evidence suggests is that if a stan¬ dard of 2 mg/cu m is adhered to, the likelihood of a miner reaching cate¬ gory 2 or above with 35 years of un¬ derground exposure is less than 3%.2 Implicit in the assumption that a miner is disabled after 35 years in a coal mine is the concept that no mat¬ ter how effective the dust control pro¬ gram proves to be, disability is inevi¬ table. There would, therefore, seem to be little purpose in having a dust con¬ trol program, and the millions of dol¬ lars that are currently being spent on dust control are being wasted. There is little doubt that for many years the US coal miner was treated unfairly, but past injustices are not expunged by creating a new set of in¬ justices that discriminate against the rest of the working population. If Congress wishes to expiate its past neglect of coal miners by creating a premature retirement system for them, let it do so openly and not by trying to justify social legislation by willfully misrepresenting the medical facts and by maudlin appeals to the public's guilty conscience. W. Keith C. Morgan, MD West Virginia University Medical Center
Morgantown Morgan WKC: Respiratory disease in coal miners. JAMA 231:1347-1348, 1975. 2. Jacobson M: Progression of coal workers' pneu1.
moconiosis in Britain in relation to environmental conditions underground. Proceedings of the Conference on Technical Measures of Dust Prevention and Suppression in Mines. Luxembourg, Commission of European Communities, 1973, pp 77-93.
Geriatric Doses To the Editor.\p=m-\Drs.Solomon and Vickers (231:280, 1975) do not appear to appreciate that geriatric doses of psychoactive medication are lower than doses for younger people. Acceptable therapeutic lithium ion levels for people more than 50-60 years of age is 0.2 to 0.9 mEq/liter. For older people, 300-mg tablets of lithium carbonate often have to be broken in half; 150 mg three times daily is a frequent geriatric dosage. Sometimes even less is appropriate. For this reason, tablet form is better than capsule form of lithium carbonate. Ruth Wharton, MD
Chicago
In Reply.\p=m-\Itis true that extra care should be exercised when prescribing medication for elderly patients because of the prevalence of side effects and complications. We do not agree, however, with the broad general-
ization that doses of psychoactive medications are lower than doses for younger people; each case must be treated individually to achieve a satisfactory serum level. We find that the use of capsules
produces
a more
predictable
serum
level. Studies we performed four years ago showed that some tablets remained intact and were excreted in the stools. The purpose of our article was to point out that dysphasia may occur as an isolated effect of lithium administration in the absence of true toxicity. The patient is almost unaware of the symptom and suffers no real inconvenience from it. We think that it is better not to give a medication at all if the dosage level is too low to produce a therapeutic effect; this would apply to the lower limits of the thera¬ peutic range acceptable to Dr. Whar¬ ton.
Raymond Vickers, MD Kenneth Solomon, MD Albany, NY
of chloroquine, 500 mg daily for five days. In each case, a slight to moderate transient rise in transaminase and uroporphyrin levels new course
followed the
new course
of chloro¬
quine therapy, but symptoms of a chloroquine reaction developed in only one of the five patients, and were
very mild.
Although
none of the patients showed clinical manifestations of PCT at the time of recurrent porphyrinuria, the experience suggests that porphyrin levels should be ob¬ served periodically in patients who have had PCT, or that chloroquine therapy should be repeated, at per¬ haps six-month intervals, to ensure
against relapse.
