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Medical Aid for Developing Countries
973
Two Hypertensive Problems OPINIONS differ not only about the nature of hypertension but also about how it should be treated. Indeed, these issues are not separate, for the concept of disease"leads more directly to thoughts of treatment than does that of a graded character ". But, besides this central controversy, two subjects related to hypertension are of current interest-the setiological role of anomalies of the renal arteries, and the development of the" intermediate-range " hypotensive drugs. No-one disputes that abnormalities of the renal arteries can lead to renal ischaemia and so to clinically significant hypertension, nor that correction of the abnormalities can be followed by restoration of the blood-pressure to normal levels. But when we consider the different types of renal-artery anomaly and the practical problem of selecting patients with curable" hypertension, many difficulties arise. Multiple rend arteries are quite common : but it is still not clear whether they are more common in hypertensive patients,l or whether the incidence in normotensive (21%) and hypertensive (23%) patients is broadly the same.2 Renal-artery stenosis in older patients is often due to atheroma, but its cause in young people remains a mystery; the pulseless disease of Takayashi and occlusion of the arteries by pressure from neighbouring slips of psoas or diaphragmcan account for only the occasional case. In the individual patient, the difficulty is to predict the chances of surgery successfully relieving the hypertension. A run of failures may tempt the surgeon to yearn after the Laodicean days when only non-functioning " kidneys were removedalthough we now know that these are unlikely to be the root cause of hypertension. Compared with reconstructive arterial surgery, nephrectomy is a counsel of despair. Mistakes have surely been made by relying solely on structural evidence. Radiology may display stenosis, but this is not, in itself, an indication for radical surgery. A sizeable drop in pressure across the apparent stenosis must also be demonstrated; but this unfortunately demands an exploratory operation. Not surprisingly, therefore, much effort has gone into the search for indirect methods of establishing the presence of renal ischsemia. STAMEY and his colleagues4 have criticised the types of radioactive renogram and divided renal-function study currently used. They argueand, in a small series, demonstrate-that the essential functional change in ischasmic renal tissue is excessive reabsorption of water and the consequent secretion of a small volume of concentrated urine. This change accounts for the denser shadow sometimes seen on the ischxmic side in the intravenous pyelogram; and it can be clearly demonstrated by study of the separate urines formed by each kidney during sustained osmotic diuresis in response to urea infusion. This procedure, however, is lengthy and involves the passage of "
"
"
"
1. Robertson, P. W., Klidjian, A., Hull, Sept. 22, 1962, p. 567. 2. Brown, J. J., Owen, E., Peart, ibid.Oct. 20, 1962, p. 832.
W.
D.
H., Hilton, D. D. Lancet,
S., Robertson, J. I. S., Sutton, D.
3 d’Abreu, F., Strickland, B. ibid. Sept. 15, 1962, p. 517. 4. Stamey, T. A., Nudelman, I. J., Good, P. H., Schwentker, Hendricks, F. Medicine, Baltimore, 1961, 40, 347.
F.
N.,
ureteric and intravenous catheters, the instrumentation being done under spinal anaesthesia. All this is an ordeal for any patient. We badly need a simple test for detecting the reversibly ischaemic kidney. Meanwhile, the hypertensive in need of medical treatment is still with us-although even the wisdom of has been questioned.5 lowering the blood-pressure " there has been a Hitherto, therapeutic gap " between guanethidine, for the patient with severe and progressive hypertension, and sedatives and the thiazide diuretics for the patient in whom these milder medicaments achieve sufficient control. Patients not uncommonly have alarming readings on the sphygmomanometer but, although clearly in for trouble in the future, have no symptoms; and the doctor hesitates to make invalids of them by prescribing the more stringent hypotensive agents. Drugs such as methyldopa are therefore welcome because of their useful hypotensive action and freedom from the crippling side-effects of the more potent drugs. 6-8 The hypotensive action of methyldopa is also less limited to the erect posture than is that of therapeutic doses of the ganglion-blocking
indwelling urological
agents. In last week’s issue Dr. MONTUSCHI and Dr. PICKENS9 reported a clinical trial of two new compounds related to bretylium and guanethidine. These may prove more suitable than guanethidine for the treatment of moderately severe hypertension, since they do not cause troublesone diarrhoea and their action is less protracted. Most of the patients in their trial were severely hypertensive, but some were included whose " resting " diastolic pressure was only moderately raised. These may well be among the patients for whom these drugs are indicated-perhaps in smaller dosagesince side-effects are strikingly few.
