- Email: [email protected]
TIME IS THE ESSENCE
1203
This hospital is not in the centre of a busy city, nor is waiting-times are significantly reduced when appointments are given for both return and new patients. its casualty department overburdened with work. I feel New patients are seen more quickly, there being fewer though that these findings speak for themselves, that the people in the waiting-room at any one time. As can be system is easily capable of adaptation to busier departments with more staff; and I believe that the increase in seen from fig. 4, this is not due to any decrease in treatment times. There have been no complaints yet from efficiency will be as noticeable as it has been here. were not the SUMMARY 60% system, liking punctual, and, patients cannot an who An increasingly, patients keep appointment appointments system can be designed for return to the trouble to it. are taking telephone change Certainly patients to a casualty department. With this system, is the to the system easy run, necessary paper-work being waiting-times are reduced, hours of peak loading become done by the nurse who attends to the patient. rare, less nursing staff required, and the efficiency of the As far as efficiency is concerned, this can be measured department is increased. I thank Mr. E. R. Guest, departmental charge-nurse, and the in three ways: (1) less staff required to do the same amount sister and nursing staff in the department without whose help this of work; (2) a decrease in waiting-times; and (3) an even survey could not have been attempted. workload throughout the day. REFERENCES Before November, 1964, it was necessary for the Abson, E. P., Caro, D. B. (1965) Lancet, i, 1158. maximum amount of staff to be on duty by 9 A.M. each Blanco White, M. J., Pike, M. C. (1964) Med. Care, 2, 133. With Hospitals?; p. 15. London. Cohen, G. L. (1964) What’s day. The waiting-room presented a familiar and depress- Manning, D. P., Pugh, W. V.Wrong N. (1964) Lancet, i, 604. Provincial Hospitals Trust (1965) Waiting in Outpatient Departing picture with standing-room only; by lunchtime Nuffield ments. London. tempers would be frayed. The afternoons were com- Patients Association (1964) Analysis of Complaints. London. paratively peaceful. Now the department is rarely swamped with arrivals except when there is a seriously ill Occasional Book patient requiring prolonged attention. In addition, the work has not remained static but has increased by 3842 TIME IS THE ESSENCE ... (15%) patient-visits over 1964, and yet there has been a saving of 69 nurse-hours per week. THIS survey of man’s views of time1 is a remarkable As far as the second criterion is concerned, more than book. The subject is dauntingly difficult, and its difficul50°of patients are seen in 5 minutes, an increase of 1700 ties are nowhere disguised. It covers a vast range of over the figures for the department before the system was human feeling and thought, and extends into some of the introduced. most obscure areas of recent scientific discovery. It consists of 27 essays by different authors, yet it preserves an One of the main bugbears of any casualty department is the so-called mass emergency, which is not necessarily unusual sense of artistic unity which it clearly owes to the a time when many seriously injured are present, but is an editor, Dr. J. T. Fraser. He conceived it, gathered aggregate of medical or social emergency situations in the together a number of experts as contributors, provided a same time and the same place (Abson and Caro 1965). It unifying thread of his own interpolated reflections and some beautiful illustrations, and dedicated the outcome is of these that hours of peak loading are formed. Each situation is time-consuming so that there is a build-up of " to those who have shared my restless search for the work which may be carried over throughout the day. This meaning of time". In his introduction he explains that situation can be dealt with by providing more medical staff, the book is not the record of an achievement so much as the stimulus to an enterprise. or by spreading that part of the load that can be spread. Appropriately, it begins with the past. A. Cornelius Benjamin In the present case, the improvement in the distribution writes on ideas of time in the history of philosophy, J. L. Russell of patient-arrivals is disappointing (fig. 1). The reasons on time in Christian thought, Hajime Nakamura on time in for this could have been that too many patients had been Indian and Japanese thought, and Joseph Needham on time booked for the morning, or that afternoon patients were and knowledge in China and the West. The first part of the coming early. Earliness is as much a nuisance as lateness, book ends with an essay by S. G. F. Brandon on time and the since patients are seen in order of arrival; and early destiny of man. He suggests that the representation of a dancer patients may therefore find that they wait longer than if on the wall of a cave by palaeolithic man was an attempt to conthey had arrived on time. Similarly, those arriving on the serve the magical efficacy of the dance by depicting it in permanent form. This picture, therefore, was a prototype of a wrong day will add to the designed load. Unpunctuality show that
total of 20-8% of those seen in the 2-week survey (table ill). The ideal would be when all patients were punctual or rang to change an appointment, but this is unattainable. Among other factors, this hospital is a quarter of a mile from the nearest bus stop, and the service is infrequent. Human nature is an additional factor. In their investigation into the effect of patients’ unpunctuality on outpatient appointment systems, Blanco White and Pike (1964) argued that since the doctor has a variable consultation time, and can therefore rarely see any patient exactly on time, punctuality to the minute is unnecessary. While patients should always be encouraged to be punctual, they should in any case be dealt with as efficiently as possible, and the system designed accordingly. Consequently, it is intended in future to book only 5 patients per hour in the mornings, and 7 per hour in the afternoons. This ratio can be further adjusted if necessary.
