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BLACK DAY FOR THE GREEN-PAPER
1035
has shown 4-that such seropositivity probably represents in the main a response to immunisation through the agency of infection, especially some chronic infections. Although diseases of the reticuloendothelial system (which includes the immune system) that are associated with hypergammaglobulinaemia or macroglobuImaEmia can produce antiglobulins, the principal stimulus to R.F. production in rheumatoid and in most non-rheumatoid seropositive subjects alike still seems most likely to be IgG antibody complexed with antigen ; although what this antigen may be in rheumatoid arthritis remains for most workers a mystery. Yet although the reaction patterns and levels of seropositivity in rheumatoid arthritis differ quite strikingly from those in non-rheumatoid subjects, it is confirmed again that a core of rheumatoid-arthritis patients (a core that can differ widely in size, it appears, in different populations 5), and also the majority of children with even active Still’s disease, remain obstinately seronegative by tests that use conformationally altered IgG molecules in one form or another as reactant. (Chemically cross-linked IgG, it appears from another report,6can give a different
picture.) But is conformationally altered IgG the true target at which R.F. antibodies are directed ? Purified R.F., it is reported, shows a selective affinity for antigenic determinants exposed only on polymeric (e.g., aggregated) forms of human IgG, a result that confirms the conclusion that its specificity is for similar determinants revealed by interaction of antibody IgG with antigen. That these determinants can be antigenically significant is demonstrated by analysis of anti-antibody produced in animals immunised against such complexes containing homologous antibody. On the other hand, purified 19S rheumatoid factor forms 22S complexes in the ultracentrifuge with 7S aggregate-free IgG, although it was reported too that these 22S complexes nevertheless precipitate with aggregated IgG as readily as free 19S R.F. Thus the question whether R.F. is antibody to native or altered IgG is still as far from being settled as ever. A puzzling new observation is that R.F.s may be found which show reactivity with trinitrophenyl hapten, and with denatured D.N.A., as well as with IgG. Is it possible that the reactivity OfR.F. with IgG is no more than a chance cross-reaction, and the true stimulus to its production is a distinctly different antigen, or, even more difficult to accept, that the IgM R.F. molecule can display a uniquely bispecific reactivity ? Anomalous specificity as the resultof R.F. complexing with IgG antibodiesis another explanation that needs to be excluded first. There is already good evidence that rheumatoid 4. 5. 6.
Christian, C. L. J. exp. Med. 1963, 18, 827. Greenwood, B. M. Ann. rheum. Dis. 1969, 28, 488. Torrigiani, G., Ansell, B. M., Chown, E. E. A., Roitt, p. 424.
7.
McCormick, J. N., Day, J. Lancet, 1963, ii,
554.
I. M. ibid.
joint fluids are low in complement,8 and that R.F. complexed with IgG, and IgG complexed with complement, are deposited in rheumatoid synovial membrane. 9, 10 Now it is reported that in patients with peripheral vasculitis serum-R.F. titres are higher and serum-complement levels lower than in those without vasculitis-all of which points to a role for immune complexes in rheumatoid disease. A highly relevant addition to knowledge of the biological activity of R.F. is the demonstration that, after all, its reaction with IgG can be complement-fixing, provided the complement is of human, not guineapig, origin. This would also account, at least in part, for the striking results from Philadelphia on the production of acute arthritis in previously unaffected joints of rheumatoid subjects by intra-articular injection of autologous isolated IgG." Especially interesting in this context is the finding of y-globulin complexes composed only of IgG in rheumatoid joint fluids, and the identification of rheumatoid factor of IgG class as a component of these complexes. The observation, now also reported, of a relationship between the amount of such IgG complexes present in a given joint fluid and the diminution in its total hasmolytic activity implies that the biological activity of rheumatoid factor most significantly related to the initiation of immune injury in the joint may be a property of the IgG rather than the IgM antiglobulin molecule.