Medical Aid for
Countries THE lay Press, commenting on the report of a working party which, under the chairmanship of Sir ARTHUR
Developing
PORRITT, has considered medical aid to the developing countries has seized on the statement that Great Britain is falling behind other nations (particularly the U.S.A. and the U.S.S.R.) in its contribution to the medical advance of the countries of Africa, the Middle East, and Asia. While this statement is true, it should not obscure the fact that, in nearly all developing countries where English is used, the medical and health services have been constructed by men and women from this country or trained here. The great medical schools of English-speaking Asia, Africa, and the Caribbean; what remains of the organisation of the Colonial Medical Service; the fact that the great killing infections of the tropics are now under partial, if precarious, controlthese are achievements of British medicine which cause 5. Evans, W. Brit. med. J. Sept. 15, 1962, p. 722. 6. Irvine, R. O. H., O’Brien, K. P., North, J. D. K. Lancet, 1962, i, 300. 7. Dollery, C. T., Harington, M. ibid. p. 795. 8. Bayliss, R. I. S., Harvey-Smith, E. A. ibid. p. 763. 9. Montuschi, E., Pickens, P. T. ibid. Nov. 3, 1962, p. 897. 10. Medical Aid to the Developing Countries: Report by a Working Party. Published for the Department of Technical Cooperation by H.M. Stationery Office. 1962. Pp. 38. 2s.
974
and women know about the opportunities awaiting them. Numerically, the need for doctors and auxiliaries who can run the rural and preventive medical services is greater than the need for specialists. Until medical graduates can be produced in far greater numbers, much medical work must be done by medical assistants and by auxiliaries of all kinds. It is neither practicable nor desirable to bring large numbers of these to be trained in the United Kingdom: it would cost too much; we could not accommodate them; and in any new factor, greatly to the advantage of the aid-seeking event they should learn their jobs in the countries where countries-and one that gives us no reason for complaint they are to work. We can-and to a limited extent door, if we rise to the occasion, for fear. But if Great help by sending out doctors, sister tutors, senior techBritain is to compete with other aid-giving countries nicians, and others who, by helping to devise curricula and thus retain her prestige, she must (as the working and examinations, and by taking a hand in teaching and research, can ensure that standards of work are high. party says) spend a good deal more money. A most important form of aid is the advisory visit by The developing countries can afford to spend on health only a very small fraction of the amount per caput spent experts on the subjects that especially concern developby this and other " developed " countries. Yet their ing countries-nutrition, control of infective diseases continued development will depend largely on their such as malaria, schistosomiasis, and trypanosomiasis, health services, which are overworked, understaffed, and and administrative medicine covering epidemiology, woefully lacking in trained indigenous personnel. The - statistics, and occupational health. For such experts we working party has examined the forms of medical aid must look principally to the two great schools of tropical that we in the United Kingdom could give. medicine and hygiene, in London and in Liverpool. We are at present training about 900 overseas medical For their work these schools are too small. Their most undergraduates in this country. This is about as many urgent tasks are to maintain their research and teaching, to send members of their staff overseas to advise and to as our medical schools can accept; but effort should be made to increase the number despite the difficulty at help with teaching, and to train students from overseas. this time when Britain herself needs more doctors. They would be better able to fulfil these tasks if they Postgraduate training calls for even more decisive action. could add to their establishments specialists in prevenOur National Health Service employs over 3000 men tive and clinical tropical medicine, including protoand women graduates from developing countries, among zoologists, helminthologists, nutritionists, malariologists, them not a few who will go back to teach and to lead in clinicians, and others with years of tropical experience. their own countries. Some form of educational super- British doctors and research workers are at present vision and teaching for such people is badly needed; and tending to leave the developing countries to take up the report also recommends the creation of bursaries to more secure employment at home, not always of a kind in which they can use their tropical experience; and the bring more postgraduate students from overseas. special posts be -created for Turning to aid which could be given by British report ofrecommends that these men, so that they can be available for graduates going overseas, the working party remarks some of work overseas and, especially, so that they can that trained British men and women are needed especially spells hand on their knowledge to younger men. Furthermore, to train medical and surgical specialists and underif assured now of an ultimate post at home, would graduates, and also medical assistants and auxiliaries some, remain longer in their specialty posts overseas. of all