Preventive Medicine

846 decline because of my more leisurely adult pursuits, such as drinking and girls. At the age of 18 I started my first job in the costing department of a civil engineering company, and the following two years were quiet so far as bleeds were concerned. I had finally to join another company when mine went into voluntary liquidation. I sustained my worst bleed ever when, at the age of 20, I strained my right hip. I had a massive haemorrhage which resulted in swelling from hip to knee, loss of sensation along the top of my thigh, and extreme pain. After five months I was mobile again, but had lost my job meanwhile, because of the injury. Later that year the same leg gave way and I was back where I started. A year later it happened again. This time I developed haematuria and was admitted to the local hospital. Fortunately, one of the doctors had heard of treatment at the Royal Infirmary, Sheffield (now transferred to the Royal Hallamshire). Soon after arrival at the Infirmary I was put on an intravenous plasma drip. I was overjoyed with the result; the discomfort began to ease and the swelling soon became softer to the touch. From that day I was registered at the haemophilia centre. Therapy continued to improve, and the advent of cryoprecipitate factor VIII and fibrinogen extracted from plasma reduced treatment to an injection on an outpatient basis. Ironically, in 1973, after an injection of cryoprecipitate, I developed serum hepatitis. During my recovery, chickenpox added to my troubles. I was in an isolation ward for six weeks. It is unfortunate that serum hepatitis remains a risk of replacement therapy, yet it is a risk I am sure that most haemophiliacs are prepared to take in view of the tremendous advantages. At the age of 29 I was fortunate enough to be chosen to administer my own treatment, which consists of an intravenous injection of dried factor VIII concentrate reconstituted with sterile pyrogen-free distilled water. My lifestyle since home treatment has improved dramatically. I am now able to treat each bleed immediately, and so avoid discomfort, inconvenience, and reduce future damage to a minimum. Over the past two years the single injections have totalled an average of two bottles per week (one bottle contains 260 I.U. factor VIII). My daily routine is rarely disrupted and my employment in administration with a local bus company is no longer at risk. During 1981I was off sick for a total of seven days, of which two were because of influenza. Holidays present few problems, provided I choose appropriately and I take sufficient supplies of factor VIII with me. My wife, whom I married when I was 24, despite her family’s misgivings regarding my condition, and I have recently returned from three weeks in Thailand. I consider myself fortunate to have loving parents and a wife who have helped me through the darker days of my childhood and adult life. The only reminders I have of those days are reduced bending from a straight position in each leg and a weakened right thigh muscle, but my general appearance gives no indication of these restrictions. I am an avid snooker player enjoying the game’s competition and skill. Golf is my other game which I play whenever I feel up to a round during the summer. I also serve as a committee member on the Sheffield and District branch of the Haemophilia Society. My wife and I have not had children because we did not want to add to our difficulties during the early days of our marriage. In view of present-day treatment and the promise of tomorrow, I do not consider that the possibility of transmitting haemophilia to future generations should deter any married couple from having children. My lifestyle is now as normal as possible within the confines of the disease. New

Tupton, Chesterfield, Derbyshire

GERALD FLAVELL

Preventive Medicine The report that follows summarises a

roMpAeMa TTig C:7M.FbMKd<2tMK,

meeting* of an ad-hoc working

London, on May 26, 1981. Theaim

establish a broad consensus on the position of the prevention of coronary heart disease in the U.K. Agreement was freely reached by independent experts, none of whom were representing sectional interests, but were expressing their personal views. was to

PREVENTION OF CORONARY HEART DISEASE IN THE UNITED KINGDOM BACKGROUND

THERE is little coordinated action on the prevention of coronary heart disease (CHD) in the U.K., despite the importance of the disease. Support for public action on prevention should be based on practical and effective measures which receive the broad agreement of expert opinions. The Coronary Prevention (CPG), believing that there are areas of agreement which could now be applied to prevent CHD, convened a working group.

Group

AIM OF THE WORKING GROUP

The aim was

to

identify measures which on the basis of available

knowledge were appropriate for CHD prevention programmes in the U.K. Such measures could form an acceptable basis for immediate action and yet remain subject to modification with the emergence of new knowledge. Other measures on which there was less agreement could also be defined and should remain subjects for legitimate debate before being included in public recommendations. CONCLUSIONS AND RECOMMENDATIONS

These refer

only to the major risk factors:

Smoking Smoking is a particularly important risk factor, especially in those under the age of 50. The Government should take much more effective action to encourage a reduction in smoking and to discourage others, especially children, from starting.