Michael J. Kowertz, MD Permanente Medical Group Sunnyvale, Calif
Neisseria lactamicus
Pharyngitis
To the Editor.\p=m-\A26-year-old man to Harbor General Hospital with fever, chills, and a sore throat. His temperature was 40 C (104 F) and came
Retreatment With Chloroquine in Porphyria Cutanea Tarda To the Editor.\p=m-\Twoyears ago, I
re-
ported in The Journal (223:515,1973) the correction of the hepatic abnor-
malities as well as the cutaneous manifestations of porphyria cutanea tarda (PCT) by the oral administration of chloroquine, and suggested that this agent, directly or indirectly, selectively destroyed those cells (or
their organelles) that were responsible for abnormal porphyrin synthesis. Although I still believe this to be the case, longer observation of the two patients reported, and of three additional patients with PCT who were similarly treated, has revealed a slight to moderate increase in uroporphyrin excretion six months to three years after initial treatment. This would imply that all porphyrinproducing structures had not been destroyed, or that they were capable of regeneration. The rise after only six months would favor the former explanation; the increase after three years, the latter. Alcohol intake was evidently not causally related to the rise. The patient whose urinary porphyrin levels remained normal longest and rose least after chloroquine treatment consumes large amounts of alcohol; one patient drinks no alcohol. In all five patients, the second episode of
porphyrinuria responded rapidly
to
a
there was marked pharyngeal and tonsillar inflammation, with a peritonsillar exudate. Pharyngeal culture grew Neisseria lactamicus in pure culture. This organism appears identical to N meningitidis on culture media, and distinction between the two can only be made on serologic or biochemical grounds.1,2 Neisseria lactamicus differs from N meningitidis in that it ferments lactose and produces a \g=b\-galactosidase. The carrier rate of N lactamicus in adults is 0% to 2%.2 The importance of distinguishing
the different Neisseria
species lac-
tamicus, meningitidis, and
gonor-
rhoeae) has obvious epidemiologic and therapeutic importance. S. Fisher, MD Paul Edelstein, MD Lucien B. Guze, MD Harbor General Hospital Larry
Torrance, Calif 1. Hollis
DG, Wiggins GL, Weaver RE: Neisseria lactamicus: A lactose-fermenting species resembling Neisseria meningitidis. Appl Microbiol 17:71-77, 1969. 2. Hollis DG, Wiggins GL, Weaver RE, et al: Current status of
Sci
lactose-fermenting
Neisseria. Ann NY Acad
174:444-449, 1970.
Health in the Developing World To the Editor.\p=m-\Dr.Tavassoli's article (230:1527, 1974), which stresses the inability of modern medicine to improve the health of people in the developing world, demonstrates the im-
Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/16/2015
portant point that physicians acquire
knowledge in the fields of history, sociology, and social anthropology, and must increasingly apply this knowledge to health care provision. The author cites the following reasons for
the failure: (1) much of modern medicine is irrelevant; (2) medical progress is too far removed from the greater number of the population for them to be impressed, and they may even distrust it or hold it in contempt; (3) training does not suit the needs and the problems and physicians, so the trained tend to migrate; (4) there is lack of infrastructure; and (5) the majority of the population is rural, widely scattered, and not easily reached by modern technology. He sees further hope in the Chinese system of pyramidal structure of health care provision, the base of which con¬ sists of barefoot doctors, recruits from the rural areas to which they go to practice after training. By and large, physicians are an in¬ tegral part of any society in which they serve, and the services they pro¬ vide reflect and are influenced by the structure of that society. Proper health care results from a delicate balance between different factors act¬ ing together. These include the indi¬ vidual and his perception of his needs; the society and its organization and ordering of priorities; the govern¬ ment and the impetus it can provide; the physician and other health work¬ ers and the types of training received and the mode of utilization of their services; and lastly, the scientific knowledge available about aspects of health care and disease entities, to¬ gether with the means for utilization, and the technology for the provision of health care. We do not know the proper "mix" of these variables, but one suspects that these differ from one country to another and from soci¬ ety to society. However, without ef¬ forts aimed at attaining the "right" combination, good health care cannot result. In the United States today, there are receptive individuals, a
fairly well-informed, relatively or¬ derly society, an excellent technical knowledge, and a relatively high ratio of physicians to population, yet health care is excellent for some people, and
poor or nonexistent for others. We have blamed this on maldistribution
of physicians,
a
heavy emphasis
on re¬
search, an equally low concern with provision of services, and finally, a lack of
regional
comprehensive national health policies.
