- Email: [email protected]
UNEMPLOYMENT AND HEALTH
558 system in pathogenesis. While on this evidence this drug constitutes logical and effective treatment, the dependence of arterial pressure on a high plasma-angiotensin-n concentration in these circumstances is emphasised. Extreme caution is therefore required when captopril is first given as it may, in normal
dosage, precipitate severe hypotension. A detailed report will be
published elsewhere. A. B. ATKINSON
M.R.C. Blood Pressure Unit, Western Infirmary, Glasgow G116NT
J. J. BROWN B. LECKIE A. F. LEVER
J. J. MORTON R. FRASER
J. I. S. ROBERTSON
UNEMPLOYMENT AND HEALTH p. 498) is right to point finding of Dr Harvey Brenner and his colleaguesl-that unemployment rates are positively associated with certain morbidity and mortality rates-are challenged by Eyer’s wofk.2 However, quite apart from technical questions about the different data and procedures used, it seems prudent to judge the work of the Brenner group in the context of the
SIR,-Dr Scott-Samuel (March 3,
out
that the main
many studies of different kinds which tend to support their conclusions. We cited three illustrations in our paper of Feb. 17 (p. 373)-prospective clinical studies, research into stress,
and work on poverty. Given the far-reaching importance of this debate for health and economic policy, it would be a happy outcome if the subleties and implications of the "Brenner/Eyer controversy" received more attention in the U.K. Certainly the last word has not been said nor has the definitive analysis been completed-indeed, Brenner’s team has yet to publish its recent studies of the U.K. Scott-Samuel’s other reservation concerns our "interdisciplinary approach to health". He mentions that Illich has characterised such an approach (in relation to Canadian health policy) as creating a "new corporate biocracy" . As ever, Illich seems to be losing the baby with the bathwater. To argue that human health is greatly affected, for example, by agricultural, transport, manufacturing, and trading policies, as we have done4 is not to commend a biocracy, corporate or otherwise. Indeed, all we suggest is that "health should be given a seat at the table" when policy decisions are taken that strongly affect health. Furthermore, the issue is not, as Illich seems to see it, somehow to try to do without specialist skills and knowledge, to reject all aspects of "professionalism", it is, rather, to demystify expertise and mobilise it more effectively for the public good. Our unit’s formal terms of reference include the basic aim of trying to "promote the informed public discussion of issues of health policy". Attempting to contribute to and inform public debates (and even to advocate what we judge to be "healthier policies") seem to us to be activities more in sympathy with "ecologically informed democracy" than with biocracy. However, we recognise that would-be biocrats exist: Scott-Samuel’s warning is well taken. Study of Health Policy, Department of Community Medicine, Guy’s Hospital Medical School,
Unit for the
London SE1 1YR
PETER DRAPER JOHN DENNIS JENNY GRIFFITHS
JAMES PARTRIDGE JENNIE POPAY
SIR,-Isupport the views expressed by Dr Draper and his colleagues (Feb. 17, p. 373). The burden of their argument is that the medical profession, and particularly those involved with community medicine, should rise from their procrustean bed and dare to encompass issues of a broader nature. 1. Brenner, H. Estimating the Social Costs of National Economic Policy. U.S. Government Printing Office, Washington, 1976. 2. Eyer, J. Int. J. Hlth Serv. 1977, 7, 125. 3. Illich, I. The Right to Useful Unemployment. London, 1978. 4. Draper, P., and others. The NHS in the Next 30 Years: a new perspective on the health of the British. London, 1978.
