from a common condition for which no effective treatment is available we must be prepared to allocate the appropriate need equivalents. Black and Pole'5 have shown how difficult it is to equate satisfactorily need with use of services on the basis of the information currently available. If in answering these questions it becomes clear that changes in practice are desirable, it follows that changes in attitudes must be brought about, whether by peer review and medical audit or by some other means. Since good medical practice involves a close relation between physician and patient, both of whom are members of the general public, education leading to changes in attitude must be directed towards the medical profession. This will, however, be difficult because attitudes change slowly; if we are to indicate to the public that what was appropriate 30 or even 10 years ago is now to be questioned in the common interest, we must be prepared to take much time and trouble in doing so. Whatever means we use to educate the public - and in television we have a medium for communication that is more penetrating and powerful than any in history - in the terms we have considered, it is essential that we stress that need equivalents should be changed. Not only must the patient and public agree, but both should be working actively with health professionals towards the redefinition of need equivalents. Among the most difficult problems to be faced is that of whether the development of medical care of the highest quality is really in the public interest. Health professionals should therefore* be prepared to reconsider, in open and informal discussion with the public, what constitutes the most suitable care in the light of research. Thus, in response to Glass' I suggest that need is a useless concept only if we are unprepared to set limits on the

equivalents we mobilize to meet it. If we are to meet the serious needs of everybody, we must be prepared to set limits on the extent to which we are willing to meet the needs of anybody. We must also be prepared to identify those who, though they demand medical care, do not really need it. Roy M. ACHESON, MD, SC University department of community Addenbrooke's Cambridge,

D, FRCP medicine Hospital England

References I. GLASS N: in Seminars in Community Medicine: Health Information, Planning and Monitoring, ACHESON RM, HALL DJ (eds), Oxford, Oxford U Pr, 1977, pp 41-2 2. DONABEDIAN A: Aspects of Medical Care A d,ninistration: Specifying Requirements for Health Care, Cambridge, Mass, Harvard U Pr, 1973, pp 61, 64 3. COOPER MH: Rationing Health Care, London, Croom Helm, 1975, p 20 4. KESSNER DM, FLOREY C DU V: Mortality trends for acute and chronic nephritis and infections of the kidney. Lancet 2: 979, 1967 5. ACHESON RM, CRAGO A, WEINERMAN RE: New Haven survey of joint disease. XIII. Institutional and social care for the arthritic. J Chronic Dis 23: 843, 1971 6. ELDER RG, AcHasoN RM: New Haven survey of joint diseases. XIV. Social class and behaviour in response to symptoms of osteoarthrosis. Milbank Mem Fund Q 48: 449, 1970 7. SPITZER WO, HARTH M, GOLDSMITH CH, Ct al: The arthritic complaint in primary care: prevalence, related disability, and costs. J

Rheumatol 3: 88, 1976 8. MATrHEW GK: Measuring need and evaluating services, in Portfolio for Health, Problems and Progress in Medical Care; Essays on Current Research, MCLACHLAN G (ed), London, Oxford U Pr, 1971, pp 27-46

9. COCHRANE AL: Effectiveness and Efficiency: Random Thoughts on the Health Service,

Oxford, Oxford U Pr for Nuffield Provincial Hospitals Trust, 1972 10. LOGAN RFL, ASHLEY JSA, KLEIN RE, Ct al:

Dynamics of Medical Care, London, London School of Hygiene and Tropical Medicine, 1972 11. ACHESON RM: The definition and identification of need for health care. J Epidemiol Community Health 38: Mar 1978

12. SWEENY GP, HAY WI: The Burlington experience: a study of nurse practitioners in family practice. Can Fain Phys 19: 101, 1973 13. SACKETT DL, SPITZER WO, GENT MH, et al: The Burlington randomized trial of the nurse practitioner: health outcomes of patients. Ann

Intern Med 80: 137, 1974

14. SPITZER WO, SACKEIT DL, SIBLEY JC, et al: The Burlington randomized trial of the nurse practitioner. N Engi J Med 290: 251, 1974 15. BLACK DAK, POLE JD: Priorities in biomedical research: indices of burden. Br I

Prey Soc Med 29: 222, 1975

Prevention or cure? Prevention is now a bandwagon for politicians and planners, who claim that physicians neglect preventive medicine. and that the method of remuneration, fee for service, makes them uninterested in prevention. In Quebec the government has sponsored a new kind of centre, the centre local de services cornmunautaires, where the physician is by no means captain of the team, and where a broad attack on the problems of society is envisaged. A recent number of Le M.decin du Qu6bec (12: 32-

93, 1977), in several articles on the general practitioner and the expectations of Quebec society, promoted the idea that curative medicine is not enough. Examples are given: we act as if we are resuscitating a succession of drowning men without investigating why so many are falling into the water; we must not just treat rat bites but also abolish slums; curative medicine is nothing, the real work is to change society; and physicians form a closed, self-serving and obstructive guild.