affected
a
form of human faith and practice which may be described as the ritual perpetuation of the past. He ends his essay with a section on the Dilemma of Western Thought, in which he notes " the gradual replacement of this essentially theological estimate of the temporal process of the drama of Man’s destiny under the hand of God, by the evaluation authorised by science". This leads to a hiatus between the verdict of our science and of our instincts which is responsible for " that spiritual malaise which afflicts our culture, and, inevitably, our personal lives ". The second part of the book begins with essays on time in language and literature, by C. F. P. Stutterheim, and on rhythm in music, by Walter Durr. Jean Piaget writes on time perception in children, and M.-L. Von Franz on time and synchronicity in analvtic psychology. This last essay, together with a note on synchronicity by Fraser, cannot at present be harmonised with current scientific concepts. The word synchronicity was used by Jung to describe a non-temporal type of causal relationship 1.
The
Voices of Time: A
co-operative survey of man’s
views
of
time as
understood and described by the sciences and by the humanities. Edited by J. T. FRASER. New York: George Braziller. 1966. Pp. 710. S12.50.
1204 ithe impossibility of constructing space-time models for microwhich might explain, among other things, meaningful coincidences. physical systems". Quantisation, of course, means that changes The psychoanalysts, whose views on time are discussed byat this level are discontinuous and occur, as it were, in packets, Joost A. M. Meerloo in an essay on the time sense in psychiatry, which suggests the probability that " space and time themhold that the unconscious has no conception of time as duration selves are, in the very small, not mathematically continuous, and continuity. For man, time symbolises the compelling and but discrete ". Time, as we understand it, therefore, may be a intruding external forces that offend his infantile feeling of concept applicable only to macroscopical systems, leading to magic omnipotence. Time is considered as submission to, or the strange paradox that it may not mean the same thing where we have to deal with minute constituents of which those larger revolt against, paternal commands, as money, as boredom, as the sexually desired parent, as the beloved, as creation, and as systems are composed. the process which ends inevitably in death. Subjective time is Richard Schlegel writes on time and thermodynamics, and discussed from the psychological standpoint by John Cohen, discusses the meaning of entropy increase for cosmology, who describes laboratory experiments on the estimation of which leads him to consider the fundamental question whether duration and the relationship between time, speed, and space; time is constitutive or relational. Should we regard time " as " and also considers the symbolism of time in myth and art. physically prior to events, and regulative of them " or is time In part three, which deals with time and life, Karl C. a concept, or universal property, that we construct to our Hamner discusses the experimental evidence for the biological experience " ? It may ultimately be possible to settle this clock, and J. L. Cloudsley-Thompson the time sense of animals. question by installing an atomic clock in an artificial satellite. These essays set out recent work on the internal rhythms of Satousi Watanabi in his essay on time and the probabilistic animals as shown, for example, in diurnal variations in view of the world considers the implications of a probabilistic behaviour, and the dependence of migrating birds on their view of causality. " Becoming," he says, " implies creative time-sense in orientating themselves in relation to the sun or action, pregnant with purpose, fortified by volition and, above the stars. In his essay on biochemical considerations of time all, nurtured with freedom and guided by knowledge. Our Hudson Hoagland gives evidence that in man the rate at which temporal experience of life is precisely a one-way chain of time appears to move is influenced by temperature and ’becoming’ in this sense." Perhaps the lower animals, he metabolism. Time may appear to move more quickly in age suggests, are not living in time as we are, nor are the robot and than in youth because in age metabolic processes, and with computer, because they are blindly obeying the predestined them the subjective internal clock, go more slowly. But, in programmes. " Time is awakened when one is faced with freegeneral, biological clocks are remarkably independent of dom of choice." Space," he concludes, " is the vehicle of detertemperature, otherwise they would not be so reliable. Precisely mination and being, time is the vehicle of freedom and value." how they work and how they are compensated for temperature The penultimate essay on time and the universe, by G. J. changes is unknown; since biological clocks are found in Whitrow, deals with the origin of time, the age of the universe, unicellular organisms, they may exist in every cell of a multiand the implications of its expansion. There is no need, he cellular organism. Writing on organic evolution and time, Hans says, to accept a basically timeless view of physical reality, but, Kalmus discusses the time-scale of evolution and the rate of again, in