LETTERS * CORRESPONDANCE
er, perhaps many doctors do not know, since it is not specifically stated in the product information, that aerosol pharmaceutical products use CFCs as the main propellants. The two CFCs most widely used in pharmaceutical products, CFC 11 (CCIF3) and CFC 12 (CC12F2), are also two of the most harmful to the ozone layer.2 Under the Montreal Protocol Seules peuvent etre retenues pour publications les lettres recues en double dont la to Control Substances Which Delongueur n'exceide pas 450 mots. Elles plete the Ozone Layer 64 coundoivent etre mecanographiees en qualite "correspondance" sans espacement propor- tries, including Canada and the tionnel. Tous les auteurs doivent signer United States, agreed to reduce by une lettre d'accompagnement portant ces- 50% the world's production of sion du copyright. Les lettres ne doivent CFCs by 1998.3 However, prerien contenir qui ait ete presente ailleurs pour publication ou deja~paru. En prin- scription medical products were cipe, la redaction correspond uniquement specifically exempted. avec les auteurs des lettres retenues pour Is it not time for us in the publication. Les lettres refusees sont de- medical profession to review our truites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications individual prescribing policies, considering in particular increasd'ordre redactionnel. ing the use of breath-activated inhalers (e.g., Spinhalers, Rotahalers and Diskhalers), which do not need propellants, and excluding Let's have "ozonefrom our formularies nonessential friendly" pharmaceutical products that contain CFCs, such products as local anesthetic sprays? We should insist on stronger incenT he use of chlorofluorocar- tives for the pharmaceutical inbons (CFCs) is now a dustry to develop safe alternatives major environmental issue - "ozone-friendly" products. world-wide, but there has been Robert A. Mclvor, MB, BCh little discussion in the medical Department of Medicine press.' Environment Canada has University Hospital estimated that Canada produces Edmonton, Alta. about 20 000 tonnes of CFCs an- References nually (accounting for 2.5% of the world's production); Ontario con- 1. Last JM: A vision of health in the 21st century: medical response to the greensumes 50%.2 Propellants in aerohouse effect. Can Med Assoc J 1989; sol sprays account for 8%.2 140: 1277-1279 Advertising companies have 2. Ontario phase-out of ozone-depleting recognized the public's concern substances. Facts (Environment Ontario factsheet) 1989: Feb about destruction of the ozone TML: Future CFC concentralayer and are now promoting 3. Wigley tions under the Montreal Protocol and many aerosol products as CFCtheir greenhouse-effect implications. free or "ozone-friendly". HowevNature 1988; 335: 333-335 We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Has the CMA become "big business"? D
r~. Jacques Genest's question (Can Med Assoc J 1990; 142: 97) would be easy for him to answer if only he did not believe that "we all recognize the great benefits of the national health system - free, universal and comprehensive". The system is certainly not free, and that direct conduit into the pocket of the taxpayer, the goods and services tax, will not make it so. Nor is it universal and comprehensive, as we note from the sad fact that British Columbia is having to send patients to the United States for cardiac surgery and from the huge inadequacies in funding that are affecting many urgently needed services throughout Canada. Clinicians knew that these evils would occur when the Trudeau government rammed in the socialized system against the advice of the profession. A group, of which I was secretary, composed of doctors and lay people, unsuccessfully challenged the legislation that abolished Medical Services Incorporated and the medical insurance companies in 1970; the legal costs were covered by the Calgary and District Medical Society and members of the general public. The legal battle is again in progress, and Genest would, I feel sure, welcome the trend away from materialism that will occur when clinicians can again deal with their patients without gross third-party interference. In the interim the CMA is to be most strongly commended for its attempts to see that members of the CAN MED ASSOC J 1990; 142 (7)
705
improvement we have here! The Hippocratic tradition that doctors treat all humanity seems ridiculously dated. John C.L. Wade, MB, BS Of course, political structures 2254 Seabank Rd. change, and in the future our sociCourtenay, BC ety may drift one way or the other. When "a woman and her doctor" no longer seems in touch with the political reality, who then The CMA and abortion shall set the criteria for patienthood? To whom shall the CMA eriodically all societies re- pass this authority? And which view their admission crit- future elite shall update and imeria. This can be accompa- prove the Hippocratic view of panied by intense debate. The tienthood to exclude which other French Revolution, the abolition classless humans? of slavery, the abolition of the death penalty - such great mo- Mark Richard Dube, MD ments of choice always threaten to RR 3 move a society in one of two Mont Laurier, PQ directions: either the criteria will be more selective, so that a more elitist structure is created, or they will be more general, so that a Trends in use more egalitarian society results. of medical services The greater the number of privileged, the less will be the actual by the elderly in British Columbia privilege, and vice versa. The Hippocratic tradition of medicine seeks to comfort and ,H- ' aving read both the letter heal all humanity regardless of by Dr. J.J. Rosenberg social status. The Roman Repub(Can Med Assoc J 1989; lic fell. The French aristocracy 141: 1220) and the response from fell. Dictators have come and Drs. Morris L. Barer and Robert gone. But the admission criteria G. Evans (ibid: 1220-1221) I am for patienthood have not changed. reminded of the adage that comToday Canadian society is ex- munication means not just speakamining its admission criteria: ing and listening but actually un"Which fetuses should have derstanding. I think that what Rorights?" As this political debate senberg is trying to say is that if rages the medical profession is all the services given to the elderly faced with an equally agonizing had been provided by a constant question: "Who should set the number of doctors, those doctors admission criteria for patient- would be all wealthy. Thus, the hood?" Our choices are many: the profession "has funded its own individual doctor, the mother of expansion". Of course, to provide the being involved, the CMA, Par- that level of service would have liament, the Supreme Court and required an expansion of the day even Hippocrates. by many hours or a decrease in It seems that the CMA has the time spent per visit, somedecided to take this authority thing that is not happening with from Hippocrates and place it in the elderly, for very good reasons. the hands of "a woman and her It may be naive and simplisdoctor". After 2000 years of all tic, but I believe that the expanmanner of political structure, elit- sion in services to the elderly is a ist and egalitarian, what a great good thing and is necessary. In medical profession do not retire in near poverty more frequently than their patients.
