664
capillary blood flow.8 Furthermore, the potentially adverse effect of increased plasma viscosity may be aggravated by the usually rapid rise in platelet count in response to therapy. In patients at risk of cardiovascular disorders, the indication for IVIG should thus be assessed carefully and restricted to those with life-threatening bleeding. We thank Mrs E. Schlappritzi and Mrs E. assistance and Mrs R. Pfdffli for secretarial work.
Schupbach
for technical
REFERENCES Rheology of paraproteinaemias and the plasma hyperviscosity syndrome. Baillières Clin Haematol 1987; 1: 695-723.
1. Somer T.
J, Cox EB, Cohen HJ. Evaluation of hyperviscosity in monoclonal gammopathies. Am J Med 1985; 79: 13-22. 3. Woodruff RK, Grigg AP, Firkin FC, Smith IL. Fatal thrombotic events during treatment of autoimmune thrombocytopenia with intravenous immunoglobulin in elderly patients. Lancet 1986; ii: 217-18. 4. Reinhart WH, Chien S. Roles of cell geometry and cellular viscosity in red cell passage through narrow pores. Am J Physiol 1985; 248: C473-79. 5. Reinhart WH, Singh A. Erythrocyte aggregation: the roles of cell deformability and geometry. Eur J Clin Invest 1990; 20: 458-62. 6. Chien S. Biophysical behavior of red cells in suspension. In: Surgenor D McN, ed. The red blood cell. New York, Academic Press, 1975: 1031-133. 7. Reinhart WH, Singh-Marchetti M, Straub PW. The influence of the erythrocyte shape on suspension viscosities. Eur J Clin Invest (in press). 8. Reinhart WH, Lütolf O, Nydegger U, Mahler F, Straub PW. Plasmapheresis for hyperviscosity syndrome in macroglobulinemia Waldenström and multiple myeloma: influence on blood rheology and the microcirculation. J Lab Clin Med (in press). 2. Crawford
VIEWPOINT Prevention vs cure in developing countries: the pendulum syndrome PETER S. V. COX Mankind in general seems to find it necessary to formulate new policies by veering from one extreme to the other--doing something, discovering its limitations, and swinging in the opposite direction. In the process many of the good and useful aspects of the original plan are swept aside along with the newly discovered weaknesses that prompted the change. Consider health care in developing countries. Huge hospitals were built in the 1950s; in the 1960s and 1970s these "disease palaces" were derided and village dispensaries were promoted as the answer to everything. The training of doctors was given pride of place at one stage; then it was said that village health workers were cheaper, more effective, and far better at relating to ordinary people. Highly organised vertical programmes for individual diseases were suddenly replaced by broad-based, community-involving, horizontal strategies. And so one could go on. In each case both the original concept and the counter concept have much to give, even if what they give is very different. I believe that health is far too important to indulge in this method of progress. I have always worked at the bottom of the heap, mainly as a clinician making forays into the community, and very much aware that I was not spending nearly enough time and effort in training people in the scattered nomadic communities that I was privileged to serve. However, I never felt an urge to shut the only hospital, buy a camel, and spend my time moving from camp fire to camp fire, training people to pick out at-risk pregnancies or treating the early diarrhoeas. I did, and still do, believe passionately that this should be done-but not at the expense of failing to provide a first class curative service at the appropriate level. One reason for expounding my views in this article is that some of the aid agencies are now so committed to community health that any project containing a curative element seems to be viewed with suspicion. Today I doubt if anybody would even think of using these funds for building large hospitals. Yet cure and community are surely all part of the same activity-a village health worker without
curative back up is in as poor a position as a doctor with no work in the community. A visit to a village-based health development project in the foothills of the Himalayas to the west of Pokhara provided a vivid illustration of this thesis. The project, by strict agreement with the Government of Nepal, has been asked to work in this area, which is in a network of valleys and settlements about two days walk from anywhere (or at least anywhere with vehicular access). The brief was to work within the existing system; to educate; to assist the underprivileged; and to seek to improve the health of the area by helping with agriculture, nutrition, and economics as well as with the more traditional provision of specific health education and health workers. When I got there I found a thoroughly researched, well planned, and highly successful venture. The local people had been consulted, the things that could be done by the team had been laid out, and the fact that the team had not come to build a hospital had been explained. Local committees had been formed, decisions made, and nonformal education classes started. The classes were immediately successful, mainly among the women, whose literacy rate was almost nil (an effect that is readily comprehensible when one knows that only 1 girl attends school for every 10 boys). The subsequent establishment of "post-literate clubs" consolidated the advance and essentially introduced a new stratum into society. Here were people, along with those who had enjoyed formal education, who were ready and eager for any training that could be given. From these individuals the local committees nominated some to become village animal workers and others to be "sudenis" or village health workers, with a strong slant towards midwifery. Village drug-workers, with a small stock of simple, essential drugs; vegetable seed ADDRESS. Tropical Health Unit, Department of Public Health Medicine, University of Leeds, 20 Hyde Terrace, Leeds LS29LN (Dr Peter S. V Cox, MD).
