1005
skills, but the technical procedure discovered in 1796, soon became well known, and has since only been modified in respect of details. There are many other diseases each common in various parts of the world that could be eradicated or reduced to insignificance. The Declaration points the ways for achievement, often in a practical manner, and it will be a misfortune if it is dismissed by those concerned with preventive medicine as no more than utoadministrative
Primary
Care
THE DECLARATION OF ALMA-ATA AND THE FUTURE OF PRIMARY CARE R. PASSMORE
Department of Physiology, University Medical School, Teviot Place, Edinburgh EH8 9AG
employed
was
pianism. HUMAN RIGHTS
IN September, 1978, the World Health Organisation and the United Nations Children’s Fund (UNICEF) held a conference on primary health care at Alma-Ata, the capital of the Soviet Republic of Kazakstan. Immediately after the conference the Declaration of Alma-Ata was issued. The Declaration, which consists of ten statements of aims or intentions, appeared in full in The The Lancet of Nov. 11, 1978. Since then a report of the conference has been published and the conference was the major theme of the 32nd World Health Assembly in May, 1979.2 At least eight press-release notices related to the conference have been sent out by WHO, and the Declaration is clearly intended as a basis of future WHO policy. This is sensible, since the major problem in contemporary medicine, both in the rich countries of Europe and North America and in the poor countries of Africa, Asia, and Latin America, is the discovery of
effective means of providing primary care. It is therefore unfortunate that the conference as yet appears to have had little impact. It is seldom, if ever, discussed in the innumerable articles and programmes on contemporary medicine that appear in the Press and on radio and television. It is not mentioned in the report of the Royal Commission on the National Health Service.3 There are probably two reasons for this. First, the initial sentence of the Declaration ("the Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity, is a fundamental human right") contains two concepts, health and human rights, about which most of us are confused and suspicious. The report does not discuss either of these. Secondly, it is stated that primary health care "involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors". Furthermore "an acceptable level of health for all the people of the world by the year 2000 can be obtained through a fuller and better use of the world’s resources". The concept that primary health care can bring about a utopia in some twenty years appears to run counter to our knowledge of human nature and of its biological evolution. It is easy to say, and say correctly, that the Alma-Ata Declaration sets forth a number of pious but impractical hopes and to regret that WHO is committed to following a will-of-thewisp. But the Declaration and the report of the conference merits serious study and discussion. Many of its specific aims could be achieved in many countries within twenty years. WHO has proved its ability to work miracles, as the eradication of smallpox has shown. This has been done by rousing enthusiasms and applying
The concept of human rights has a long history set in a four-page article in the Encyclopaedia Britannica. No formal statement of any human right appears to have been formulated by either the Greeks or Romans. The English Magna Carta (1215) extracted by feudal barons from King John at Runnymede sets out their rights, and has had a great influence. Later, in the 17th century, the struggles between the people and the kings in England, led to the Petition of Right (1628) and Bill of Rights (1689), two important documents. These influenced American and French revolutionaries in the eighteenth century who both produced general statements of human rights-e.g., the Virginia Declaration of Rights (1776) and the American Bill of Rights (1791), and various French statements of les droits de l’homme. The 20th century has seen the United Nations International Bill of Rights proclaimed by the General Assembly in 1948 which sets out various civil and political
out
rights. All those declarations and bills
are
concerned with the
protection of people against the abuse of power by kings and Governments. They are essentially statements of what a Government may not do. The Alma-Ata Declaration states positively that man has a right to primary health care and implies that Governments have a duty to see that this is provided in one form or another. The concept that man has a right to certain services which provide him with material goods and care is essentially different from the concept of rights that ensure his liberty against abuses of power by his rulers. Rights are also related to duty. Mahatma Gandi wrote: "I learned from my illiterate but wise mother that all rights to be deserved and preserved came from duty well done. Thus the very right to live accrues to us only when we do the duty of the citizenship of the world And since every right carries with it a corresponding duty and the corresponding remedy for resisting an attack upon it, it is merely a matter of finding out the corresponding duties and remedies to vindicate the elementary equality". The last sentence may not be quite clear but the general meaning is obvious. The delegates at Alma-Ata do not appear to have considered duties. Human societies have always provided some material care for their less fortunate members through the exercise of charity. Charity is a virtue, which all the great religions, and notably Christianity, enjoin upon their followers, but charity is a duty for those who can afford it and not a right which the poor can demand. ...