speaking of a common cosmic time, we must restrict evolutionary change of living organisms. Taking evolution as ourselves to macroscopic events. Whether everything can be a stochastic process, he discusses its directional character and subsumed under a universal time order is an open question. possible explanations of its irreversibility. He concludes that The editor has the last word. Pleading for the recognition of the concept of organic evolution presupposes the idea of time chronosophy, to designate the interdisciplinary and normative as something unidirectional. study of time, he makes the important suggestion " that a Roland Fischer, in his essay on biological time and the contriworld model which can accommodate not only our biological bution of the nervous system and perception to our psychofunctions or bodies, but also the operational characlogical differentiation between space and time, maintains that teristics of the brain, should not beunique sought through constructhe spatial and temporal components of the space-time events tions of higher spaces but through an improved understanding about which judgments are made are psychologically interof the temporal, as well as the quasi-spatial, aspects of dependent. " As a spider excretes his web," he writes, we time ".strictly With enriching insight he ends with a brief sketch of excrete our dimensions of existence, space-time, to catch as the late autumn landscape in which the last words of the book much world in it as we can." are being written, and which speak to him of a world " whose Part four, on time and matter, begins with a review of contents and properties we may experience, contemplate, and methods of measuring time from a mechanical clock to atomic but never completely describe or precisely formulate ". clocks, by H. Allen Lloyd, which is followed by essays on time share, This book should appeal to many tastes. Those who in relativity theory by Olivier Costa de Beauregard, Milic a want comprehensive review of the current scientific Capek, and Herbert Dingle. The special theory of relativity raises problems which puzzle many people when it deals with approach to time will find it here, but its wide scope caters the measurement of space and time made by two observers in for many other tastes from the eschatology of ancient relative motion to one another, and has led some people to religions to modern cosmology, from horology to physioconceive of the universe as a four-dimensional continuum in logical clocks, from the quantum theory and antimatter to which the dimension of time has much the same status as those the general and special theories of relativity, from psychoof space. On this view, the future may be said to exist already " logy and psychoanalysis to attempts to explain coinciand " coming into being is only coming into awareness ". ". As the editor recognises, in dealing with so vast Capek, however, maintains that " the relativistic union of space dences and all-embracing a subject there must be some gaps. with time is far more appropriately characterised as a dynamisation of space rather than a spatialisation of time ". Becoming, Perhaps in a future edition he will find room for an essay therefore, is real, but Capek remarks " how complex and diffi- on memory, which surely is fundamental to our awareness cult the problem of correct interpretation of the relativistic of time. If we were aware only of the current instant, we fusion of space and time still is ". could have no conception of time, but even to have In the essay by E. J. Zimmerman on time and quantum memories is not enough, for having a memory is a present theory fresh problems arise. He says that the distinction state, and we recognise it as a memory only because it has between microscopic and macroscopic measurements is so the quality of pastness. It can be argued, therefore, that fundamental " that it can be questioned whether it is valid to human consciousness must have an extended duration in conceive of an atom as composed of parts in spatial and temporal relation to each other ". The three general features of time to enable it to distinguish successiveness, and hence the quantum theory, he suggests, are " the existence of arrive at the idea of time itself. Be that as it may, we are quantization, the essential use of probability statements, and still far from any acceptable explanation of memory, and "
"
1205
the obstacles in the way of thinking of it, either as based upon reverberating neuronal circuits or molecular changes, are at present so great that one wonders whether we may not need some new interpretative concept, the nature of which we cannot at present foresee. Perhaps the most fundamental issue raised in this book is whether time is something fundamental to the universe, so that all that happens must have some temporal quality, or whether it is only a way of describing relations between events. If the latter is true, though time enters into our description of macroscopic physical events (but not in the same way into events at the quantum-level), this does not exclude the possibility that there may be relations between physical events in the description of which time plays no part. " Time," the lawyers say, " is the essence of a contract." Is time a mode of existence, or its essence ? BRAIN.
Intercepted
Letters
WHAT IS HEALTH EDUCATION? Dr.