665
producers; There
and
were
tree nursery men were likewise chosen. to train the secretaries of the village
plans
BO KSHELF
committees to handle money and
acquire simple management as they handled their own other The affairs. highly popular activity was to try and get a clean water supply to each village, all done on a self-help basis with the team providing only the skills and material. Ultimately one of the workers was equipped with the tools to maintain the taps and pipes that he had helped to install. The principle that governed all the team’s work was that nothing was started that could not be sustained when they went away. Every skill enabled the recipient to set up a little business, from the person producing seeds to a young man trained to use a microscope and examine blood and sputum, skills, which would be needed
stools and urine, at the request of the man in the medicine hall, or the health assistant in the health post. It was textbook perfect. Yet down in the village centre there was a health post used by very few people and staffed by dispirited individuals who were poorly supervised (hardly surprising in view of the distances involved) and showing little motivation. Much of the medical care was actually given at the private "medicine hall", a sort of glorified pharmacy. I saw the young man in charge put a plaster cast on a fractured wrist and in another village observed efficient administration of intravenous saline to a dehydrated child on a table in the front of his 8’ x 8’ shop, right by the roadside. Overall, it was the curative dimension that was missing. I could not help thinking that however good the primary health care there would still be the sick, the injured, the difficult labour, the surgical conditions, and the people who caught preventable diseases. Unless these are dealt with efficiently and well the preventive message gets blunted-if people get good treatment, they will listen to what is advised in the area of prevention. What does the efficient village health worker do when she finds someone who needs special care if everyone refuses to go to the health post? The solution is not easy. Governments have limited funds, too few workers, and numerous problems often spread over large areas (in Nepal, largely inaccessible valleys). Doctors, meanwhile, do not want to be posted to the remote areas and they would prefer to be specialists anyway. In Nepal they have to run scattered district hospitals with outposts under their care that are at least two days’ hard walking distance away, and they have junior staff in key health posts who have little knowledge of community work. It is not easy for those on the spot either, whether they are visiting health teams or local community leaders. How can they support a unit that should of necessity be able to deal with moderately severe conditions, and ensure financial support for the workers needed to run it? The balance is hard to achieve. Whatever happens we must not go back to the static curative centre that absorbs all the resources, but neither can we afford to neglect the curative side that is in such demand by the people. Prof Madura Shrestha in the Ministry of Health in Nepal listed the prime ingredients needed by all of us: "enthusiasm, motivation, and an acknowledgment of the spiritual dimension". These features apply right across the board, but the failure to generate doctors with these qualities lies at out own door. We need generalists, not specialists; we need people not afraid to innovate and take initiative; and above all we need doctors who get their kicks by seeing a
village change and overcoming difficulties as they give the best service they can. Community health must not be divorced from curative medicine; and curative medicine
adapt itself
the pendulum in the middle?