'ZyIop rim* (avopurinol) lidieatims ZYLOPRIM is intended for the treatment of gout as well as primary and secondary hyperuricaemia. ZYLOPRIM is indicated in the treatment of primary orsecondary uric acid nephropathy. ZYLOPRIM is especially useful in patients with gouty nephropathy, in those who form renal urate stones, and those with unusually severe disease. ZYLOPRIM is effective in preventing the occurrence and recurrence of uric acid stones and gravel. ZYLOPRIM is useful in the therapy and prophylaxis of tissue urate deposition, renal calculi and for acute urate nephropathy in patients with neoplastic disease who are particularly susceptible to hyperuricaemia and uric acid stone formation, especially after radiation therapy or the use of antineoplastic drugs. Oeutraiadiutieu: Zyloprim should not be given to patients who are hypersensitive or who have had a severe reaction to this drug. Preea.tiua aid Waruluge Acute gouty attacks may be precipitated at the start of treatment with Zyloprim in new patients, and these may continue even after serum uric acid levels begin to fall. Prophylactic administration of coichicine and a low dosage of Zyloprim are advisable, particularly in new patients and in those where the previous attack rate has been high. Zyloprim is not recommended for use during pregnancy or in women of child-bearing potential unless in the jud gement of the physician, the potential benefits outweigh the possible risks to the fetus. Zyloprim should not be given to children except those with hyperuricaemia secondary to malignancy or with Lesch-Nyhan syndrome. Patients with impaired renal or hepatic functions should be carefully observed during the early stages of Zyloprim administration and the drug withdrawn if increased abnormalities in hepatic or renal functions appear. Uriesearles aid Zyle.ri.: Combined therapy of Zyloprim and uricosurics will result often in a reduction in dosage of both agents. Perimethel or Imira. with Zyleprim: In patients receiving PURl N ETHOL* (mercaptopurine) or MURAN * (azathioprine), the concomitant administration of 300600 mg of ZYLOPRIM per day will require a reduction in dose to approximately ¼ to ¼ of the usual dose of mercapto p urine or azathioprine. Subsequent adjustment of doses of PURINETHOL or IMURAN should be based on therapeutic response and any toxic effects. Oblerprepainide with Zylepuim: In the presence of allopurinol, there may be competition in the renal tubule for the excretion of chiorpropamide. When renal function is poor, the recognised risk of prolonged hypoglycaemic activity of chlorpropamide may be increased if ZYLOPRIM is given concomitantly. Ceemarie a.lieeagelauls wilh Zyleprim: It has been reported that under experimental conditions allopurinol pro. longs the half-life of the anticoagulant, dicumarol. The clinical significance of this has not been established, but this interaction should be kept in mind when allopurinol is given to patients already on anticoagulant therapy, and the coagulation time should be reassessed. Advorne readiems: Skin reactions associated with exfoliation, fever, chills, nausea and vomiting, lymphadenopathy, arthralgia and/or eosinophilia are the most common and may occur at any time during treatment. Gastrointestinal disorders were reported but may diminish if Zyloprim is taken after meals. ymplems aid trealmeint of everdesage: Overdosage of allopurinol is usually manifested by nausea and vomiting. No treatment is normally required, provided the drug is withdrawn and adequate hydration is maintained to facilitate excretion of the drug. If, however, other forms of acute distress are observed, gastric lavage should be considered, otherwise the treatment is symptomatic. Phar.iaeelegy: When taken orally, allopurinol is rapldl. metabolized. The main metabolite is oxypurinol, is itself a xanthine oxidase inhibitor. A liopurinol and its metabolites are excreted by the kidney, but the renal handling is such that allopurinol has a plasma half-life of about one hour, whereas that of oxypurinol exceeds 18 hours. Thus, the therapeutic effect can be achieved by a once-a-day dosage of ZYLOPRIM in patients taking 300 mg or less per day. Deage aid idmimisluatlee: ZYLOPRIM, administered orally should be divided into 1 to 3 daily doses. Daily doses up to and including 300 mg may be taken once daily after a meal. Divided doses should not exceed 300 mg. The minimum effective dose is 100 to 200 mg. The average is 200 to 300 mg/day for patients with mild gout, 400 to 600 mg/day for moderately severe tophaceous gout, and 700 to 800 mg/day in severe conditions. The maximal recommended dose is 800 mg per day in patients with normal renal function. Treatment with 600 to 800 mg daily for two or three days prior to chemotherapy or x-irradiation is advisable to prevent uric acid nephropathy. Treatment should be continued at a dosage adjusted to the serum uric acid level until there is no longer a threat of hy peruricaemia and hyperuricosuria. It is essential thata d ally urinary output of two litres or more be maintained during ZY I OPRIM therapy, and neutral or alkaline urine is desirable. OhiMum: For the treatment of secondary hyperuricaemia associated with malignancies and in the Lesch-Nyhan syndrome, ZYLOPRI M should be given in doses of 10 mg/kg/day. The response should be evaluated after approximately 48 hours by monitoring serum uric acid and/or urinary uric acid levels and adjusting the dose if necessary. Preseetatlee: ZYLOPRIM 100 mg scored white tablets. Bottles of 100 and 500 tablets; Code: Wellcome U4A. ZYLOPRIM 300 mg scored peach coloured tablets. Bottles of 100 tablets. Code: Welicome C9B. Prided Meeegraph available.. reqineat. *Trade Mark