Kalinga Zongo,
Director of Medical Services, Overseasia. DEAR K. Z. In your last letter you ask me: " what is health education " ? You say you are putting this question to a whole lot of different people, and you will certainly get a whole lot of different answers. If your correspondents spell it with a capital H and a capital E, they may insist that it is a new concept, and they will probably concentrate on audiovisual techniques. From their description some of the duties of the health educationist may be difficult to differentiate from those of community developers and other social or welfare workers. But I prefer to look on health education as a medical way of life. Let us go back to Hippocrates. " Life is short. Art is long, opportunity fleeting, experience treacherous, judgment difficult. The physician must be ready not only to do his duty himself, but also to secure the cooperation of the patient, of those about him, and of his surroundings." The second part of this aphorism is less well known and less trenchant than the first, but it is just It indicates the whole scope of health as important.
education. Medicine used to maintain an unvarying priority: service, teaching, and research. (Nowadays it is true that the plums and the bouquets mostly go to research, but that may pass.) Teacher after all is what " doctor " means, and the taught should be the patient and his parents, your personnel, and the public-what my students called the 4 Ps system. And of course there is the eternal obligation to go on teaching oneself, and that is research. In fact a fifth P for personal. Education of patients and parents (or other attendants) demands continuity. The generic type of family doctor knew his patients, their relatives, homes, and work, and in the main their anxieties. When he was called in to see the
ten-year-old with whooping-cough, he
only confirmed the diagnosis and prescribed belladonna and bromides, he advised bed rest, bland diet, and segregation from the infant brother. The infant-mortality rate in England and Wales was reduced from 150 in 1900 to 30 in 1950 mainly thanks to personal care from doctors, nurses, and health visitors, not to lectures and audiovisual aids. not
The education of personnel must help them to correlate disease with the things that produce it, to realise that treatment and prevention must go hand-in-hand when we are dealing with people, and that follow-up is essential. Otherwise we will go on wasting a great deal of medical effort and cohorts of variegated manpower. Nowadays doctors and nurses are mainly educated in institutions by specialists who concentrate on one small area of the patient. The ornithologists have long recognised that they cannot learn much by studying birds in cages. But doctors and nurses are still doing just that. It is to compensate for the defects of the purely institutional outlook that so many non-medical workers are now being brought in to the medical services. Besides knowing the material context in which diseases develop and patients live and die, we must observe attitudes and disciplines. It is quite out of fashion to talk about ethics or morals. But as Chesterman once remarked1 it is easy enough to teach medical personnel the facts of physiology and pharmacology, but much more difficult to teach them to be honest with their drugs and kind to their patients. It is frankly impossible to achieve health or education if you shirk ethics and responsibility. As for educating the public, we are still pretty incompetent. Advertising methods can stimulate appetite, but they rarely teach wisdom. We are notably unsuccessful, for example, in selling fluoridation, no smoking, and keeping Britain tidy. I know you are particularly interested in family planning. Mayone Stycos2 believes that for a birth-control programme in an overpopulated area " audiovisual material holds out more promise of success than doctors, nurses, and social workers ". Yet later on in the same article he suggests that the comparatively moderate birth-rates of Britain and the United States are due to " responsibility and persistence of individuals rather than to governments, voluntary organisations or to physicians ". There is urgent need for research into the efficacy of mass programmes compared with those that depend on satisfied patients and doing good by stealth. My impression is that where family planning is offered as a routine service in a well-organised maternity and child-health section it is more effective than when it is loudly, vigorously, and independently presented. People are not easily interested in a mass problem unless it affects them personally. They are deeply preoccupied with their own concerns. Ten words to the individual are more effective than ten thousand to the mass. So much of what is now taken for granted in a sophisticated country has to be introduced as health education in a less developed area. When I work in an economically developing area, I expect to spend much more of my time in teaching at every level, and there is much less time for
it, so teaching has to be simple, specific, concise, highly selective, and convincing. The type and the quantity of the education must be made to measure, just as much as any other form of prescription. All this is very hard work. As for educating oneself, that is the fifth p, I believe it is the duty of every child to educate his parents. So I expect my patients, my pupils, and the public to educate This is research. I could summarise all this letter in two sentences. Health education is a way of life; health education is me too.
listening. Yours sincerelv, CICELY D. WILLIAMS. 1. 2.
Chesterman, C. C. J. trop. Med. Hyg. 1953, 56, 123. Stycos, J. M. Fam. Plann. 1966, 14, 88.
