THE STRUGGLE FOR HEALTH

963

of the criticisms levelled at Witzel’s paperl7,18 also apply to all the studies except that of Fleig. Thus the results remain

conflicting and no clear guidelines have emerged. The important message from Munich is that prophylaxis, including prophylactic sclerotherapy, in patients with cirrhosis who have not yet bled from oesophageal varices is not justified other than in controlled clinical trials. Future controlled trials should include only patients at high risk of variceal bleeding and should be designed to stratify for risk factors and have similar follow-up. Treatment of acute variceal haemorrhage should be the same in both groups, including use of sclerotherapy when indicated. Present indications are that prophylactic sclerotherapy is unlikely to improve survival if the best available treatment is used for the first acute variceal bleed.

Department of Surgery, University of Cape Town, and Academic Department of Surgery, Royal Free Hospital, London

JOHN TERBLANCHE

The author acknowledges the support of the Staff Research fund of the University of Cape Town, the South African Medical Research Council, the Ernest Oppenheimer Memorial Trust, and the Royal Society, London.

RH, Chalmers TC, Ishihara AM, et al. A controlled study of the prophylactic A final report. Ann Intern Med 1969, 70: 675-88. 3. Conn HO, Lindenmuth WW, May CJ, Rambsy GR. Prophylactic portacaval anastomosis. A tale of two studies. Medicine 1972; 51: 27-40 4 Terblanche J, Bornman PC, Kahn D, et al. Failure of repeated injection sclerotherapy to improve long-term survival after oesophageal variceal bleeding A five year prospective controlled clinical trial Lancet 1983; ii: 1328-32. 5. The Copenhagaen esophageal varices and sclerotherapy project. Sclerotherapy after first variceal hemorrhage in cirrhosis. N Engl J Med 1984; 311: 1594-600. 6. Westaby D, Macdougall BRD, Williams R. Improved survival following injection sclerotherapy for esophageal varices. Final analysis ofa controlled trial. Hepatology 1985, 5: 827-30. 7. Korula J, Balart LA, Radvan G, et al. A prospective, randomized controlled trial of chronic esophageal variceal sclerotherapy Hepatology 1985; 5: 584-89. 8 Paquet K-J Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices—a prospective controlled trial. Endoscopy 1982, 14: 4-5. 9. Beppu K, Inokuchi K, Koyanagi N, et al Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endoscopy 1981; 27: 213-18 10. Inokuchi K. Prophylactic portal nondecompression surgery in patients with esophageal varices Ann Surg 1984, 200: 61-65. 11. Japanese Research Society for Portal Hypertension. The general rules for recording endoscopic findings on esophageal varices. Jpn J Surg 1980; 10: 84-87. 12. Witzel L, Wolbergs E, Merki H. Prophylactic endoscopic sclerotherapy ofoesophageal varices. A prospective controlled study Lancet 1985; i: 773-75. 13. International symposium on prophylaxis of variceal bleeding, Munich, Jan 24-25, 1986 (abstracts). 14. Terblanche J The long-term management of patients after an oesophageal variceal bleed: The role of sclerotherapy. Br J Surg 1985; 72: 88-90. 15 Macdougall BRD, Westaby D, Theodossi A, Dawson JL, Williams R Increased longterm survival in variceal haemorrhage using injection sclerotherapy Lancet 1982; i: 2. Resnick

portacaval shunt.

124-27. 16. Health and Public

Policy Committee, American College of Physicians. Position paper. Endoscopic sclerotherapy for esophageal varices. Ann Intern Med 1984; 100: 608-10

REFERENCES 17. 1.

Jackson FC, Perrin EB, Smith AG, Dagradi AE, Nudal HM. A clinical investigation of the portacaval shunt. II. Survival analysis of the prophylactic operation. Am J Surg 1968; 115: 22-42.