must
to
community. Why
not
stop the
Oxford Textbook of Clinical Hepatology Edited
by Neil McIntyre, Jean-Pierre Benhamou, Johannes Bircher, Mario Rizzetto, and Juan Rodes. Oxford: Oxford University Press. 1991. Pp 1631 (2 vols). 195 CC225 after July 1,1992). ISBN 0-192619683. Students of the liver have been well served with textbooks the years. Sherlock’s classic monograph was first published thirty seven years ago, and is now in its eighth edition, but our increasing knowledge of the liver and its disorders has led to ever larger and more comprehensive multi-author compilations. Now, as if to herald the "single market" of the European Community, comes a new blockbuster with five editors drawn from different EC countries. How does it compare with earlier efforts? Two volumes, 1550 pages (excluding the 80 page index), and almost 200 authors contribute to a truly impressive
over
production. Unquestionably the most comprehensive compendium yet devoted to the liver, it covers every aspect of hepatology and also devotes much space to discussions of the hepatic effects of systemic disorders. Among the latter group of chapters the quality of the contributions is slightly uneven, and some read as though compiled by trawling of journals rather than from clinical experience. The book is generously illustrated with excellent diagrams and a small number of colour plates, although the black-and-white photomicrographs are of variable quality and clarity; more extensive use of indicator arrows might have helped. In their eagerness to offer the reader as much as possible, the editors provide appropriate references within the text and yet more at the end of chapters as a guide to further reading; the logic of their choice is sometimes hard to follow because the number of follow-on references varies from none to over 170. A notable feature is the inclusion of several appendices, which reproduce the handouts devised for patients by the American Liver Foundation as well as providing useful tables to show the geographical distribution of infections that cause liver disease. Overall, the Oxford Textbook of Clinical Hepatology is an excellent book, and the minor faults merely reflect the difficulties inevitably encountered in the production of such a huge, multi-author work of reference. No doubt, if the editors still have stomach for the fight, the second edition will be even better, larger still, and yet more expensive. But are such behemoths in danger of becoming extinct; at what stage do size, cost, and organisational obstacles prove insuperable? As the first electronic medical journal is about to come on line, should we now look for electronic reference books? Perhaps they would be a more commercial proposition. An ever-increasing proportion of the individuals and institutions that can afford textbooks such as this have access to the necessary computer technology, high-quality digital photographic reproduction is now available on CD-ROM, and the benefits of rapid updating are obvious. As a specialist textbook, this one is hard to beat; but publishers would do well to reassess the benefits of other modes of disseminating information. Medical School, University of Sheffield, Sheffield S10 2RX, UK
DAVID TRIGER
capillary blood flow.8 Furthermore, the potentially adverse effect of increased plasma viscosity may be aggravated by the usually rapid rise in platelet count in response to therapy. In patients at risk of cardiovascular disorders, the indication for IVIG should thus be assessed carefully and restricted to those with life-threatening bleeding. We thank Mrs E. Schlappritzi and Mrs E. assistance and Mrs R. Pfdffli for secretarial work.
Schupbach
for technical
REFERENCES Rheology of paraproteinaemias and the plasma hyperviscosity syndrome. Baillières Clin Haematol 1987; 1: 695-723.
1. Somer T.
J, Cox EB, Cohen HJ. Evaluation of hyperviscosity in monoclonal gammopathies. Am J Med 1985; 79: 13-22. 3. Woodruff RK, Grigg AP, Firkin FC, Smith IL. Fatal thrombotic events during treatment of autoimmune thrombocytopenia with intravenous immunoglobulin in elderly patients. Lancet 1986; ii: 217-18. 4. Reinhart WH, Chien S. Roles of cell geometry and cellular viscosity in red cell passage through narrow pores. Am J Physiol 1985; 248: C473-79. 5. Reinhart WH, Singh A. Erythrocyte aggregation: the roles of cell deformability and geometry. Eur J Clin Invest 1990; 20: 458-62. 6. Chien S. Biophysical behavior of red cells in suspension. In: Surgenor D McN, ed. The red blood cell. New York, Academic Press, 1975: 1031-133. 7. Reinhart WH, Singh-Marchetti M, Straub PW. The influence of the erythrocyte shape on suspension viscosities. Eur J Clin Invest (in press). 8. Reinhart WH, Lütolf O, Nydegger U, Mahler F, Straub PW. Plasmapheresis for hyperviscosity syndrome in macroglobulinemia Waldenström and multiple myeloma: influence on blood rheology and the microcirculation. J Lab Clin Med (in press). 2. Crawford