This hospital is not in the centre of a busy city, nor is waiting-times are significantly reduced when appointments are given for both return and new patients. its casualty department overburdened with work. I feel New patients are seen more quickly, there being fewer though that these findings speak for themselves, that the people in the waiting-room at any one time. As can be system is easily capable of adaptation to busier departments with more staff; and I believe that the increase in seen from fig. 4, this is not due to any decrease in treatment times. There have been no complaints yet from efficiency will be as noticeable as it has been here. were not the SUMMARY 60% system, liking punctual, and, patients cannot an who An increasingly, patients keep appointment appointments system can be designed for return to the trouble to it. are taking telephone change Certainly patients to a casualty department. With this system, is the to the system easy run, necessary paper-work being waiting-times are reduced, hours of peak loading become done by the nurse who attends to the patient. rare, less nursing staff required, and the efficiency of the As far as efficiency is concerned, this can be measured department is increased. I thank Mr. E. R. Guest, departmental charge-nurse, and the in three ways: (1) less staff required to do the same amount sister and nursing staff in the department without whose help this of work; (2) a decrease in waiting-times; and (3) an even survey could not have been attempted. workload throughout the day. REFERENCES Before November, 1964, it was necessary for the Abson, E. P., Caro, D. B. (1965) Lancet, i, 1158. maximum amount of staff to be on duty by 9 A.M. each Blanco White, M. J., Pike, M. C. (1964) Med. Care, 2, 133. With Hospitals?; p. 15. London. Cohen, G. L. (1964) What’s day. The waiting-room presented a familiar and depress- Manning, D. P., Pugh, W. V.Wrong N. (1964) Lancet, i, 604. Provincial Hospitals Trust (1965) Waiting in Outpatient Departing picture with standing-room only; by lunchtime Nuffield ments. London. tempers would be frayed. The afternoons were com- Patients Association (1964) Analysis of Complaints. London. paratively peaceful. Now the department is rarely swamped with arrivals except when there is a seriously ill Occasional Book patient requiring prolonged attention. In addition, the work has not remained static but has increased by 3842 TIME IS THE ESSENCE ... (15%) patient-visits over 1964, and yet there has been a saving of 69 nurse-hours per week. THIS survey of man’s views of time1 is a remarkable As far as the second criterion is concerned, more than book. The subject is dauntingly difficult, and its difficul50°of patients are seen in 5 minutes, an increase of 1700 ties are nowhere disguised. It covers a vast range of over the figures for the department before the system was human feeling and thought, and extends into some of the introduced. most obscure areas of recent scientific discovery. It consists of 27 essays by different authors, yet it preserves an One of the main bugbears of any casualty department is the so-called mass emergency, which is not necessarily unusual sense of artistic unity which it clearly owes to the a time when many seriously injured are present, but is an editor, Dr. J. T. Fraser. He conceived it, gathered aggregate of medical or social emergency situations in the together a number of experts as contributors, provided a same time and the same place (Abson and Caro 1965). It unifying thread of his own interpolated reflections and some beautiful illustrations, and dedicated the outcome is of these that hours of peak loading are formed. Each situation is time-consuming so that there is a build-up of " to those who have shared my restless search for the work which may be carried over throughout the day. This meaning of time". In his introduction he explains that situation can be dealt with by providing more medical staff, the book is not the record of an achievement so much as the stimulus to an enterprise. or by spreading that part of the load that can be spread. Appropriately, it begins with the past. A. Cornelius Benjamin In the present case, the improvement in the distribution writes on ideas of time in the history of philosophy, J. L. Russell of patient-arrivals is disappointing (fig. 1). The reasons on time in Christian thought, Hajime Nakamura on time in for this could have been that too many patients had been Indian and Japanese thought, and Joseph Needham on time booked for the morning, or that afternoon patients were and knowledge in China and the West. The first part of the coming early. Earliness is as much a nuisance as lateness, book ends with an essay by S. G. F. Brandon on time and the since patients are seen in order of arrival; and early destiny of man. He suggests that the representation of a dancer patients may therefore find that they wait longer than if on the wall of a cave by palaeolithic man was an attempt to conthey had arrived on time. Similarly, those arriving on the serve the magical efficacy of the dance by depicting it in permanent form. This picture, therefore, was a prototype of a wrong day will add to the designed load. Unpunctuality show that
total of 20-8% of those seen in the 2-week survey (table ill). The ideal would be when all patients were punctual or rang to change an appointment, but this is unattainable. Among other factors, this hospital is a quarter of a mile from the nearest bus stop, and the service is infrequent. Human nature is an additional factor. In their investigation into the effect of patients’ unpunctuality on outpatient appointment systems, Blanco White and Pike (1964) argued that since the doctor has a variable consultation time, and can therefore rarely see any patient exactly on time, punctuality to the minute is unnecessary. While patients should always be encouraged to be punctual, they should in any case be dealt with as efficiently as possible, and the system designed accordingly. Consequently, it is intended in future to book only 5 patients per hour in the mornings, and 7 per hour in the afternoons. This ratio can be further adjusted if necessary.