Draper et al. emphasise the pivotal importance of the environment in relation to human health. Since its inception the Centre for Human Ecology in Edinburgh University has consistently adhered to this view. The centre is basically the university’s "futures unit", and it has been established to deal with the key issues affecting mankind in the final quarter of the 20th century. The whole ethos of the centre is interdisciplinary, and as such it is able to draw extensively upon, and yet be complementary to, the work of individual departments within the university. The areas with which the centre has so far been mainly concerned include overpopulation, and its effects, birth control, economic growth versus sustainability, energy policy, nuclear proliferation, and human needs both physical and ethical. With the addition to the staff of the centre of a newly appointed health economist in the university’s department of community medicine, who is strongly sympathetic to the perspective presented by Draper et al. it is hoped that in future the centre will be engaged in and promote, research into the very fundamental questions which they have raised. There is a great need for universities, not just in the U.K. but globally, to conduct pioneering work in the vital area of futures research. It seems regrettable that up till now doctors, with a few notable exceptions, have shown a singular reluctance to become heavily involved with these issues. Centre for Human
Ecology, University of Edinburgh,
Edinburgh
EH8 9LN
JOHN A. LORAINE
FIREARMS AND CONFIDENTIALITY on the course of action be taken by a Canadian physician who learns that a mentally unstable patient possesses a firearm (Feb. 3, p. 262) suggests an imprecise appreciation of Canadian law and customs. The federal legislation referred to fails specifically to enjoin a physician to report such activities. In such cases, provincial law applies. For example, the Ontario Health Disciplines Act specifically forbids the transmission of any information about a patient to anyone, without the patient’s permission, unless a specific statute compels the physician to do so. About two dozen pieces of legislation do permit or enjoin the physician to breach confidence (in suspected child abuse, venereal disease, and workman’s compensation, for example) but otherwise the Act is completely free of loopholes. One Ontario physician has already been disciplined for revealing confidences in a marital therapy setting where he felt that one of the partners was in danger of being harmed by the other. The application of "common sense" in Canadian medicine has become a risky venture. The need of a legal safeguard for the physician, then, is not "debatable", but clear, compelling, and urgent.
SIR,-Your Round the World item
to
Department of Psychiatry, University of Toronto, and Sunnybrook Hospital, Toronto, Ontario, Canada
MORTON S. RAPP
H.D.L. CHOLESTEROL IN PERIPHERAL VASCULAR DISEASE
SIR,-Dr Bradby and colleagues’ found no statistical signifidifference in H.D.L.-cholesterol of patients with peripheral vascular disease (P.v.D.) and controls. However, H.D.L.-cholesterol related to total cholesterol in their findings is surprisingly low (14%) in patients free of P.V.D. With respect to coronary heart-disease (C.H.D.), various studies2-4 show a cut-off point
cant
1. 2. 3. 4.
Bradby, G. V. H., Valents, A. J., Walton, K. W. Lancet, 1978, ii, 1271. Miller, N. E., Thelle, D. S., Førde, O. H., Myøs, O. D. ibid. 1977, i, 965. Stanhope, J. M., Sampson, V. M., Clarkson, P. M. ibid. 1977, i, 968. Castelli, W. P., Doyle, J. T., Gordon, T., Hames, C. G., Hjortland, M. C., Hulley, S. B., Kagan, A., Zuskel, W. J. Circulation, 1977, 55, 767.
dosage, precipitate severe hypotension. A detailed report will be
published elsewhere. A. B. ATKINSON
M.R.C. Blood Pressure Unit, Western Infirmary, Glasgow G116NT
J. J. BROWN B. LECKIE A. F. LEVER
J. J. MORTON R. FRASER
J. I. S. ROBERTSON
UNEMPLOYMENT AND HEALTH p. 498) is right to point finding of Dr Harvey Brenner and his colleaguesl-that unemployment rates are positively associated with certain morbidity and mortality rates-are challenged by Eyer’s wofk.2 However, quite apart from technical questions about the different data and procedures used, it seems prudent to judge the work of the Brenner group in the context of the
SIR,-Dr Scott-Samuel (March 3,
out
that the main
many studies of different kinds which tend to support their conclusions. We cited three illustrations in our paper of Feb. 17 (p. 373)-prospective clinical studies, research into stress,
and work on poverty. Given the far-reaching importance of this debate for health and economic policy, it would be a happy outcome if the subleties and implications of the "Brenner/Eyer controversy" received more attention in the U.K. Certainly the last word has not been said nor has the definitive analysis been completed-indeed, Brenner’s team has yet to publish its recent studies of the U.K. Scott-Samuel’s other reservation concerns our "interdisciplinary approach to health". He mentions that Illich has characterised such an approach (in relation to Canadian health policy) as creating a "new corporate biocracy" . As ever, Illich seems to be losing the baby with the bathwater. To argue that human health is greatly affected, for example, by agricultural, transport, manufacturing, and trading policies, as we have done4 is not to commend a biocracy, corporate or otherwise. Indeed, all we suggest is that "health should be given a seat at the table" when policy decisions are taken that strongly affect health. Furthermore, the issue is not, as Illich seems to see it, somehow to try to do without specialist skills and knowledge, to reject all aspects of "professionalism", it is, rather, to demystify expertise and mobilise it more effectively for the public good. Our unit’s formal terms of reference include the basic aim of trying to "promote the informed public discussion of issues of health policy". Attempting to contribute to and inform public debates (and even to advocate what we judge to be "healthier policies") seem to us to be activities more in sympathy with "ecologically informed democracy" than with biocracy. However, we recognise that would-be biocrats exist: Scott-Samuel’s warning is well taken. Study of Health Policy, Department of Community Medicine, Guy’s Hospital Medical School,
Unit for the
London SE1 1YR
PETER DRAPER JOHN DENNIS JENNY GRIFFITHS
JAMES PARTRIDGE JENNIE POPAY
SIR,-Isupport the views expressed by Dr Draper and his colleagues (Feb. 17, p. 373). The burden of their argument is that the medical profession, and particularly those involved with community medicine, should rise from their procrustean bed and dare to encompass issues of a broader nature. 1. Brenner, H. Estimating the Social Costs of National Economic Policy. U.S. Government Printing Office, Washington, 1976. 2. Eyer, J. Int. J. Hlth Serv. 1977, 7, 125. 3. Illich, I. The Right to Useful Unemployment. London, 1978. 4. Draper, P., and others. The NHS in the Next 30 Years: a new perspective on the health of the British. London, 1978.