VIEWPOINT Prevention vs cure in developing countries: the pendulum syndrome PETER S. V. COX Mankind in general seems to find it necessary to formulate new policies by veering from one extreme to the other--doing something, discovering its limitations, and swinging in the opposite direction. In the process many of the good and useful aspects of the original plan are swept aside along with the newly discovered weaknesses that prompted the change. Consider health care in developing countries. Huge hospitals were built in the 1950s; in the 1960s and 1970s these "disease palaces" were derided and village dispensaries were promoted as the answer to everything. The training of doctors was given pride of place at one stage; then it was said that village health workers were cheaper, more effective, and far better at relating to ordinary people. Highly organised vertical programmes for individual diseases were suddenly replaced by broad-based, community-involving, horizontal strategies. And so one could go on. In each case both the original concept and the counter concept have much to give, even if what they give is very different. I believe that health is far too important to indulge in this method of progress. I have always worked at the bottom of the heap, mainly as a clinician making forays into the community, and very much aware that I was not spending nearly enough time and effort in training people in the scattered nomadic communities that I was privileged to serve. However, I never felt an urge to shut the only hospital, buy a camel, and spend my time moving from camp fire to camp fire, training people to pick out at-risk pregnancies or treating the early diarrhoeas. I did, and still do, believe passionately that this should be done-but not at the expense of failing to provide a first class curative service at the appropriate level. One reason for expounding my views in this article is that some of the aid agencies are now so committed to community health that any project containing a curative element seems to be viewed with suspicion. Today I doubt if anybody would even think of using these funds for building large hospitals. Yet cure and community are surely all part of the same activity-a village health worker without
curative back up is in as poor a position as a doctor with no work in the community. A visit to a village-based health development project in the foothills of the Himalayas to the west of Pokhara provided a vivid illustration of this thesis. The project, by strict agreement with the Government of Nepal, has been asked to work in this area, which is in a network of valleys and settlements about two days walk from anywhere (or at least anywhere with vehicular access). The brief was to work within the existing system; to educate; to assist the underprivileged; and to seek to improve the health of the area by helping with agriculture, nutrition, and economics as well as with the more traditional provision of specific health education and health workers. When I got there I found a thoroughly researched, well planned, and highly successful venture. The local people had been consulted, the things that could be done by the team had been laid out, and the fact that the team had not come to build a hospital had been explained. Local committees had been formed, decisions made, and nonformal education classes started. The classes were immediately successful, mainly among the women, whose literacy rate was almost nil (an effect that is readily comprehensible when one knows that only 1 girl attends school for every 10 boys). The subsequent establishment of "post-literate clubs" consolidated the advance and essentially introduced a new stratum into society. Here were people, along with those who had enjoyed formal education, who were ready and eager for any training that could be given. From these individuals the local committees nominated some to become village animal workers and others to be "sudenis" or village health workers, with a strong slant towards midwifery. Village drug-workers, with a small stock of simple, essential drugs; vegetable seed ADDRESS. Tropical Health Unit, Department of Public Health Medicine, University of Leeds, 20 Hyde Terrace, Leeds LS29LN (Dr Peter S. V Cox, MD).
