What price medical progress?

THE LANCET

What price medical progress?

estimated 20 000 haemophiliacs then living in the USA, received a “headsCry Bloody Murder: A Tale of Tainted blood up” alert from the Centers for Disease Elaine DePrince. New York: Random House. 1997. Control in 1982 that haemophiliacs Pp 209. $23 ISBN 0-679-45676-7 would be “prime candidates” to develop the new immunodeficiency syndrome, but continued to issue he 1990s have been flooded statistics in her chronology of the periodic reassurances about the safety with books of AIDS memoirs, American blood banking and factor of factor concentrates throughout the each supplying a different purification industry over the past 20 early 1980s nonetheless. chapter of the same wrenching story. years. Only towards the end of the 1980s, Elaine DePrince, a genetic carrier of Among Cry Bloody Murder’s motivated, says DePrince, by industry Von Willebrand’s disease, birth mother highlights is the fact that a technique competition rather than any more of two sons with Von Willebrand’s, and for treating factor VIII to inactivate humanitarian concerns, did the giant adopted mother of three others with both the hepatitis B virus and HIV blood-product companies introduce classic haemophilia A, relives here that was perfected in Germany in heat-treated factor with sufficient viral the devastation HIV-contaminated 1978 and marketed there in 1980, but inactivation into the US market. And clotting factor brought into her life 10 was not approved by the Food and even then, as the extent of the HIV years ago. Drug Administration for use in the epidemic among haemophiliacs In 1986, Adam, Erik, Teddy, Cubby, USA until 1986. Meanwhile, the became evident, so-called “blood and Mike were a cheerful band of National Hemophilia Foundation, shield” laws in most states protected New Jersey brothers who kept their the manufacturers from full product ostensibly an advocate for the factor concentrate in the cabinet and liability. In many European their cryoprecipitate in countries with national the fridge, entertained health insurances, governeach other while they ment and industry recuperated from bleeds, My ears are the platters collaborated to create and generally proceeded you fill because you are hungry. with aplomb through the programmes of financial constraints of life with a compensation for HIVYou offer up treatable chronic disease. infected haemophiliacs and pink salmon flesh, Then untreatable disease their families. But in the the stain of berries descended. 10 years later USA, “haemophilia surstored in cedar bark baskets, Mike and Cubby had vivors” like DePrince’s and a root died of AIDS, Teddy was family were on their own, I don’t recognize. infected with HIV, and struggling to file claims the lives of the survivors against industry giants You’ve gathered them carefully: had been shattered. while statutes of limitations dug deeply, DePrince tells the story threatened to run out. braved tangled vines, of her two dead sons with Although DePrince is a bent over falls with your net. the same eloquent good writer, her story has a anguish that parents, tendency to get away from As you speak, lovers, friends, and her and become more of a from the dark forest floor doctors of other infected polemic than a balanced a fern is unfurling people have brought to narrative. The reasons are one tender shoot towards the light. other AIDS books. But understandable enough: a hers has a unique clear picture of these events I know you will find it. subtext: the evidence she requires both a broader slowly accumulated over international perspective years of grass-roots than hers and full access to Pat Cason activism that the giant industry materials that are Vancouver, Washington, USA price her family paid for simply out of her reach. medical progress in Nonetheless, two aspects of haemophilia treatment her book’s contents are might have been avoided. unlikely to be equalled by any of the more People with haemdispassionate and fully ophilia usually receive referenced accounts that medical care in are bound to come along. specialised centres rather One is the haunting than in general primaryglimpse she gives into the care facilities. For this mechanics of family life reason, most medical with three mortally ill professionals both in the young boys, all of whom USA and in Europe have contribute voices to this probably had little book. “Sixty-four reasons personal experience with why you do not want to get the story DePrince AIDS”, 11-year old Cubby presents here, and know A huge plane flew past wrote before he died. its outlines only vaguely. Claudia Böse “Reason #23: Your brain She cites some damning