706
CAN MED ASSOC J 1990; 142 (7)
1974 or 1975 dementia was termed "senility", and the sufferers (along with their suffering caregivers) were written off. Now, through the use of expensive technology such as computed tomography we can distinguish among such disorders as low-pressure hydrocephalus, multi-infarct dementia and Alzheimer's disease. With repeated visits and further assessments, including such expensive procedures as radioimmune thyroid assays and vitamin B12 and folate determinations, we can determine which patients have pseudodementia and are likely to be helped by treatment, which may
involve expensive surgical intervention. Once the disorder has been defined, proper follow-up often requires further visits and further biochemical testing. I therefore agree with the original article that the increase in the number of visits and in the amount spent on laboratory and other investigations has been much more rapid than the increase in the number of elderly. The driving force, however, has not been a desire to increase doctors' incomes but the obligation to treat the elderly with the best that medical science has to offer. Many other diseases have become definable and treatable in the elderly. And this leads us to consider the ethical issues discussed by Dr. Kevin Schwartzman
(ibid: 1262-1265). Between 1974 and 1984 the use of medical services by the elderly grew at a faster rate than the number of elderly. What a positive comment on the improvement in our care of the elderly! How appropriate! But what does it mean for the future? Probably a continuation of the same trend until the elderly are adequately cared for and not simply warehoused. Philip G. Winkelaar, MD 1865 Dunmore Rd. SE Medicine Hat, Alta.
er, perhaps many doctors do not know, since it is not specifically stated in the product information, that aerosol pharmaceutical products use CFCs as the main propellants. The two CFCs most widely used in pharmaceutical products, CFC 11 (CCIF3) and CFC 12 (CC12F2), are also two of the most harmful to the ozone layer.2 Under the Montreal Protocol Seules peuvent etre retenues pour publications les lettres recues en double dont la to Control Substances Which Delongueur n'exceide pas 450 mots. Elles plete the Ozone Layer 64 coundoivent etre mecanographiees en qualite "correspondance" sans espacement propor- tries, including Canada and the tionnel. Tous les auteurs doivent signer United States, agreed to reduce by une lettre d'accompagnement portant ces- 50% the world's production of sion du copyright. Les lettres ne doivent CFCs by 1998.3 However, prerien contenir qui ait ete presente ailleurs pour publication ou deja~paru. En prin- scription medical products were cipe, la redaction correspond uniquement specifically exempted. avec les auteurs des lettres retenues pour Is it not time for us in the publication. Les lettres refusees sont de- medical profession to review our truites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications individual prescribing policies, considering in particular increasd'ordre redactionnel. ing the use of breath-activated inhalers (e.g., Spinhalers, Rotahalers and Diskhalers), which do not need propellants, and excluding Let's have "ozonefrom our formularies nonessential friendly" pharmaceutical products that contain CFCs, such products as local anesthetic sprays? We should insist on stronger incenT he use of chlorofluorocar- tives for the pharmaceutical inbons (CFCs) is now a dustry to develop safe alternatives major environmental issue - "ozone-friendly" products. world-wide, but there has been Robert A. Mclvor, MB, BCh little discussion in the medical Department of Medicine press.' Environment Canada has University Hospital estimated that Canada produces Edmonton, Alta. about 20 000 tonnes of CFCs an- References nually (accounting for 2.5% of the world's production); Ontario con- 1. Last JM: A vision of health in the 21st century: medical response to the greensumes 50%.2 Propellants in aerohouse effect. Can Med Assoc J 1989; sol sprays account for 8%.2 140: 1277-1279 Advertising companies have 2. Ontario phase-out of ozone-depleting recognized the public's concern substances. Facts (Environment Ontario factsheet) 1989: Feb about destruction of the ozone TML: Future CFC concentralayer and are now promoting 3. Wigley tions under the Montreal Protocol and many aerosol products as CFCtheir greenhouse-effect implications. free or "ozone-friendly". HowevNature 1988; 335: 333-335 We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Has the CMA become "big business"? D
r~. Jacques Genest's question (Can Med Assoc J 1990; 142: 97) would be easy for him to answer if only he did not believe that "we all recognize the great benefits of the national health system - free, universal and comprehensive". The system is certainly not free, and that direct conduit into the pocket of the taxpayer, the goods and services tax, will not make it so. Nor is it universal and comprehensive, as we note from the sad fact that British Columbia is having to send patients to the United States for cardiac surgery and from the huge inadequacies in funding that are affecting many urgently needed services throughout Canada. Clinicians knew that these evils would occur when the Trudeau government rammed in the socialized system against the advice of the profession. A group, of which I was secretary, composed of doctors and lay people, unsuccessfully challenged the legislation that abolished Medical Services Incorporated and the medical insurance companies in 1970; the legal costs were covered by the Calgary and District Medical Society and members of the general public. The legal battle is again in progress, and Genest would, I feel sure, welcome the trend away from materialism that will occur when clinicians can again deal with their patients without gross third-party interference. In the interim the CMA is to be most strongly commended for its attempts to see that members of the CAN MED ASSOC J 1990; 142 (7)
