Saturday 29 November 1975

OUR LIVES AND HARD TIMES* T. W. MEADE

with the processes and organisation of health care as with an overall strategy to take account of the circumstances we

M.R.C.-D.H.S.S. Epidemiology and Medical Care Unit, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ

TEN or fifteen years ago, the balance between costs and benefits in medical practice was largely an occasional subject for coffee-break chit-chat. Topics that were discussed were often, if not usually, of a quite trivial nature-the relative expense and clinical value of iron preparations in the treatment of anaemia, for example. Today, one can hardly look at a professional journal and avoid the cost-effectiveness or cost-benefit question in some form or another. Increasing efforts are being made actually to measure the resources devoted to this or that practice, and its outcome. And, of course, this reflects our actual situation. In 1960, it might have been a new maternity block and a new pathology laboratory; today it is one or the other-or neither. There are three main reasons for the change. First, knowledge and technology have rapidly advanced in some fields to the extent that conditions which were more or less untreatable not so very long ago (chronic renal failure, certain types of leukaemia, and so on) are now treatable. Secondly, the National Health Service’s clientele has effectively increased-not just, at any rate until recently, by population growth, but by the mounting concern rightly expressed about groups for whom custodial care had previously often been the only attention they received. It took a series of scandals to bring the plight of many of the long-term psychiatrically sick and subnormal to the public attention-but these are now among the priority groups for health-service expenditure. Thirdly, of course, the economic deterioration of the last few years has had its effect on the provision of health care, as it has on everything else. Many would add a fourth reason-the administrative consequences of the 1974 reorganisation of the N.H.S. Difficult times have accentuated all the inherent shortcomings of the N.H.S.—lengthy waiting-lists, unequal regional distribution of resources, and so on. The view that I want to consider, however, deals not so much *Based on the Caradog Jones Lecture, 7944

given on

Oct. 29, 1975.

find ourselves in.

Redeployment have become increasingly stretched over

As resources the past few years, attempts have been made to obtain the information we need to use them more effectively. Observational studies have been carried out, many very successfully, to measure the prevalence and health-service implications of various diseases; and the randomised controlled trial has evolved from a technique originally applied mainly to the evaluation of medicines to a means of assessing the effectiveness of a variety of treatment and management methods.’ A milestone in this story was the comparison by Mather et al. of outcome, in terms of mortality, of patients who had had

myocardial infarcts, according to whether they were treated at home or in hospital. Among the patients where randomisation was considered justifiable, the mortality-rates in those treated at home and in hospital were the same (the higher rate in the hospital group [14.2%]being not significantly different from that [9.8%] in the home-treated group). Perhaps even more important than these results themselves, however, is the single fact that the trial took place at all-that it was shown to be feasible, and that the preconceived idea that treatment in hospital must be better than treatment at home was exposed as questionable, if not wrong. Today, there are dozens of trials of this sort in progress. There is little doubt that there is a large element of waste in the N.H.S. which arises from the use of ineffective or inappropriate measures; it is clearly impossible to ensure that there is no wastage at all in an organisation the size of the N.H.S., but a potential answer to perhaps quite a large part of our present difficulties lies in making much better use of what we already have. Translating redeployment from theory into practice is easy enough to talk about, but bound to be extremely difficult; nevertheless, we have to try. Having said this, however, what other options should we consider? Turning off the Tap

virtually all health-care systems, the N.H.S. is geared predominantly to a policy of managing established disease. By contrast with many of the acute infecLike

1054 tions of fifty years ago, where full recovery or death were often the only outcomes, today’s epidemic illnesses are insidious in onset, of chronic duration, and frequently the cause of long-term disability; coronary and cerebrovascular disease, chronic respiratory disease, lung, breast, and large-bowel cancer, the aftermath of road traffic accidents, survivors of congenital disorders who would previously have died, patients with chronic renal failure on intermittent dialysis-it is to these and similar problems that we have to devote an uncomfortably large share of our resources. And yet we would probably all agree that many cases of every one of these (and other) diseases need never have occurred. We are, quite simply, coping with the wreckage of our failures to prevent. So far, our main response to adverse economic pressures has been to try and get more skilful at picking up the pieces. The nature of the central dilemma for health care at the present time is not new, but its intensity is: are we serious about prevention? Are we serious about trying to "turn off the tap"? Now if each of us were asked this question in a private capacity, we should mostly say yes; and we should all say yes in our official capacities if we had to answer in public. But let us think about the implications of a real policy decision to attempt the effective prevention of chronic non-communicable disease (much progress having, of course, been made in the control of infectious dis-