ALTRUISM
Altruism is the principle of living and acting for the interest of others. The term was first used by Auguste
1006 Comte in his book Systeme de Politique Positive, published in Paris in 1851. This had the subtitle Traité de Sociologie and was the foundation upon which the science of sociology has grown. He made altruism the main feature of the ethics of his positive philosophy which he hoped would form the basis of a new political organisation for industrial society. The word comes from the French phrase le bien d’autri, the good of others. Comte contrasted altruism with egotism and stated that the great human problem was the subordination of egotism to altruism. Comte, who took all knowledge into his system, was influenced by the Viennese physiologist, Gall, whose book4 introduced the theory that functions of the brain could be localised in the cerebral cortex. Gall also thought that variations in the shape of the cerebrum were reflected in the shape of the skull and from this built up a popular interest in phrenology. Comte was too critical a man to accept phrenology as a science, but he did attribute altruism to the development of the human cerebral cortex and appear to have considered it as a property unique to man and not exhibited by other species. Two eminent neurophysiologists, Sir Charles Sherrington and Sir John Eccles, have each discussed the place of altruism in nature in Gifford Lectures which they delivered in Edinburgh in 1934-35 and 1978-79 respectively.5-7 In both series of lectures altruism is presented as a late development in the long evolution of brain and associated mind. Sherrington describes altruism as a passion "that would seem as yet nature’s noblest product; the greatest contribution made by man to life". He adds: "It marks, we think, at the present time the climax of mind. It is well to note it is not essentially rational. It is often more germane to emotion than to intellect. It belongs, if you will to sentiment so that intellect at best ranks but as a tool for sentiment. It creates a reasoned emotion. It may have the conquest of the world before it, in which case reason will play its part as a tool. It may mean a human future led by womankind more eminently than by men". Maternal care, exhibited by many animal species, and also the social behaviour of members of insect colonies is selfless but not true altruism. As Eccles points out such behaviour is fixed and determined by genetic constitution. Unlike altruism it is not concerned with values. In discussing the great predaceous animals-
shark, hawk, panther, wolf-Sherrington states: "Wrong is and was impossible to them. More hopeless still, equally impossible is ’right’. Those other creatures than himself, even the likest to himself, would seem without ’values’, or it may be at most ’some values’ ad hoc for a given situation. Nothing of values as concepts, such as man’s, constantly vouchsafing him counsel in situations widely circumstanced. Whence has he got them? Inventions of his own? How far can he trust them?" Altruism requires compassion and Eccles can find no scientific evidence of this in animals. Thus Washburn, in a review of the behaviour of primates,8 states that they do not display altruism in the wild. Lawick-Goodall,9 studied for many years a colony of chimpanzees living in their natural habitat in Indonesia. The colony was hit by an epidemic of poliomyelitis which left several members incapacitated. The other chimpanzees were
totally indifferent to the plight of the disabled. The sufferings of one member of the colony, named McGregor, who had lost the use of both his legs are poignantly described. He received no help from his fellows and his misery ended only when he was shot by a member of the research team. The fossil records indicate that the earliest form of man, Homo habilis, was differentiated from his predecessor, Ramapithecus, two to three million years ago. During this period there has been a striking evolution in the size of the skull cavity, compared with relatively small changes in other parts of the skeleton. Two million years ago the calculated size of the brain of H6mo habilis was 700 g. About 750 000 years ago Homo erectus had a brain weighing about 1000 g and, when about 100 000 years ago Homo sapiens neanthalis appeared, his brain weighed about 1550 g. Modern man has a slightly smaller brain, average weight 1450 g. This decrease in overall size may be associated with an increase in neocortex and hippocampus and a decrease in the olfactory bulb. Although the fossil records now provide much information about the nature of the life led by early man, the first evidence that he exhibited compassion is only 60 000 years old. This comes from the Shandihar cave situated in that area of northern Iraq now occupied by the Kurds, and is recorded by Solecki.10,11 Two of the skeletons found in the cave give evidence that in life their owners were so disabled that they could not have survived without the care and attention of their fellows. One was an old man who had severe arthritic changes and a congenital abnormality that must have made his right arm useless. The other showed evidence of recent injury to a rib, possibly caused by a stab wound. Further, the area round these two and five other skeletons in the cave was shown to be very rich in pollen, indicating that floral tributes were paid to the dead, and this may be taken as evidence of compassion. EGOTISM AND PREDATORINESS
Whereas Comte contrasts altruism with human ego-
tism, Sherrington contrasts it with animal predatoriness. He notes that tropical jungles in which most terrestrial animal species, including Homo, evolved were and are cruel places. The "zest to live" is accompanied by a "zest to kill". Sherrington’s discussion of altruism is preceded by the life story of plasmodia. Malarial parasites have a chancy existence. It on their finding suitable mammalian and insects hosts, and on their ability to plunder red blood cells. This has caused untold suffering and the deaths of innumerable men--over 1 million a year in India alone at one time. There is no sign of mind in this slaughter. Plunder, preying, and violence are the way of life for many mammalian species. They may know what they are doing, but appear to have no thought for the suffering of their victims. Primitive man was a hunter and contemporary man continues to exhibit violence and to kill, though his motives are now more complex. He can still be described as Homo predatorius. A new form of predatoriness completely unique to man is corruption or bribery. This is accomplished without consideration for the suffering of the victims. That highly attractive fictional rogue, Hajji Baba, when in-
depends
1007
structed by the Grand Vizier
general ineffectiveness.