and
In almost all developing countries, the social structure is wobbly. Social order is nonexistent, and a unified theme for action is more often lack¬ ing. The factors listed by Tavassoli play a part, but it is doubtful that health care in these countries would change appreciably if these factors could be corrected. That China has succeeded is to a large extent due to the central theme, namely the teach¬ ing of Chairman Mao. As Dr. Moser has pointed out (230:1566,1974), tradi¬ tional medical practice in China for about 5,000 years was influenced by the Net Ching dialogues. The advent of present-day communist China dates back to 1949, but the seeds for the structure were sown about 1928, at about the beginning of the Long March.' Among the basic rules for the behavior of the Red Army were or¬ ders requiring obedience, no confisca¬ tion of properties from peasants, and delivery of all goods taken from the landlords to the army. Eight other rules were added, among which was a request to be clean and to "build la¬ trines at a safe distance from people's houses." The emphasis on health care and social order has essentially remained unchanged and is still emphasized to¬ day. More scientific progress has been introduced in science and medicine, but this has been done through the inspiration, wisdom, and power of the Chairman and his deification. Whether such single-mindedness and indoctrination are necessary is debat¬ able, but we cannot deny that it has brought progress and a general im¬ provement in the standard of life when compared to the "Old Hundred Names" of the past Chinese gener¬ ations. That the barefoot doctor pro¬ gram has worked in China is no guar¬ antee that similar programs will work in any of the developing countries. Similar programs in the Soviet Union have not been too successful. In discussing economic develop¬ ment in the developing countries, Myrdal2 has pointed out the general absence of social discipline in most of these countries and has coined the phrase "soft state" to describe these communities. He has concluded that there is little chance of any social and economic development without greater social discipline, which will not appear without legislation and regulations compulsorily enforced. These same factors also operate in the field of health care in the develop¬ ing countries. Health care is poor in
developing countries in part because the resources and personnel are lim¬ ited, but available resources are often
wasted because of inefficiency, greed, and corruption. Developing countries need proper training programs and more physi¬ cians and other health workers. They need research in the causes of dis¬ eases, to design ways of preventing and curing them. Modern medicine is irrelevant on¬
ly because social development has lagged too far behind scientific devel¬
opment. We have developed the
knowledge, but we have not devel¬ oped at the same pace the social
structure and the social vehicle for
spreading the benefits of our scien¬ tific knowledge. We can modify our present activities
to correct the im¬ no reason to blame scientific progress.
balance, but there is
Edem Ekwo, MD, MPH
Lincoln, Rl
1. Goldston R: The long march into history, in The Rise of Red China. Greenwich, Conn, Fawcett Publications, Inc, 1967, pp 114-115. 2. Myrdal G: The "soft state," in The Challenge of Poverty. New York, Vintage Books, 1971, pp 208-252.
To the Editor.\p=m-\Dr.Ekwo and I appear to agree that social development has lagged too far behind scientific progress. Scientific progress is, of course, an integral aspect of social de-
velopment, and precisely for this reason, science must be responsive to the needs of society. One may accept that science leads society in a forward movement, but scientific progress
far ahead of social when this occurs, the relevance of science to society is lost. Science is then isolated, functioning within a vacuum.
gallop too development, for
cannot
Mehdi Tavassoli, MD Scripps Clinic and Research Foundation La Jolla, Calif
Hypomagnesemia as a Cause Of Persistent Hypokalemia To the Editor.\p=m-\We wish to call to the attention of your readers the documented but little-appreciated importance of hypomagnesemia as a cause of persistent hypokalemia.
Report of a Case.\p=m-\A40-year-old healthy woman was
admitted to
trauma unit after
burn and 65% total treated in the convenour
sustaining
body burns. She was tional manner but progressive dehydration and hypokalemia developed during four weeks of hospitalization. A medical consultation was requested when her serum elec-
Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/16/2015
Morgantown Morgan WKC: Respiratory disease in coal miners. JAMA 231:1347-1348, 1975. 2. Jacobson M: Progression of coal workers' pneu1.
moconiosis in Britain in relation to environmental conditions underground. Proceedings of the Conference on Technical Measures of Dust Prevention and Suppression in Mines. Luxembourg, Commission of European Communities, 1973, pp 77-93.
Geriatric Doses To the Editor.\p=m-\Drs.Solomon and Vickers (231:280, 1975) do not appear to appreciate that geriatric doses of psychoactive medication are lower than doses for younger people. Acceptable therapeutic lithium ion levels for people more than 50-60 years of age is 0.2 to 0.9 mEq/liter. For older people, 300-mg tablets of lithium carbonate often have to be broken in half; 150 mg three times daily is a frequent geriatric dosage. Sometimes even less is appropriate. For this reason, tablet form is better than capsule form of lithium carbonate. Ruth Wharton, MD
Chicago
In Reply.\p=m-\Itis true that extra care should be exercised when prescribing medication for elderly patients because of the prevalence of side effects and complications. We do not agree, however, with the broad general-
ization that doses of psychoactive medications are lower than doses for younger people; each case must be treated individually to achieve a satisfactory serum level. We find that the use of capsules
produces
a more
predictable
serum
level. Studies we performed four years ago showed that some tablets remained intact and were excreted in the stools. The purpose of our article was to point out that dysphasia may occur as an isolated effect of lithium administration in the absence of true toxicity. The patient is almost unaware of the symptom and suffers no real inconvenience from it. We think that it is better not to give a medication at all if the dosage level is too low to produce a therapeutic effect; this would apply to the lower limits of the thera¬ peutic range acceptable to Dr. Whar¬ ton.
