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AFTER COURT
500 rates of 0-73-1-37%.4-5 In most of these childhood studies the
Letters
to
the Editor
AFTER COURT
SIR,-The paper by Dr Alberman, Professor Morris, and Dr Pharoah (Aug. 20, p. 393) is an indictment of nationalisation as an instrument of health-services management. Professor Court’s committee made an appropriate diagnosis, but the remedies it suggested cannot be implemented for administrative reasons. Because a free health service-which we all support-is identified with national uniformity, every organisational change is raised to the status of a principle which all relevant parties (and sectional interests). must negotiate with Government at national level for the entire country. The Court committee’s gauche attempt to change the nature of the whole of general practice in the interests of bureaucratic consistency has harmed the cause it was intended to further. Surveillance and care systems have never been evaluated. There are many legitimate differences of opinion about their validity, about their objectives, and about the principles upon which they should be organised. But most people would agree that educational provision, social services support, and elementary medical advice are the essential ingredients of any service which aims to alleviate disability and disadvantage in the child population; that medical treatment is needed for only a fraction of cases (which usually require consultant services); and that it is necessary to participate in a service for a whole (not a practice) population in order to appreciate the constituent elements of the subject. Thus a "population community medicine" approach, as suggested by Alberman and her colleagues, is the only one that will allow all facets of a problem to be seen, and all the resources of local and health authorities to be brought together to tackle it. If there are 3000 clinic doctors, or 30 per area health authority (no small capability, that-and the prospect is for more, not fewer, married women doctors, to increase it), the new authorities should be able to design their own schemes, inviting the collaboration (for a fee), in whatever way is most appropriate according to local circumstances, of G.P.S who are interested, willing to undertake the training along with other clinic-doctor colleagues, and able, moreover, to advise on the character of local children’s services from the point of view of general practice. Comparison of systems with different philosophies will contribute more to progress than the administrative imposition of a single ideal model which devotes itself over decades to acquiring the resources to enable it to be implemented. The "extreme reorganisation" to which Alberman et al. object is not only impossible to bring about, it is not required. The role of the G.P. is ancillary not only because the appropriate therapies are educational and social but also because the organisation, coordination, and evaluation of a surveillance and care service is not susceptible to control by independent contractors-G.p.s or G.P.P.s. Avon Area Health Authority Greyfriars, Lewins Mead, Bristol BS1 2EE
age of onset of asthma has been below 6 years. In Africa asthma in childhood is rare; the typical asthmatic is a town dweller and his illness develops during the second or third decade of life.6-Ø An exception was the report of a prevalence of asthma of 3.3% in Tanzanian schoolchildren,9 but the validity of the criteria for the diagnosis of asthma in this study
has been questioned. 10 Are these differences racial or geographic-or do they reflect a difference in environment and life style? Racial and geographic factors are unlikely because children of West African origin born in the U.K. had a similar or higher prevalence-rate of asthma as White children of the same age. 11 We looked for asthma in two groups of Black children of the same genetic stock (Xhosa); these children were all aged between 6 and 9 years. One group lived in a Western-style urbanised environment in Cape Town. The second group lived in a rural area in Transkei where many of the people live according to tribal custom. The children from both groups had lived in the same area for at least 4 years, and in most cases since birth. The samples were selected to avoid any statistical or other bias. Our criterion for asthma was a fall in the peak expiratoryflow rate (P.E.F.R.) and forced expiratory volume in one second (F.E.VoI) of 15% or more from pre-exercise values after the child had run on the level for 6 min at submaximal effort. Godfrey has labelled this exercise-induced asthma as "the hallmark of the asthmatic".’2 By these criteria, 22 of the 694, urban children from Cape Town had asthma compared with only 1 of 671 rural children in Transkei had asthma (3-17% and
0 14%, respectively). Since the children were all Xhosa a racial difference can be excluded. There are pointers to a difference in allergenic exposure between the two groups studied-breast feeding, early introduction of cow’s milk, sleeping habits (mattresses or mats), allergic contact in the home (e.g. pets)-and these are being further evaluated. There is a difference in breast-feeding rates of the two groups. In Transkei the mean period of breast feeding was 17.6months, while in Cape Town it was 7.1months. This would support the views of Glaser and Johnstone in 195313 and Matthew et al,t4 both of whom emphasised the value of breast feeding in the prophylaxis of allergic disease. Our preliminary findings suggest that asthma is a disease of Western-style society. Prolonged breast feeding may well play a role in modifying the prevalence, age of onset, severity, and natural history of asthma. The work is supported by the Wellcome Trust, London, the Instiof Child Health, University of Cape Town, and the South African
tute
B).r.1 ÐpCØo03rroh rru1nl"’i1
E. G. WEINBERG Institute of Child Health C. H. VAN NIEKERK and Department of Pædiatrics and Child Health, S. C. SHORE University of Cape Town, H. DE V. HEESE Rondebosch, 7700 Cape, South Africa Institute of Biostatistics, South African Medical Research
Tygerberg
Council,
D. J. VAN SCHALKWYK
(Teaching), A. H. SNAITH Kraepelien, S. Acta. pœdiat. scand. 1954, 43, suppl. 100, p. 149. 5. Frandsen, S. Acta. allergol. 1958, 12, 341. 6. Warrel, D. A., Fawcett, J. W., Harrison, E. D. W., Agamah, A. J., Ibu,
4.