Iran
to tell people to eat fresh fruit daily, to bed early, to bathe regularly, and to take plenty go of outdoor exercise. I do all these things because I enjoy them and perhaps because I learnt to do them in my home as a child. They are habits and if for any reason I cannot do them I feel ill at ease. I know of no good evidence that any of these habits prevent any acute disease or that they delay the onset of degenerative or neoplastic diseases from which we all suffer if we live long enough. In 1963 two colleagues and I wrote an article entitled Does Exercise Promote Health?" It set out data consistent with the view that regular exercise may lengthen life and prevent obesity and cardiovascular disease. Since then more data consistent with this view has been presented, but this still does not convince. I am a keen advocate of outdoor activities because they are enjoy7 able, and not because they may promote health. Education and services are needed to prevent diseases and not to provide health. It is indisputable that many diseases are present in every country affecting both individuals and whole communities which can be eradicated or reduced to insignificant proportions if effective action is taken. Effective action can be taken only if the people are educated. The stories of the discoveries that have led to the great advances in preventive medicine by the use of scientific methods and observation, beginning with that of Jenner and vaccination, are true stories and not hot air. They are fascinating and carry practical messages. Both for young people and Cabinet ministers, disease education is much easier and more likely to be effective than health education.
was told 12 "The people of like the earth; they require rishweh, their interests must be highly excited before they will bring forth fruit". A footnote states that the word rishweh, bribery, was also used for manure in 1824. The Grand Vizier went on: "The Franks talk of feelings in public life of which we are ignorant: They pretend to be actuated by no other feeling than the good of their country. These are words without meaning to us. Certain privileges and enjoyments are the lawful inheritance of the Shahs of Persia; let them possess them in the name of Allah! And their viziers also should have their allotted portion: why should they refuse them? Certainly not for the good of the country, because not one individual throughout the whole empire even understands what that good means, much less would he work for it". It is probable that the vizier’s remarks are still applicable to most of the population in poor countries, and it is commonly reported that a significant proportion of all foreign aid is directed to venal use. Sir Robert Walpole’s much quoted remark "everyman has his price" appears less applicable today than when he made it some 250 years ago, and for this we must be grateful. However a decline in personal bribery appears to have been associated with an increase in collective bribery. In the United Kingdom now almost all groups of workers in the medical and social services are prepared to stop work or go slow, if they do not receive what they consider their proper financial reward. A patient with dysentery in a hospital in India who cannot get a bedpan because he has not been able to satisfy the attendant and a patient with arthritis in England who cannot get surgical treatment because some group of hospital workers are going slow are each victims of are
Homo predatorius. In all countries medical services will
improve only
as
altruism grows and predatoriness declines. Both Sherrington and Eccles are optimists. They see the evolution of brain and mind and the development of values. But in Eccles’s graph of the development of the human brain, the time scale is in millions of years. HEALTH
The Alma-Ata conference
uses
the word "health"
re-
peatedly and reaffirms in its first declaration the WHO definition, already quoted. Unfortunately this definition is meaningless to most people. Health is a useful word in everyday speech and we can sometimes recognise it, as when we see a man vaulting over a gate rather than go to the trouble of undoing a chain to open it. Neither the WHO definition nor any other is useful for scientific purposes, because they cannot be made quantitative. Attempts to measure health are expressed mainly in terms of morbidity and mortality. We now have the World Health Organisation, Departments of Health, National Health Services, and Health Education. It would be unrealistic to suggest that these should change their names, but it might be a benefit if they each ceased to talk about health. The use of the word may deceive some naive people who think that it is readily attainable. More important the public and especially young people know that much education about "healthy" living is hot air and not scientific. This may discredit health education and account for its
It is orthodox to
WHAT IS
PRACTICAL?
It is easy to dismiss the Alma-Ata declaration and the report of the conference as the work of starry-eyed enthusiasts who neglected to define their terms and did not consider the nature of man. This would be a great mistake. "Health for all in the year 2000" is an absurdity, but there is no doubt that many of the objectives of W.H.O. could be achieved in the next 20 years if they pursued with the energy and competence that in the past 20 years have put men on the moon and eradicated smallpox. These great achievements permit optimism for the future. There are at least eight targets at which it would be reasonable to aim and which take in a large part of primary medical care.
(1) The eradication of or the reduction to insignificance of the mortality from those diseases against which there are known immunological methods of protection (i.e., poliomyelitis, diphtheria, tetanus, tuberculosis, measles and whooping-cough). (2) The eradication or the reduction to insignificance of the mortality from water-borne diseases by the provision of safe drinking water for every household. (3) The containment of malaria and schistosomiasis; it is unrealistic to hope that these two diseases can be eradicated with techniques at present available. (4) the eradication of endemic goitre and of blindness due to keratomalacia by provision of iodine and vitamin A to those at risk. (5) The provision of instruction of all mothers on how to feed their children and themselves when pregnant and lactating, and of suitable supplements of nutrients when needed. (6) The provision to all of freely available instruction on birth control.
