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MATERNITY SERVICE
663 MATERNITY SERVICE SiR,-In your review (Aug. 1, p. 252) of the recent report on domiciliary midwifery and matemity,bed needs one fundamental issue was not discussed-namely, whether the membership of the committee was appropriate. I wish to raise this issue now. There were eight members of the committee, including the chairman. Of this number, only two were women, and only one of the women is married. The latter is described in the published list of the membership of the committee as being President of the Royal College of Midwives. The implication is, therefore, that she was a member of the committee in her professional capacity and not as a married woman with children. In addition, her profession in effect precludes her from being a spokesman for the " average woman ". The curious situation arises, therefore, that not one member of the committee was appointed to represent the consumer viewpoint. Futhermore, there is a list of organisations in the report from which evidence was invited. This list includes, quite properly, all the relevant learned bodies and administrative authorities. But there is no mention of evidence being received or invited from any women’s organisations at all. Yet this is the only branch of medicine exclusively serving women.
Nor is this the only drawback to the committee membership. There was only one general-practitioner member. Any suggestion he might have wished to make which would be inconvenient to obstetricians could be outvoted immediately by the three distinguished obstetricians on the committee. If the suggestion was also administratively difficult, the two medical administrators could also vote it down. For example, one of the recommendations was that each patient should see a consultant obstetrician twice during her pregnancy at his clinic, but that other routine antenatal visits could be to see her general practitioner at his surgery. Now there is no inherent reason why the obstetrician should not see the patients at the general practitioner’s surgery. This would be easier for the patients, and would do much for general practitioner/specialist integration. On the other hand, it would be administratively inefficient, and tiresome for the obstetricians. Can we really believe that one general practitioner on the committee could sway three obstetricians and two administrators ? My wish is not to criticise the members of this committee, nor to imply that they reached any wrong decisions. But I do suggest that a committee constituted as this one can never keep in touch with its public. Nor can it ever produce a new approach to a problem, since it has a majority potentially committed to maintaining the existing arrangements.
C. P. TREVES BROWN.
MEDICAL CARE IN THE UNITED STATES SIR,—I have been in East and Central Africa studying medical-care services since Professor Holland’s paper (July 25, p. 202) appeared. Now I have returned I am not surprised at the xenophobic and nationalistic response that his views have received. No-one who is working happily in a country that he loves is keen to have criticisms levelled at its system of medical care. The United States of America is still a relatively young and developing nation, sensitive of comment and criticism. However, it is always good for a system to be analysed and commented upon by an expert. I agree with all of Professor Holland’s comments, but I would make the point that no system of medical care is
perfect and all
are faced with common problems. In a book1 and in an analytical factual comparison of medical services in U.S.A., U.S.S.R., and the United King-
recent
1.
Fry, J. Medicine in Three Societies. Aylesbury,
1970.
dom, I find that many of the problems delineated by Professor Holland are also found in the other two nations. My recent visit to Africa has confirmed my belief that we There is an insoluble are all facing similar challenges. equation in medical care." No nation can ever match " wants ", " needs ", and resources ". We are therefore all faced with the challenge of maximum utilisation of our available resources. This applies equally to United States with one physician to 800 persons as to Tanzania with one
physician to 22,000. There is, of course, no single " best-buy " system of medical care, and it is sad to read the mud-slinging of your correspondents at the British and American systems. Each is evolving a system to match its historical and cultural backgrounds. What the Americans are trying to do is to decide how they can provide a system that will be equal as well as being excellent. We wish them luck. They will, however, be able to achieve one only if they define their problems and heed advice and comments of observers such as Professor Holland. JOHN FRY.