Raymond Vickers, MD Kenneth Solomon, MD Albany, NY
of chloroquine, 500 mg daily for five days. In each case, a slight to moderate transient rise in transaminase and uroporphyrin levels new course
followed the
new course
of chloro¬
quine therapy, but symptoms of a chloroquine reaction developed in only one of the five patients, and were
very mild.
Although
none of the patients showed clinical manifestations of PCT at the time of recurrent porphyrinuria, the experience suggests that porphyrin levels should be ob¬ served periodically in patients who have had PCT, or that chloroquine therapy should be repeated, at per¬ haps six-month intervals, to ensure
against relapse.
Michael J. Kowertz, MD Permanente Medical Group Sunnyvale, Calif
Neisseria lactamicus
Pharyngitis
To the Editor.\p=m-\A26-year-old man to Harbor General Hospital with fever, chills, and a sore throat. His temperature was 40 C (104 F) and came
Retreatment With Chloroquine in Porphyria Cutanea Tarda To the Editor.\p=m-\Twoyears ago, I
re-
ported in The Journal (223:515,1973) the correction of the hepatic abnor-
malities as well as the cutaneous manifestations of porphyria cutanea tarda (PCT) by the oral administration of chloroquine, and suggested that this agent, directly or indirectly, selectively destroyed those cells (or
their organelles) that were responsible for abnormal porphyrin synthesis. Although I still believe this to be the case, longer observation of the two patients reported, and of three additional patients with PCT who were similarly treated, has revealed a slight to moderate increase in uroporphyrin excretion six months to three years after initial treatment. This would imply that all porphyrinproducing structures had not been destroyed, or that they were capable of regeneration. The rise after only six months would favor the former explanation; the increase after three years, the latter. Alcohol intake was evidently not causally related to the rise. The patient whose urinary porphyrin levels remained normal longest and rose least after chloroquine treatment consumes large amounts of alcohol; one patient drinks no alcohol. In all five patients, the second episode of
porphyrinuria responded rapidly
to
a
there was marked pharyngeal and tonsillar inflammation, with a peritonsillar exudate. Pharyngeal culture grew Neisseria lactamicus in pure culture. This organism appears identical to N meningitidis on culture media, and distinction between the two can only be made on serologic or biochemical grounds.1,2 Neisseria lactamicus differs from N meningitidis in that it ferments lactose and produces a \g=b\-galactosidase. The carrier rate of N lactamicus in adults is 0% to 2%.2 The importance of distinguishing
the different Neisseria
species lac-
tamicus, meningitidis, and
gonor-
rhoeae) has obvious epidemiologic and therapeutic importance. S. Fisher, MD Paul Edelstein, MD Lucien B. Guze, MD Harbor General Hospital Larry
Torrance, Calif 1. Hollis
DG, Wiggins GL, Weaver RE: Neisseria lactamicus: A lactose-fermenting species resembling Neisseria meningitidis. Appl Microbiol 17:71-77, 1969. 2. Hollis DG, Wiggins GL, Weaver RE, et al: Current status of
Sci
lactose-fermenting
Neisseria. Ann NY Acad
174:444-449, 1970.
Health in the Developing World To the Editor.\p=m-\Dr.Tavassoli's article (230:1527, 1974), which stresses the inability of modern medicine to improve the health of people in the developing world, demonstrates the im-
Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/16/2015
portant point that physicians acquire
knowledge in the fields of history, sociology, and social anthropology, and must increasingly apply this knowledge to health care provision. The author cites the following reasons for
the failure: (1) much of modern medicine is irrelevant; (2) medical progress is too far removed from the greater number of the population for them to be impressed, and they may even distrust it or hold it in contempt; (3) training does not suit the needs and the problems and physicians, so the trained tend to migrate; (4) there is lack of infrastructure; and (5) the majority of the population is rural, widely scattered, and not easily reached by modern technology. He sees further hope in the Chinese system of pyramidal structure of health care provision, the base of which con¬ sists of barefoot doctors, recruits from the rural areas to which they go to practice after training. By and large, physicians are an in¬ tegral part of any society in which they serve, and the services they pro¬ vide reflect and are influenced by the structure of that society. Proper health care results from a delicate balance between different factors act¬ ing together. These include the indi¬ vidual and his perception of his needs; the society and its organization and ordering of priorities; the govern¬ ment and the impetus it can provide; the physician and other health work¬ ers and the types of training received and the mode of utilization of their services; and lastly, the scientific knowledge available about aspects of health care and disease entities, to¬ gether with the means for utilization, and the technology for the provision of health care. We do not know the proper "mix" of these variables, but one suspects that these differ from one country to another and from soci¬ ety to society. However, without ef¬ forts aimed at attaining the "right" combination, good health care cannot result. In the United States today, there are receptive individuals, a
fairly well-informed, relatively or¬ derly society, an excellent technical knowledge, and a relatively high ratio of physicians to population, yet health care is excellent for some people, and
poor or nonexistent for others. We have blamed this on maldistribution
of physicians,
a
heavy emphasis
on re¬
search, an equally low concern with provision of services, and finally, a lack of
regional
comprehensive national health policies.