Occasional Book THE STRUGGLE FOR HEALTH "ON entering these houses you have a fine specimen of the in which the lower orders of Westminster live. Living by day and night in one wretched room, with scarcely any light-an intermittent supply of water, and a shocking foetid atmosphere-full of rags and filth-it is dreadful! In the corner of the room may be seen what may be termed an apology for a bed and bedding, being a mass of rags piled together, in the midst of which are the poor sickly children, whose very countenances bespeak that they will soon cease to trouble their parents; with hair uncombed, barefooted and in rags-with their skin unwashed-the majority of them never live to manhood, while one third of them die before they attain the age of 5 years." Exchange Lagos, Caracas, or Bombay for Westminster in this grim description from 1848 and you have the health problems of the developing world in a nutshell. Poverty, impure water, lack of hygiene, a burgeoning child mortality; is the answer then Victorian plumbing and welfare legislation, plus immunisation? Dr David Sanders in a new bookl on health care worldwide suggests not, but draws fascinating parallels between developments in health in rich and poor countries, and gives pointers from the Third World which should be taken to heart as much in Scotland as in manner

Zimbabwe. In Britain and other developed countries people are healthier now than a hundred years ago mainly because of better nutrition and general living standards. This is well known, but Sanders traces the history of these improvements back firstly to the agricultural revolution, which massively increased food output in the 18th century, and secondly to the industrial revolution, which provided urban employment.

Hamilton G. Prophylactic endoscopic Lancet 1985; i: 1105-06. 18 Hayes PC, Westaby D, Williams R Prophylactic oesophageal varices. Lancet 1985; i: 1106.

Burroughs AK,

sclerotherapy of oesophageal

varices.

endoscopic sclerotherapy

of

Many development experts seek a similar industrial revolution in developing countries but Sanders reminds us that it was partly as a result of this very revolution in England that the colonies became "underdeveloped", a term he insists on using throughout the book rather than the fashionable "developing", to indicate where the blame lies. Industrialisation in the UK required capital, and this came largely from overseas trade-to a considerable extent, from the slave trade. Such a source of revenue is, fortunately, not open to most poor countries today. A positive feature of the industrial era was the popular pressure which led to trades unions, better working conditions, compulsory education, and public health legislation-"People had to fight for improved conditions". The struggle which lies ahead for the masses in underdeveloped countries will be greater because the odds stacked against them are far heavier. Sanders analyses the causes of underdevelopment in a way that is familiar to members of the aid lobby but may be less familiar in health circles; at the heart of the issue is the "dual economy" in poor countries. This term implies that two populations are served by the food producers and the industrial manufacturers (both of which tend to be monopolies, sometimes trans-national ones): the poor majority, mainly rural but increasingly urban, who provide the workforce; and the rich urban elite, who are lavish consumers in the Western style. Enough land is available for all but the food does not reach the poor, either because it is too costly or because the wrong kind is grown (usually a cash crop). For example, "In Senegal, desert has been irrigated so that multinational firms can grow eggplant and mangoes for Europe’s wealthy ... in Costa Rica the beef export business expands as local consumption of meat and dairy products decline." So next time you buy a melon or a pineapple, check that it was not grown in a famineridden country. Turning to the health services, Sanders covers familiar ground in analysing the curative and urban orientation of the colonial system and its successors in underdeveloped countries. He enters a more provocative arena in discussing the growth of the health professions in Britain. Women were excluded from the profession from the

964 earliest days, first and most drastically by burning (the fate of those early traditional healers, better known as witches); later by forbidding midwives to use forceps; and in Florence Nightingale’s day by reinforcing women’s subservient role (Nightingale on women doctors: "They have tried to be men, and have succeeded only in being third rate men"). The early bias in the profession towards curative care is ascribed to the commodity nature of health care, a commodity being something that can be sold for money. The commodity which doctors possess (and on which, in a freeenterprise society, their profits depended) is their access to a unique body of knowledge, or rather knowledge of the body. In Sanders’ analysis, doctors control the production of their commodity and jealously guard its character and distribution. It would not then be in their interests to identify the causes of ill-health (especially the social causes), because these are outwith their control. Once such a system based on the withholding of knowledge has become established within professional traditions, it is hard to challenge or reform; the system becomes equally entrenched in rich and poor countries alike.

As a result of these deliberations, Sanders believes that doctors are much more part of the problem of underdevelopment than of its solution. He even includes the idealistic expatriate health worker in the problem category: this person may "become the unwitting agent of medical big business". The worker (whether doctor, nurse, or paramedic) will tend to mix with the medical elite who "do not challenge the social order that produces ill-health"; he will not usually speak the language of the poor, nor easily identify with their

struggle. Nevertheless, the book ends on a positive note. Having discussed at length the means by which poor countries can