BLACK DAY FOR THE GREEN-PAPER
The green-paper was grudgingly accepted by the B.M.A. Representative Body at a meeting on May 7 as a basis for discussion-but no more. There was a great deal of sympathy for a motion proposed by Dr. Ivor Jones, demanding that " an immediate and comprehensive inquiry into the financing of the N.H.S." should take place concurrently with any negotiations on the Second Green Paper ". However, Dr. Ronald Gibson, chairman of council, pointed out that, if the motion were accepted, representatives would have no chance of continuing discussion on the green-paper, should Mr. Crossman decide not to grant such a financial inquiry. Representatives, on the whole, recognised the wisdom of being constructive where conscience allowed, and defeated the motion. But conscience did not allow very much. Having expressed its support for the principle of integration, the meeting went on to disagree with practically all the green-paper’s detailed proposals. Its quarrels with the green-paper fell under three main heads: finance, centralisation, and representation. Dr. Jones’s motion was defeated, but the idea that nothing was wrong with the Health Service that more money could not put right was shared by many. A recommendation by council that the cost of reorganisation should be met "
Hedberg, H. Acta rheum. scand. 1963, 9, 165. Kinsella, T. D., Baum, J., Ziff, M. Clin. exp. Immun. 1969, 4, 265. Bonomo, L., Tursi, A., Trizio, D., Gillardi, U., Dammacco, F., Carlo Erba International Symposium on Immune Complexes, Spoleto, 1969. 11. Hollander, J. L., Rawson, A. J. Bull. rheum. Dis. 1968, 18, 502. 8. 9. 10.
1036
by funds additional to those at present provided for the N.H.S. was easily passed. On the other hand, a recommendation that funds for the hospital service should be separately earmarked led to a split between hospital and general-practice representatives. The hospital doctors were accused of wishing to hog all the money, and the general practitioners of opposing the process of unification. The sensible (if not particularly helpful) principle that money should be allocated by the area health authorities as needed was accepted, but the suggestion that they should be given some guidance in sorting out priorities was howled down as centralisation.
Centralisation, indeed, seemed to be the chief bogey, that the spectre of local government control no longer looms very large. A recommendation was therefore passed deploring the increased centralisation which the proposals in the green-paper will necessitate. Representatives also voted overwhelmingly in favour of giving executive power to the regional health councils, so interposing an effective tier between the Department and the area health authorities. It was also agreed that all medical and dental staff of registrar level and above should be employed by the regional health council. There was, in fact, considerable support for the belief that the area health authorities were a bad idea altogether. The argument was that they were both too large and too small in their scope, and that a district health board, centred on the district general hospital and responsible for 200,000-300,000 people, would be the " viable structure ". There would then be no possibility of alienating local voluntary help. Loud approval was voiced when it was suggested that the area health authorities had been invented simply to fit in with local-authority reorganisation. General practitioners were suspicious of the area health authorities, too, because, while their independent contractor status was guaranteed by the promised statutory committees, the green-paper contained no definition of the relationship between the area health authority and the statutory committee. A strong movement for recommending that the area health authorities should be under statutory obligation to consult the area medical committee was, however, defeated. now
Medical representation at all levels was the third rallying-point of the meeting. A recommendation was carried demanding that not less than one-third of the all new administrative authorities should be reserved for the medical profession, as opposed to the figure of one-third from all the health professions proposed in the green-paper. After some debate, it was granted that these representatives need not be " in active practice ", as there was general agreement that a retired doctor might be just as useful on a committee as a practising one. A further amendment was then passed allowing that half of all seats should be reserved for all the health professions. It was also decided that the proportion of one-third local-authority representation on area health authorities was excessive. This led to a further recommendation that " at both regional and area levels there should be a designated chief executive of each authority who must be medically qualified " and responsible to the authority and not the Department. This aroused the disapproval of those who beseats on
lieved that an administrator should be chosen for his administrative qualities, and need not be a doctor, but the majority wished to keep administration within the profession. However, a movement demanding that members of regional health councils be solely elected from members of area health authorities was defeated, because the meeting was persuaded that at regional level an independent viewpoint was essential. The meeting was also convinced that the Health Service should as far as possible be disentangled from local-government machinery. It decided that area health authorities need not be strictly coterminous with unitary areas where boundaries conflicted with expediency, adding that " catchment areas must not be rigidly enforced for individual patients ". A recommendation was passed asking that several services additional to those mentioned in the green-paper should be transferred from the local authority to the N.H.S. For a final touch to their vote of no-confidence in the green-paper, representatives decided that they could see no justification for the idea of a health commissioner. Mr. Crossman seems to be in for a tough time when he meets for discussions with B.M.A. representatives on June 9.