PREVALENCE OF ASTHMA
SiR,—The prevalence of bronchial asthma in childhood has been
widely
studied and
a
wide range of
rates
has been
reported in different populations and in different areas. Figures for the U.K., U.S.A., and Australia have been 2-0-4.9%.’-’ In contrast, Scandinavia has lower prevalenceGraham, P. J., Rutter, M. L., Yule, W., Pless, I. B. 1967, 21, 78. 2. Williams, H., McNicol. K. N. Br. med. J. 1969, iv, 321. 3. Arbeiter, H. J. Clin. Pediat. 1967, 6, 140. 1.
Br.
J.
prev.
soc.
Med.
J. O., Pope, H. M., Maberley, D. J. Q. Jl. Med. 1975, 174, 325. 7. Cookson, J. B., Makoni, G. Clin. Allergy, 1975, 5, 375. 8. Reese, P. H., Gitoho, F., Mitchell, H. S., Reese, C. E. Afr. med. J. 1974, 51, 729. 9. Carswell, F., Meakins, R. H., Harland, P. S. E. G. Lancet, 1976, ii, 706. 10. van Niekerk, G. H., Weinberg, E. G., Shore, S. C., Heese, H. de V. ibid. 1977, i, 96. 11. Smith, J. M. Br. J. Dis. Chest. 1976, 70, 73. 12. Godfrey, S. Exercise Testing in Children; Applications in Health and Disease; p. 118. London, 1974. 13. Glaser, J., Johnstone, D. E. J. Am med. Ass. 1953, 53, 620. 14. Matthew, D. J., Taylor, B., Norman, A. F., Turner, M. W., Soothill, J. F. Lancet, 1977, i, 321.
Letters
to
the Editor
AFTER COURT
SIR,-The paper by Dr Alberman, Professor Morris, and Dr Pharoah (Aug. 20, p. 393) is an indictment of nationalisation as an instrument of health-services management. Professor Court’s committee made an appropriate diagnosis, but the remedies it suggested cannot be implemented for administrative reasons. Because a free health service-which we all support-is identified with national uniformity, every organisational change is raised to the status of a principle which all relevant parties (and sectional interests). must negotiate with Government at national level for the entire country. The Court committee’s gauche attempt to change the nature of the whole of general practice in the interests of bureaucratic consistency has harmed the cause it was intended to further. Surveillance and care systems have never been evaluated. There are many legitimate differences of opinion about their validity, about their objectives, and about the principles upon which they should be organised. But most people would agree that educational provision, social services support, and elementary medical advice are the essential ingredients of any service which aims to alleviate disability and disadvantage in the child population; that medical treatment is needed for only a fraction of cases (which usually require consultant services); and that it is necessary to participate in a service for a whole (not a practice) population in order to appreciate the constituent elements of the subject. Thus a "population community medicine" approach, as suggested by Alberman and her colleagues, is the only one that will allow all facets of a problem to be seen, and all the resources of local and health authorities to be brought together to tackle it. If there are 3000 clinic doctors, or 30 per area health authority (no small capability, that-and the prospect is for more, not fewer, married women doctors, to increase it), the new authorities should be able to design their own schemes, inviting the collaboration (for a fee), in whatever way is most appropriate according to local circumstances, of G.P.S who are interested, willing to undertake the training along with other clinic-doctor colleagues, and able, moreover, to advise on the character of local children’s services from the point of view of general practice. Comparison of systems with different philosophies will contribute more to progress than the administrative imposition of a single ideal model which devotes itself over decades to acquiring the resources to enable it to be implemented. The "extreme reorganisation" to which Alberman et al. object is not only impossible to bring about, it is not required. The role of the G.P. is ancillary not only because the appropriate therapies are educational and social but also because the organisation, coordination, and evaluation of a surveillance and care service is not susceptible to control by independent contractors-G.p.s or G.P.P.s. Avon Area Health Authority Greyfriars, Lewins Mead, Bristol BS1 2EE
