- Email: [email protected]
EPIDEMIOLOGY AND THE CLINICIAN
154 or in conjunction with other specialists. Some specialist physicians do have expertise in the immunopathology of their system of interest but this is by no means universal and is often limited to research departments. Perhaps this reflects the lack of a clinical approach to immunology in undergraduate and postgraduate training in many medical schools,
fundamental role either alone
which is itself
immunologists
a
in
strong argument for the presence of clinical at least.
teaching hospitals
Department of Medicine, Clinical Sciences Centre, Northern General Hospital, Sheffield S5 7AU
MARTYN A. H. FRENCH
EPIDEMIOLOGY AND THE CLINICIAN
StR,—The letters from Dr Cole (July 4, p. 45) and Dr Meade (May 30, p. 1214) in response to a statement from my predecessor Sir John Brotherston (April 11, p. 839) make it clear that there is some fundamental misunderstanding concerning epidemiology and the clinician. Dr Cole complains of "the meagre opportunities open to potential medical epidemiologists" while Sir John expresses satisfaction with the range and variety of current opportunities both for training and for practice. Some clues to the source of the confusion occur in both Dr Meade’s and Dr Cole’s letters when they use such phrases as "the uses of epidemiology" and "technical training in epidemiological method". Professional epidemiologists view their discipline as a science and not merely a method or technique. Indeed, the methods of epidemiology are eclectically derived from various other population sciences and are mostly simple to learn and use. A science must be characterised by its domain of inquiry and theoretical constructs rather than its methods. Epidemiology is classically the science that seeks to provide an understanding of the health of human communities principally to furnish the basis of public health action in pursuit of the improvement of community health. The professional practice identified with this action is now called community medicine. A minimum training requirement for the professional practice of epidemiology is represented by the syllabus of the M.F.C.M. examination which tests the basic knowledge and understanding in its part 1 and offers the opportunity to demonstrate a practical grasp of epidemiology in its part 2. The part 1 syllabus has recently been reformulated and will shortly be published by the Faculty of Community Medicine. The Faculty of Community Medicine, and indeed professional epidemiologists generally, acknowledge the significant contributions that have been made both to epidemiology and to the practice of community medicine by clinicians in a wide variety of specialties. To some extent all thoughtful doctors are community
physicians and a great deal of medical research has epidemiological relevance. The Faculty is particularly anxious to promote a wider pursuit of epidemiological research and a more general involvement of all doctors in the practice of community medicine. But no really useful purpose will be served by dismissing epidemiology as a set of techniques that may be turned to almost any use. If clinicians aspire to the title of epidemiologist they must acquire much more than an expertise in survey techniques. Faculty of Community Medicine, 28 Portland Place. London W 1N4DE
ALWYN SMITH
PUTATIVE MARKERS IN NON-A, NON-B HEPATITIS RESEARCH
SIR,-We
were
surprised by
Dr Eddleston and his
colleagues’
(May 2, p. 1000) of our letter (April 25, p. 946) in which we compared our findings with those of Dr Suh, Dr Eddleston and criticisms
colleagues (Jan. 24, p. 178). We were not refuting Suh’s findings but interesting that his chromatographic data fit our interpretation of what could be putative antibody and putative antigen better than his own data do. The identity and similar (independently arrived at) interpretation of the serum marker in question and markers being studied in at least three other laboratories (Shirachi’s,l L. Overby’s r unpublished!, and Vitviski’s-’) as compared with the opposite interpretation indicated by Suh et al. 3-5 merely confirms that a controversy, however inconvenient, exists. A similar conflict of interpretation relating toa (? similar) putative non-A, non-B marker studied in the United States was referred to at the International Viral Hepatitis
do find it
Symposium in New York, in April. Our finding of a predominance of putative antibody in haemo. philiacs is in keeping with evidence of exposure to hepatitis B virus (HBV), while the presence of a more or less equal occurrence of putative antibody and putative antigen in the acute disease is analogous to the situation relating to the "e" system of HBV. We can only repeat that, in many aspects of this most intriguing agree with Suh
al. and, like them, cannot define its What is needed now is further collaboration between interested groups. We hope that Eddleston et al. will be heartened to know that our other (particulate) putative marker seems to be better versed in the "basic immunological laws", as evidenced by the stimulation of IgM and IgG responses in the host. We are now investigating the specificity of this particulate marker for non-A, non-B hepatitis.
marker,
we
exact nature or
et
significance.
South-East of Scotland Blood Transfusion Service,
Royal Infirmary. Edinburgh EH3 9HB
R. HOPKINS A. E. ROBERTSON G. HAASE
Infectious Diseases Unit.
