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FATAL VARICELLA IN AN ADULT
1097 AFRICAN TRAINED SiR,ņThe medical student in Africa is no different from his counterpart elsewhere when it comes to vocational preferences. He is motivated by a desire to be a clinician, and for preference a specialist clinician. It is also a fact of life in Africa that not only is there a desperate shortage of doctors but even more importantly, for the present, there is a geographic maldistribution. So that whereas a country may have an average physician: population ratio of 1:10,000, in fact the larger urban areas may be nearly adequately serviced in terms of this ratio, while the rural areas are grossly undersupplied, having an average ratio of 1 : 50,000 or worse. 60-85 % of the physicians of a country may be found in the capital city which accounts for a mere 10-25% of the national population. Unless these factors are to be corrected there is little point in your insisting (April 16) that " preventive medicine ... must take first place " in the medical student’s curriculum. The town general practitioner and the specialist are little concerned with rural areas-where the inertia and the need exist. If only 10-15% of physicians are eventually to serve in rural areas why must all students undergo instruction in rural medicine ? Medical education must be related to the future career of the majority. Alternatively, if preventive medicine is to occupy such a prominent place in the undergraduate curriculum then national planning should insist that the products of such training are properly utilised. By this I mean that by a combination of coercion and inducement the balance between urban and rural areas should be corrected. Medical education and health services need to be directly related. I have referred before to the need to define the purpose of the physician and of medical education. Is the physician’s role limited to the physicianpatient contract, or has he a physician-society responsibility as well ? Should he not hold the balance between curative and preventive medicine on the one hand and the individual and society on the other ? But before such a decision (i.e., to send or attract doctors to rural areas) is made the implications must be clear. The main reason in my opinion for urban/rural imbalance is that the doctor is being " educated to dissatisfaction " with the medical and health facilities that the public services can afford to provide. He is unable to put his learning to total advantage because of lack of facilities. Hospitals, laboratories, X-rays, pharmaceutical supplies, vaccines, personnel, and intellectual companionship are all inadequate, and he suffers from a grave lack of job satisfaction. Correct this and the doctor may be attracted to the rural area; but the correction will be costly. Can the public-health services afford this ? A physicianmanned service means a physician’s standard of service. Until this can be afforded a few dedicated physicians working through many auxiliaries is a more realistic approach. The need for a more intimate relation between health planners and health educators is patently obvious. While present conditions appertain preventive medicine might be better taught at postgraduate level to those who elect to join public service and serve in rural areas. If rotating internships were obligatory a three-months practical course for a certificate of public health could be elective. Those who finally decide on a career in public health could, after a minimum of two years’ field practice, return to academic life to complete the diploma in public health. Preaching to the converted is much more realistic than preaching to the unconverted.. Whatever the decision on undergraduate or postgraduate teaching of rural medicine, at least there should be coordination of education with health service. I would also question what is meant by preventive medicine ". What needs to be taught is how to practice medicine in a rural setting-and only a part of this is preventive medicine. Managerial medicine is the most important-how to make the best of the limited resources of staff, money, and facilities in the face of excessive demand. Next comes vocational skillsparticularly in obstetrics and emergency surgery. Medical education must stress child disease and maternity: 50% of the population are children and the birth-rates are high. The "
1.
Fendall,
N. R. E.
Lancet, 1964, ii,
961.
common diseases, not the esoteric, are the important ones. Mental disease and mental health is another underemphasised aspect that is important. I would classify all this under rural medicine rather than preventive medicine. Health services grow out of the attempt to provide total individual medical care. This is what the individual family wants. Preventive medicine is part of rural medicine-not the whole. Moreover, a medical student will not learn this nearly as well by being taught it as a separate subject as he will if it pervades the whole of medical education. The prime function of the department of preventive medicine is to see that other departmental faculties are converted to this outlook, so that it permeates their teaching. Infiltration, not separatism, is the key. Much of this has already been accomplished. The pxdiatrics department in Makerere and the department of medicine, Ibadan, are examples of how to teach to rural-medicine requirements. Moreover, the teaching must be by the exponents of rural medicine as well as by the proponents. Finally, the physician in Africa, not merely the teachers of medicine, must be taught the methods of education, for every physician has to be an educator. Ignorance as well as poverty is at the root of ill health. Promotive medicine is an essential constituent of every physician’s " black bag ". To summarise, comparability of standards of medical education does not mean uniformity of content of curriculum. And if only a minority of students are eventually to practise in rural areas under the present adverse circumstances, then it is cogent to consider whether the whole undergraduate education programme should be changed merely to meet the needs of a few. Or would it not be preferable to postpone instruction, in what after all may be defined as a specialist field (rural medicine) for the few, to the Dostsraduate period ? The Rockefeller Foundation, 111 West 50th Street, N. R. E. FENDALL. New York, New York 10020.