kinds. But many overseas posts lie vacant for long The report repeatedly stresses the importance of periods because men and women from this country cannot be attracted into them. The report indicates enabling senior men in all specialties to travel, so that how this difficulty might be partly overcome by facili- they may from their own experience know the circumtating secondment, by increasing security of those going stances and needs of countries that seek their aid, and for a spell of service overseas, and by establishing a code make and reinforce the personal links that are essential of terms of appointment that might ensure satisfactory for effective cooperation. conditions of work and living. Service in one of the The developing countries in which English is the bigger hospitals or schools in the developing countries language of medical education and practice still have a should be recognised as an additional, and valuable, strong preference for British medicine. Their good will qualification in applicants for hospital and university is an asset of great practical worth to Great Britain. If appointments at home. The report also draws attention we are to retain and develop this good will, an immediate to the great value of senior men at or near the retiring effort along the lines suggested by the working party must take in who can overseas medical schools for be made, and for this the first requirement is money. age posts a few years, and also of senior teachers who could go Undoubtedly the Department of Technical Cooperation for shorter spells to work as " professors with their is fully aware of the needs and of the possibilities. We shirt sleeves rolled up ". In addition, more should be hope that the Department will not be denied the means.
many developing countries to seek and prefer British aid, if they can get it. Moreover, because so many British doctors know the developing countries well, we are likely to be able to give effective aid more economically than can countries that in the past have been less intimately concerned. What British medicine accoinplished overseas in the past was accomplished relatively slowly over the years, and always on an exiguous budget. Now that the pace of development is accelerating, the need for technical (including medical) aid is increasing fast. International competition to provide this aid is a
done
to
let young
men
Two Hypertensive Problems OPINIONS differ not only about the nature of hypertension but also about how it should be treated. Indeed, these issues are not separate, for the concept of disease"leads more directly to thoughts of treatment than does that of a graded character ". But, besides this central controversy, two subjects related to hypertension are of current interest-the setiological role of anomalies of the renal arteries, and the development of the" intermediate-range " hypotensive drugs. No-one disputes that abnormalities of the renal arteries can lead to renal ischaemia and so to clinically significant hypertension, nor that correction of the abnormalities can be followed by restoration of the blood-pressure to normal levels. But when we consider the different types of renal-artery anomaly and the practical problem of selecting patients with curable" hypertension, many difficulties arise. Multiple rend arteries are quite common : but it is still not clear whether they are more common in hypertensive patients,l or whether the incidence in normotensive (21%) and hypertensive (23%) patients is broadly the same.2 Renal-artery stenosis in older patients is often due to atheroma, but its cause in young people remains a mystery; the pulseless disease of Takayashi and occlusion of the arteries by pressure from neighbouring slips of psoas or diaphragmcan account for only the occasional case. In the individual patient, the difficulty is to predict the chances of surgery successfully relieving the hypertension. A run of failures may tempt the surgeon to yearn after the Laodicean days when only non-functioning " kidneys were removedalthough we now know that these are unlikely to be the root cause of hypertension. Compared with reconstructive arterial surgery, nephrectomy is a counsel of despair. Mistakes have surely been made by relying solely on structural evidence. Radiology may display stenosis, but this is not, in itself, an indication for radical surgery. A sizeable drop in pressure across the apparent stenosis must also be demonstrated; but this unfortunately demands an exploratory operation. Not surprisingly, therefore, much effort has gone into the search for indirect methods of establishing the presence of renal ischsemia. STAMEY and his colleagues4 have criticised the types of radioactive renogram and divided renal-function study currently used. They argueand, in a small series, demonstrate-that the essential functional change in ischasmic renal tissue is excessive reabsorption of water and the consequent secretion of a small volume of concentrated urine. This change accounts for the denser shadow sometimes seen on the ischxmic side in the intravenous pyelogram; and it can be clearly demonstrated by study of the separate urines formed by each kidney during sustained osmotic diuresis in response to urea infusion. This procedure, however, is lengthy and involves the passage of "
"
"
"
1. Robertson, P. W., Klidjian, A., Hull, Sept. 22, 1962, p. 567. 2. Brown, J. J., Owen, E., Peart, ibid.Oct. 20, 1962, p. 832.