.

W-6019

. Burroughs Welicome Ltd. I LaSalle, Qu6.

The great advances in preventive medicine have come when the persons engaged in curative medicine have discovered the cause of disease, which has then been reduced or eliminated by others. This has happened with malaria, yellow fever, schistosomiasis, typhus and the water-borne enteric diseases. Engineers provided pure water and drained the swamps once they knew it had to be done, and chemists found substances to kill the insect vectors, which were then used over large areas. Vaccines have been developed that, with antibiotics, have made childhood unbelievably safe. A pediatrician noted an epidemic of phocomelia, established its cause and made us aware that the fetus could be damaged by drugs. Physicians have played a leading part in the research into traffic injuries and have recommended and supported every measure to reduce them. In military medicine great emphasis is placed on prevention because, until this century, when weapons became so terrible, sickness was a greater cause of disability and death than was battle. Perhaps the industrial physician was less active in the past in the preventive field than he might have been (one thinks of the asbestos and mining industries and of industrial pollution), but this is no longer so. Nowhere can it be said that physicians have been complacent in the mere acceptance of sickness and injury, but prevention is usually a largescale operation, as wide as the community. Much of our work is in the earliest detection and treatment of disease if prevention is impossible. Screening programs were developed for phenylketonuria, diabetes, hypertension, pulmonary tuberculosis and cervical cancer. Antipsychotic drugs are used preventively in remitted schizophrenia, lithium in manic-depressive disease and anti convulsants in epilepsy. Antenatal care and routine examinations in infancy and childhood have been accepted everywhere. Tubal ligation is known to prevent much disease in women, and is widely accepted by society and by physicians. Methods of prevention of postoperative infection and thrombosis have been ardently sought, and it was a gynecologist who found the cause and means to prevent puerperal sepsis. The preventable causes of much current ill health are known to everyone: smoking, poor nutrition, excessive eating and drinking, the abuse of drugs obtained without prescription, lack of exercise, aggressive driving, venereal disease and marital instability. It is beyond the power of a physician to remove these causes. They reflect our society and will only be altered by changes in society that even governments seem powerless to bring about.