R. BRETTLE
City Hospital, Edinburgh Regional Virus Laboratory, Ninewells
Hospital, Dundee
D. GREEN
Virus
Laboratory, Bacteriology Department, University Medical School,
Aberdeen
T. BROWN
DEBENDOX IN PREGNANCY
SIR,-At face value Professor Clarke and Mr Clayton’s figures (March 21, p. 659) for the reported use of’Debendox’ (dicyclomine, doxylamine, plus pyridoxine) by Leicestershire women whose babies died in the perinatal period seem to show that the drug is safe. We believe that debendox is a low-grade teratogen probably affecting around 5 in every 1000 births when the drug has been taken before the eighth week of pregnancy. If a drug is responsible for malformations these will arise at this very early stage in pregnancy, and surely this is the period on which epidemiologists should focus. However, many studies include large numbers of women from well outside this period, as late as the fourth or fifth month, and can have little chance of detecting low to medium grade
CIVIL DEFENCE AND NUCLEAR ATTACK
SIR,-Dr Holdstock (July 4, p. 44) says "Unfortunately, civil defence may even increase the risk of nuclear attack". Why, then, does the Soviet Union have the most comprehensive civil defence programme in the world and why do the Swiss and the Swedes, neither of whom even have (or want) nuclear weapons, have highly comprehensive civil defence programmes which protect the vast majoritv of their population ?
1 Shirachi R, Shiriashi H, Tateda A, Kikuchi K, Ishida N. Hepatitis "C" antigen in non A, non B post-transfusion hepatitis. Lancet 1978; ii: 853-56. 2. Vitvitski L, Trepo C, Prince AM, Brotman B. Detection of virus-associated antigen in serum and liver of patients with non A, non B hepatitis. Lancet 1979, ii 1263-67 3. Prince AM, Brotman B, Van Der Ende MC, Richardson L, Kellnor A non A, non B hepatitis Identification of a virus specific antigen and antibody, a preliminary report. In Vigas GN, Cohen SN, Schmidt R, eds Viral hepatitis. Philadelphia Franklin Press, 1978 419-21. 4. Tabor E, Mitchell ED, Goudeau AM. Gere’y RJ Detection of an antigen-antibody system in serum associated with human non A, non B hepatitis J Med Virol 1979, 4:
Monthly, Protect& Survive 80 Fleet Street London EC4Y 1EL
161-69. 5. Alter HJ, Purcell
ALASTAIR WATTS
RH, Holland PV, Popper H Transmissible agent in non B hepatitis
Lancet 1978; i 459-63
fundamental role either alone
which is itself
immunologists
a
in
strong argument for the presence of clinical at least.
teaching hospitals
Department of Medicine, Clinical Sciences Centre, Northern General Hospital, Sheffield S5 7AU
MARTYN A. H. FRENCH
EPIDEMIOLOGY AND THE CLINICIAN
StR,—The letters from Dr Cole (July 4, p. 45) and Dr Meade (May 30, p. 1214) in response to a statement from my predecessor Sir John Brotherston (April 11, p. 839) make it clear that there is some fundamental misunderstanding concerning epidemiology and the clinician. Dr Cole complains of "the meagre opportunities open to potential medical epidemiologists" while Sir John expresses satisfaction with the range and variety of current opportunities both for training and for practice. Some clues to the source of the confusion occur in both Dr Meade’s and Dr Cole’s letters when they use such phrases as "the uses of epidemiology" and "technical training in epidemiological method". Professional epidemiologists view their discipline as a science and not merely a method or technique. Indeed, the methods of epidemiology are eclectically derived from various other population sciences and are mostly simple to learn and use. A science must be characterised by its domain of inquiry and theoretical constructs rather than its methods. Epidemiology is classically the science that seeks to provide an understanding of the health of human communities principally to furnish the basis of public health action in pursuit of the improvement of community health. The professional practice identified with this action is now called community medicine. A minimum training requirement for the professional practice of epidemiology is represented by the syllabus of the M.F.C.M. examination which tests the basic knowledge and understanding in its part 1 and offers the opportunity to demonstrate a practical grasp of epidemiology in its part 2. The part 1 syllabus has recently been reformulated and will shortly be published by the Faculty of Community Medicine. The Faculty of Community Medicine, and indeed professional epidemiologists generally, acknowledge the significant contributions that have been made both to epidemiology and to the practice of community medicine by clinicians in a wide variety of specialties. To some extent all thoughtful doctors are community