and
In almost all developing countries, the social structure is wobbly. Social order is nonexistent, and a unified theme for action is more often lack¬ ing. The factors listed by Tavassoli play a part, but it is doubtful that health care in these countries would change appreciably if these factors could be corrected. That China has succeeded is to a large extent due to the central theme, namely the teach¬ ing of Chairman Mao. As Dr. Moser has pointed out (230:1566,1974), tradi¬ tional medical practice in China for about 5,000 years was influenced by the Net Ching dialogues. The advent of present-day communist China dates back to 1949, but the seeds for the structure were sown about 1928, at about the beginning of the Long March.' Among the basic rules for the behavior of the Red Army were or¬ ders requiring obedience, no confisca¬ tion of properties from peasants, and delivery of all goods taken from the landlords to the army. Eight other rules were added, among which was a request to be clean and to "build la¬ trines at a safe distance from people's houses." The emphasis on health care and social order has essentially remained unchanged and is still emphasized to¬ day. More scientific progress has been introduced in science and medicine, but this has been done through the inspiration, wisdom, and power of the Chairman and his deification. Whether such single-mindedness and indoctrination are necessary is debat¬ able, but we cannot deny that it has brought progress and a general im¬ provement in the standard of life when compared to the "Old Hundred Names" of the past Chinese gener¬ ations. That the barefoot doctor pro¬ gram has worked in China is no guar¬ antee that similar programs will work in any of the developing countries. Similar programs in the Soviet Union have not been too successful. In discussing economic develop¬ ment in the developing countries, Myrdal2 has pointed out the general absence of social discipline in most of these countries and has coined the phrase "soft state" to describe these communities. He has concluded that there is little chance of any social and economic development without greater social discipline, which will not appear without legislation and regulations compulsorily enforced. These same factors also operate in the field of health care in the develop¬ ing countries. Health care is poor in
developing countries in part because the resources and personnel are lim¬ ited, but available resources are often
wasted because of inefficiency, greed, and corruption. Developing countries need proper training programs and more physi¬ cians and other health workers. They need research in the causes of dis¬ eases, to design ways of preventing and curing them. Modern medicine is irrelevant on¬
ly because social development has lagged too far behind scientific devel¬
opment. We have developed the
knowledge, but we have not devel¬ oped at the same pace the social
structure and the social vehicle for
spreading the benefits of our scien¬ tific knowledge. We can modify our present activities
to correct the im¬ no reason to blame scientific progress.
balance, but there is
Edem Ekwo, MD, MPH
Lincoln, Rl
1. Goldston R: The long march into history, in The Rise of Red China. Greenwich, Conn, Fawcett Publications, Inc, 1967, pp 114-115. 2. Myrdal G: The "soft state," in The Challenge of Poverty. New York, Vintage Books, 1971, pp 208-252.
To the Editor.\p=m-\Dr.Ekwo and I appear to agree that social development has lagged too far behind scientific progress. Scientific progress is, of course, an integral aspect of social de-
velopment, and precisely for this reason, science must be responsive to the needs of society. One may accept that science leads society in a forward movement, but scientific progress
far ahead of social when this occurs, the relevance of science to society is lost. Science is then isolated, functioning within a vacuum.
gallop too development, for
cannot
Mehdi Tavassoli, MD Scripps Clinic and Research Foundation La Jolla, Calif
Hypomagnesemia as a Cause Of Persistent Hypokalemia To the Editor.\p=m-\We wish to call to the attention of your readers the documented but little-appreciated importance of hypomagnesemia as a cause of persistent hypokalemia.
Report of a Case.\p=m-\A40-year-old healthy woman was
admitted to
trauma unit after
burn and 65% total treated in the convenour
sustaining
body burns. She was tional manner but progressive dehydration and hypokalemia developed during four weeks of hospitalization. A medical consultation was requested when her serum elec-
Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/16/2015