W.
D.
H., Hilton, D. D. Lancet,
S., Robertson, J. I. S., Sutton, D.
3 d’Abreu, F., Strickland, B. ibid. Sept. 15, 1962, p. 517. 4. Stamey, T. A., Nudelman, I. J., Good, P. H., Schwentker, Hendricks, F. Medicine, Baltimore, 1961, 40, 347.
F.
N.,
ureteric and intravenous catheters, the instrumentation being done under spinal anaesthesia. All this is an ordeal for any patient. We badly need a simple test for detecting the reversibly ischaemic kidney. Meanwhile, the hypertensive in need of medical treatment is still with us-although even the wisdom of has been questioned.5 lowering the blood-pressure " there has been a Hitherto, therapeutic gap " between guanethidine, for the patient with severe and progressive hypertension, and sedatives and the thiazide diuretics for the patient in whom these milder medicaments achieve sufficient control. Patients not uncommonly have alarming readings on the sphygmomanometer but, although clearly in for trouble in the future, have no symptoms; and the doctor hesitates to make invalids of them by prescribing the more stringent hypotensive agents. Drugs such as methyldopa are therefore welcome because of their useful hypotensive action and freedom from the crippling side-effects of the more potent drugs. 6-8 The hypotensive action of methyldopa is also less limited to the erect posture than is that of therapeutic doses of the ganglion-blocking
indwelling urological
agents. In last week’s issue Dr. MONTUSCHI and Dr. PICKENS9 reported a clinical trial of two new compounds related to bretylium and guanethidine. These may prove more suitable than guanethidine for the treatment of moderately severe hypertension, since they do not cause troublesone diarrhoea and their action is less protracted. Most of the patients in their trial were severely hypertensive, but some were included whose " resting " diastolic pressure was only moderately raised. These may well be among the patients for whom these drugs are indicated-perhaps in smaller dosagesince side-effects are strikingly few.
Medical Aid for
Countries THE lay Press, commenting on the report of a working party which, under the chairmanship of Sir ARTHUR
Developing
PORRITT, has considered medical aid to the developing countries has seized on the statement that Great Britain is falling behind other nations (particularly the U.S.A. and the U.S.S.R.) in its contribution to the medical advance of the countries of Africa, the Middle East, and Asia. While this statement is true, it should not obscure the fact that, in nearly all developing countries where English is used, the medical and health services have been constructed by men and women from this country or trained here. The great medical schools of English-speaking Asia, Africa, and the Caribbean; what remains of the organisation of the Colonial Medical Service; the fact that the great killing infections of the tropics are now under partial, if precarious, controlthese are achievements of British medicine which cause 5. Evans, W. Brit. med. J. Sept. 15, 1962, p. 722. 6. Irvine, R. O. H., O’Brien, K. P., North, J. D. K. Lancet, 1962, i, 300. 7. Dollery, C. T., Harington, M. ibid. p. 795. 8. Bayliss, R. I. S., Harvey-Smith, E. A. ibid. p. 763. 9. Montuschi, E., Pickens, P. T. ibid. Nov. 3, 1962, p. 897. 10. Medical Aid to the Developing Countries: Report by a Working Party. Published for the Department of Technical Cooperation by H.M. Stationery Office. 1962. Pp. 38. 2s.
