WHAT ABOUT THE COLLEGES?

563

taken to break the chain of contamination; already various commercial organisations are improving meat hygiene by retraining personnel, removing the piecerate system of payment, and providing qualified supervision with adequate laboratory facilities. The finding of a large number of drug-resistant bacteria, many of which are capable of transferring antibiotic resistance to organisms such as Salmonella typhimurium, is further evidence that intestinal bacteria are being disseminated during the slaughtering process. The mere presence of transferable chloramphenicol resistance at this very early stage of food production does not imply danger to human health; nevertheless, the situation requires strict surveillance and indicates a definite need for further studies using marked strains of bacteria to trace the fate of these organisms during food production. I thank the owners of the two slaughterhouses concerned; Dr. K. C. Sellers and Dr. H. Williams Smith for helpful discussion ; and Mr. R. Green and Mr. F. Bateman for technical assistance. REFERENCES

Smith, H. W. R. Soc. Hlth J. 1969, 89, 271. Shooter, R. A., Cooke, M., Rousseau, S. A., Breaden, A. Lancet, 1970, ii, 226. 3. Walton, J. R. ibid. 1966, ii, 1300. 4. Simmons, C. W. R. Meat Trades J. April 16, 1970, p. 12. 5. Report of the Joint Committee on the Use of Antibiotics in Animal Husbandry and Veterinary Medicine. H.M. Stationery Office,

1. 2.

1969.

Population Projections 1969 data the Office of Population Census and now projects the population of England and Surveys Wales to 58,590,000 by the year 2001. This is an increase of 9,700,000 (about 20%), and represents a compound growth-rate of 0-6% per annum. Projections have had to be revised drastically in the past fifteen years, and there is no reason to suppose that the latest turn-of-the-century estimate is any more accurate then previous efforts. In 1955 the Registrar General was predicting a fairly stable population up to the mid-1990s. Five years later he was thinking in terms of 56 million by the end of the 20th century; in 1964 the estimate was up again, to more than 67 million. It fell in 1968, and again in 1969. The nroiected mid-vear totals are:

Based

on

The elements of population change (births, deaths, and emigration) are simple enough to measure, but much less easy to predict. Death-rates among males

migration,

under forty and females under fifty are expected to fall to 50% (or less) of the 1969 rates after forty years. Above these ages death-rates will fall progressively less strikingly. At all ages the rate of fall will be more rapid for females than for males. Short-term fluctuations in birth-rate are a constant problem for demographers: fortunately it seems that the long-term factor (i.e., completed family size) is fairly stable. The completed family size is now put at

2-41, compared with 2-50 in 1968.

In

terms

of school,

working, and retirement the pattern is not likely to change strikingly from the 1969 picture of 23-5% under age fifteen, 60 7%, of working 1.

age,

and 15-8% of retirement age.

Registrar General’s Quarterly Return for England and Wales: Quarter ended March 31, 1970, appendix. H.M. Stationery Office, 1970. 4s. 6d.

Intercepted

Letter

WHAT ABOUT THE COLLEGES? THE

TREASURER,

ROYAL COLLEGE EDINBURGH.

OF

PHYSICIANS,

DEAR TREASURER, I have received your letter announcing that the Fellows’ annual subscription, initiated a few years ago, is to be raised to E25Łor E20 for those working among the tribes south of the Border. As I read this heavy news, my hand flew protectively to my pocket-book. A week later the hand is still there. May I explain ? Back in the year dot I sat the examination for Membership as an inescapable step on the promotional ladder. I got the Membership: the College got a fee. Both sides were happy. (One reason, as you know better than I, for the jump in Fellows’ subscription-rates is the falling off in examination fees.) Later, when I was accorded the richly undeserved honour of Fellowship, much the same sort of transaction took place, though this time without an examination; and again the advancement could have been vital to my future. I put it to you that if our College (among others) is lucky enough to hold one or more hoops through which young men must jump (for a consideration) in order to make their way in life, it can’t expect an automatically generous response to subsequent claims for money. After all, the university which, by accepting a thesis, converted my M.B. to an M.D. does not now seek to dun me. Here I tread tender ground. I hear voices saying: What about the General Medical Council’s new annual subscription ? But the G.M.C. conducts business essential to the whole profession; and the profession would be foolish if it failed to keep the Council strong and independent. If, then, Fellows, need not automatically support the College in its admittedly difficult circumstances, what is the case for supporting it from choice ? Two main reasons spring to mind for not supporting it. The first is the shabby record of our College-among others-in lifting money from overseas graduates attracted to this country by the cachet of a College diploma. Young doctors have come here in droves, have worked in hospitals ill equipped to provide any sort of medical education or have swotted in the precincts of large institutions, and after a year or two have returned to their own countries, with or without a diploma, or have settled here. How should we like it if in our own country, starved of doctors, we saw our young graduates taking off for a couple of years in Chile or Peru, in Nigeria or Malaysia, just at the time when they should contribute most while they learn how to apply their early vocational training ? We should not like it at all. The second, and more important, reason for hesitating to nurture the College lies in its constitution. Our College, like the other ancient ones, is blatantly elitist. The solemn progression from Licentiateship to Membership to Fellowship to the inner councils encourages a reverence for rank which ill becomes a supposedly single and humane profession ; and this respect is reflected in the relish with which Fellows of other Colleges savour their privileges: a Fellowship can be the in thing. (Maybe not much longer. The rush to elect Fellows, and thus, by a happy chance, to raise more money, may soon make Membership the more unusual, and therefore more desirable, state.) All this, you may say, amounts to no more than harmless professional snobbery : after all, we are herd creatures, and what more harmless aggregations than a flutter of physicians