FETOPROTEIN IN PREGNANT AFRICAN WOMEN and Dr. Zuckerman (Aug. 29, p. 465) SIR Dr. Alpert report complete absence of a-fetoprotein (A.F.P.) in women between 6 and 40 weeks pregnant. Their findings parallel those of workers in Europe1 but are in sharp contrast to those of others in the U.S.S.R. and South Africa and ourselves in Nairobi. Tatarinov2 found A.F.P. in the serum of women after spontaneous abortion, and Abelev 3 finds 100% O’Conor et al.4 positivity in women over 15 weeks pregnant. also cite similar findings in South Africa.’*Ó The reason for these differences is obscure. We said 8 that it was odd that all pregnant women should not have A.F.P. in their serum at some stage of their pregnancy, since they all have fetuses presumably synthesising A.F.P. We suggested that this might be because (1) the fetoprotein molecule was not crossing the placenta; (2) the molecule lost its immunological identity during its passage through the placenta; or (3) its presence in the baby and absence or reduced amount in the mother was a simple dilution phenomenon. Regarding (1), the molecular weight of this protein is probably less than 100,0001 and could therefore pass from the fetus to the mother. We do not know its configuration, but if it is non-spherical, passage from the fetus to the mother might be hindered in a proportion of cases. Concerning (2), we are unaware of any information on this question, and (3), since the blood-volume of the fetus is much smaller than that of the mother (200-300 ml., compared with 5 litres) dilution must be a factor. However, if any or all of these explanations are applicable it is difficult to understand why they should not operate uniformly in all pregnant women. Dr. Alpert’s results again raise the question of racial or geographical differences in the presence of A.F.P. in between pregnant Caucasians and Negroes. We presume that Dr. Alpert’s tests were done on pregnant Caucasians: ours were done on Africans. There are racial differences in the presence of A.F.P. in proven liver cancers-in Britain it is found in 30% of cases, compared with 65-80% in Africans. There
are
striking differences
even
within Africa itself-
Gitlin, D., Boesman, M. J. clin. Invest. 1966, 45, 1826. Tatarinov, Y. S. Vop. med.Khim. 1964, 10, 584. Translated in Fedn Proc. 1965, 24, T.916. 3. Abelev, G. I. Personal communication. 4. O’Conor, G. T., Tatarinov, Y. S., Abelev, G. I., Uriel, J. Cancer, N.Y. 1970, 25, 1091. 5. Purves, L. R., Bersohn, I., Geddes, E. W. ibid. p. 1261. 6. Foy, H., Kondi, A., Parker, A. M., Stanley, R., Vennings, C. D. Lancet, 1970, i, 1336. 7. Foli, K., Sherlock, S., Adninolfi, M. ibid. 1969, ii, 1267.
1. 2.
Nor is this the only drawback to the committee membership. There was only one general-practitioner member. Any suggestion he might have wished to make which would be inconvenient to obstetricians could be outvoted immediately by the three distinguished obstetricians on the committee. If the suggestion was also administratively difficult, the two medical administrators could also vote it down. For example, one of the recommendations was that each patient should see a consultant obstetrician twice during her pregnancy at his clinic, but that other routine antenatal visits could be to see her general practitioner at his surgery. Now there is no inherent reason why the obstetrician should not see the patients at the general practitioner’s surgery. This would be easier for the patients, and would do much for general practitioner/specialist integration. On the other hand, it would be administratively inefficient, and tiresome for the obstetricians. Can we really believe that one general practitioner on the committee could sway three obstetricians and two administrators ? My wish is not to criticise the members of this committee, nor to imply that they reached any wrong decisions. But I do suggest that a committee constituted as this one can never keep in touch with its public. Nor can it ever produce a new approach to a problem, since it has a majority potentially committed to maintaining the existing arrangements.
C. P. TREVES BROWN.
MEDICAL CARE IN THE UNITED STATES SIR,—I have been in East and Central Africa studying medical-care services since Professor Holland’s paper (July 25, p. 202) appeared. Now I have returned I am not surprised at the xenophobic and nationalistic response that his views have received. No-one who is working happily in a country that he loves is keen to have criticisms levelled at its system of medical care. The United States of America is still a relatively young and developing nation, sensitive of comment and criticism. However, it is always good for a system to be analysed and commented upon by an expert. I agree with all of Professor Holland’s comments, but I would make the point that no system of medical care is
perfect and all
are faced with common problems. In a book1 and in an analytical factual comparison of medical services in U.S.A., U.S.S.R., and the United King-
recent
1.