ease). Smoking We have the

knowledge

we

need

to

prevent

most

lung

of chronic bronchitis, and probably cancers, large cases heart-disease. We have had this knowlofischaemic many now for when I say we, I don’t just many years-and edge mean health professionals, but the butcher, the baker, and the candlestick maker; but we haven’t applied it. Knowledge does not mean application; in my view there are really only two ways of applying it in the case of smoking. The first is based on the assumption that heightening the already universal awareness of the dangers of smoking will work; in other words, we need a campaign of health education that matches the sales promotion campaign of the tobacco industry in depth, expense, and even deviousness. I have doubts about this approach; the reason smokers continue to smoke is that they know perfectly well what health educators have so far glossed over-namely, that their chances of getting away with smoking are probably considerably greater than their chances of not doing so. (While we are on the subject of anti-smoking measures we ought to consider other recommended modifications of life-style. Virtually every driver and front seat passenger knows that he ought to use his seat-belt; only about a third habitually do so. Less than half the young adult population regularly goes to the dentist; we could avert much of the need for this anyway if we accepted fluoridation more widely. Even assuming that the "prudent diet" will prevent coronary disease, the evidence is that even the highly motivated often won’t stick to it. The preservation of health is not an easily saleable commodity.) The other approach to smoking is to make it safer. New smoking materials and the like are in the course of developa

amount

assessment; but there is every reason to be sceptical about their value. Might it, therefore, be possible more accurately to define, within those who do smoke, those who are at a specially high risk of various diseases, and concentrate preventive efforts on them as individuals? For ischaemic heart-disease, the presence of other factors such as hypertension and high blood-lipid levels are a guide, but not a very good one. In the case of lung cancer, recent work3 has suggested that arylhydrocarbon-hydroxylase inducibility may be a useful predictor of increased risk. Even if this particular method eventually ment or

(and it has been criticised4), the general identify and concentrate on those smokers at special risk has much to be said for it. But no approach to dealing with the problem of smoking will be cheap. We can forget all about diseases fading away simply because we know enough about their causes to make prevention theoretically possible. We can write the prescription, but that doesn’t mean the patient will take the medicine; clinicians have always known this-those in the field of preventive medicine are learning much too slowly.

proves unsuccessful

idea of trying

to

Hypertension Let us briefly consider another example, which stands at the boundary between research and the application of knowledge gained from research. It has, for many years now, been known that there is a direct relationship between blood-pressure level and the risk of clinically manifest arterial disease. Within the past seven or eight years it has also become obvious that the treatment of very high blood-pressure is strikingly effective in reducing the incidence of strokes and of the direct consequences of hypertension such as heart and kidney failures6; for some reason (as yet unknown), the same is not true of the incidence of coronary thrqmbosis. The question therefore now arises as to whether those with milder degrees of hypertension should be detected by screening (most of them being without symptoms, and unknown to their doctors) and, once identified, started on treatment. However, modern antihypertensive agents are not without side-effects, occasionally quite serious, and there is obviously also a possibility that psychological harm could be done by, in effect, telling people who feel perfectly well that they are ill. In other words, at lower levels of hypertension we probably have to balance the likely clinical benefits of screening and treatment against the possible clinical hazards. (We also, of course, have to demonstrate that there is a benefit; this seems likely, but other experiences in the field of arterial disease show that it is dangerous to take anything for granted.) There is a very great deal at stake here. Probably 5% of the adult population has mild hypertension. Even a quite modest reduction in the incidence of the sequels of high bloodpressure would probably have substantial effects on health-service and social-security costs-and is in any case desirable on general medical and humanitarian grounds. If, on the other hand, there are no benefits, or if the hazards to patients exceed the benefits, this knowledge might help to minimise the consequences of drifting into an ineffective or even harmful policy of treatment for mild hypertension. But to provide the answers to these questions means a very large controlled trial; it might need as many as 18 000 individuals with mild hypertension and these could only be recruited by screening perhaps 450 000 people.’ It seems very likely that such a trial is practicable and feasible-but it would be very costly (though not by comparison with the potential benefits outlined, or the costs of a drift into an ineffective policy of treatment). In today’s climate, though, such a trial could only be mounted if other activities were stopped or curtailed; if it is carried out, and if it indicates that screening and treatment are beneficial, the implications for translating this result into practice are enormous.