1008
(7) The provision to every community of a sufficient supply of those drugs which they need, selected from the list of some 200 essential drugs provided by W.H.O. 14 (8) The provision of greatly improved surgical care for the injured. All of these are already part of the W.H.O. policy and of them are explicitly mentioned in the Alma-Ata report. The last is seldom mentioned but is of great importance. All of us at some time or another require professional care for an injury. Wounds have to be dressed and stitched, and fractures set. This inevitably and obviously brings us in need of care. The treatment of some severe injuries requires the highest professional skill and costly equipment which could never be made readily available to those who live in remote areas. But fortunately most injuries are minor, and the skill and equipment needed to ensure full healing are relatively simple. A primary medical service which provides prompt and effective treatment of injuries is respected in the community, and in this way is a good advertisement for itself and the preventive services, whose value may not be obvious to many. most
OPERATIONAL ASPECTS
Added to the report of the conference is a report by Director-General of W.H.O. and the Executive Director of UNICEF on the operational aspects of primary care, which are especially directed to the needs of developing countries where the provision of such care is a "burning necessity". There is strong emphasis on the desirability of decentralising services. Whilst central Government has to supply money and technical advice and to take an overall responsibility, local communities should plan and run their own services. The development and running of new services depends on local enthusiasms and these are inhibited by rigid central regulations. In all countries there are many different local problems that require local solutions. In the provision of primary care the principle of "small is beautiful" holds and central Governments should appear as unobtrusive as possible without escaping from their responsibilities. There is need for an international commitment to primary care. Many countries need financial aid from national and international funds but, perhaps more important, they should be able to sense a positive climate of opinion. Maybe this can best be done by example. In preventive medicine, the richer countries can help the poorer ones best by setting their own houses in order. This requires that their leaders and also W.H.O. concentrate their attention on the treatment and prevention of specific diseases. All of those who work in the medical services have much to learn about disease. They cannot be expected to be responsible professionally with the social problems arising from poverty and from failure of people to get on with their family and neighbours. This is the task of those who work in the social services. Members of the medical and social services have to understand each others problems and often must work together on specific problems arising for individuals and communities. But a single system of primary health care, as envisaged at Alma-Ata, is an illusion, since health is a mirage. However it would be wrong to end on a critical note. The Alma-Ata report is recommended to all with the hope that readers will catch some of the
enthusiasm
nothing
can
Without
of the delegates. be achieved.
enthusiasm
REFERENCES 1. Primary Health Care. Alma-Ata, 1978. Geneva: WHO, 1978. 2. 32nd World Health Assembly. WHO Chron 1979; 33: 243-49. 3. Royal Commission on the N.H.S. Cmnd. 7615. London: H.M. Stationery Office. 4. Gall F. J., Spurzheim J.C. Anatomie et physiologic du systeme nerveux en general, et du cerveau en particulier. Paris, 1810-19. 5. Sherrington CS. Man on his Nature. Cambridge: University Press, 1951. 6. Eccles J.C. The Human Mystery. Berlin: Springer International, 1979. 7. Eccles J.C. The Human Psyche. Berlin: Springer International (in press). 8. Washburn S.L. The evolution of human behaviour. In: The uniqueness of man. Poslansky J.D. ed. Amsterdam: North Holland, 1969. 9. Lawick-Goodal J. van. In the shadow of man. New York: Dell, 1971. 10. Solecki R.S. Shanidar. New York: Knopf, 1971. 11. Solecki R.S. The implication of the Shanidar care. Neanderthal flower
burial. Ann N Y Acad Sci 1977; 293, 114-24. J. The Adventures of Hajji Babba of Ispahan. World Classics edition (1923). London: Oxford University Press (World Classics edition), 1923. 13. Davies CTM, Drysdale HC, Passmore R. Does exercise promote health? Lancet 1963; ii: 930-32. 14. The selection of essential drugs. WHO Technical Rep Ser 1977; no 615. 12. Morier
Point of View THE COMPONENTS OF SICKNESS: DISEASES, ILLNESSES, AND PREDICAMENTS* THERE are different ways of being sick. This paper outlines some steps towards an organisation of the components of sickness into a world of diseases, substantial realities to the sense organs; illnesses, processes, enactments, reports of the self; and predicaments the situations, systems, and extracorporeal elements in which the patient is placed. A series of postulates by which disease can be distinguished from illness is offered and the concept of the predicament is introduced in a similar way. The division draws attention to areas of medical practice which are less adequately systematised and more difficult to substantiate despite their undoubted importance to sick people. Increasing emphasis on disease because it is bioscientifically respectable and accessible may prove to be another factor alienating medicine from the people it serves. DISEASES
1. Diseases are discernible as physical reality. Disease is discernible as tangible evidence to the specially tuned senses of the physician. Extreme limits of anatomical variation, deformities, inborn errors, congenital anomalies, wounds, infections, infestations and tumours are included. Disease is the most important area of medical categorisation because of the strength of predictions which derive from it, its independence from the testimony of the patient, and the rationality of treatment.
2. Disease requires specific changes in the tissues but is not necessarily organ-specific.
structure
of
Evidence of specific changes at a structural level may not be limited to a single organ or system. The signature of a disease comes from the regularity of the structural changes or from detailed knowledge of its aetiology.
