Phantom illness

THE LANCET

A t the edge of development

decline in breastfeeding that has occurred throughout Brazil (and the rest of the world) and the limited success of efforts to correct that decline. Yet there are successes. A chapter on the combination of oral rehydration therapy with traditional medicine provides hope that a clearly effective intervention can be introduced and used successfully if culturally accepted approaches are employed. However, the book also warns that current biomedical advances, which have been the underpinning of modern public health, may not reach those most in need and that health is an issue of national and global security. A t the Edge of Development’s treatment of topics ranges from the very broad, for example, the culture and beliefs of the people of north-east Brazil, to the very specific, such as the pathophysiology of H pylon’ and enterotoxigenic Escherichiu coli. Some may be frustrated by the dispersion of ideas and perhaps inevitable repetition: there are seven chapters scattered through the book dealing primarily with diarrhoea, enteric infection, or oral rehydration therapy. Nonetheless, the book is a commendable effort to bring together years of research into a coherent whole. The extensive references, most dating before 1990, will be useful to the serious scholar. Most important, those who are students of human development will find that this well-written text convincingly argues that development and health are inextricably linked but provides no easy answer as to how the two can be improved.

Health crisis in a transitional society--Edited by Richard L Guerrant, Auxiliadora de Souza, Marilyn K Nations. Durham, N Carolina: Carolina Academic Press. 1996. PP 449.$65.ISBN 0-89089-788-3.

A t the Edge of Development relates 17 years of study of the major publichealth problems of north-east Brazil to the status of human development in one of the poorest regions in the western hemisphere. It is the result of collaboration among specialists in public health, epidemiology, infectious diseases, nutrition, anthropology, and other disciplines, who were affiliated mainly with the University of Virginia in the USA, and with the Federal University of Ceara in Brazil at the time the work was done. Appropriately, the text begins by firmly linking poverty to disease and identifies economic disparity as the greatest contributor; Brazil ranks third worst in the world for distribution of income. The gaps between the rich and the poor are widening, and according to the World Bank, Latin America as a whole is the most inequitable region. The second chapter provides an important backdrop, pointing out that north-east Brazil has experienced a remarkable mixing of cultures but is still sharply divided by race and class. Unfortunately, this valuable anthropological information is not used in much of the book, except in one of the concluding chapters on blending oral rehydration therapy and popular (traditional) medicine. The first section concludes with a description of the patterns of morbidity and mortality as revealed by vital statistics, hospital data, and health surveys. Diarrhoea1 diseases and acute respiratory infections are the principal causes of illness and death

among infants and children. The entire range of infant and childhood mortality rates is seen, and it is striking that the poorest areas of northeast Brazil have rates that are among the highest in the world; similar to those in sub-Saharan Africa. The factors that probably contribute to these high levels of morbidity and mortality are identified, but specific causal links are not demonstrated. When the editors turn their attention to the major endemic tropical diseases in Brazil’s north-east, most attention is given to diarrhoea and malnutrition, which were evidently a focus of study during the 17 years of work. Nevertheless, viral respiratory tract infections, blood and tissue parasites, Chagas’ disease, and AIDS in north-east Brazil, in Brazil generally, and worldwide also covered. Most chapters also have sections describing the general epidemiology, pathophysiology, and treatment of these diseases, similar to what one would find in a textbook on tropical medicine. It is interesting to note that the editors have included infection with Helicobacter pylon as an endemic tropical disease, an unusual but probably correct perspective given the high prevalence of infection that the researchers found. The section on household water quality and availability identifies the problems of insufficient water supply and frequent contamination and describes the common frustration at failing to find a causal link between adequate water supplies and health status. Frustrating also is the terrible

A D Brandling-Bennett Pan American Health Organization 25 Twenty-third Street, Washington DC 20037. USA