Research More expensive, almost by definition, will be the acquisition of new knowledge--even before its application, should it have any. The search for new knowledge as a means of prevention is prompted by two main forces: one is opportunism; and the other is the size and relative importance of the problem.

Large-bowel Cancer The

case

of opportunism is well illustrated

by

recent

work

1055 of the large-bowel-the next most frequently occurring malignant disease in men after lung cancer, and in women after breast cancer. About five years ago it was shown that the stools of healthy people in countries with a low incidence of large-bowel cancer contain low levels of faecal bile acids (F.B.A.), and few anaerobic bacteria, compared with the stools of healthy people in countries with a high incidence. This observation ties in with biochemical evidence that some bacteria can produce cancer-promoting substances from F.B.A., interest being centred on nuclear dehydrogenating clostridia (N.D.c.).* 9 It has now been shown that some 70% of large-bowel cancer patients have faecal N.D.C., and high F.B.A. levels, as against only 9% of other patients. This is a very large difference ; the test is both sensitive and specific. What now needs to be done to pursue these very encouraging findings, and perhaps use them in evolving preventive measures? First, the findings in patients with large-bowel cancer could be the result of the disease rather than its cause. This is perhaps rather unlikely, for several reasons, but it is enough of a possibility to make necessary a prospective study in which stool samples are collected and the F.B.A./N.D.C. findings related to the subsequent onset of large-bowel cancer. Secondly, we need to know what causes the F.B.A./N.D.C. abnormality; diet almost certainly plays a major part, fat and/or dietary fibre being the most likely constituents involved, though there may be others. Thirdly, how can the F.B.A./N.D.C. abnormality be modified, and will modifications lead to a decrease in large-bowel cancer incidence? Fourthly, the laboratory estimations of F.B.A. and N.D.C. need to be modified from their present laborious methods so that another possibility can be explored-namely, that even if the F.B.A./N.D.C. abnormality proves not to be involved in the causation of large-bowel cancer, it may obviously still be of considerable use in early diagnosis; large-bowel cancer has a relatively good prognosis if treated early, so there is everything to play for here. Finally, it may be that the F.B,A./N.D.C. abnormality is involved in a proportion of cases of breast cancer-not as strikingly as in large-bowel cancer, but, even so, perhaps to an extent where all these questions may need to be asked in relation to this malignancy as well. 10 But even if, in five or ten years’ time, we feel confident that F.B.A. and N.D.C. are a major cause of large-bowel cancer, and perhaps of breast cancer as well, and even if we can modify the abnormality of large-bowel cancer, we shall still be in a similar position to the one we find ourselves in with smoking or high blood-pressure-the need to cope with powerful vested interests, to persuade people to change their habits and doctors many of their traditional modes of practice. on cancer

tions, and overpopulation. But whether

dealing prevention in the developing world or in the developed, major costs are involved. But is the pursuit of prevention as I have outlined it a luxury in the context of our present circumstances; is it simply too much of a distraction from the apparently more immediate problems of cure and care and the pursuit of effectiveness and efficiency in dealing with illwe are

with

health ? I do

think so, for two main reasons. First, it would be naive to assume that work which shows that matters can be improved will automatically lead to the changes that are indicated in the provision of cure and care. There are too many examples of research that has been overtaken by, or has actually followed, a policy decision; not infrequently, the results of perfectly good studies just don’t get taken up. Studies may be inconclusive for a variety of reasons, or take too long. It is unduly optimistic to believe that rational decisions will always, or even usually, be made on the basis of information or research not previously available. This is not, of course, to suggest that we ought never to look at the effectiveness of both new and traditional methods of care; but we do need to be careful about what we choose to examine. In our concern with the clinical outcome for patients, we also have to be careful not to overlook the interests of those who provide the care. Just because some surgeons, for example, discharge patients five or six days after an operation, it doesn’t follow that those who discharge them at a week or even 10 days are pracnot

tising ineffectively or inefficiently-though we might reasonably suspect this was so for the surgeon who regularly keeps his patients in for three .weeks. There are many reasons, often related to individual and perfectly valid opinions as to what constitutes good medical practice, for doubting that all doctors ought to do the same job in exactly the same way. (This is the positive side of the rather intangible concept of "clinical freedom",

