PRIMARY CARE

1332

patient’s husband may be unemployed or that the standard of cooking may be poor so that the main meal of the day will often be chips. We are encouraged to lower the perinatal mortality rate, but possibly this is a false concept. A caesarean section rate of 40% or more for diabetics may be tolerable, but such a rate for the

rest

of

our

pregnant

obstetrics, with

an

astronomical

will

women

morbidity and occasional death. The

maternal of Brazilian section rate, are a cause

excesses

caesarean

-

nightmare which we must strive to avoid.

Department of Obstetrics and Gynaecology,

New Cross

Hospital, Wolverhampton

ALAN M. SMITH

agree with your editorial’s recommendation for rigorous studies of perinatal care, including aspects other than intensive care, and for longer term, more broadly based assessments of outcome. We do not, however, agree with your

SIR,-We

more

conclusion, drawn from our study, that regionalisation of perinatal care has no effect on outcome. We concluded that regionalisation, at least as indicated by the progressive, selective concentration of very-low-birthweight deliveries into tertiary centres, was strongly associated with the decline in neonatal mortality in both programme and comparison areas in the decade 1970-79. By this indicator, regionalisation had occurred in both programme and comparison areas at a comparable pace. What we unable to demonstrate was the effect of a programme funded to accelerate regionalisation, in part because there were apparently strong pressures, independent of special funding, which fostered regionalisation more broadly. Moreover, besides improving access to tertiary services, such regional networks of perinatal services serving geographically defined populations would appear to be a necessary framework for the types of studies needed. were

specially

Pediatric Epidemiology and Health Services Research, School of Medicine, University of Pennsylvania,

Philadelphia, Pennsylvania 19104,

individuals responsible are no longer around to appreciate it. True prevention is therefore a difficult approach but it should not be ignored because of that. A recent review of the results of mortality data since the mid-century2 indicates that the battle against cancer is being lost and that a shifting of resources to prevention holds the only prospect of achieving the goal of the National Cancer Institute of a 50% reduction in cancer-related mortality by the year 2000.

USA

MARIE C. MCCORMICK SAM SHAPIRO

1. McCormick MC, Shapiro S, Starfield B. The regionalization of

perinatal services: Summary of the evaluation of a national demonstration program. JAMA 1985;

253: 799-804.

PREVENTION OF CERVICAL CANCER p 1095) is. If anaesthetist is actually thinking about the significance of the exploits his surgical colleagues are undertaking on the patients he anaesthetises, who knows where it may lead? He is, of course, quite right. Our efforts in relation to cervical cancer do not involve prevention except in the euphemistic sense of "secondary prevention". This means diagnosing a disease process at an early stage and preventing it from going on to an advanced, untreatable form. It is primary prevention, real prevention, to which Hill directs our attention. Knox, using a computer model and starting from the assumption that some form of infective factor transmitted at intercourse is involved in cervical cancer, forecast how frequency of change of sexual partners would be expected to influence incidence.Reversion to monogamy, in the zoological sense of the term, could be expected to lead to cervical cancer’s virtual disappearance. Perhaps we do live in an age in which doctors are afraid to put a view to the public which carries any suggestion of moralising, even though many lives are at risk. An alternative, and just as unflattering, explanation is that the profession’s inaction relates to finance. In secondary prevention, the "cervicology industry", with its smears, colposcopies, biopsies,

SIR,-How worrying Dr Hill’s letter (May 10,

an

cervicectomies, hysterectomies, freezing, cremating, lasering, and so on-is booming. It provides many incomes, some of them not small. Primary prevention is unlikely to provide anyone with significant income; it does not even carry the expectation of a patient’s gratitude since the individual who avoids a cancer is never aware of the fact. The only reward is statistical-and that is not likely to be available until the

JAMES S. SCOTT

Leeds LS2 9NS

1. Knox EG.

Epidemic cancer of the cervix? In: WolffJ-P, Scott JS, eds. Hormones and sexual factors in human cancer aetiology: European Organisation for Co-operation in Cancer Prevention Studies Symposium. Amsterdam: Excerpta Medica, 1984: 125-38. 2. Bailar JC III, Smith EM. Progress against cancer? N Engl J Med 1986; 314: 1226-32.

