, since postnaLE 15 AVRIL 1991
ples of prevalence of disease and timing of screening, when, in fact, the main point I was trying to make pertained to treatment. No matter how high the prevalence of a disease, the lack of effective therapy will enter the cost-benefit ratio in a negative fashion. At this time there is no effective, licensed therapy available for asymptomatic HIV-infected infants. Parker argues that the risk of transmission through breast milk justifies screening to protect uninJames E. Parker, MB, FRCPC fected infants born to seropositive 303-2151 McCallum Rd. women. The only cases of HIV Abbotsford, BC transmission through breast-feeding that have been documented References worldwide have occurred in infants whose mothers were infected 1. Schechter MT, Ballem PJ, Buskard NA not during pregnancy or at birth et al: An anonymous seroprevalence survey of HIV infection among preg- but, rather, post partum, in most nant women in British Columbia and cases through contaminated blood the Yukon Territory. Can Med Assoc J transfusions.3 It has not been 1990; 143: 1187-1192 demonstrated that breast-feeding 2. Ziegler JB, Cooper DA, Johnson RD et an incremental risk to inposes al: Postnatal transmission of AIDS astal transmission of HIV has been recorded.23 The American Academy of Pediatrics recommends that HIV-positive mothers not breastfeed their infants because of the risk of infection from virus in the milk.4 Although newborn screening for HIV antibodies may not be the way to go, Hankins and associates' valuable paper5 makes a strong case for screening at an even earlier stage - pregnancy.
sociated retrovirus from mother to infant. Lancet 1985; 1: 896-898 3. Lepage P, Van de Perre P, Carael M et al: Postnatal transmission of HIV from mother to child [C]. Lancet 1987; 2: 400 4. American Academy of Pediatrics, Task Force on Pediatric AIDS: Perinatal human immunodeficiency virus infection. Pediatrics 1988; 82: 941-944 5. Hankins CA, Laberge C, Lapointe N et al: HIV infection among Quebec women giving birth to live infants. Can MedAssoc J 1990; 143: 885-893
[Dr. Hankins responds:] Dr. Parker wishes to contrast the relatively high prevalence of HIV seropositivity in newborns (1 in 1638 in Quebec) found in our study' with the prevalence of other diseases for which population-based screening in the newborn period may be performed. As an aside, the rate he provides for the BC prenatal study conducted by Schechter and colleagues2 is for women aged 15 to 29 years; the overall rate was 1 in 3752 for women of all ages in British Columbia. Parker indicates that my comments pertained to the princiAPRIL 15, 1991
fants who have received placentally acquired antibodies during gestation.4 I must reiterate that the conditions for routine HIV screening of either newborns or pregnant women in Canada have not been met to date. Catherine A. Hankins, MD, FRCPC Public health epidemiologist Centre for AIDS Studies Department of Community Health Montreal General Hospital Montreal, Que.
References 1. Hankins CA, Laberge C, Lapointe N et al: HIV infection among Quebec women giving birth to live infants. Can Med Assoc J 1990; 143: 885-893 2. Schechter MT, Ballem PJ, Buskard NA et al: An anonymous seroprevalence survey of HIV infection among pregnant women in British Columbia and the Yukon Territory. Can Med Assoc J 1990; 143: 1187-1192 3. Ryder RW, Hassig SE: The epidemiolo-
X..X~ ~ ~ ~ ~-~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
>~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~0 -M. . . . . . .
FOR THE HIDDEN CAUSES OF INFECTION IN COMMON DERMATOSES CAN MED ASSOC J
1991; 144 (8)
955
There is considerable research in the literature refuting this position. A major component of the Heart Check Centre's underlying philosophy is clearly false. Patients who come to the office are now confused as to the role played by community family physicians, who have always been doing primary preventive medicine and health promotion - to varying extents, depending on their interest and knowledge. Yet we have the heart institute clearly stating that physicians have not 954
CAN MED ASSOC J 1991; 144 (8)
been doing this important aspect of medicine. The public deserves an explanation. Living next to an elephant is not always easy. One would hope that as the heart institute moves forward, on sound philosophic grounds, it will somehow find a place for the conscientious community family physician without squashing him or her along the way. Howard R. Cohen, MD, CCFP 5-2286 Carling Ave. Ottawa, Ont.