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Medical education: the fourth element Teaching Medicine in the Community A Guide for Undergraduate Education Carl Whitehouse, Martin Roland and Peter Campion, Editors. Oxford General Practice Series 38. Oxford: Oxford University Press. 1997. Pp 229. $69.50. £35. ISBN 0-19-262653-1. Community-Based Teaching A Guide to Developing Education Programs for Medical Students and Residents Susan L Deutsch, Editor. Philadelphia: American College of Physicians. 1997. Pp 284. $25. ISBN 0-943126-59-2. ormal education has three major elements: planning of content (objectives and curriculum), the actual processes of teaching and learning, and assessment of outcomes by examinations and course audits. Depending on their inclinations, medical schools can tinker with these elements or alter them drastically. A fourth structural element receives less attention, and that is the context in which medical education happens. Context includes physical environment and social climate. Perhaps we still think of medical schools too much in terms of their immutable geographical properties as university buildings and teaching hospitals, and not enough about their purpose. While we have been busy planning new problembased curricula, economic imperatives have propelled reorganisation of health-care systems all around us, and medical education has had to tag along as well as it can. The context has changed. It is easy to advocate that medical education outside of teaching hospitals makes intuitive sense because most illness is to be found there. Clinical

teaching in the community makes cognitive sense too, because we tend to remember our patients’ illnesses in context. More difficult are the practical questions of the appropriate content of community-based medical education, what academic qualities are required in the teachers, and how to measure effectiveness vis-a-vis the traditional hospital context. These two multiauthor guide-books describe how to set about shifting the centre of gravity of medical education. Both are mostly about basic clinical education in the context of primary care rather than hospital specialties (there is no mention of “Calmanisation”). In Teaching Medicine in the Community, 15 of the 19 contributors are affiliated with academic departments of general practice of primary care. The 35 short chapters offer succinct outlines of modern medical education that will be of value to anyone who wants to be a better teacher. Several communitybased projects are reported and there are good ideas for educational partnerships with communities, ethnic groups, other health-care profes-

shrinks and you sometimes forget what you are talking about, and suddenly you forget how to write cursive. . . . Reason #62: You do a lot of important things because you have to squeeze them into a short time like ten or eleven years instead of eightyseven . . .”. The other nuance of the story on which DePrince is quite superb is her own slow realisation of the extent to which all facets of health care in late 20th century America are permeated by, and often dependent on, industry profit margins and bottom lines. The deep financial ties between the National Hemophilia Association, the plasma-fractionating industry, and individual practising haematologists are hardly unique in medicine. For

this reason medical professionals without the slightest interest in either AIDS or haemophilia might make a point of looking through this book. It disabuses the reader of the wishful thinking most of us indulge in all too often—that the pharmaceutical giants and other for-profit health-care concerns are actually the selfless humanitarian ventures their advertising so energetically depicts. DePrince learned that, when push comes to shove, the industry of medicine goes with the bottom line. The rest of us would do well to keep this lesson in mind.

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sionals, and with patients and their families. The concepts of medical skills “laboratories” are introduced, in which students and doctors may learn in a predictable context, not subject to the vagaries of hospital admissions, like a pilot in a flight simulator. Community-based Teaching, published by the American College of Physicians (ACP), has 23 contributors, with diverse medical backgrounds. The ACP has a current promotional campaign that characterises its membership as physicians who practise internal medicine for adults, at all levels of complexity, including primary care in the community. There is discussion of the economic and demographic barriers to increased community-based teaching in North America. Academic medical centres derive income from the presence of residents (junior medical trainees), but for many independent communitybased physicians time spent on teaching is time lost from the pressures of fee-for-service office practice. The ACP book gives practical advice and educational templates for teaching clinical clerks and residents in the context of urban or rural communities. Its guidelines should reassure those residency programme directors who worry about loss of educational quality beyond the walls of their teaching hospitals. This is a handbook of how to integrate academic expectations and community realities, and how to do it well. Ray Lewkonia Department of Medicine and Office of Medical Education, University of Calgary, Alberta, Canada T2N 4N1

Abigail Zuger Department of Medicine, Beth Israel Medical Center, New York, NY 10003, USA

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