INFANT DEATHS
IN England and Wales infant mortality declined from 25-4 per 1000 live births in 1954 to 18.3 per 1000 in 1968. Most of this decrease was accounted for by reduction in neonatal mortality (from 17.7 to 12.4) and less by reduction in mortality at 1-12 months (from 7-7 to 5°9). Accordingly the Department of Health organised a three-year survey of three areas; and the report of this survey1 provides useful
guidelines. In the three areas there were some 120,000 live births, with 679 deaths in the postneonatal (1-12 months) period; and most of these deaths were in the first 6 months of life. 36% of the deaths were due primarily to respiratory disease; and the second commonest cause was congenital anomalies (24%). No fewer than 250 of the 679 were " cot deaths " or " sudden unexpected deaths " in which a child not known to be ill, or at most known to have a trifling illness, was found dead in its cot. Avoidable factors were deemed to be present in 187 instances (28%); and responsibility was rated as social in about a third, and parental in another third, and to lie with the general practitioner in a sixth, and with a hospital, local authority, or other source in the remainder. As regards avoidable factors attributed to parents: "
In some instances inadequacy, failure of appreciation of the situation and failure to summon medical aid, were associated with maternal immaturity-not necessarily related to the stated age. These three factors accounted for 69% per cent of the total of factors attributed to parents and it would seem that there is scope for increased endeavours to teach the elements of child health to mothers and potential mothers ..."
The
commonest
1. Confidential
avoidable factors attributed
to
Enquiry into Postneonatal Deaths, 1964-66. Rep. publ. Hlth med. Subj., Lond., no. 125. H.M. Stationery Office. 6s. 6d. (32½ p.)
has shown 4-that such seropositivity probably represents in the main a response to immunisation through the agency of infection, especially some chronic infections. Although diseases of the reticuloendothelial system (which includes the immune system) that are associated with hypergammaglobulinaemia or macroglobuImaEmia can produce antiglobulins, the principal stimulus to R.F. production in rheumatoid and in most non-rheumatoid seropositive subjects alike still seems most likely to be IgG antibody complexed with antigen ; although what this antigen may be in rheumatoid arthritis remains for most workers a mystery. Yet although the reaction patterns and levels of seropositivity in rheumatoid arthritis differ quite strikingly from those in non-rheumatoid subjects, it is confirmed again that a core of rheumatoid-arthritis patients (a core that can differ widely in size, it appears, in different populations 5), and also the majority of children with even active Still’s disease, remain obstinately seronegative by tests that use conformationally altered IgG molecules in one form or another as reactant. (Chemically cross-linked IgG, it appears from another report,6can give a different
picture.) But is conformationally altered IgG the true target at which R.F. antibodies are directed ? Purified R.F., it is reported, shows a selective affinity for antigenic determinants exposed only on polymeric (e.g., aggregated) forms of human IgG, a result that confirms the conclusion that its specificity is for similar determinants revealed by interaction of antibody IgG with antigen. That these determinants can be antigenically significant is demonstrated by analysis of anti-antibody produced in animals immunised against such complexes containing homologous antibody. On the other hand, purified 19S rheumatoid factor forms 22S complexes in the ultracentrifuge with 7S aggregate-free IgG, although it was reported too that these 22S complexes nevertheless precipitate with aggregated IgG as readily as free 19S R.F. Thus the question whether R.F. is antibody to native or altered IgG is still as far from being settled as ever. A puzzling new observation is that R.F.s may be found which show reactivity with trinitrophenyl hapten, and with denatured D.N.A., as well as with IgG. Is it possible that the reactivity OfR.F. with IgG is no more than a chance cross-reaction, and the true stimulus to its production is a distinctly different antigen, or, even more difficult to accept, that the IgM R.F. molecule can display a uniquely bispecific reactivity ? Anomalous specificity as the resultof R.F. complexing with IgG antibodiesis another explanation that needs to be excluded first. There is already good evidence that rheumatoid 4. 5. 6.