affected
a
form of human faith and practice which may be described as the ritual perpetuation of the past. He ends his essay with a section on the Dilemma of Western Thought, in which he notes " the gradual replacement of this essentially theological estimate of the temporal process of the drama of Man’s destiny under the hand of God, by the evaluation authorised by science". This leads to a hiatus between the verdict of our science and of our instincts which is responsible for " that spiritual malaise which afflicts our culture, and, inevitably, our personal lives ". The second part of the book begins with essays on time in language and literature, by C. F. P. Stutterheim, and on rhythm in music, by Walter Durr. Jean Piaget writes on time perception in children, and M.-L. Von Franz on time and synchronicity in analvtic psychology. This last essay, together with a note on synchronicity by Fraser, cannot at present be harmonised with current scientific concepts. The word synchronicity was used by Jung to describe a non-temporal type of causal relationship 1.
The
Voices of Time: A
co-operative survey of man’s
views
of
time as
understood and described by the sciences and by the humanities. Edited by J. T. FRASER. New York: George Braziller. 1966. Pp. 710. S12.50.
1204 ithe impossibility of constructing space-time models for microwhich might explain, among other things, meaningful coincidences. physical systems". Quantisation, of course, means that changes The psychoanalysts, whose views on time are discussed byat this level are discontinuous and occur, as it were, in packets, Joost A. M. Meerloo in an essay on the time sense in psychiatry, which suggests the probability that " space and time themhold that the unconscious has no conception of time as duration selves are, in the very small, not mathematically continuous, and continuity. For man, time symbolises the compelling and but discrete ". Time, as we understand it, therefore, may be a intruding external forces that offend his infantile feeling of concept applicable only to macroscopical systems, leading to magic omnipotence. Time is considered as submission to, or the strange paradox that it may not mean the same thing where we have to deal with minute constituents of which those larger revolt against, paternal commands, as money, as boredom, as the sexually desired parent, as the beloved, as creation, and as systems are composed. the process which ends inevitably in death. Subjective time is Richard Schlegel writes on time and thermodynamics, and discussed from the psychological standpoint by John Cohen, discusses the meaning of entropy increase for cosmology, who describes laboratory experiments on the estimation of which leads him to consider the fundamental question whether duration and the relationship between time, speed, and space; time is constitutive or relational. Should we regard time " as " and also considers the symbolism of time in myth and art. physically prior to events, and regulative of them " or is time In part three, which deals with time and life, Karl C. a concept, or universal property, that we construct to our Hamner discusses the experimental evidence for the biological experience " ? It may ultimately be possible to settle this clock, and J. L. Cloudsley-Thompson the time sense of animals. question by installing an atomic clock in an artificial satellite. These essays set out recent work on the internal rhythms of Satousi Watanabi in his essay on time and the probabilistic animals as shown, for example, in diurnal variations in view of the world considers the implications of a probabilistic behaviour, and the dependence of migrating birds on their view of causality. " Becoming," he says, " implies creative time-sense in orientating themselves in relation to the sun or action, pregnant with purpose, fortified by volition and, above the stars. In his essay on biochemical considerations of time all, nurtured with freedom and guided by knowledge. Our Hudson Hoagland gives evidence that in man the rate at which temporal experience of life is precisely a one-way chain of time appears to move is influenced by temperature and ’becoming’ in this sense." Perhaps the lower animals, he metabolism. Time may appear to move more quickly in age suggests, are not living in time as we are, nor are the robot and than in youth because in age metabolic processes, and with computer, because they are blindly obeying the predestined them the subjective internal clock, go more slowly. But, in programmes. " Time is awakened when one is faced with freegeneral, biological clocks are remarkably independent of dom of choice." Space," he concludes, " is the vehicle of detertemperature, otherwise they would not be so reliable. Precisely mination and being, time is the vehicle of freedom and value." how they work and how they are compensated for temperature The penultimate essay on time and the universe, by G. J. changes is unknown; since biological clocks are found in Whitrow, deals with the origin of time, the age of the universe, unicellular organisms, they may exist in every cell of a multiand the implications of its expansion. There is no need, he cellular organism. Writing on organic evolution and time, Hans says, to accept a basically timeless view of physical reality, but, Kalmus discusses the time-scale of evolution and the rate of again, in speaking of a common