Fry, J. Medicine in Three Societies. Aylesbury,
1970.
dom, I find that many of the problems delineated by Professor Holland are also found in the other two nations. My recent visit to Africa has confirmed my belief that we There is an insoluble are all facing similar challenges. equation in medical care." No nation can ever match " wants ", " needs ", and resources ". We are therefore all faced with the challenge of maximum utilisation of our available resources. This applies equally to United States with one physician to 800 persons as to Tanzania with one
physician to 22,000. There is, of course, no single " best-buy " system of medical care, and it is sad to read the mud-slinging of your correspondents at the British and American systems. Each is evolving a system to match its historical and cultural backgrounds. What the Americans are trying to do is to decide how they can provide a system that will be equal as well as being excellent. We wish them luck. They will, however, be able to achieve one only if they define their problems and heed advice and comments of observers such as Professor Holland. JOHN FRY.
FETOPROTEIN IN PREGNANT AFRICAN WOMEN and Dr. Zuckerman (Aug. 29, p. 465) SIR Dr. Alpert report complete absence of a-fetoprotein (A.F.P.) in women between 6 and 40 weeks pregnant. Their findings parallel those of workers in Europe1 but are in sharp contrast to those of others in the U.S.S.R. and South Africa and ourselves in Nairobi. Tatarinov2 found A.F.P. in the serum of women after spontaneous abortion, and Abelev 3 finds 100% O’Conor et al.4 positivity in women over 15 weeks pregnant. also cite similar findings in South Africa.’*Ó The reason for these differences is obscure. We said 8 that it was odd that all pregnant women should not have A.F.P. in their serum at some stage of their pregnancy, since they all have fetuses presumably synthesising A.F.P. We suggested that this might be because (1) the fetoprotein molecule was not crossing the placenta; (2) the molecule lost its immunological identity during its passage through the placenta; or (3) its presence in the baby and absence or reduced amount in the mother was a simple dilution phenomenon. Regarding (1), the molecular weight of this protein is probably less than 100,0001 and could therefore pass from the fetus to the mother. We do not know its configuration, but if it is non-spherical, passage from the fetus to the mother might be hindered in a proportion of cases. Concerning (2), we are unaware of any information on this question, and (3), since the blood-volume of the fetus is much smaller than that of the mother (200-300 ml., compared with 5 litres) dilution must be a factor. However, if any or all of these explanations are applicable it is difficult to understand why they should not operate uniformly in all pregnant women. Dr. Alpert’s results again raise the question of racial or geographical differences in the presence of A.F.P. in between pregnant Caucasians and Negroes. We presume that Dr. Alpert’s tests were done on pregnant Caucasians: ours were done on Africans. There are racial differences in the presence of A.F.P. in proven liver cancers-in Britain it is found in 30% of cases, compared with 65-80% in Africans. There
are
striking differences
even
within Africa itself-
Gitlin, D., Boesman, M. J. clin. Invest. 1966, 45, 1826. Tatarinov, Y. S. Vop. med.Khim. 1964, 10, 584. Translated in Fedn Proc. 1965, 24, T.916. 3. Abelev, G. I. Personal communication. 4. O’Conor, G. T., Tatarinov, Y. S., Abelev, G. I., Uriel, J. Cancer, N.Y. 1970, 25, 1091. 5. Purves, L. R., Bersohn, I., Geddes, E. W. ibid. p. 1261. 6. Foy, H., Kondi, A., Parker, A. M., Stanley, R., Vennings, C. D. Lancet, 1970, i, 1336. 7. Foli, K., Sherlock, S., Adninolfi, M. ibid. 1969, ii, 1267.
1. 2.