974
and women know about the opportunities awaiting them. Numerically, the need for doctors and auxiliaries who can run the rural and preventive medical services is greater than the need for specialists. Until medical graduates can be produced in far greater numbers, much medical work must be done by medical assistants and by auxiliaries of all kinds. It is neither practicable nor desirable to bring large numbers of these to be trained in the United Kingdom: it would cost too much; we could not accommodate them; and in any new factor, greatly to the advantage of the aid-seeking event they should learn their jobs in the countries where countries-and one that gives us no reason for complaint they are to work. We can-and to a limited extent door, if we rise to the occasion, for fear. But if Great help by sending out doctors, sister tutors, senior techBritain is to compete with other aid-giving countries nicians, and others who, by helping to devise curricula and thus retain her prestige, she must (as the working and examinations, and by taking a hand in teaching and research, can ensure that standards of work are high. party says) spend a good deal more money. A most important form of aid is the advisory visit by The developing countries can afford to spend on health only a very small fraction of the amount per caput spent experts on the subjects that especially concern developby this and other " developed " countries. Yet their ing countries-nutrition, control of infective diseases continued development will depend largely on their such as malaria, schistosomiasis, and trypanosomiasis, health services, which are overworked, understaffed, and and administrative medicine covering epidemiology, woefully lacking in trained indigenous personnel. The - statistics, and occupational health. For such experts we working party has examined the forms of medical aid must look principally to the two great schools of tropical that we in the United Kingdom could give. medicine and hygiene, in London and in Liverpool. We are at present training about 900 overseas medical For their work these schools are too small. Their most undergraduates in this country. This is about as many urgent tasks are to maintain their research and teaching, to send members of their staff overseas to advise and to as our medical schools can accept; but effort should be made to increase the number despite the difficulty at help with teaching, and to train students from overseas. this time when Britain herself needs more doctors. They would be better able to fulfil these tasks if they Postgraduate training calls for even more decisive action. could add to their establishments specialists in prevenOur National Health Service employs over 3000 men tive and clinical tropical medicine, including protoand women graduates from developing countries, among zoologists, helminthologists, nutritionists, malariologists, them not a few who will go back to teach and to lead in clinicians, and others with years of tropical experience. their own countries. Some form of educational super- British doctors and research workers are at present vision and teaching for such people is badly needed; and tending to leave the developing countries to take up the report also recommends the creation of bursaries to more secure employment at home, not always of a kind in which they can use their tropical experience; and the bring more postgraduate students from overseas. special posts be -created for Turning to aid which could be given by British report ofrecommends that these men, so that they can be available for graduates going overseas, the working party remarks some of work overseas and, especially, so that they can that trained British men and women are needed especially spells hand on their knowledge to younger men. Furthermore, to train medical and surgical specialists and underif assured now of an ultimate post at home, would graduates, and also medical assistants and auxiliaries some, remain longer in their specialty posts overseas. of all kinds. But many overseas posts lie vacant for long The report repeatedly stresses the importance of periods because men and women from this country cannot be attracted into them. The report indicates enabling senior men in all specialties to travel, so that how this difficulty might be partly overcome by facili- they may from their own experience know the circumtating secondment, by increasing security of those going stances and needs of countries that seek their aid, and for a spell of service overseas, and by establishing a code make and reinforce the personal links that are essential of terms of appointment that might ensure satisfactory for effective cooperation. conditions of work and living. Service in one of the The developing countries in which English is the bigger hospitals or schools in the developing countries language of medical education and practice still have a should be recognised as an additional, and valuable, strong preference for British medicine. Their good will qualification in applicants for hospital and university is an asset of great practical worth to Great Britain. If appointments at home. The report also draws attention we are to retain and develop this good will, an immediate to the great value of senior men at or near the retiring effort along the lines suggested by the working party must take in who can overseas medical schools for be made, and for this the first requirement is money. age posts a few years, and also of senior teachers who could go Undoubtedly the Department of Technical Cooperation for shorter spells to work as " professors with their is fully aware of the needs and of the possibilities. We shirt sleeves rolled up ". In addition, more should be hope that the Department will not be denied the means.
many developing countries to seek and prefer British aid, if they can get it. Moreover, because so many British doctors know the developing countries well, we are likely to be able to give effective aid more economically than can countries that in the past have been less intimately concerned. What British medicine accoinplished overseas in the past was accomplished relatively slowly over the years, and always on an exiguous budget. Now that the pace of development is accelerating, the need for technical (including medical) aid is increasing fast. International competition to provide this aid is a
done
to
let young
men