3. Disease may be trivial. As defined above, many diseases will prove of a change, define its existence.
significance *
or
its
severity,
to
be trivial. The be used to
cannot
Based on a lecture given to the Irish Paediatric Association in 1973 and developed at meetings in Oxford, in 1976, and in Waterville, Maine, in 1977.
skills, but the technical procedure discovered in 1796, soon became well known, and has since only been modified in respect of details. There are many other diseases each common in various parts of the world that could be eradicated or reduced to insignificance. The Declaration points the ways for achievement, often in a practical manner, and it will be a misfortune if it is dismissed by those concerned with preventive medicine as no more than utoadministrative
Primary
Care
THE DECLARATION OF ALMA-ATA AND THE FUTURE OF PRIMARY CARE R. PASSMORE
Department of Physiology, University Medical School, Teviot Place, Edinburgh EH8 9AG
employed
was
pianism. HUMAN RIGHTS
IN September, 1978, the World Health Organisation and the United Nations Children’s Fund (UNICEF) held a conference on primary health care at Alma-Ata, the capital of the Soviet Republic of Kazakstan. Immediately after the conference the Declaration of Alma-Ata was issued. The Declaration, which consists of ten statements of aims or intentions, appeared in full in The The Lancet of Nov. 11, 1978. Since then a report of the conference has been published and the conference was the major theme of the 32nd World Health Assembly in May, 1979.2 At least eight press-release notices related to the conference have been sent out by WHO, and the Declaration is clearly intended as a basis of future WHO policy. This is sensible, since the major problem in contemporary medicine, both in the rich countries of Europe and North America and in the poor countries of Africa, Asia, and Latin America, is the discovery of
effective means of providing primary care. It is therefore unfortunate that the conference as yet appears to have had little impact. It is seldom, if ever, discussed in the innumerable articles and programmes on contemporary medicine that appear in the Press and on radio and television. It is not mentioned in the report of the Royal Commission on the National Health Service.3 There are probably two reasons for this. First, the initial sentence of the Declaration ("the Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity, is a fundamental human right") contains two concepts, health and human rights, about which most of us are confused and suspicious. The report does not discuss either of these. Secondly, it is stated that primary health care "involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors". Furthermore "an acceptable level of health for all the people of the world by the year 2000 can be obtained through a fuller and better use of the world’s resources". The concept that primary health care can bring about a utopia in some twenty years appears to run counter to our knowledge of human nature and of its biological evolution. It is easy to say, and say correctly, that the Alma-Ata Declaration sets forth a number of pious but impractical hopes and to regret that WHO is committed to following a will-of-thewisp. But the Declaration and the report of the conference merits serious study and discussion. Many of its specific aims could be achieved in many countries within twenty years. WHO has proved its ability to work miracles, as the eradication of smallpox has shown. This has been done by rousing enthusiasms and applying
The concept of human rights has a long history set in a four-page article in the Encyclopaedia Britannica. No formal statement of any human right appears to have been formulated by either the Greeks or Romans. The English Magna Carta (1215) extracted by feudal barons from King John at Runnymede sets out their rights, and has had a great influence. Later, in the 17th century, the struggles between the people and the kings in England, led to the Petition of Right (1628) and Bill of Rights (1689), two important documents. These influenced American and French revolutionaries in the eighteenth century who both produced general statements of human rights-e.g., the Virginia Declaration of Rights (1776) and the American Bill of Rights (1791), and various French statements of les droits de l’homme. The 20th century has seen the United Nations International Bill of Rights proclaimed by the General Assembly in 1948 which sets out various civil and political
out
rights. All those declarations and bills
are
concerned with the
protection of people against the abuse of power by kings and Governments. They are essentially statements of what a Government may not do. The Alma-Ata Declaration states positively that man has a right to primary health care and implies that Governments have a duty to see that this is provided in one form or another. The concept that man has a right to certain services which provide him with material goods and care is essentially different from the concept of rights that ensure his liberty against abuses of power by his rulers. Rights are also related to duty. Mahatma Gandi wrote: "I learned from my illiterate but wise mother that all rights to be deserved and preserved came from duty well done. Thus the very right to live accrues to us only when we do the duty of the citizenship of the world And since every right carries with it a corresponding duty and the corresponding remedy for resisting an attack upon it, it is merely a matter of finding out the corresponding duties and remedies to vindicate the elementary equality". The last sentence may not be quite clear but the general meaning is obvious. The delegates at Alma-Ata do not appear to have considered duties. Human societies have always provided some material care for their less fortunate members through the exercise of charity. Charity is a virtue, which all the great religions, and notably Christianity, enjoin upon their followers, but charity is a duty for those who can afford it and not a right which the poor can demand. ...
