Physicians and the state in the U.S.A. and Israel.

The paper focuses on two patterns of policy-making: a professional pattern in which physicians dominate, and a political pattern in which state authorities take the lead. It looks into the causes of the emergence of each of these patterns and their consequences, in terms of the equity of the health services and their efficiency. The U.S.A. and Israel provide examples for the professional and political patterns of health policy making. The causes for the development of the political pattern in the U.S.A. are grounded in the social salience of medical care, in physicians' economic power, and in the individualistic political culture. The politicization of health services in Israel came about owing to the low placement of health on the social agenda, the proletarianization of physicians, and the hierarchical administrative culture. Analysis of the results indicates that Israel portrays more equity in health services. However, in terms of efficiency results are mixed. In both countries, changes are taking place in opposite directions: more politicization in the U.S.A.; less in Israel.     

Fever in general practice. I. Frequency and diagnoses.

Although fever is a common symptom, few studies have broadly addressed this as a clinical problem in general practice. The aims of this study were to determine the frequency of fever among general practice patients in two rural municipalities in Norway, the diagnoses (according to ICHPPC-2-def.) of conditions causing fever, and the receptionist's role in the management of these problems. All the general practitioners and their receptionists within the study area participated. During 4 weeks throughout 1988 all individuals attending their general practitioner had their body temperature measured with an electronic thermometer (orally > or = 7 years, rectally < 7 years). Fever was defined as an oral body temperature > or = 37.5 degrees C (rectally > or = 38.0 degrees C in those < 7 years). All telephone applications, including telephone encounters for fever, were recorded. Fever was detected in 80 (5%) of a total of 1610 direct encounters: 36% of those below 7 years of age (n = 70) were febrile. One-third of the total encounters for fever were telephone encounters (n = 36), of which 30% were managed by the receptionists. A wide range of diagnoses were made, most of which were associated with infectious diseases. The distribution of the diagnoses of primary care patients with fever is different from those admitted to hospital for fever of unknown origin. General practitioners and their receptionists should consider fever a diagnostic challenge, especially when the patient is handled over the telephone.     

Pharma in the bedroom . . . and the kitchen. . . . The pharmaceuticalisation of daily life

This paper examines the consequences of a new emphasis on lifestyle in the production, marketing and consumption of pharmaceuticals. Over the past decade, a range of medicines have become available that address aspects of lifestyle, while others have been the subject of lifestyle marketing. We argue, with recourse to a broad literature from the social sciences, economics and health services research and from our study of pharmaceutical consumption, that two processes can be discerned. First, there is a domestication of pharmaceutical consumption, with drugs available via home computers, and marketing of pharmaceuticals that focuses upon private or personal conditions and addresses domestic activities such as sex and cooking. Secondly, there is a pharmaceuticalisation of everyday life as the pharmaceutical industry introduces profitable medicines for a range of daily activities and pharmaceuticals come to be seen by consumers as a 'magic bullet' to resolve problems of daily life. We suggest that the pharmaceuticalisation of daily life links the economics and politics of pharmaceutical production to the private lives of citizens.     

Lactation and pregnancy in Iran. III. Hormonal factors.

Lactation failure is common in urban areas of industrially developing countries, but little is known about its epidemiology and causality. The study reported here was undertaken to investigate the serum levels of some hormones other than prolactin that have been shown in animal studies to play a role in lactation, and to examine their relationship to adequacy of lactation and to nutritional and socioeconomic status in urban Iranian women. Serum levels of placental lactogen, growth hormone, cortisol, and thyroid hormones were measured under standard conditions in two groups of pregnant women from low and low middle socioeconomic areas of Teheran, 1 or 2 weeks before parturition and the latter three hormones again in the 3rd month postpartum. Significant differences were found in the biochemical parameters between socioeconomic groups. Hemoglobin and serum albumin values were lower and all the globulin fractions (except alpha 2 globulin during pregnancy), growth hormone and cortisol were higher in the low than the middle socioeconomic subjects, both during pregnancy and postpartum. The discrepancies between the socioeconomic groups were greater postpartum. Growth hormone level was significantly lower in subjects with adequate lactation than inadequate or ceased, and cortisol values show the same trend. No correlations were found between the measured parameters of nutritional status nor free thyroxine values and lactation adequacy. In view of the role of growth hormone and cortisol in stress and malnutrition and some evidence of a reciprocal relationship between growth hormone and prolactin, these hormones may be a link in the chain between the urban environment, malnutrition and lactation failure.     