665
producers; There
and
were
tree nursery men were likewise chosen. to train the secretaries of the village
plans
BO KSHELF
committees to handle money and
acquire simple management as they handled their own other The affairs. highly popular activity was to try and get a clean water supply to each village, all done on a self-help basis with the team providing only the skills and material. Ultimately one of the workers was equipped with the tools to maintain the taps and pipes that he had helped to install. The principle that governed all the team’s work was that nothing was started that could not be sustained when they went away. Every skill enabled the recipient to set up a little business, from the person producing seeds to a young man trained to use a microscope and examine blood and sputum, skills, which would be needed
stools and urine, at the request of the man in the medicine hall, or the health assistant in the health post. It was textbook perfect. Yet down in the village centre there was a health post used by very few people and staffed by dispirited individuals who were poorly supervised (hardly surprising in view of the distances involved) and showing little motivation. Much of the medical care was actually given at the private "medicine hall", a sort of glorified pharmacy. I saw the young man in charge put a plaster cast on a fractured wrist and in another village observed efficient administration of intravenous saline to a dehydrated child on a table in the front of his 8’ x 8’ shop, right by the roadside. Overall, it was the curative dimension that was missing. I could not help thinking that however good the primary health care there would still be the sick, the injured, the difficult labour, the surgical conditions, and the people who caught preventable diseases. Unless these are dealt with efficiently and well the preventive message gets blunted-if people get good treatment, they will listen to what is advised in the area of prevention. What does the efficient village health worker do when she finds someone who needs special care if everyone refuses to go to the health post? The solution is not easy. Governments have limited funds, too few workers, and numerous problems often spread over large areas (in Nepal, largely inaccessible valleys). Doctors, meanwhile, do not want to be posted to the remote areas and they would prefer to be specialists anyway. In Nepal they have to run scattered district hospitals with outposts under their care that are at least two days’ hard walking distance away, and they have junior staff in key health posts who have little knowledge of community work. It is not easy for those on the spot either, whether they are visiting health teams or local community leaders. How can they support a unit that should of necessity be able to deal with moderately severe conditions, and ensure financial support for the workers needed to run it? The balance is hard to achieve. Whatever happens we must not go back to the static curative centre that absorbs all the resources, but neither can we afford to neglect the curative side that is in such demand by the people. Prof Madura Shrestha in the Ministry of Health in Nepal listed the prime ingredients needed by all of us: "enthusiasm, motivation, and an acknowledgment of the spiritual dimension". These features apply right across the board, but the failure to generate doctors with these qualities lies at out own door. We need generalists, not specialists; we need people not afraid to innovate and take initiative; and above all we need doctors who get their kicks by seeing a
village change and overcoming difficulties as they give the best service they can. Community health must not be divorced from curative medicine; and curative medicine
adapt itself
the pendulum in the middle?
must
to
community. Why
not
stop the
Oxford Textbook of Clinical Hepatology Edited
by Neil McIntyre, Jean-Pierre Benhamou, Johannes Bircher, Mario Rizzetto, and Juan Rodes. Oxford: Oxford University Press. 1991. Pp 1631 (2 vols). 195 CC225 after July 1,1992). ISBN 0-192619683. Students of the liver have been well served with textbooks the years. Sherlock’s classic monograph was first published thirty seven years ago, and is now in its eighth edition, but our increasing knowledge of the liver and its disorders has led to ever larger and more comprehensive multi-author compilations. Now, as if to herald the "single market" of the European Community, comes a new blockbuster with five editors drawn from different EC countries. How does it compare with earlier efforts? Two volumes, 1550 pages (excluding the 80 page index), and almost 200 authors contribute to a truly impressive
over
production. Unquestionably the most comprehensive compendium yet devoted to the liver, it covers every aspect of hepatology and also devotes much space to discussions of the hepatic effects of systemic disorders. Among the latter group of chapters the quality of the contributions is slightly uneven, and some read as though compiled by trawling of journals rather than from clinical experience. The book is generously illustrated with excellent diagrams and a small number of colour plates, although the black-and-white photomicrographs are of variable quality and clarity; more extensive use of indicator arrows might have helped. In their eagerness to offer the reader as much as possible, the editors provide appropriate references within the text and yet more at the end of chapters as a guide to further reading; the logic of their choice is sometimes hard to follow because the number of follow-on references varies from none to over 170. A notable feature is the inclusion of several appendices, which reproduce the handouts devised for patients by the American Liver Foundation as well as providing useful tables to show the geographical distribution of infections that cause liver disease. Overall, the Oxford Textbook of Clinical Hepatology is an excellent book, and the minor faults merely reflect the difficulties inevitably encountered in the production of such a huge, multi-author work of reference. No doubt, if the editors still have stomach for the fight, the second edition will be even better, larger still, and yet more expensive. But are such behemoths in danger of becoming extinct; at what stage do size, cost, and organisational obstacles prove insuperable? As the first electronic medical journal is about to come on line, should we now look for electronic reference books? Perhaps they would be a more commercial proposition. An ever-increasing proportion of the individuals and institutions that can afford textbooks such as this have access to the necessary computer technology, high-quality digital photographic reproduction is now available on CD-ROM, and the benefits of rapid updating are obvious. As a specialist textbook, this one is hard to beat; but publishers would do well to reassess the benefits of other modes of disseminating information. Medical School, University of Sheffield, Sheffield S10 2RX, UK
DAVID TRIGER