ALTRUISM
Altruism is the principle of living and acting for the interest of others. The term was first used by Auguste
1006 Comte in his book Systeme de Politique Positive, published in Paris in 1851. This had the subtitle Traité de Sociologie and was the foundation upon which the science of sociology has grown. He made altruism the main feature of the ethics of his positive philosophy which he hoped would form the basis of a new political organisation for industrial society. The word comes from the French phrase le bien d’autri, the good of others. Comte contrasted altruism with egotism and stated that the great human problem was the subordination of egotism to altruism. Comte, who took all knowledge into his system, was influenced by the Viennese physiologist, Gall, whose book4 introduced the theory that functions of the brain could be localised in the cerebral cortex. Gall also thought that variations in the shape of the cerebrum were reflected in the shape of the skull and from this built up a popular interest in phrenology. Comte was too critical a man to accept phrenology as a science, but he did attribute altruism to the development of the human cerebral cortex and appear to have considered it as a property unique to man and not exhibited by other species. Two eminent neurophysiologists, Sir Charles Sherrington and Sir John Eccles, have each discussed the place of altruism in nature in Gifford Lectures which they delivered in Edinburgh in 1934-35 and 1978-79 respectively.5-7 In both series of lectures altruism is presented as a late development in the long evolution of brain and associated mind. Sherrington describes altruism as a passion "that would seem as yet nature’s noblest product; the greatest contribution made by man to life". He adds: "It marks, we think, at the present time the climax of mind. It is well to note it is not essentially rational. It is often more germane to emotion than to intellect. It belongs, if you will to sentiment so that intellect at best ranks but as a tool for sentiment. It creates a reasoned emotion. It may have the conquest of the world before it, in which case reason will play its part as a tool. It may mean a human future led by womankind more eminently than by men". Maternal care, exhibited by many animal species, and also the social behaviour of members of insect colonies is selfless but not true altruism. As Eccles points out such behaviour is fixed and determined by genetic constitution. Unlike altruism it is not concerned with values. In discussing the great predaceous animals-
shark, hawk, panther, wolf-Sherrington states: "Wrong is and was impossible to them. More hopeless still, equally impossible is ’right’. Those other creatures than himself, even the likest to himself, would seem without ’values’, or it may be at most ’some values’ ad hoc for a given situation. Nothing of values as concepts, such as man’s, constantly vouchsafing him counsel in situations widely circumstanced. Whence has he got them? Inventions of his own? How far can he trust them?" Altruism requires compassion and Eccles can find no scientific evidence of this in animals. Thus Washburn, in a review of the behaviour of primates,8 states that they do not display altruism in the wild. Lawick-Goodall,9 studied for many years a colony of chimpanzees living in their natural habitat in Indonesia. The colony was hit by an epidemic of poliomyelitis which left several members incapacitated. The other chimpanzees were
totally indifferent to the plight of the disabled. The sufferings of one member of the colony, named McGregor, who had lost the use of both his legs are poignantly described. He received no help from his fellows and his misery ended only when he was shot by a member of the research team. The fossil records indicate that the earliest form of man, Homo habilis, was differentiated from his predecessor, Ramapithecus, two to three million years ago. During this period there has been a striking evolution in the size of the skull cavity, compared with relatively small changes in other parts of the skeleton. Two million years ago the calculated size of the brain of H6mo habilis was 700 g. About 750 000 years ago Homo erectus had a brain weighing about 1000 g and, when about 100 000 years ago Homo sapiens neanthalis appeared, his brain weighed about 1550 g. Modern man has a slightly smaller brain, average weight 1450 g. This decrease in overall size may be associated with an increase in neocortex and hippocampus and a decrease in the olfactory bulb. Although the fossil records now provide much information about the nature of the life led by early man, the first evidence that he exhibited compassion is only 60 000 years old. This comes from the Shandihar cave situated in that area of northern Iraq now occupied by the Kurds, and is recorded by Solecki.10,11 Two of the skeletons found in the cave give evidence that in life their owners were so disabled that they could not have survived without the care and attention of their fellows. One was an old man who had severe arthritic changes and a congenital abnormality that must have made his right arm useless. The other showed evidence of recent injury to a rib, possibly caused by a stab wound. Further, the area round these two and five other skeletons in the cave was shown to be very rich in pollen, indicating that floral tributes were paid to the dead, and this may be taken as evidence of compassion. EGOTISM AND PREDATORINESS
Whereas Comte contrasts altruism with human ego-
tism, Sherrington contrasts it with animal predatoriness. He notes that tropical jungles in which most terrestrial animal species, including Homo, evolved were and are cruel places. The "zest to live" is accompanied by a "zest to kill". Sherrington’s discussion of altruism is preceded by the life story of plasmodia. Malarial parasites have a chancy existence. It on their finding suitable mammalian and insects hosts, and on their ability to plunder red blood cells. This has caused untold suffering and the deaths of innumerable men--over 1 million a year in India alone at one time. There is no sign of mind in this slaughter. Plunder, preying, and violence are the way of life for many mammalian species. They may know what they are doing, but appear to have no thought for the suffering of their victims. Primitive man was a hunter and contemporary man continues to exhibit violence and to kill, though his motives are now more complex. He can still be described as Homo predatorius. A new form of predatoriness completely unique to man is corruption or bribery. This is accomplished without consideration for the suffering of the victims. That highly attractive fictional rogue, Hajji Baba, when in-
depends
1007
structed by the Grand Vizier
general ineffectiveness.