research, development, and application that need to be carried out in the pursuit of an increasingly effective capability. And it is not just our lives in this country, or , in the West, that we have to consider. There is the same case for the need, within even tighter budgets than ours,

which is, however, very much at risk at present, thanks largely and unfortunately to doctors themselves. If medicine insists on turning itself from a profession with a strong vocational element, where much of the reward is in the job itself, into a business with one eye either on the clock or the cash-box, then it has no right to expect to be handled other than as a business, with all the management and regimentation that this implies.) The second reason for pressing ahead energetically with prevention is that we run the risk of becoming so preoccupied with the provision and rationalisation of services for those sick, injured, or disabled that we lose any sense of real concern that so many find themselves in need of these services anyway. Our priorities are in danger of becoming immutable. As we get better and better at the evaluation and assessment of treatment methods, these means to an end may become an end in themselves, as they already are to some extent. One improvement in the care of the disabled becomes the starting-point in the search for another, and its evaluation ; and the process feeds itself. There could be few things more appalling than the prospect that the price of our relentless pursuit of effectiveness in the management of the clinical manifestations of chronic disease might be our ability to prevent them. In the 1950s and 1960s we might have been able to do both; but the rela-

seek to prevent, rather than have to treat, conditions such as leprosy, malnutrition, gastrointestinal infec-

tive affluence of that era made the first largely unnecessary, and, on the whole, we chose only to pay lip-service

Ischcemic Heart-disease Ischsemic heart-disease is, in my view, the most obvious of the need for research into preventive measures because of the sheer size and apparent intractability of the problem. There is much controversy about our potential for preventing this epidemic, which causes more deaths in this country than all malignant diseases together; the very existence of this controversy is a good indication of our failure, at least so far, to deal with this disease. I do not propose to go into it in any detail; once again, however, any prospects for success depend not only on the acquisition of new knowledge -mainly on how to improve our ability to predict those at high risk, and on effective measures for prevention that people will accept-but also on their successful application. There are many other examples that could be given of

example

I

to

already

1056

the second. It might be argued that now was not the time to think about ways and means of redressing the balance; on the contrary, the longer ahead we see constraints on our health-care resources, the more pressing the need to make the adjustment. For it is not only our capacity for prevention itself which is at stake; if we are to have room for manreuvre in the study, treatment, and management of established disease, which we must, we need to avoid as many chronic and intractable burdens as we can. Moreover, the established diseases with which we have to be concerned include those that are rare, as well as the common ones. No civilised society can give up the search for advances in the care of those with muscular dystrophy, or inborn errors of metabolism, for example, on the grounds that these diseases occur too infrequently. It is conditions of this sort, however, that tend to finish up low down on lists of priorities when the goingis difficultt and even the resources for dealingwith everyday problems are stretched. to

have, unfortunately, been aggravated by increasingly prevalent view that we can do without technology to make prevention and, for that matter, more effective treatment, possible; this has arisen for a Our difficulties an

number of reasons. There have been gathering doubts about the value of science generally, many of them genuine and well-founded-many, not. Those who have found it convenient have misinterpreted something in the Late Lord Rosenheim" said: "If, for the next 20 years no further research were to be carried out, if there were a moratorium on research, the application of what is already known, of what has already been discovered, would result in widespread improvement in health". We have seen how true this is, though we have also seen how applications are more difficult to bring about than is usually realised. But Lord Rosenheim did not say, though this is what has often been implied, that there should be no more research. What he went on to say is too often not quoted: "It must increasingly be the purpose of the medical profession, and of all who work with them, to aim at prevention rather than cure", and of course he knew, as well as anyone, that this meant research. The view that we can dispense with research and technology is one which often coalesces with almost metaphysical concepts of the objectives and organisation of health services into a flim-flam which, whatever else it will do, certainly won’t promote good health and the avoidance of illness. Much of the technology we need is social, to do with the modification of life-styles-this is a challenge to the behavioural scientists, which they have so far not successfully met-and much of it is medical, to do not only with discovering and developing preventive measures, but also with the better treatment of disabling or fatal diseases, sometimes comparatively rare, that tend to be overlooked in today’s preoccupation with priorities.