Hypertension General practitioners are of crucial importance in the detection and treatment of hypertension. The control of severe hypertension is essential. However, a general policy of treating mild hypertension with antihypertensive drugs should be discouraged until the results of the current M.R.C. trial are published. Even moderate reduction of overweight and of sodium intake in the population might reduce the risks of CHD through lowering blood pressure. Whenever a doctor identifies mild hypertension, advice on weight and salt intake should be given when necessary. Salt intake in the population as a whole could be reduced by a quarter from the estimated average level of 12 g/head-day without harm. The food industry should avoid increasing the salt content of foods and explore ways of decreasing the amounts added at present. Exercise

Adequate physical exercise may reduce the risks of CHD. Active improves cardiovascular performance and is useful in weight control. Exercise at a level appropriate for age and cardiorespiratory function should be widely encouraged. exercise

*The participants were: Prof. J. F. Goodwin (chairman), Sir Douglas Black, Dr K. P. Ball, Dr D. J. Coltart, Prof. M. A. Crawford, Dr D. W. Evans, Dr J. A. M. Gray, Dr W. P. T. James, Dr D. Lambert (D.H.S.S. observer), Dr M. G. Marmot, Dr N. E. Miller, Prof. J. N. Morris, Prof. M. F. Oliver, Mr C. J. Robbins (secretary), Prof. G. A. Rose, Prof. H. Tunstall-Pedoe, Dr R. W. D. Turner, Ms C. Walker. The following were invited, could not attend, but agree on the final report: Dr D. Chamberlain, Prof. B. Lewis, Dr J. I. Mann, Dr T. W. Meade, Prof. A. G. Shaper, Prof. Alwyn Smith.

847 Diet

be made in the body-e.g., by the inclusion of fish, and pulses and of polyunsaturated vegetable oils where vegetable oils are used. Reduction in fat contribution to energy requirements can be offset by foods rich in complex carbohydrates, particularly bread, vegetables, potatoes, and fruit; this would also increase dietary fibre intake. It was also agreed that special attention should be directed to children since dietary, smoking, and exercise habits are often established in early life. Together with age, sex, and family history, there are important social class differences in risk factors and prevalence of disease. These factors should be taken into account in the design and implementation of prevention programmes.

which

Overweight is associated with an increased risk of CHD, particularly in younger age groups. Diets to reduce obesity and maintain desirable weight should not increase the risks of CHD by being high in fats. The contribution of fat to average total energy intake, including alcohol, should be reduced, as far as is practical, by a quarter towards 30% of total energy, with a halving of saturated fats towards 10% of the total energy. There is no evidence that the consequent moderate increase in the ratio of polyunsaturated to saturated fats would be harmful. It is necessary to ensure that the above dietary changes do not reduce the levels of polyunsaturated fatty acids

cannot

cereals,

Round the World From

our

Correspondents

United States THE SELF-IMAGE AND THE REALITY

As Dr Harold Morowitz has recently pointed out,I the self-image of the medical profession in the U.S.- "a highly selected group of cosmopolitan individuals"-is devoid of reality. This, he perceives, is the only possible conclusion to be drawn from the composition of the student bodies in this country’s medical schools, as shown by the American Association of Medical Colleges’ own handbook of Medical School Admission Requirements, for 78% of the entering candidates are residents in the State where the medical school is located. But even this figure understates the true situation. Ten schools admit no out-of-State residents at all and over half have classes with 90-100% State residents. Even some which might consent to admit out-of-State residents have high fees, as in Denver, where the annual fee is over$25,000; not surprisingly, it has no such entrants.

Morowitz calculates that on a nationwide basis about 30% of those

entering any medical school should be out-of-State residents and only thirteen schools meet this criterion, and of these two are predominantly Black institutions, Howard and Meharry. Nearly all the other eleven would rank high in the list of outstanding institutions, as judged by those outside the U.S. There are nine others, mostly also internationally admired medical centres (for example, Stanford, Chicago-Pritzker, Tulane, Vermont, and the Boston schools), which admit more than 50% but less than 70% nonState residents. Thus, only about one-fifth of the medical colleges of this country could be considered national or semi-national institutions, and the rest are all provincial and parochial and getting more so.