Iran
to tell people to eat fresh fruit daily, to bed early, to bathe regularly, and to take plenty go of outdoor exercise. I do all these things because I enjoy them and perhaps because I learnt to do them in my home as a child. They are habits and if for any reason I cannot do them I feel ill at ease. I know of no good evidence that any of these habits prevent any acute disease or that they delay the onset of degenerative or neoplastic diseases from which we all suffer if we live long enough. In 1963 two colleagues and I wrote an article entitled Does Exercise Promote Health?" It set out data consistent with the view that regular exercise may lengthen life and prevent obesity and cardiovascular disease. Since then more data consistent with this view has been presented, but this still does not convince. I am a keen advocate of outdoor activities because they are enjoy7 able, and not because they may promote health. Education and services are needed to prevent diseases and not to provide health. It is indisputable that many diseases are present in every country affecting both individuals and whole communities which can be eradicated or reduced to insignificant proportions if effective action is taken. Effective action can be taken only if the people are educated. The stories of the discoveries that have led to the great advances in preventive medicine by the use of scientific methods and observation, beginning with that of Jenner and vaccination, are true stories and not hot air. They are fascinating and carry practical messages. Both for young people and Cabinet ministers, disease education is much easier and more likely to be effective than health education.
was told 12 "The people of like the earth; they require rishweh, their interests must be highly excited before they will bring forth fruit". A footnote states that the word rishweh, bribery, was also used for manure in 1824. The Grand Vizier went on: "The Franks talk of feelings in public life of which we are ignorant: They pretend to be actuated by no other feeling than the good of their country. These are words without meaning to us. Certain privileges and enjoyments are the lawful inheritance of the Shahs of Persia; let them possess them in the name of Allah! And their viziers also should have their allotted portion: why should they refuse them? Certainly not for the good of the country, because not one individual throughout the whole empire even understands what that good means, much less would he work for it". It is probable that the vizier’s remarks are still applicable to most of the population in poor countries, and it is commonly reported that a significant proportion of all foreign aid is directed to venal use. Sir Robert Walpole’s much quoted remark "everyman has his price" appears less applicable today than when he made it some 250 years ago, and for this we must be grateful. However a decline in personal bribery appears to have been associated with an increase in collective bribery. In the United Kingdom now almost all groups of workers in the medical and social services are prepared to stop work or go slow, if they do not receive what they consider their proper financial reward. A patient with dysentery in a hospital in India who cannot get a bedpan because he has not been able to satisfy the attendant and a patient with arthritis in England who cannot get surgical treatment because some group of hospital workers are going slow are each victims of are
Homo predatorius. In all countries medical services will
improve only
as
altruism grows and predatoriness declines. Both Sherrington and Eccles are optimists. They see the evolution of brain and mind and the development of values. But in Eccles’s graph of the development of the human brain, the time scale is in millions of years. HEALTH
The Alma-Ata conference
uses
the word "health"
re-
peatedly and reaffirms in its first declaration the WHO definition, already quoted. Unfortunately this definition is meaningless to most people. Health is a useful word in everyday speech and we can sometimes recognise it, as when we see a man vaulting over a gate rather than go to the trouble of undoing a chain to open it. Neither the WHO definition nor any other is useful for scientific purposes, because they cannot be made quantitative. Attempts to measure health are expressed mainly in terms of morbidity and mortality. We now have the World Health Organisation, Departments of Health, National Health Services, and Health Education. It would be unrealistic to suggest that these should change their names, but it might be a benefit if they each ceased to talk about health. The use of the word may deceive some naive people who think that it is readily attainable. More important the public and especially young people know that much education about "healthy" living is hot air and not scientific. This may discredit health education and account for its
It is orthodox to
WHAT IS
PRACTICAL?
It is easy to dismiss the Alma-Ata declaration and the report of the conference as the work of starry-eyed enthusiasts who neglected to define their terms and did not consider the nature of man. This would be a great mistake. "Health for all in the year 2000" is an absurdity, but there is no doubt that many of the objectives of W.H.O. could be achieved in the next 20 years if they pursued with the energy and competence that in the past 20 years have put men on the moon and eradicated smallpox. These great achievements permit optimism for the future. There are at least eight targets at which it would be reasonable to aim and which take in a large part of primary medical care.
(1) The eradication of or the reduction to insignificance of the mortality from those diseases against which there are known immunological methods of protection (i.e., poliomyelitis, diphtheria, tetanus, tuberculosis, measles and whooping-cough). (2) The eradication or the reduction to insignificance of the mortality from water-borne diseases by the provision of safe drinking water for every household. (3) The containment of malaria and schistosomiasis; it is unrealistic to hope that these two diseases can be eradicated with techniques at present available. (4) the eradication of endemic goitre and of blindness due to keratomalacia by provision of iodine and vitamin A to those at risk. (5) The provision of instruction of all mothers on how to feed their children and themselves when pregnant and lactating, and of suitable supplements of nutrients when needed. (6) The provision to all of freely available instruction on birth control.