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Phantom illness

cure diseases and treat the sick. A hypochondriac runs counter to that Shattering the myth of hypochondria.-Carla Cantor with Brian A Fallon. core principle of medicine. Boston: Houghton Mifflin. 1996.Pp 351.$22.95.ISBN 0-395-68988-0. ! In Phunton Illness, Carla Cantor Many physicians concede that they i providers until they get the answer does a good job of elevating dread when a hypochondriac crosses they are looking for. Primary-care i hypochondriasis to give it the respect their office’s threshold. Despite their doctors I have talked to say that they she thinks it deserves among the medvery real obsession with illness, these i are sympathetic to the somatic ical community. Cantor’s goal in this stresses that burden hypochondriacs. i easy-to-read book is to arm patients patients can be a nightmare for the average physician. i They complain, however, that a lack and their doctors with an arsenal of They are difficult and demanding, i of adequate training and tolerance i information and advice that can lead renders them impotent when it to better coping skills for an often they solicit diagnoses and then reject them, and they distrust doctors so i comes to treating these individuals. i debilitating condition and a “much maligned malady”. Cantor’s research much that they will easily switch i After all, physicians are trained to

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shows that, in the USA, hypochon- i so bad that she was admitted to a driasis is a serious problem for about i psychiatric ward after a futile search one in ten people and costs the i for a diagnosis of lupus-wrote the health-care system an estimated i book under the supervision of Brian $20-$30 billion a year. i Fallon, a New York psychiatrist who Researchers claim that somatisers i teaches at Columbia University and have medical costs as much as 14 i in 1993 won the first federal grant to times higher than the national aver- i study hypochondria from the age. Cantor writes that 25-75% of all National Institute on Mental Health. of well--tten patients who visit doctors’ offices i report symptoms that seem to lack i her own long struggle with medical basis. Lowering those costs i hypochondria is compelling reading and stemming gratuitous office visits as are the stories of patients she interseems a worthy goal for the $1 trillion i viewed. A seasoned journalist, and growing US health-care system. i Cantor did her homework, drawing on popular literature and scientific on Until recently, teaching hypochondriacs and somatisers were research for her resources. She also not even part of the medical-school i interviewed many physicians, psychicurriculum. Consequently, doctors i atrists, and patients to hear their peremerge from training shocked by the i spectives. The book is filled with case real world where such patients make i studies of people with hypochondriaup a third to half of their medical sis, the paths to they have practices. One doctor Cantor inter- i taken, and the links of the condition viewed admits: “I don’t know how to i to obsessive compulsive disorder. Phantom Illness is essential reading help [hypochondriacs]. T o avoid an i unproductive relationship for both of for physicians trying to better underus, I either refer them or get them to i stand their patients who have abandon me.” Cantor-whose own i hypochondriasis. While the book may experience with hypochondriasis was i not include any new insights into the

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causes of this condition, it offers well: balanced perspectives from both the

i patients and the experts. It offers sug-

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gestions on how patients and doctors can put their swords down and together find treatments for this costly medical dilemma. Janet fir.shein 1716 Irving Street NW. Washington DC 20010, USA

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: i Selected books: surgery i :i i i i i i i i i i

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HaifnOViCi’S Vascular SUfgefy-4th edn. -Henry Haimovici, Enrico Ascer, Larry H Eugene Strandness Jr, Hollier, Jonathan B Towne. Oxford: Blackwell Science. 1996. Pp 1388. €145. o-86542-344-x.

Acherman ssSurgical Pathology vol and 2 4 t h edn.-Juan Rosai. St Louis: Mosby. 1996. pp 2732. f229/$339. ISBN @8016-7004-7, surgery for Cardiovascular Disease-2nd edn.-Wesley S Moore. Philadelphia Saunders. 1996 Pp 713. €154. ISBN 0-7216-3624-1.

Endpiece

Time since beginning of intraepithelialphase Natural history of cervical lntraeplthellal neoplasla Although the mean time taken for cervical intraepithelial neoplasia to progress t o invasive carcinoma is generally accepted to be 10-15 years, a small number of women will fall at the two extremes of the distribution curve of natural history. This suggestion reconciles the very different progression times in different women with the belief that they all have the same disease. Taken from Integrated Colposcopy, second edition, by Malcolm Anderson, Joe Jordan, Anne Morse, Frank Sharp. (London: Chapman and Hall.

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