The X%

Mentality considering plan taking the prevention of chronic disease seriously, nothing that follows is directed against the present framework for gearing medical research to the needs of medical practice and health care. Underinvestment in prevention was a problem long before the Rothschild Report and the subsequent White-paper. In

a

for

If society’s strategy for showing that it takes prevention seriously does not fit into the framework we have at present, this is a criticism of our current strategy, and not of the framework (which is another story). Hard times lead to an acute manifestation of a chronic disease-the "x% mentality". Although there is much talk of priorities, our cumbersome planning cycles, our innate cautiousness, and our sense of fair play combine to ensure that if x% is the going rate for growth (positive or negative), then x% is applied to more or less everything. There may be some 2x or 3 x% changes, but not many; in general, retrenchment here means retrenchment there, and everywhere else, mostly by much the same amount. What we need are some 10 x% or 100 x% decisions in favour of whatever steps are necessary for chronic-disease prevention; and we need them now, in hard times, even more than in good times, if we are ever to stop having to run faster and faster simply to stay where we are. Recently, one Western country, Canada, has expressed itself so appalled by the consequences of, in effect, failures to prevent chronic illness and disability, that it has put up for general discussion the case for a very radical shift indeed in the use of its health resources." Canadian health expenditure (in$million) in 1973-74 was as follows:

Health-care organisation covers the provision of health services; environment includes those facets of life which are largely or completely outside the individual’s control (safety of food and water supplies, control of pollution, and so on); life-style covers individual decisions which may affect health, such as smoking; and human biology covers those aspects of health and disease through whose study in the biomedical field will gradually emerge a better understanding of the causes of disease. The enormous expenditure on health services compared with the other elements is obvious. Very much the same picture is to be seen in this country. The Canadian document sets challenging objectives and strategies many of which would indeed involve major changes in health-care policy, with a real shift towards prevention, and spells out their implications. There are certainly lessons for us here. Demonstrating large differences between health-care expenditure and research expenditure in itself, however, means very little;-5 there is no simple answer to what is the right balance. But, by analogy with the Canadian proposals, what we have to ask ourselves is whether there is a case for encouraging the provider of this care, the Health (and perhaps other) Departments, to spend more on the lifestyle, environment, and human-biology elements, which today means spending less on health care; this is a question of concern and consequence to the whole of our society. I do not believe we can think of ourselves as taking the prevention of chronic disease seriously unless we ask ourselves these questions not just as a theoretical exercise but with a prior commitment actually to do something about the answers we get. To help us, however, we should not forget that a really rather large proportional increase in what we currently spend on research and its applications

1057

by a very small proportional decrease in what we spend on coping with established disease, and that much of this decrease, in turn, could come from the increasingly effective use of what we already have.

could be paid for

Conclusion I have only defined the main outlines, as I see them, of the dilemmas confronting medical practice and research in hard times, of their intensity, and of possible approaches to their resolution; I have, of course, made many oversimplifications in doing so. Medicine never has been, and never will be, solely a matter of prevention ; nor is high technology the only means to therapeutic or preventive progress. To say that we will devote greater efforts to prevention is no more a guarantee of success, in the absence of opportunity and careful planning, than arbitrarily committing large sums to any other worthy cause. We do already spend quite a lot on prevention of various sorts. Even so, the opportunity and many of the means for a better preventive capacity than we now have in the field of chronic disease are to hand-and the need is more pressing than ever. Increasing effectiveness and efficiency in cure and care might provide some of the wherewithal, but the x% mentality is what we really have to overcome. There is, however, another difficulty. Sick patients have names; they present immediate problems, which appeal to those we choose and train as doctors. Those whose illnesses we may forestall are usually, almost by definition, nameless, faceless, and unidentifiable either to themselves or to others. There is a challenge here to medical education, as well as practice and research. Hard times have provided us with the chance and the incentive to make what could be some of the most sig-

nificant advances in health of modern times. If we were at war, we should act as though our lives depended on what we did-which of course they do-and we should almost certainly succeed; but we can’t quite talk ourselves into this frame of mind, and it is difficult to be optimistic about the outcome. We shall, presumably, muddle through, and enjoy better times-but the x% mentality and medicine’s predominant concern with the sick rather than the healthy will prevail, then as now. My guess is that in twenty or thirty years, or whenever it is that we have to tighten our belts again, we shall look back at the opportunities we had in the 1970s, hard though the times were, and have to confess that we let them slip by, unexploited.