FATAL VARICELLA IN AN ADULT SIR,-The conclusion of Dr. Bagdade and Dr. Melman (April 16) that " corticosteroids are probably contraindicated in the treatment of disseminated varicella " is based on a selected review of published reports and their single fatal case-an adult patient with Down’s syndrome who already had hsmorrhagic varicella with subarachnoid bleeding before steroid therapy in unspecified dosage was given. For such a fulminating attack in a subnormal subject they may be right, although they do not append any alternative therapeutic suggestions. But there is now a risk that steroids may be withheld in severe varicella pneumonia affecting previously fit adults. This carries an acknowledged mortality, as Fish1 and others have shown. Having seen four patients with this serious condition, I am convinced that steroids can be lifesaving when the clinical battle is being lost. Two of my patients were gravely ill despite oxygen, antibiotics, analeptics, and full supportive measures; the emergency use of systemic hydrocortisone in therapeutic doses2 produced dramatic response in both, with subsequent complete recovery. The effects were very similar to those seen3 in severe pandemic influenzal pneumonia. To recall that all four patients reported by Fish died without receiving steroid therapy4 is to conclude that there is really very little to lose, and possibly much to gain, by the use of adrenal steroids in these desperate circumstances. Varicella affecting patients who are being maintained on long-term steroids for some morbid condition is another problem. Unfortunate experiences in those circumstances should not influence the decision to use these drugs in an urgent therapeutic role during the course of severe varicella pneumonia in an otherwise fit subject. Taunton Isolation and Chest Hospital, Somerset.
J. P. ANDERSON.
1. Fish, S. A. J. Am. med. Ass. 1960, 173, 978. 2. Breen, G. E., Talukdar, P. K. Lancet, 1965, 3. Rotem, C. E. ibid. 1957, ii, 948. 4. Fish, S. A. Personal communication.
i,
158.
1.
Fendall,
N. R. E.
Lancet, 1964, ii,
961.
common diseases, not the esoteric, are the important ones. Mental disease and mental health is another underemphasised aspect that is important. I would classify all this under rural medicine rather than preventive medicine. Health services grow out of the attempt to provide total individual medical care. This is what the individual family wants. Preventive medicine is part of rural medicine-not the whole. Moreover, a medical student will not learn this nearly as well by being taught it as a separate subject as he will if it pervades the whole of medical education. The prime function of the department of preventive medicine is to see that other departmental faculties are converted to this outlook, so that it permeates their teaching. Infiltration, not separatism, is the key. Much of this has already been accomplished. The pxdiatrics department in Makerere and the department of medicine, Ibadan, are examples of how to teach to rural-medicine requirements. Moreover, the teaching must be by the exponents of rural medicine as well as by the proponents. Finally, the physician in Africa, not merely the teachers of medicine, must be taught the methods of education, for every physician has to be an educator. Ignorance as well as poverty is at the root of ill health. Promotive medicine is an essential constituent of every physician’s " black bag ". To summarise, comparability of standards of medical education does not mean uniformity of content of curriculum. And if only a minority of students are eventually to practise in rural areas under the present adverse circumstances, then it is cogent to consider whether the whole undergraduate education programme should be changed merely to meet the needs of a few. Or would it not be preferable to postpone instruction, in what after all may be defined as a specialist field (rural medicine) for the few, to the Dostsraduate period ? The Rockefeller Foundation, 111 West 50th Street, N. R. E. FENDALL. New York, New York 10020.
FATAL VARICELLA IN AN ADULT SIR,-The conclusion of Dr. Bagdade and Dr. Melman (April 16) that " corticosteroids are probably contraindicated in the treatment of disseminated varicella " is based on a selected review of published reports and their single fatal case-an adult patient with Down’s syndrome who already had hsmorrhagic varicella with subarachnoid bleeding before steroid therapy in unspecified dosage was given. For such a fulminating attack in a subnormal subject they may be right, although they do not append any alternative therapeutic suggestions. But there is now a risk that steroids may be withheld in severe varicella pneumonia affecting previously fit adults. This carries an acknowledged mortality, as Fish1 and others have shown. Having seen four patients with this serious condition, I am convinced that steroids can be lifesaving when the clinical battle is being lost. Two of my patients were gravely ill despite oxygen, antibiotics, analeptics, and full supportive measures; the emergency use of systemic hydrocortisone in therapeutic doses2 produced dramatic response in both, with subsequent complete recovery. The effects were very similar to those seen3 in severe pandemic influenzal pneumonia. To recall that all four patients reported by Fish died without receiving steroid therapy4 is to conclude that there is really very little to lose, and possibly much to gain, by the use of adrenal steroids in these desperate circumstances. Varicella affecting patients who are being maintained on long-term steroids for some morbid condition is another problem. Unfortunate experiences in those circumstances should not influence the decision to use these drugs in an urgent therapeutic role during the course of severe varicella pneumonia in an otherwise fit subject. Taunton Isolation and Chest Hospital, Somerset.
J. P. ANDERSON.
1. Fish, S. A. J. Am. med. Ass. 1960, 173, 978. 2. Breen, G. E., Talukdar, P. K. Lancet, 1965, 3. Rotem, C. E. ibid. 1957, ii, 948. 4. Fish, S. A. Personal communication.
i,
158.