705
improvement we have here! The Hippocratic tradition that doctors treat all humanity seems ridiculously dated. John C.L. Wade, MB, BS Of course, political structures 2254 Seabank Rd. change, and in the future our sociCourtenay, BC ety may drift one way or the other. When "a woman and her doctor" no longer seems in touch with the political reality, who then The CMA and abortion shall set the criteria for patienthood? To whom shall the CMA eriodically all societies re- pass this authority? And which view their admission crit- future elite shall update and imeria. This can be accompa- prove the Hippocratic view of panied by intense debate. The tienthood to exclude which other French Revolution, the abolition classless humans? of slavery, the abolition of the death penalty - such great mo- Mark Richard Dube, MD ments of choice always threaten to RR 3 move a society in one of two Mont Laurier, PQ directions: either the criteria will be more selective, so that a more elitist structure is created, or they will be more general, so that a Trends in use more egalitarian society results. of medical services The greater the number of privileged, the less will be the actual by the elderly in British Columbia privilege, and vice versa. The Hippocratic tradition of medicine seeks to comfort and ,H- ' aving read both the letter heal all humanity regardless of by Dr. J.J. Rosenberg social status. The Roman Repub(Can Med Assoc J 1989; lic fell. The French aristocracy 141: 1220) and the response from fell. Dictators have come and Drs. Morris L. Barer and Robert gone. But the admission criteria G. Evans (ibid: 1220-1221) I am for patienthood have not changed. reminded of the adage that comToday Canadian society is ex- munication means not just speakamining its admission criteria: ing and listening but actually un"Which fetuses should have derstanding. I think that what Rorights?" As this political debate senberg is trying to say is that if rages the medical profession is all the services given to the elderly faced with an equally agonizing had been provided by a constant question: "Who should set the number of doctors, those doctors admission criteria for patient- would be all wealthy. Thus, the hood?" Our choices are many: the profession "has funded its own individual doctor, the mother of expansion". Of course, to provide the being involved, the CMA, Par- that level of service would have liament, the Supreme Court and required an expansion of the day even Hippocrates. by many hours or a decrease in It seems that the CMA has the time spent per visit, somedecided to take this authority thing that is not happening with from Hippocrates and place it in the elderly, for very good reasons. the hands of "a woman and her It may be naive and simplisdoctor". After 2000 years of all tic, but I believe that the expanmanner of political structure, elit- sion in services to the elderly is a ist and egalitarian, what a great good thing and is necessary. In medical profession do not retire in near poverty more frequently than their patients.
706
CAN MED ASSOC J 1990; 142 (7)
1974 or 1975 dementia was termed "senility", and the sufferers (along with their suffering caregivers) were written off. Now, through the use of expensive technology such as computed tomography we can distinguish among such disorders as low-pressure hydrocephalus, multi-infarct dementia and Alzheimer's disease. With repeated visits and further assessments, including such expensive procedures as radioimmune thyroid assays and vitamin B12 and folate determinations, we can determine which patients have pseudodementia and are likely to be helped by treatment, which may
involve expensive surgical intervention. Once the disorder has been defined, proper follow-up often requires further visits and further biochemical testing. I therefore agree with the original article that the increase in the number of visits and in the amount spent on laboratory and other investigations has been much more rapid than the increase in the number of elderly. The driving force, however, has not been a desire to increase doctors' incomes but the obligation to treat the elderly with the best that medical science has to offer. Many other diseases have become definable and treatable in the elderly. And this leads us to consider the ethical issues discussed by Dr. Kevin Schwartzman
(ibid: 1262-1265). Between 1974 and 1984 the use of medical services by the elderly grew at a faster rate than the number of elderly. What a positive comment on the improvement in our care of the elderly! How appropriate! But what does it mean for the future? Probably a continuation of the same trend until the elderly are adequately cared for and not simply warehoused. Philip G. Winkelaar, MD 1865 Dunmore Rd. SE Medicine Hat, Alta.