Draper et al. emphasise the pivotal importance of the environment in relation to human health. Since its inception the Centre for Human Ecology in Edinburgh University has consistently adhered to this view. The centre is basically the university’s "futures unit", and it has been established to deal with the key issues affecting mankind in the final quarter of the 20th century. The whole ethos of the centre is interdisciplinary, and as such it is able to draw extensively upon, and yet be complementary to, the work of individual departments within the university. The areas with which the centre has so far been mainly concerned include overpopulation, and its effects, birth control, economic growth versus sustainability, energy policy, nuclear proliferation, and human needs both physical and ethical. With the addition to the staff of the centre of a newly appointed health economist in the university’s department of community medicine, who is strongly sympathetic to the perspective presented by Draper et al. it is hoped that in future the centre will be engaged in and promote, research into the very fundamental questions which they have raised. There is a great need for universities, not just in the U.K. but globally, to conduct pioneering work in the vital area of futures research. It seems regrettable that up till now doctors, with a few notable exceptions, have shown a singular reluctance to become heavily involved with these issues. Centre for Human
Ecology, University of Edinburgh,
Edinburgh
EH8 9LN
JOHN A. LORAINE
FIREARMS AND CONFIDENTIALITY on the course of action be taken by a Canadian physician who learns that a mentally unstable patient possesses a firearm (Feb. 3, p. 262) suggests an imprecise appreciation of Canadian law and customs. The federal legislation referred to fails specifically to enjoin a physician to report such activities. In such cases, provincial law applies. For example, the Ontario Health Disciplines Act specifically forbids the transmission of any information about a patient to anyone, without the patient’s permission, unless a specific statute compels the physician to do so. About two dozen pieces of legislation do permit or enjoin the physician to breach confidence (in suspected child abuse, venereal disease, and workman’s compensation, for example) but otherwise the Act is completely free of loopholes. One Ontario physician has already been disciplined for revealing confidences in a marital therapy setting where he felt that one of the partners was in danger of being harmed by the other. The application of "common sense" in Canadian medicine has become a risky venture. The need of a legal safeguard for the physician, then, is not "debatable", but clear, compelling, and urgent.
SIR,-Your Round the World item
to
Department of Psychiatry, University of Toronto, and Sunnybrook Hospital, Toronto, Ontario, Canada
MORTON S. RAPP
H.D.L. CHOLESTEROL IN PERIPHERAL VASCULAR DISEASE
SIR,-Dr Bradby and colleagues’ found no statistical signifidifference in H.D.L.-cholesterol of patients with peripheral vascular disease (P.v.D.) and controls. However, H.D.L.-cholesterol related to total cholesterol in their findings is surprisingly low (14%) in patients free of P.V.D. With respect to coronary heart-disease (C.H.D.), various studies2-4 show a cut-off point
cant
1. 2. 3. 4.
Bradby, G. V. H., Valents, A. J., Walton, K. W. Lancet, 1978, ii, 1271. Miller, N. E., Thelle, D. S., Førde, O. H., Myøs, O. D. ibid. 1977, i, 965. Stanhope, J. M., Sampson, V. M., Clarkson, P. M. ibid. 1977, i, 968. Castelli, W. P., Doyle, J. T., Gordon, T., Hames, C. G., Hjortland, M. C., Hulley, S. B., Kagan, A., Zuskel, W. J. Circulation, 1977, 55, 767.