EUROPEAN COLLABORATIVE TRIAL OF CHD PREVENTION

SIR,-The details which Professor Jarrett (May 17, p 1154) our April 19 report are in our earlier paper:1 in calculating a summary of risk factor change we took into account age, plasma cholesterol, systolic blood pressure, and body mass index (this index made a trivial contribution). We agree that such a summary is not a good predictor of differences in rates between populations, but this was not our purpose: we used it only to estimate expected differences between factory missed from

pairs within populations. trial of multifactorial intervention the design does not permit rigorous sharing of credit between the different components. We speculate that little of the overall benefit was due to control of overweight (which was poor and ill-sustained) or to antihypertensive therapy (based on the experience of hypertension trials); likewise, compliance with advice on exercise did not seem very impressive, although we lacked an objective measure. This leaves cholesterol-lowering dietary advice and smoking reduction to take most of the credit. In

a

Division of Medical Statistics and Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT

GEOFFREY

ROSE,

Chairman of the Collaborative Group

1. World Health Organisation European Collaborative Group. Multifactorial trial in the prevention of coronary heart disease I: Recruitment and initial findings. Eur Heart J 1980; 1: 73-80.

PRIMARY CARE

SIR,-As a family doctor working the Italian National Health Service, may I comment on the British Government’s discussion document (May 3, p 1044) on primary health care. Some of the proposals in the green-paper deal with policies that the Italian NHS has already implemented, and not without

problems. In the UK "only 45% of a doctor’s pay is related directly to the number of patients on his list", and it is proposed that "this proportion could be increased in order to provide a greater incentive to doctors to practise in ways that will encourage patients to join their lists". In the Italian NHS almost all of a doctor’s pay is related directly to the number of patients on his list, even though the exact amount paid varies a little with the age of the patient (under 12, between 12 and 60, over 60) and with the doctor’s seniority (within 6 years of graduation and between 6 and 13, 13 and 20, and over 20 years). I do not know how simple it is for a patient to register with another doctor in the UK but in Italy all the patient has to do is sign a form at the local NHS office, whenever he or she wishes and without having to give any explanation to anybody. The 100% direct relation between a doctor’s pay and the number of patients on his list, coupled with the absolute freedom patients have to change their doctors, has made family doctors in Italy the equivalent of automatic dispensing

1333 machines. Family doctors

seeing large numbers of patients who, through ignorance, dishonesty, or pathophobia, demand false certificates, the prescription of unnecessary medicines, blood tests, X-rays, and other investigations, specialist consultations, and hospital admission. If the doctor refuses to comply, the patient may change to another doctor, bringing are

MAXIMUM TEMPERATURES AND AVERAGE RAINFALLS: VALLES

OCCIDENTAL, SPAIN

part of the doctor’s pay with him. British primary health care seems to be still in good shape: there is no reason to push it downhill to join Italy’s at the bottom; rather, please, try to help us up, by offering the good example of a sound system. Via Bezzecca 29, 22053 Lecco, Italy

ANTONIO ATTANASIO

MEDICAL EDUCATION IN EAST LONDON

SIR,-We write to correct errors in the letter from Dr Grant, general manager, City and Hackney Health Authority (May 10, p 1100). The North East Thames Regional Health Authority is not insisting that the emergency and accident department at The London Hospital (Mile End) be closed. The district health authority has demonstrated that closure would save little money and would be very inconvenient for patients, and this view has been accepted by the region. The hospital at Mile End houses about two-thirds of the acute general medical admissions and one-third of the acute general surgical admissions to The London Hospital. 64% of these come from Tower Hamlets and a substantial proportion of the remainder come from our neighbouring borough of Newham; the numbers from Newham have increased considerably since the closure of the casualty department at St Andrew’s Hospital, Bow. district

The future of Mile End is an issue because both St Bartholomew’s Hospital Medical College and The London wish to give a substantial amount of clinical teaching to preclinical students at the new Bart’s/London/Queen Mary College (BLQ) preclinical school to be built at Queen Mary College. Mile End has 355 beds, soon to be increased to 475 when the new geriatric unit is built; Bart’s has 713 beds and The London Hospital (Whitechapel) 590. This unit will contain a University Grants Committee funded professorial department of geriatrics; we hope to establish there a joint Bart’s/The London chair of geriatrics or gerontology. With 98 acute medical beds, 40 acute surgical beds, geriatrics (excellent and important for teaching), rheumatology, and orthopaedics, and with full outpatient facilities, this hospital will be quite adequate for providing patients for clinical teaching for the new preclinical medical school to be built a few yards away. Even with the small number of acute beds per 1000 allowed by the region, it would not be possible for all acute services to be transferred to The London Hospital (Whitechapel) without costly rebuilding for more than 250 beds on the Whitechapel site. This is very unlikely to happen, and so Mile End will remain an acute, busy, and viable hospital with a casualty department for many years to come. The regional chairman has guaranteed its existence for at least fifteen years; the fact that it will be part of a big university complex will be a major factor for

its continuity.