cosmic time, we must restrict evolutionary change of living organisms. Taking evolution as ourselves to macroscopic events. Whether everything can be a stochastic process, he discusses its directional character and subsumed under a universal time order is an open question. possible explanations of its irreversibility. He concludes that The editor has the last word. Pleading for the recognition of the concept of organic evolution presupposes the idea of time chronosophy, to designate the interdisciplinary and normative as something unidirectional. study of time, he makes the important suggestion " that a Roland Fischer, in his essay on biological time and the contriworld model which can accommodate not only our biological bution of the nervous system and perception to our psychofunctions or bodies, but also the operational characlogical differentiation between space and time, maintains that teristics of the brain, should not beunique sought through constructhe spatial and temporal components of the space-time events tions of higher spaces but through an improved understanding about which judgments are made are psychologically interof the temporal, as well as the quasi-spatial, aspects of dependent. " As a spider excretes his web," he writes, we time ".strictly With enriching insight he ends with a brief sketch of excrete our dimensions of existence, space-time, to catch as the late autumn landscape in which the last words of the book much world in it as we can." are being written, and which speak to him of a world " whose Part four, on time and matter, begins with a review of contents and properties we may experience, contemplate, and methods of measuring time from a mechanical clock to atomic but never completely describe or precisely formulate ". clocks, by H. Allen Lloyd, which is followed by essays on time share, This book should appeal to many tastes. Those who in relativity theory by Olivier Costa de Beauregard, Milic a want comprehensive review of the current scientific Capek, and Herbert Dingle. The special theory of relativity raises problems which puzzle many people when it deals with approach to time will find it here, but its wide scope caters the measurement of space and time made by two observers in for many other tastes from the eschatology of ancient relative motion to one another, and has led some people to religions to modern cosmology, from horology to physioconceive of the universe as a four-dimensional continuum in logical clocks, from the quantum theory and antimatter to which the dimension of time has much the same status as those the general and special theories of relativity, from psychoof space. On this view, the future may be said to exist already " logy and psychoanalysis to attempts to explain coinciand " coming into being is only coming into awareness ". ". As the editor recognises, in dealing with so vast Capek, however, maintains that " the relativistic union of space dences and all-embracing a subject there must be some gaps. with time is far more appropriately characterised as a dynamisation of space rather than a spatialisation of time ". Becoming, Perhaps in a future edition he will find room for an essay therefore, is real, but Capek remarks " how complex and diffi- on memory, which surely is fundamental to our awareness cult the problem of correct interpretation of the relativistic of time. If we were aware only of the current instant, we fusion of space and time still is ". could have no conception of time, but even to have In the essay by E. J. Zimmerman on time and quantum memories is not enough, for having a memory is a present theory fresh problems arise. He says that the distinction state, and we recognise it as a memory only because it has between microscopic and macroscopic measurements is so the quality of pastness. It can be argued, therefore, that fundamental " that it can be questioned whether it is valid to human consciousness must have an extended duration in conceive of an atom as composed of parts in spatial and temporal relation to each other ". The three general features of time to enable it to distinguish successiveness, and hence the quantum theory, he suggests, are " the existence of arrive at the idea of time itself. Be that as it may, we are quantization, the essential use of probability statements, and still far from any acceptable explanation of memory, and "
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the obstacles in the way of thinking of it, either as based upon reverberating neuronal circuits or molecular changes, are at present so great that one wonders whether we may not need some new interpretative concept, the nature of which we cannot at present foresee. Perhaps the most fundamental issue raised in this book is whether time is something fundamental to the universe, so that all that happens must have some temporal quality, or whether it is only a way of describing relations between events. If the latter is true, though time enters into our description of macroscopic physical events (but not in the same way into events at the quantum-level), this does not exclude the possibility that there may be relations between physical events in the description of which time plays no part. " Time," the lawyers say, " is the essence of a contract." Is time a mode of existence, or its essence ? BRAIN.
Intercepted
Letters
WHAT IS HEALTH EDUCATION? Dr.