The crisis in U.S. and international cancer policy.

The incidence of cancer in the United States and other major industrialized nations has escalated to epidemic proportions over recent decades, and greater increases are expected. While smoking is the single largest cause of cancer, the incidence of childhood cancers and a wide range of predominantly non-smoking-related cancers in men and women has increased greatly. This modern epidemic does not reflect lack of resources of the U.S. cancer establishment, the National Cancer Institute and American Cancer Society; the NCI budget has increased 20-fold since passage of the 1971 National Cancer Act, while funding for research and public information on primary prevention remains minimal. The cancer establishment bears major responsibility for the cancer epidemic, due to its overwhelming fixation on damage control--screening, diagnosis, treatment, and related molecular research--and indifference to preventing a wide range of avoidable causes of cancer, other than faulty lifestyle, particularly smoking. This mindset is based on a discredited 1981 report by a prominent pro-industry epidemiologist, guesstimating that environmental and occupational exposures were responsible for only 5 percent of cancer mortality, even though a prior chemical industry report admitted that 20 percent was occupational in origin. This report still dominates public policy, despite overwhelming contrary scientific evidence on avoidable causes of cancer from involuntary exposures to a wide range of environmental carcinogens. Since 1998, the ACS has been planning to gain control of national cancer policy, now under federal authority. These plans, developed behind closed doors and under conditions of nontransparency, with recent well-intentioned but mistaken bipartisan Congressional support, pose a major and poorly reversible threat to cancer prevention and to winning the losing war against cancer.     

Presence of Salmonella spp. and Campylobacter spp. in shellfish.

Bivalve molluscs, (cockles, mussels, scallops and oysters) were examined according to EC shellfish bed classification regulations for faecal coliforms, Escherichia coli and salmonella, and for coliforms and campylobacter which are not specified by these regulations. Salmonella serotypes were detected in 8% of 433 molluscs. Seven salmonella isolations (2%) were made from category A beds, nominally suitable for immediate consumption according to E. coli counts. A higher percentage of salmonella isolates (6%) was detected in shellfish which require relaying or depuration prior to eating. In another survey, thermophilic Campylobacter spp. were found in 42% of 380 shellfish. These findings show bed classification on the basis of indicator organisms alone is not sufficient to assure the absence of bacterial, and no doubt viral, pathogens. Depuration and end product specifications which require the absence of salmonellae are an essential part of these regulations. Microbiologists may wish to consider whether tests for pathogens such as salmonella and campylobacter should be included when determining the suitability of shellfish for human consumption.     

Occupational lead exposure in Finland. V. Shipyards and shipbreaking.

Three Finnish shipyards and two shipbreaking enterprises were studied for lead exposure. Blood lead (Pb-B) concentration was measured for 568 workers in the shipyards and 13 workers in the shipbreaking enterprises. Erythrocyte delta-aminolevulinic acid dehydratase (ALAD) activity was determined for 139 workers in one shipyard and 7 workers in one shipbreaking enterprise. Hemoglobin level was determined for 545 workers in the three shipyards and 7 workers in one shipbreaking enterprise. Lead exposure in the shipyards was relatively low. No Pb-B value exceeded 70mug/100 ml. The most exposed occupations were welders, plumbers, painters, repairmen, and sheet metal workers. The mean Pb-B did not exceed 40 mug/100 ml in any of these groups. In both shipbreaking enterprises one Pb-B value exceeded 70 mug/100 ml, the mean Pb-B values of all the workers in the two enterprises being 51 and 46 mug/100 ml. respectively. ALAD values corresponded well with the respective Pb-B values. All the hemoglobin mean values were normal, and there were no statistically significant differences between the hemoglobin values of different groups.     