Changes in lifestyle have followed ap- real but unavowed. It is true that in parently unrelated events: wars, techno- many illnesses understanding of the logic developments, economic crises, disease is essential and must be taught; the discovery of easy and effective con- for example, diseases such as diabetes, traception, religious movements and allergy, coronary artery disease and climatic change. They are hard to pre- neurosis. But even when physicians are dict or control. sick they have to place themselves trustGreat hopes were held once for the ingly in the hands of another, with the prevention of mental disease. The men- childlike feeling "Heal me and don't tal hygiene movement was dedicated explain." It is the patient's loss if we to this goal but unfortunately the re- demystify too far, as it is the worshipsults have been meagre. At the clinics per's loss if we demystify religion and are shy and schizoid children who the priesthood. become schizoid or schizophrenic In most developed countries there is adults; the retarded remain retarded a movement, "antimedicine", that exand the delinquent remain delinquent. presses a wish to do away with sickness These children are seen at an earlier and to bypass persons whose training stage and, with some exceptions, that and lifetime work are to treat it. Someis all. The premises were wrong: it times there is a blatant wish to break was believed that most mental illness into the health industry without trainwas caused by parental mishandling and ing. It is not far-fetched to believe that if that was corrected health would activists sometimes are seeking to use follow. Unfortunately much mental ill- sick persons as a means of revolutionness is constitutional. Better obstetric ary action. It is unscrupulous and it and neonatal care prevents some brain will fail. When someone is suffering damage but, as with all medical ad- from renal colic he will go where he vances, it permits the survival of in- will be treated, not where he will be fants who will be handicapped for life, used as an instrument for social change. thereby creating sickness as well as This is just the preference that the preventing it. Therapeutic abortion pre- people of Quebec are showing. vents some mental illness by ensuring ELLIOTT EMANUEL, MRCP that fewer children are born into un325 Dorval Ave., Ste. 201 Dorval, PQ stable homes or into situations unfavourable for mother-child bonding, as well as by a eugenic (selective) effect. The abortion of fetuses judged while in utero as destined for serious disease is preventive. The prevention of disease will always be preferable to its cure, and physicians will eagerly seek it out and foster it, but sickness and death are inevitable; the prevention of one illness leaves us This list is an acknowledgement of alive to incur another. Curative physi- books received. It does not preclude cians will always be needed and will review at a later date. not be eager to give half their time to CHILDHOOD EPILEPSY. A Pediatric-Psychiatric Roland Bouchard, Josette Lorilloux, lectures or to work in a setting so Approach. Colette Guedeney and others. 136 pp. International Press, Inc., New York, 1977. $10. egalitarian that they receive no secre- Universities ISBN 0-8236-0774-7 tarial help, where they are prevented EFFECTS OF MICROWAVE RADIATION ON from exercising the leadership for THE HUMANS. An Annotated List of References. (liwhich their training fits them, and brary bibliography series no. 5). 13 pp. Florida University Library, Orlando, 1977. where they have even been asked to Technological SO.50, paperbound hand out pamphlets from door to door. GENETIC APPROACH TO HUMAN DISEASE. Parkinson's law operates strongly in THE Vincent M. Riccardi. 273 pp. Illust. Oxford UniPress, New York, 1977. $8.95, paperbound. these establishments, especially when versity ISBN 0-19-502176-2 government pays the shot. In one such HLA AND DISEASE. Edited by Jean Dausset and establishment, whose annual report Arne 316 pp. Illust. Munksgaard Interis before me, that employs 23 pro- nationalSvejgaard. Publishers Ltd., Copenhagen, 1977. Price not stated. ISBN 87-16-02287-4 fessionals and 17 others, with a budget wisely not given, but which is easily IMMUNOLOGY OF RECEPTORS. Edited by B. Cinader. 524 pp. Illust. Marcel Dekker, Inc., New calculated at nearly a million dollars, York, 1977. Price not stated. ISBN 0-8247-6674-1 7 professionals laboured for 3 months IN TOUCH. Putting Sex Back into Love and Marto induce 4 people to give up smoking. riage. Beryl A. Chernick and Avinoam B. Chernick. by Jeniva Berger. 182 pp. Illust. The Just over 1200 files were opened, a Adapted Macmillan Company of Canada Limited, Toronto, figure many a solo family physician 1977 $9.95. ISBN 0-7705-1580-0 would consider modest (though he INTERDISCIPLINARY TOPICS IN GERONTOLOGY. would do in some ways more and in Vol. 11. Multidisciplinary Gerontology: A Structure for Research in Gerontology in a Developed others less than the team). Country. Edited by I.R. Mackay. 116 pp. Illust. S. The "demystification" of medicine is Karger AG, Basel, 1977. $24.50, paperbound. ISBN an avowed aim of this movement, as 3-8055-2679-2 continued on page 156 the downgrading of the physician is

BOOKS

CMA JOURNAL/JANUARY 21, 1978/VOL. 118 113