Kalinga Zongo,
Director of Medical Services, Overseasia. DEAR K. Z. In your last letter you ask me: " what is health education " ? You say you are putting this question to a whole lot of different people, and you will certainly get a whole lot of different answers. If your correspondents spell it with a capital H and a capital E, they may insist that it is a new concept, and they will probably concentrate on audiovisual techniques. From their description some of the duties of the health educationist may be difficult to differentiate from those of community developers and other social or welfare workers. But I prefer to look on health education as a medical way of life. Let us go back to Hippocrates. " Life is short. Art is long, opportunity fleeting, experience treacherous, judgment difficult. The physician must be ready not only to do his duty himself, but also to secure the cooperation of the patient, of those about him, and of his surroundings." The second part of this aphorism is less well known and less trenchant than the first, but it is just It indicates the whole scope of health as important.
education. Medicine used to maintain an unvarying priority: service, teaching, and research. (Nowadays it is true that the plums and the bouquets mostly go to research, but that may pass.) Teacher after all is what " doctor " means, and the taught should be the patient and his parents, your personnel, and the public-what my students called the 4 Ps system. And of course there is the eternal obligation to go on teaching oneself, and that is research. In fact a fifth P for personal. Education of patients and parents (or other attendants) demands continuity. The generic type of family doctor knew his patients, their relatives, homes, and work, and in the main their anxieties. When he was called in to see the
ten-year-old with whooping-cough, he
only confirmed the diagnosis and prescribed belladonna and bromides, he advised bed rest, bland diet, and segregation from the infant brother. The infant-mortality rate in England and Wales was reduced from 150 in 1900 to 30 in 1950 mainly thanks to personal care from doctors, nurses, and health visitors, not to lectures and audiovisual aids. not
The education of personnel must help them to correlate disease with the things that produce it, to realise that treatment and prevention must go hand-in-hand when we are dealing with people, and that follow-up is essential. Otherwise we will go on wasting a great deal of medical effort and cohorts of variegated manpower. Nowadays doctors and nurses are mainly educated in institutions by specialists who concentrate on one small area of the patient. The ornithologists have long recognised that they cannot learn much by studying birds in cages. But doctors and nurses are still doing just that. It is to compensate for the defects of the purely institutional outlook that so many non-medical workers are now being brought in to the medical services. Besides knowing the material context in which diseases develop and patients live and die, we must observe attitudes and disciplines. It is quite out of fashion to talk about ethics or morals. But as Chesterman once remarked1 it is easy enough to teach medical personnel the facts of physiology and pharmacology, but much more difficult to teach them to be honest with their drugs and kind to their patients. It is frankly impossible to achieve health or education if you shirk ethics and responsibility. As for educating the public, we are still pretty incompetent. Advertising methods can stimulate appetite, but they rarely teach wisdom. We are notably unsuccessful, for example, in selling fluoridation, no smoking, and keeping Britain tidy. I know you are particularly interested in family planning. Mayone Stycos2 believes that for a birth-control programme in an overpopulated area " audiovisual material holds out more promise of success than doctors, nurses, and social workers ". Yet later on in the same article he suggests that the comparatively moderate birth-rates of Britain and the United States are due to " responsibility and persistence of individuals rather than to governments, voluntary organisations or to physicians ". There is urgent need for research into the efficacy of mass programmes compared with those that depend on satisfied patients and doing good by stealth. My impression is that where family planning is offered as a routine service in a well-organised maternity and child-health section it is more effective than when it is loudly, vigorously, and independently presented. People are not easily interested in a mass problem unless it affects them personally. They are deeply preoccupied with their own concerns. Ten words to the individual are more effective than ten thousand to the mass. So much of what is now taken for granted in a sophisticated country has to be introduced as health education in a less developed area. When I work in an economically developing area, I expect to spend much more of my time in teaching at every level, and there is much less time for
it, so teaching has to be simple, specific, concise, highly selective, and convincing. The type and the quantity of the education must be made to measure, just as much as any other form of prescription. All this is very hard work. As for educating oneself, that is the fifth p, I believe it is the duty of every child to educate his parents. So I expect my patients, my pupils, and the public to educate This is research. I could summarise all this letter in two sentences. Health education is a way of life; health education is me too.
listening. Yours sincerelv, CICELY D. WILLIAMS. 1. 2.
Chesterman, C. C. J. trop. Med. Hyg. 1953, 56, 123. Stycos, J. M. Fam. Plann. 1966, 14, 88.