564 soufiie of surgeons ? But, alas, the pecking order (do I move too quickly to another species ?) does not end there. It cannot have escaped you that in British medicine the real power is concentrated in the hands of, shall we say, two hundred people. Nor can you be unaware that among these two hundred the Colleges are not under-represented. It is easy, even modish, to claim that medical democracy, like any other form of democracy, is inevitably a charade-that in the end, whatever the organisation, power will be found to be concentrated in the hands of two hundred. Perhaps. But do let’s try. Do let’s stop men accumulating membership of committees like blossoms for a garland. Wisdom does not reside solely in two hundred heads. Now that we have this enormously expensive machine for democracy we should seek to make it work, and in particular we should examine the hands at the levers. It would take a Snow storm to reveal all the convolutions of medical power; but, short of that, we could usefully remember that in medicine position too often is made to pass for performance: we have too many Elders. Please do not conclude that, in setting out these thoughts, I am criticising our College specifically. Believe me, I am not. Our College is wonderfully gentlemanly. Not for us the push of the elbow that brings priority: not for us the relentless courting of industry that yields a show of aldermanic affluence. It is largely the old-fashioned gentility of our College which has led to the sudden climb in the subscription-rate, and which has given me special pleasure in being a Fellow. (Here I am hoist by my own petard-an elitist in my own right, relishing the company of gentlemen.) But with the ancient Colleges, it’s all sink or all swim. And on present showing I’m not at all sure that they should be encouraged to swim. What in the world have they to do with present-day life ? or a

Ah, I hear you say, they have long histories, ancient traditions. But age in itself is no virtue; and tradition is an incubus unless it is shaped to modern needs. What, then, should be done ?

First, the College, in unison with the others, should, I. believe, exclude overseas visitors from the Membership examination. Secondly, in appeasement for wrenching time and money in years gone by from such visitors, the College, again with the others, should set up a register of members (in the broad sense) who are willing to withdraw at, say, 58 from N.H.S. or university jobs and to spend their last productive years in an emergent country. Such doctors are usually old enough to be wise yet still young enough to respond to the stimulus of a new setting; their children more likely than not are grown up, which is one great problem out of the way; and as middle-aged men (and women) they could not possibly be thought to threaten the standing of indigenous doctors. This sensible act of penance the Colleges would finance by selling their imposing buildingscostly, often modern, monuments to an imperial past-and moving into workaday offices. Of course the Colleges offer a real service-through libraries (best disbanded, and given to the nearest medical school) and sometimes through teaching (here the London Surgeons are a, special case, but otherwise there is no call for heavy outlay on buildings). We have been reminded that our own College is being called on, as never before, for expert guidance on postgraduate training, specialist standards, staffing structure, and so on. True. But this does not demand the flummery of a city livery company. Furthermore, in the years ahead, with specialist board registration, this demand will be diffused among many other specialist groups. Our thoughts - or, better, our actions-should turn to moulding all the Colleges and other specialist groups into a single organisation. But please, when we do this, do let’s avoid a United Nations situation: we don’t want the founding fathers of this new body to gain the right of perpetual veto by screw-

seats into the floor of the council it will be interesting to see what happens when the dozen or so electroencephalographic kings have an equal voice with the serried ranks of internists. But that’s democracy for you; and we’re all democrats at heart, aren’t we ? So let our cry be: Forward without fear into the twentieth century. Yours sincerely,

ing their

chamber.

own

permanent

Admittedly

OLD FELLOW.

P.S. With logical inconsequentiality I’ve decided to continue my subscription at the present lower rate until the Colleges begin to come alive. Perhaps you will withdraw my Fellowship-you must tell me about that.

Round the World United States HEALTH INSURANCE

The search for a new national health insurance plan intensified when some Senators, with Senator Edward Kennedy as the main sponsor, introduced into Congress a Bill to set up a Health Security Program which, it is stated, would pay three-quarters of the health care expenses of the American sick. The aim is to consolidate all the Federal health schemes under one system. This is only one of many possible plans, and the Administration and the conservative groups have made it clear that they don’t like it. Congress has just passed a staggering budget for the military industrial complex and can now turn to the welfare side. As Mr. Kennedy has put it, health insurance coverage in America today is more loophole than protection; and Mr. W. Cohen, former Secretary of H.E.W., has predicted that national health insurance is coming and a lot more quickly than most people realise. The problems are only too obvious, but the solutions are not at all clear. The A.M.A. and some other organisations still think the solution is private medical insurance with the Federal Government paying the premiums for those who cannot afford to do so. The snag of course is that, for those who insure already, the premiums go up and the benefits decrease; and, as in the medical malpractice insurance schemes, private insurance companies which have to make profits cannot take ever heavier losses. It’s not easy to see private insurers making much money out of these medical insurance schemes when all are covered; and drawing the line between those whose premiums are Federally paid and those who have to carry the burden themselves is going to be very difficult, especially in a country where the Medicaid schemes are in such trouble largely owing to income disparities of the States if not of individuals. So Congress will have much to do, and it is still grappling with the President’s no. 1 social priority-the family assistance plan by which a family of four would have a guaranteed Federal income of $1600 per annum. Passed by the House, the Bill is still not before the Senate though the majority leader says it soon will be. The finance committee is considering an amendment which would postpone implementation from July, 1971, to January, 1972. This would allow three trials of the system in different areas, one of which is now underway. But just what these will prove is not clear. PRESIDENT AND CONGRESS

Congress by substantial necessary majorities has again overridden a Presidential veto on one Bill but upheld it on another. The issue is the same as before: the Administration holds the view that the expense is too great and Congress that it is necessary. With the overridden veto the issue was