Christian, C. L. J. exp. Med. 1963, 18, 827. Greenwood, B. M. Ann. rheum. Dis. 1969, 28, 488. Torrigiani, G., Ansell, B. M., Chown, E. E. A., Roitt, p. 424.
7.
McCormick, J. N., Day, J. Lancet, 1963, ii,
554.
I. M. ibid.
joint fluids are low in complement,8 and that R.F. complexed with IgG, and IgG complexed with complement, are deposited in rheumatoid synovial membrane. 9, 10 Now it is reported that in patients with peripheral vasculitis serum-R.F. titres are higher and serum-complement levels lower than in those without vasculitis-all of which points to a role for immune complexes in rheumatoid disease. A highly relevant addition to knowledge of the biological activity of R.F. is the demonstration that, after all, its reaction with IgG can be complement-fixing, provided the complement is of human, not guineapig, origin. This would also account, at least in part, for the striking results from Philadelphia on the production of acute arthritis in previously unaffected joints of rheumatoid subjects by intra-articular injection of autologous isolated IgG." Especially interesting in this context is the finding of y-globulin complexes composed only of IgG in rheumatoid joint fluids, and the identification of rheumatoid factor of IgG class as a component of these complexes. The observation, now also reported, of a relationship between the amount of such IgG complexes present in a given joint fluid and the diminution in its total hasmolytic activity implies that the biological activity of rheumatoid factor most significantly related to the initiation of immune injury in the joint may be a property of the IgG rather than the IgM antiglobulin molecule.
BLACK DAY FOR THE GREEN-PAPER
The green-paper was grudgingly accepted by the B.M.A. Representative Body at a meeting on May 7 as a basis for discussion-but no more. There was a great deal of sympathy for a motion proposed by Dr. Ivor Jones, demanding that " an immediate and comprehensive inquiry into the financing of the N.H.S." should take place concurrently with any negotiations on the Second Green Paper ". However, Dr. Ronald Gibson, chairman of council, pointed out that, if the motion were accepted, representatives would have no chance of continuing discussion on the green-paper, should Mr. Crossman decide not to grant such a financial inquiry. Representatives, on the whole, recognised the wisdom of being constructive where conscience allowed, and defeated the motion. But conscience did not allow very much. Having expressed its support for the principle of integration, the meeting went on to disagree with practically all the green-paper’s detailed proposals. Its quarrels with the green-paper fell under three main heads: finance, centralisation, and representation. Dr. Jones’s motion was defeated, but the idea that nothing was wrong with the Health Service that more money could not put right was shared by many. A recommendation by council that the cost of reorganisation should be met "
Hedberg, H. Acta rheum. scand. 1963, 9, 165. Kinsella, T. D., Baum, J., Ziff, M. Clin. exp. Immun. 1969, 4, 265. Bonomo, L., Tursi, A., Trizio, D., Gillardi, U., Dammacco, F., Carlo Erba International Symposium on Immune Complexes, Spoleto, 1969. 11. Hollander, J. L., Rawson, A. J. Bull. rheum. Dis. 1968, 18, 502. 8. 9. 10.
1036
by funds additional to those at present provided for the N.H.S. was easily passed. On the other hand, a recommendation that funds for the hospital service should be separately earmarked led to a split between hospital and general-practice representatives. The hospital doctors were accused of wishing to hog all the money, and the general practitioners of opposing the process of unification. The sensible (if not particularly helpful) principle that money should be allocated by the area health authorities as needed was accepted, but the suggestion that they should be given some guidance in sorting out priorities was howled down as centralisation.