Alive and well: geriatric medicine in the U.K. in 1984.

The function of the hospital geriatric service in the U.K. is described within the context of the overall support for the frail, disabled, and sick elderly in this country. It plays an important part in the secondary care of the very old, and perhaps an even more important part educating the public and the profession to the needs of this rapidly expanding section of the population. A short account is given of the nature of geriatric medicine and the role of the consultant geriatrician. The history, achievements, and current status of the specialty are briefly reviewed, and some of the directions which future developments may take are indicated. Whether or not a comprehensive separate service on the U.K. model emerges in other countries, it is certain that they will need centres of geriatric expertise to pursue research and to provide education and enlightenment for all concerned with the medical problems of old age.     

The use of e.m.d.r. in children and adolescents

This paper follows the author's professional involvement with the use of Eye Movement Desensitisation and Reprocessing (E.M.D.R.).

E.M.D.R. was developed in the late 1980's by Dr. Francine Shapiro. The complex method, involving the bilateral stimulation of brain hemispheres, is described where trauma is processed rapidly and the client becomes desensitised to painful memories or images. Initially E.D.M.R. was developed for adults but was soon modified for children. Whilst it is seen as an adjunct to other therapies it does have far reaching applications, as demonstrated in this paper by two case studies. Some ideas with therapeutic possibilities in the treatment of attachment disorder are outlined. The author advocates that attachment disorder can be theoretically conceptualised by a type of Post-Traumatic Stress Disorder. Two further case studies are given to demonstrate the effectiveness of E.M.D.R. for this disorder.     

Poliomyelitis: Epidemiology and prophylaxis. 6. Geographic synchronism in poliomyelitis epidemics in Kenya.

In the 1950s, van Loghem drew attention to what he called ”synchronism” in the epidemics of poliomyelitis in western Europe. The 1952 epidemic in the Netherlands affected Belgium and neighbouring parts of the Federal Republic of Germany at the same time. A comparable phenomenon is described from Kenya. Notwithstanding the fact that in the three population concentrations of the country the three poliovirus types may well be endemic, epidemics of poliomyelitis repeatedly occurred synchronously in these areas. However, there seems to be no synchronism between poliomyelitis epidemics in Kenya and those in neighbouring East African countries. Tentative explanations are put forward for the similarities and differences between Europe and East Africa. The importance of the phenomenon as observed in Kenya for control by mass immunization campaigns is stressed.     

Prenatal Depression in Latinas in the U.S. and Mexico

Objectives The study aimed to investigate the prevalence of depressive symptoms and their associated risk factors during pregnancy in Latinas in the United States (U.S.) and Mexico. Method The sample included 108 women in the U.S. whose data were obtained from medical chart reviews in a community clinic in Washington, D.C., and 117 women in Mexico who participated in face-to-face interviews in the waiting rooms of primary care community centers in Mexico City. Variables, chosen to match in both countries for comparisons, were: socio-demographics, pregnancy gestation and order, social support, depressive symptoms, personal history of depression, family psychiatric history, and suicidal thoughts. Depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale (CES-D). Results The prevalence of depressive symptoms was 32.4% for pregnant Latinas and 36.8% for Mexicans (CES-D ≥ 16), and 15.7% and 23.9% (CES-D ≥ 24), respectively, with no differences between groups. Separate multiple logistic regression analyses showed that for U.S. Latinas: (1) being more educated predicted depressive symptoms (CES-D ≥ 16), and (2) second trimester, as compared to first, also predicted symptoms (CES-D ≥ 24). (3) History of suicidal thoughts predicted symptoms in Latinas in the U.S. (CES-D ≥ 24) and in Mexico (using both definitions of high symptoms), and (4) living with a partner but not formally married and multi-parous condition predicted symptoms (CES-D ≥ 24) among pregnant Mexicans. Conclusions A high prevalence of depressive symptoms and significant risk factors during pregnancy were found in Latinas in U.S. and Mexico, suggesting increased risk for postpartum major depression. Implications for screening and interventions are discussed.