In

England Now

"I AM sure, Watson, that you have read The Lancet of March 22 and seen the letter on page 684 from the chairman of the Medical Group of the Publishers Association. He says that the average price of a medical textbook is 20, and he telephoned an elderly Scottish psychiatrist, whose mental hospital is being closed down, to confirm that this is not a great sum of money for a doctor to afford." "I’m not sure that I follow you, Holmes. As I recall, the publisher telephoned a colleague in the medical profession to find out what else a doctor might spend f20 on and was given the following listtwo bottles of whisky, one shirt, a compact disc recording of Mahler’s 9th symphony, 35 days of antidepressants, half an ultrasound scan, 20 litres of antacid, eight courses of anti-bacterials, one-third ofaconsultant session, half a day of nursing sister, and one outpatient attendance. How do you know he is a Scottish

psychiatrist?" "Elementary my dear Watson! In the last account from your wine merchant, ordinary blended whisky costs less than f8abottle, and a who spends £ 20 on two bottles must be drinking a single malt regularly and has received his education in Scotland. His need for antidepressants and antacids shows he is worried, while his familiarity with these medicines points to someone versed in the treatment of mental distress. No surgeon would spend his money like this but would buy two new scalpels. A psychiatrist who has at his fingertips the cost of nursing services, consultants, and outpatients has clearly been asked by his new manager to close his man

for his patients with limited assistance in the Not a task you would welcome yourself Watson! His new shirt, which he bought to make a good impression at the committee that argued against this change made no difference. He went home to console himself with Mahler’s 9th. His possession ofa a compact disc player, but acceptance of half an ultrasound scan, means that like many of us older people he is trying to come to terms with high technology, but has not yet mastered it. Have you thought of the curious business of half an ultrasound scan?"

wards and

community.

care

their people’s health (the answer being primary health care, social mobilisation, and the politicised village health worker), Sanders provides very useful pointers for health workers abroad-pointers which might well be taken to heart closer to home. Rather than emulate the imperialist Albert Schweitzer, whose photograph opens the book with the caption (from an advertisement by a development agency): "You won’t be the first long haired idealist to go into the jungle and teach his skills," the expatriate health worker should (a) help to develop a genuine community health worker scheme (b), show solidarity with the people and demystify medical knowledge, and (c) collect local disease statistics and relate them to social conditions. Clearly there are equally strong lessons to be drawn for doctors in developed countries assuming you agree, as I do, with Sanders’ admittedly radical analysis. The book has its irritations: the layout lacks logic, the facts about China and Cuba may be somewhat selective, and the references are confusing (ibid is very widely cited!). The illustrations are a delight, and a moral in themselves, from Dr Kildare as the flash and fashionable doctor of the ’60s, to village health workers in Bangladesh performing tubectomy (with a lower infection rate than doctors). Read it, as a guide not only to famine in Africa and its antecedents, but also to the reasons why London women demonstrated against the suspension of Dr Wendy Savage.

improve

Raeden 1. The

TONY WATERSTON

Centre, Aberdeen

Struggle for Health. David Sanders with Richard Carver. Basingstoke. Macmillan. Pp 232. £2.95 (paperback); £12.00 (hardback).

1985.

"I don’t

understand, Holmes."

"Telephone your friends in Scotland to find a hospital where an ultrasound scanner broke down half way through an examination of a patient from a mental hospital, and it will be easy to identify the doctor. We can then get him proper advice on how to spend his money before it is too late and he becomes enmeshed in fraud. "Good Lord, Holmes, I am lost in admiration. I’ll get on to it right

away." *

*

*

I LEARNED a lot in the RAMC. Among other things, not to use a word which is still in common parlance. For a time I was medical officer to a large Victorian barracks, situated near the centre of one of our famous cities. It was an interesting place. A high stone wall encircled it, blocking the view of the myriads of people who passed by. Inside were the trappings of a standard military establishment. From sleeping huts to canteens and from parade ground to a motor pool. But in addition it had a gaol, a church, a school, stables, and a hospital. The soldiers therein were many and varied: infantry and cavalry, gunners and engineers; teachers and transporters. There was a detachment of red-capped military police together with a mysterious group who I was told not to recognise if they crossed my path wearing different uniforms and other badges of rank. I was the only doctor. Late one afternoon a soldier from the gaol was marched in to my MI room at the double. "He is a malingerer," said the senior of the two escorts. A malingerer, I thought! If there is one thing I cannot stand, it is a malingerer. I will soon send him about his business. In ill humour I told him to undress and started my examination. Thank goodness I obeyed my old chiefsgolden rule: eyes, hands, and stethoscope first-brains later. He had a massive pleural effusion. I admitted the lad to hospital immediately and three days later he was in a sanatorium. From that day to this, I have never again used the word malingerer.