physicians and a great deal of medical research has epidemiological relevance. The Faculty is particularly anxious to promote a wider pursuit of epidemiological research and a more general involvement of all doctors in the practice of community medicine. But no really useful purpose will be served by dismissing epidemiology as a set of techniques that may be turned to almost any use. If clinicians aspire to the title of epidemiologist they must acquire much more than an expertise in survey techniques. Faculty of Community Medicine, 28 Portland Place. London W 1N4DE
ALWYN SMITH
PUTATIVE MARKERS IN NON-A, NON-B HEPATITIS RESEARCH
SIR,-We
were
surprised by
Dr Eddleston and his
colleagues’
(May 2, p. 1000) of our letter (April 25, p. 946) in which we compared our findings with those of Dr Suh, Dr Eddleston and criticisms
colleagues (Jan. 24, p. 178). We were not refuting Suh’s findings but interesting that his chromatographic data fit our interpretation of what could be putative antibody and putative antigen better than his own data do. The identity and similar (independently arrived at) interpretation of the serum marker in question and markers being studied in at least three other laboratories (Shirachi’s,l L. Overby’s r unpublished!, and Vitviski’s-’) as compared with the opposite interpretation indicated by Suh et al. 3-5 merely confirms that a controversy, however inconvenient, exists. A similar conflict of interpretation relating toa (? similar) putative non-A, non-B marker studied in the United States was referred to at the International Viral Hepatitis
do find it
Symposium in New York, in April. Our finding of a predominance of putative antibody in haemo. philiacs is in keeping with evidence of exposure to hepatitis B virus (HBV), while the presence of a more or less equal occurrence of putative antibody and putative antigen in the acute disease is analogous to the situation relating to the "e" system of HBV. We can only repeat that, in many aspects of this most intriguing agree with Suh
al. and, like them, cannot define its What is needed now is further collaboration between interested groups. We hope that Eddleston et al. will be heartened to know that our other (particulate) putative marker seems to be better versed in the "basic immunological laws", as evidenced by the stimulation of IgM and IgG responses in the host. We are now investigating the specificity of this particulate marker for non-A, non-B hepatitis.
marker,
we
exact nature or
et
significance.
South-East of Scotland Blood Transfusion Service,
Royal Infirmary. Edinburgh EH3 9HB
R. HOPKINS A. E. ROBERTSON G. HAASE
Infectious Diseases Unit.
R. BRETTLE
City Hospital, Edinburgh Regional Virus Laboratory, Ninewells
Hospital, Dundee
D. GREEN
Virus
Laboratory, Bacteriology Department, University Medical School,
Aberdeen
T. BROWN
DEBENDOX IN PREGNANCY
SIR,-At face value Professor Clarke and Mr Clayton’s figures (March 21, p. 659) for the reported use of’Debendox’ (dicyclomine, doxylamine, plus pyridoxine) by Leicestershire women whose babies died in the perinatal period seem to show that the drug is safe. We believe that debendox is a low-grade teratogen probably affecting around 5 in every 1000 births when the drug has been taken before the eighth week of pregnancy. If a drug is responsible for malformations these will arise at this very early stage in pregnancy, and surely this is the period on which epidemiologists should focus. However, many studies include large numbers of women from well outside this period, as late as the fourth or fifth month, and can have little chance of detecting low to medium grade
CIVIL DEFENCE AND NUCLEAR ATTACK
SIR,-Dr Holdstock (July 4, p. 44) says "Unfortunately, civil defence may even increase the risk of nuclear attack". Why, then, does the Soviet Union have the most comprehensive civil defence programme in the world and why do the Swiss and the Swedes, neither of whom even have (or want) nuclear weapons, have highly comprehensive civil defence programmes which protect the vast majoritv of their population ?
1 Shirachi R, Shiriashi H, Tateda A, Kikuchi K, Ishida N. Hepatitis "C" antigen in non A, non B post-transfusion hepatitis. Lancet 1978; ii: 853-56. 2. Vitvitski L, Trepo C, Prince AM, Brotman B. Detection of virus-associated antigen in serum and liver of patients with non A, non B hepatitis. Lancet 1979, ii 1263-67 3. Prince AM, Brotman B, Van Der Ende MC, Richardson L, Kellnor A non A, non B hepatitis Identification of a virus specific antigen and antibody, a preliminary report. In Vigas GN, Cohen SN, Schmidt R, eds Viral hepatitis. Philadelphia Franklin Press, 1978 419-21. 4. Tabor E, Mitchell ED, Goudeau AM. Gere’y RJ Detection of an antigen-antibody system in serum associated with human non A, non B hepatitis J Med Virol 1979, 4:
Monthly, Protect& Survive 80 Fleet Street London EC4Y 1EL
161-69. 5. Alter HJ, Purcell
ALASTAIR WATTS
RH, Holland PV, Popper H Transmissible agent in non B hepatitis
Lancet 1978; i 459-63