JOHN ALWAY,

Tower Hamlets Health Authority The London Hospital Medical London El 2AD

District general manager

College,

M. A.

FLOYER,

Dean

CLIMATIC FACTORS IN RESURGENCE OF MEDITERRANEAN SPOTTED FEVER

SIR,-There has lately been a resurgence in Mediterranean spotted fever in countries bordering the Mediterranean.1-3 Our area of the Valles Occidental (Barcelona, Spain) has experienced this increase,4 the incidence rising from 3-28 per 100 000 inhabitants in 1979

to

19-05 in 1984.

Mediterranean spotted fever is caused by Rickettsia conorii, the dog tick (Rhipicephalus sanguineus) being the vector and main reservoir. The disease peaks during the summer, which coincides with the biological cycle of the tick. We have noticed increases in ticks, amounting to plagues, in both urban and rural areas over the past few years, without detecting any change in hygiene conditions that could explain such increases. Ticks prefer warm weather and their activity increases with rising temperature. In warm climates the ticks can have up to two generations per year. Experimental studies’ have revealed the influence of humidity on ticks. In Rocky Mountain spotted fever the influence of a climatic factor has been suggested.6 Meteorological data show that in the Valles Occidental over the past ten years the summers have got hotter and drier (table). Since the biological cycle and the activity of ticks is influenced by temperature and humidity, it seems logical to relate the climatic changes observed to the resurgence of this tick-borne disease. Have other geographical areas with an increase in tick-borne rickettsiosis experienced similar climatic changes?

Departments of Internal Medicine, Sant Llatzer Hospital, Terrassa, and Mare de Déu de la Salut Hospital, Sabadell, Spain

E. B. F. F.

ESPEJO ARENAS FONT CREUS BELLA CUETO SEGURA PORTA

1. Gross EM, Yagupsky P, Torok V, Goldwassar RA. Resurgence of Mediterranean spotted fever. Lancet 1982; ii: 1107. 2. Scaffidi V. Attuale espansione endemo-epidemica della febre bottonosa in Italia. Minerva Med 1981; 72: 2063-70. 3. Segura LF, Font B. Resurgence of Mediterranean spotted fever in Spain. Lancet 1982; ii: 280. 4. Font-Creus B, Bella-Cueto F, Espejo-Arenas E, et al. Mediterranean spotted fever: a cooperative study of 227 cases. Rev Infect Dis 1985; 7: 635-42. 5. Sonenhine DE. A preliminary report on the humidity behavior of several species of ticks. In: Naegele, JA, ed. Advances in acarology: vol I. Ithaca, NY: Cornell University Press, 1963: 431-34. 6. Woodward WE, Hornick RB. Rickettsia rickettsii (Rocky Mountain spotted fever). In: Mandell GL, Douglas RG Jr, Bennet JE, eds. Principles and practice of infectious diseases, 2nd ed. New York: John Wiley and Sons, 1985: 1082-87.

AEROALLERGENS IN AN ASTHMA OUTBREAK

SIR,-We wish to reply to Dr Morrow Brown’s letter (April 26, p 980) on our study of the role ofaeroallergens in an asthma outbreak in Birmingham during a thunderstorm (April 12, p 850). The clinical details we gave related to the 18 patients we studied who were involved in the asthma outbreak and not to the controls, who were recruited from asthma clinics and so had more troublesome asthma. Although none of the controls could recall being affected during the outbreak, they were examined some months later, and, as Morrow Brown suggests, they may not have been able to recollect accurately their symptoms at the time of the outbreak. Furthermore they were on regular treatment for asthma, which may have masked any symptoms. Ideally the controls would have been atopic asthmatics living in Birmingham who were not on treatment and who definitely had no symptoms at the time of the outbreak-but such a group would have been very difficult if not impossible to find. We agree that the most rigorous test for fungal spore allergy would have been bronchial challenges with mould extracts on