The reasons are evident and clearly financial; and they spring from policies mandated by legislatures dominated by local politicians. But, beyond this, it is clearly unjust for medical colleges to offer to consider applications which have no hope of success. Morowitz notes that the Louisiana State University Medical School had 204 completed, and paid for, applications from out-of-Staters, but filled its 175 places from the 656 in-State applicants. On the other hand, the Johns Hopkins, to fill its 120 completely open places, scrutinised over 3000 applicants. Moreover, there is evidence that the number of applicants has diminished and that as admission becomes easier fewer students apply. Though each institution has to exercise considerable selection because of multiple applications, there is in fact a "rather low degree of overall choice on who enters". Morowitz thinks that this will not affect the skills of the practitioner but only his or her attitudes. Others, those who deal with medical malpractice suits for example, are not so certain that skills are unaffected. But he does emphasise that the image of a cosmopolitan rigorously selected group of entering students is an illustration and that in reality it is a locally oriented largely self-selected group. This picture, he thinks, will come as a blow to the collective ego of the medical profession. 1. Morowitz HJ. 169-70.

Through

an

ophthalmoscope darkly. Hospital Practice 1982; 17:

The American Association of Medical Colleges has exercised a parochialism which has had unfortunate consequences; and the Association is losing both public esteem and confidence. Firstly, by restricting the number of places available in medical school for U.S. citizens the Association created a serious shortage of physicians. These places are filled by foreign medical graduates to such an extent that the W.H.O. now estimates that a quarter of physicians now practising in the U.S. are foreign medical graduates and half of these are from Asian countries. The U.S. citizen whose son or daughter, adequately academically qualified, has been rejected after application to many medical schools does not take too well when he or she finds that the only medical help available in emergency at the local hospital is from a foreign graduate. The A.A.M.C. and the U.S. parochial medical schools tend to hold all foreign graduates in low regard and as cut from a single cloth. The products of the oldest and most famous medical schools of Europe, whence derived American medicine, are sometimes treated as the equivalents of those from the world’s least satisfactory medical schools.2 The same attitude is manifest towards those overseas medical schools which are largely attended by the U.S. students who failed to get entrance to medical schools in the U.S. All these are lumped together regardless of the differences. The A.A.M.C. and various medical schools are exposing themselves to criticism by their opposition to such medical schools as that in Grenada. When one of its students obtained the highest marks in the National Boards Examination part i, and his colleagues gained passes at a higher rate than those of many schools in the U.S., the response was to restrict admission to those students being educated in the U.S. In its place the medical knowledge profile examination was instituted, and in 1981 two St Georges, Grenada, students achieved perfect scores, all 9s, and another scored eight 9s and one 8, the perfect scores on achievement being unequalled since the examination was instituted. The students there have gained a very high rate of passes in the ECFMG examination, coming 2nd for the second successive year, and in the MSKP examination. They have a strenuous course, culminating in a severe clinical examination given jointly by the U.S. and British examiners. Deans and other officials in some medical schools are earning themselves a poor reputation by trying to dissuade members of their faculty from giving lectures in overseas medical schools, thus interfering with both academic freedom and the civil rights of their staff. The A.A.M.C. is certainly correct in its prediction that there will be, under the current administration, substantial rises in medicalschool tuition costs, and they are coming into effect amid growing student opposition. The A.A.M.C.’s policies are widely seen as a major factor both in the rising costs and in the flight of so many excellent students to seek medical education overseas. It has also been active in promoting the view that American medicine is the best in the world, when many indices show that it is not. Standards in some medical schools are low and sinking, and one schools are in a position to look down on foreign medicaTschooIs and their graduates. Naturally, such schools are exactly those who do not so discriminate and judge each applicant on merits. We badly need a new Flexner and one as astringent and sceptical as the last. 2. Bourne GH. Foreign medical schools not Education Sept. 23, 1981, p. 23.

automatically

inferior. Chron

Higher