REFERENCESS

1. Cochrane, A. L. Effectiveness and Efficiency. Nuffield Provincial Hospitals Trust, 1972. 2. Mather, H. E., et al. Br. med. J. 1971, iii, 334. 3. Kellerman, G., Luyten-Kellerman, M., Shaw, C. R. New Engl.J. Med. 1973, 289, 934. 4. Lancet, 1974, i, 910. 5. Veterans Administration. J. Am. med. Ass. 1967, 202, 1028. 6. Veterans Administration. ibid. 1970, 213, 1143. 7. Miall, W. E., Brennan, P. J. Clin. Sci. molec. Med. 1975, 48, 165s. 8. Hill, M.J., Crowther, J.S., Drasar, B. S., Hawksworth, G., Aries, V., Williams, R. E. O. Lancet, 1971, i, 95. 9. Hill, M. J., Drasar, B. S., Williams, R. E.O., Meade, T. W., Cox, A. G., Simpson, J. E. P., Morson, B. C. ibid. 1975, i, 535. 10. Hill, M. J., Goddard, P., Williams, R. E. O. ibid. 1971, ii, 472. 11. Rosenheim, M. ibid. 1968, ii, 821. 12. A New Perspective 1974.

on

the Health of Canadians. Government of Canada,

PLASMA 25-HYDROXYVITAMIN-D LEVELS DURING PREGNANCY IN CAUCASIANS AND IN VEGETARIAN AND NON-VEGETARIAN ASIANS M. M. GUPTA

C. E. DENT

Department of Human Metabolism, University College Hospital Medical School, London WC1E 6JJ

Summary

Plasma25-hydroxyvitamin-D(25-O.H.D.), Ca, P, and alkaline-phosphatase levels

were

determined in three separate

nancy in 14 Caucasian

periods during

preg-

mothers, 23 vegetarian Asians,

and 16 non-vegetarian Asians. Non-pregnant women from the same group were used as controls. The expected steady rise in alkaline phosphate during pregnancy due to increase in the placental isoenzyme, and the fall in total Ca due to hæmodilution, were noted. No appreciable changes in 25-O.H.D. levels occurred, but throughout pregnancy the levels in the vegetarian Asians were lower than in the other two groups. The same analyses were made in maternal and cord plasmas in some of these patients. The babies’ 25-O.H.D. levels averaged 87% of their mothers’. There was no clear evidence that pregnancy as such led to increased vitamin-D requirement in any case of these groups. Introduction THE catastrophic effects on childbirth of severe osteomalacia in the mother have been known for centuries, for the pelvic deformities may be gross enough to prevent normal delivery. With the definitive discovery of vitamin-D deficiency as its cause in the early 1920s, worldwide activity ensued in an attempt to eradicate the disease by preventive measures. The classic studies in China by Maxwell and his colleagues illustrate this.l2 They showed that the disease could be prevented by giving cod-liver oil, but they also noted that other environmental factors could explain further anomalies in the distribution of the disease-for instance, maternal osteomalacia was most common in mothers who had already borne several babies successfully. Another feature of the situation was that even if the mother did come to term successfully and produce a live baby, often by csesarean section, the baby might suffer from severe tetany and softening of bones. In all these discussions calcium deficiency as well as that of vitamin D was considered as a possible factor contributing to the disease in both mother and baby. The modern view is that calcium deficiency is relatively unimportant in such complications of pregnancy but that vitamin-D deficiency remains extremely important at least for the baby, for in the milder instances which we see nowadays it is possible for a mother with mild asymptomatic osteomalacia to give birth quite normally to a baby who could nevertheless have severe tetany and congenital rickets.3 In consequence, measures to supplement the diet of pregnant women with extra vitamin D have been recommended4 and fitfully adopted. Although not proven, the usual view remains that pregnancy does probably increase the requirement of vitamin D, and that repeated pregnancy does contribute further by successively depleting maternal stores of the vitamin. The state of vitamin-D nutrition in a patient can now be best assessed by assay of plasma 25-hydroxyvitamin D (23-o.H.D.). We here describe our studies of nor-

Our lives and hard times.

Saturday 29 November 1975 OUR LIVES AND HARD TIMES* T. W. MEADE with the processes and organisation of health care as with an overall strategy to ta...
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