1008
(7) The provision to every community of a sufficient supply of those drugs which they need, selected from the list of some 200 essential drugs provided by W.H.O. 14 (8) The provision of greatly improved surgical care for the injured. All of these are already part of the W.H.O. policy and of them are explicitly mentioned in the Alma-Ata report. The last is seldom mentioned but is of great importance. All of us at some time or another require professional care for an injury. Wounds have to be dressed and stitched, and fractures set. This inevitably and obviously brings us in need of care. The treatment of some severe injuries requires the highest professional skill and costly equipment which could never be made readily available to those who live in remote areas. But fortunately most injuries are minor, and the skill and equipment needed to ensure full healing are relatively simple. A primary medical service which provides prompt and effective treatment of injuries is respected in the community, and in this way is a good advertisement for itself and the preventive services, whose value may not be obvious to many. most
OPERATIONAL ASPECTS
Added to the report of the conference is a report by Director-General of W.H.O. and the Executive Director of UNICEF on the operational aspects of primary care, which are especially directed to the needs of developing countries where the provision of such care is a "burning necessity". There is strong emphasis on the desirability of decentralising services. Whilst central Government has to supply money and technical advice and to take an overall responsibility, local communities should plan and run their own services. The development and running of new services depends on local enthusiasms and these are inhibited by rigid central regulations. In all countries there are many different local problems that require local solutions. In the provision of primary care the principle of "small is beautiful" holds and central Governments should appear as unobtrusive as possible without escaping from their responsibilities. There is need for an international commitment to primary care. Many countries need financial aid from national and international funds but, perhaps more important, they should be able to sense a positive climate of opinion. Maybe this can best be done by example. In preventive medicine, the richer countries can help the poorer ones best by setting their own houses in order. This requires that their leaders and also W.H.O. concentrate their attention on the treatment and prevention of specific diseases. All of those who work in the medical services have much to learn about disease. They cannot be expected to be responsible professionally with the social problems arising from poverty and from failure of people to get on with their family and neighbours. This is the task of those who work in the social services. Members of the medical and social services have to understand each others problems and often must work together on specific problems arising for individuals and communities. But a single system of primary health care, as envisaged at Alma-Ata, is an illusion, since health is a mirage. However it would be wrong to end on a critical note. The Alma-Ata report is recommended to all with the hope that readers will catch some of the
enthusiasm
nothing
can
Without
of the delegates. be achieved.
enthusiasm
REFERENCES 1. Primary Health Care. Alma-Ata, 1978. Geneva: WHO, 1978. 2. 32nd World Health Assembly. WHO Chron 1979; 33: 243-49. 3. Royal Commission on the N.H.S. Cmnd. 7615. London: H.M. Stationery Office. 4. Gall F. J., Spurzheim J.C. Anatomie et physiologic du systeme nerveux en general, et du cerveau en particulier. Paris, 1810-19. 5. Sherrington CS. Man on his Nature. Cambridge: University Press, 1951. 6. Eccles J.C. The Human Mystery. Berlin: Springer International, 1979. 7. Eccles J.C. The Human Psyche. Berlin: Springer International (in press). 8. Washburn S.L. The evolution of human behaviour. In: The uniqueness of man. Poslansky J.D. ed. Amsterdam: North Holland, 1969. 9. Lawick-Goodal J. van. In the shadow of man. New York: Dell, 1971. 10. Solecki R.S. Shanidar. New York: Knopf, 1971. 11. Solecki R.S. The implication of the Shanidar care. Neanderthal flower
burial. Ann N Y Acad Sci 1977; 293, 114-24. J. The Adventures of Hajji Babba of Ispahan. World Classics edition (1923). London: Oxford University Press (World Classics edition), 1923. 13. Davies CTM, Drysdale HC, Passmore R. Does exercise promote health? Lancet 1963; ii: 930-32. 14. The selection of essential drugs. WHO Technical Rep Ser 1977; no 615. 12. Morier
Point of View THE COMPONENTS OF SICKNESS: DISEASES, ILLNESSES, AND PREDICAMENTS* THERE are different ways of being sick. This paper outlines some steps towards an organisation of the components of sickness into a world of diseases, substantial realities to the sense organs; illnesses, processes, enactments, reports of the self; and predicaments the situations, systems, and extracorporeal elements in which the patient is placed. A series of postulates by which disease can be distinguished from illness is offered and the concept of the predicament is introduced in a similar way. The division draws attention to areas of medical practice which are less adequately systematised and more difficult to substantiate despite their undoubted importance to sick people. Increasing emphasis on disease because it is bioscientifically respectable and accessible may prove to be another factor alienating medicine from the people it serves. DISEASES
1. Diseases are discernible as physical reality. Disease is discernible as tangible evidence to the specially tuned senses of the physician. Extreme limits of anatomical variation, deformities, inborn errors, congenital anomalies, wounds, infections, infestations and tumours are included. Disease is the most important area of medical categorisation because of the strength of predictions which derive from it, its independence from the testimony of the patient, and the rationality of treatment.
2. Disease requires specific changes in the tissues but is not necessarily organ-specific.
structure
of
Evidence of specific changes at a structural level may not be limited to a single organ or system. The signature of a disease comes from the regularity of the structural changes or from detailed knowledge of its aetiology.
3. Disease may be trivial. As defined above, many diseases will prove of a change, define its existence.
significance *
or
its
severity,
to
be trivial. The be used to
cannot
Based on a lecture given to the Irish Paediatric Association in 1973 and developed at meetings in Oxford, in 1976, and in Waterville, Maine, in 1977.