[The directors of the Heart Check Centre respond:] Dr. Cohen's major concern relates to a comment that, as he notes, appeared not in the article by
vice and advice provided by voluntary health associations, professional organizations and others regarding heart-healthy behaviour. It has been and will remain our intention to ensure that a spirit of close cooperation exists between the Heart Check Centre and family practitioners. William A. Dafoe, MD, FRCPC Andrew L. Pipe, MD Medical directors Robert Reid, MSc, MBA Program director
HIV infection among Quebec women giving birth to live infants
Anne Gilmore but in the Ottawa Citizen. That comment misrepresented remarks made by Heart Check Centre staff. We have not been aware of any confusion on the part of people who have attended the Heart Check Centre regarding the role of their family physician. Cohen will no doubt realize that it is an expectation of many in the community (and within the heart institute) that a facility such as ours should be as active in the prevention of heart disease as in its treatment. The Heart Check Centre is one response to those expressed needs. It permits a comprehensive, relatively rapid assessment of an individual's personal risk. Such an approach is particularly relevant for the family members of those who have recently experienced heart disease, those who have a high degree of curiosity about their personal risks and those who have no family physician. It is also relatively portable, which makes it ideal for worksite and other health promotion activities. We feel that the presentation of personalized information relat-
D_ r. Catherine A. Hankins' response (Can Med Assoc J 1991; 144: 280) to my letter (ibid: 277, 280) requires further debate. Epidemiology is the handmaiden of public health, not vice versa, and the health of the individual is the ultimate concern. In the second paragraph of her response Hankins considers two principles: prevalence of disease and timing of screening. I would like to address these issues. In Guthrie testing we screen for phenylketonuria (incidence 1 in 104), hypothyroidism (incidence 1 in 4 x 103) and galactosemia (incidence 1 in 6 x 104). The prevalence of HIV antibodies among pregnant women in British Columbia screened in anonymous testing is reported to be 1 in 1300 (1.3 x 103).' How high is high? As to the timing of testing, I conclude from the second principle enunciated that testing could be better later rather than sooner! I have difficulty applying this principle to infectious disease. Hankins mentions that 70% of the seropositive infants may be uninfected. These are the very ing to individual risk comple- infants in whom HIV infection ments the family physician's ad- might be prevented, since postnaLE 15 AVRIL 1991
ples of prevalence of disease and timing of screening, when, in fact, the main point I was trying to make pertained to treatment. No matter how high the prevalence of a disease, the lack of effective therapy will enter the cost-benefit ratio in a negative fashion. At this time there is no effective, licensed therapy available for asymptomatic HIV-infected infants. Parker argues that the risk of transmission through breast milk justifies screening to protect uninJames E. Parker, MB, FRCPC fected infants born to seropositive 303-2151 McCallum Rd. women. The only cases of HIV Abbotsford, BC transmission through breast-feeding that have been documented References worldwide have occurred in infants whose mothers were infected 1. Schechter MT, Ballem PJ, Buskard NA not during pregnancy or at birth et al: An anonymous seroprevalence survey of HIV infection among preg- but, rather, post partum, in most nant women in British Columbia and cases through contaminated blood the Yukon Territory. Can Med Assoc J transfusions.3 It has not been 1990; 143: 1187-1192 demonstrated that breast-feeding 2. Ziegler JB, Cooper DA, Johnson RD et an incremental risk to inposes al: Postnatal transmission of AIDS astal transmission of HIV has been recorded.23 The American Academy of Pediatrics recommends that HIV-positive mothers not breastfeed their infants because of the risk of infection from virus in the milk.4 Although newborn screening for HIV antibodies may not be the way to go, Hankins and associates' valuable paper5 makes a strong case for screening at an even earlier stage - pregnancy.
sociated retrovirus from mother to infant. Lancet 1985; 1: 896-898 3. Lepage P, Van de Perre P, Carael M et al: Postnatal transmission of HIV from mother to child [C]. Lancet 1987; 2: 400 4. American Academy of Pediatrics, Task Force on Pediatric AIDS: Perinatal human immunodeficiency virus infection. Pediatrics 1988; 82: 941-944 5. Hankins CA, Laberge C, Lapointe N et al: HIV infection among Quebec women giving birth to live infants. Can MedAssoc J 1990; 143: 885-893
[Dr. Hankins responds:] Dr. Parker wishes to contrast the relatively high prevalence of HIV seropositivity in newborns (1 in 1638 in Quebec) found in our study' with the prevalence of other diseases for which population-based screening in the newborn period may be performed. As an aside, the rate he provides for the BC prenatal study conducted by Schechter and colleagues2 is for women aged 15 to 29 years; the overall rate was 1 in 3752 for women of all ages in British Columbia. Parker indicates that my comments pertained to the princiAPRIL 15, 1991
fants who have received placentally acquired antibodies during gestation.4 I must reiterate that the conditions for routine HIV screening of either newborns or pregnant women in Canada have not been met to date. Catherine A. Hankins, MD, FRCPC Public health epidemiologist Centre for AIDS Studies Department of Community Health Montreal General Hospital Montreal, Que.
References 1. Hankins CA, Laberge C, Lapointe N et al: HIV infection among Quebec women giving birth to live infants. Can Med Assoc J 1990; 143: 885-893 2. Schechter MT, Ballem PJ, Buskard NA et al: An anonymous seroprevalence survey of HIV infection among pregnant women in British Columbia and the Yukon Territory. Can Med Assoc J 1990; 143: 1187-1192 3. Ryder RW, Hassig SE: The epidemiolo-
X..X~ ~ ~ ~ ~-~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
>~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~0 -M. . . . . . .
FOR THE HIDDEN CAUSES OF INFECTION IN COMMON DERMATOSES CAN MED ASSOC J
1991; 144 (8)
955