age of onset of asthma has been below 6 years. In Africa asthma in childhood is rare; the typical asthmatic is a town dweller and his illness develops during the second or third decade of life.6-Ø An exception was the report of a prevalence of asthma of 3.3% in Tanzanian schoolchildren,9 but the validity of the criteria for the diagnosis of asthma in this study
has been questioned. 10 Are these differences racial or geographic-or do they reflect a difference in environment and life style? Racial and geographic factors are unlikely because children of West African origin born in the U.K. had a similar or higher prevalence-rate of asthma as White children of the same age. 11 We looked for asthma in two groups of Black children of the same genetic stock (Xhosa); these children were all aged between 6 and 9 years. One group lived in a Western-style urbanised environment in Cape Town. The second group lived in a rural area in Transkei where many of the people live according to tribal custom. The children from both groups had lived in the same area for at least 4 years, and in most cases since birth. The samples were selected to avoid any statistical or other bias. Our criterion for asthma was a fall in the peak expiratoryflow rate (P.E.F.R.) and forced expiratory volume in one second (F.E.VoI) of 15% or more from pre-exercise values after the child had run on the level for 6 min at submaximal effort. Godfrey has labelled this exercise-induced asthma as "the hallmark of the asthmatic".’2 By these criteria, 22 of the 694, urban children from Cape Town had asthma compared with only 1 of 671 rural children in Transkei had asthma (3-17% and
0 14%, respectively). Since the children were all Xhosa a racial difference can be excluded. There are pointers to a difference in allergenic exposure between the two groups studied-breast feeding, early introduction of cow’s milk, sleeping habits (mattresses or mats), allergic contact in the home (e.g. pets)-and these are being further evaluated. There is a difference in breast-feeding rates of the two groups. In Transkei the mean period of breast feeding was 17.6months, while in Cape Town it was 7.1months. This would support the views of Glaser and Johnstone in 195313 and Matthew et al,t4 both of whom emphasised the value of breast feeding in the prophylaxis of allergic disease. Our preliminary findings suggest that asthma is a disease of Western-style society. Prolonged breast feeding may well play a role in modifying the prevalence, age of onset, severity, and natural history of asthma. The work is supported by the Wellcome Trust, London, the Instiof Child Health, University of Cape Town, and the South African
tute
B).r.1 ÐpCØo03rroh rru1nl"’i1
E. G. WEINBERG Institute of Child Health C. H. VAN NIEKERK and Department of Pædiatrics and Child Health, S. C. SHORE University of Cape Town, H. DE V. HEESE Rondebosch, 7700 Cape, South Africa Institute of Biostatistics, South African Medical Research
Tygerberg
Council,
D. J. VAN SCHALKWYK
(Teaching), A. H. SNAITH Kraepelien, S. Acta. pœdiat. scand. 1954, 43, suppl. 100, p. 149. 5. Frandsen, S. Acta. allergol. 1958, 12, 341. 6. Warrel, D. A., Fawcett, J. W., Harrison, E. D. W., Agamah, A. J., Ibu,
4.
PREVALENCE OF ASTHMA
SiR,—The prevalence of bronchial asthma in childhood has been
widely
studied and
a
wide range of
rates
has been
reported in different populations and in different areas. Figures for the U.K., U.S.A., and Australia have been 2-0-4.9%.’-’ In contrast, Scandinavia has lower prevalenceGraham, P. J., Rutter, M. L., Yule, W., Pless, I. B. 1967, 21, 78. 2. Williams, H., McNicol. K. N. Br. med. J. 1969, iv, 321. 3. Arbeiter, H. J. Clin. Pediat. 1967, 6, 140. 1.
Br.
J.
prev.
soc.
Med.
J. O., Pope, H. M., Maberley, D. J. Q. Jl. Med. 1975, 174, 325. 7. Cookson, J. B., Makoni, G. Clin. Allergy, 1975, 5, 375. 8. Reese, P. H., Gitoho, F., Mitchell, H. S., Reese, C. E. Afr. med. J. 1974, 51, 729. 9. Carswell, F., Meakins, R. H., Harland, P. S. E. G. Lancet, 1976, ii, 706. 10. van Niekerk, G. H., Weinberg, E. G., Shore, S. C., Heese, H. de V. ibid. 1977, i, 96. 11. Smith, J. M. Br. J. Dis. Chest. 1976, 70, 73. 12. Godfrey, S. Exercise Testing in Children; Applications in Health and Disease; p. 118. London, 1974. 13. Glaser, J., Johnstone, D. E. J. Am med. Ass. 1953, 53, 620. 14. Matthew, D. J., Taylor, B., Norman, A. F., Turner, M. W., Soothill, J. F. Lancet, 1977, i, 321.