Centralisation, indeed, seemed to be the chief bogey, that the spectre of local government control no longer looms very large. A recommendation was therefore passed deploring the increased centralisation which the proposals in the green-paper will necessitate. Representatives also voted overwhelmingly in favour of giving executive power to the regional health councils, so interposing an effective tier between the Department and the area health authorities. It was also agreed that all medical and dental staff of registrar level and above should be employed by the regional health council. There was, in fact, considerable support for the belief that the area health authorities were a bad idea altogether. The argument was that they were both too large and too small in their scope, and that a district health board, centred on the district general hospital and responsible for 200,000-300,000 people, would be the " viable structure ". There would then be no possibility of alienating local voluntary help. Loud approval was voiced when it was suggested that the area health authorities had been invented simply to fit in with local-authority reorganisation. General practitioners were suspicious of the area health authorities, too, because, while their independent contractor status was guaranteed by the promised statutory committees, the green-paper contained no definition of the relationship between the area health authority and the statutory committee. A strong movement for recommending that the area health authorities should be under statutory obligation to consult the area medical committee was, however, defeated. now
Medical representation at all levels was the third rallying-point of the meeting. A recommendation was carried demanding that not less than one-third of the all new administrative authorities should be reserved for the medical profession, as opposed to the figure of one-third from all the health professions proposed in the green-paper. After some debate, it was granted that these representatives need not be " in active practice ", as there was general agreement that a retired doctor might be just as useful on a committee as a practising one. A further amendment was then passed allowing that half of all seats should be reserved for all the health professions. It was also decided that the proportion of one-third local-authority representation on area health authorities was excessive. This led to a further recommendation that " at both regional and area levels there should be a designated chief executive of each authority who must be medically qualified " and responsible to the authority and not the Department. This aroused the disapproval of those who beseats on
lieved that an administrator should be chosen for his administrative qualities, and need not be a doctor, but the majority wished to keep administration within the profession. However, a movement demanding that members of regional health councils be solely elected from members of area health authorities was defeated, because the meeting was persuaded that at regional level an independent viewpoint was essential. The meeting was also convinced that the Health Service should as far as possible be disentangled from local-government machinery. It decided that area health authorities need not be strictly coterminous with unitary areas where boundaries conflicted with expediency, adding that " catchment areas must not be rigidly enforced for individual patients ". A recommendation was passed asking that several services additional to those mentioned in the green-paper should be transferred from the local authority to the N.H.S. For a final touch to their vote of no-confidence in the green-paper, representatives decided that they could see no justification for the idea of a health commissioner. Mr. Crossman seems to be in for a tough time when he meets for discussions with B.M.A. representatives on June 9.
INFANT DEATHS
IN England and Wales infant mortality declined from 25-4 per 1000 live births in 1954 to 18.3 per 1000 in 1968. Most of this decrease was accounted for by reduction in neonatal mortality (from 17.7 to 12.4) and less by reduction in mortality at 1-12 months (from 7-7 to 5°9). Accordingly the Department of Health organised a three-year survey of three areas; and the report of this survey1 provides useful
guidelines. In the three areas there were some 120,000 live births, with 679 deaths in the postneonatal (1-12 months) period; and most of these deaths were in the first 6 months of life. 36% of the deaths were due primarily to respiratory disease; and the second commonest cause was congenital anomalies (24%). No fewer than 250 of the 679 were " cot deaths " or " sudden unexpected deaths " in which a child not known to be ill, or at most known to have a trifling illness, was found dead in its cot. Avoidable factors were deemed to be present in 187 instances (28%); and responsibility was rated as social in about a third, and parental in another third, and to lie with the general practitioner in a sixth, and with a hospital, local authority, or other source in the remainder. As regards avoidable factors attributed to parents: "
In some instances inadequacy, failure of appreciation of the situation and failure to summon medical aid, were associated with maternal immaturity-not necessarily related to the stated age. These three factors accounted for 69% per cent of the total of factors attributed to parents and it would seem that there is scope for increased endeavours to teach the elements of child health to mothers and potential mothers ..."
The
commonest
1. Confidential
avoidable factors attributed
to
Enquiry into Postneonatal Deaths, 1964-66. Rep. publ. Hlth med. Subj., Lond., no. 125. H.M. Stationery Office. 6s. 6d. (32½ p.)