LETTERS TO THE EDITOR
centers that are now being developed in Britain are, we believe, a significant step forward toward a complete NHS which will end the isolation of general practitioners from specialist physicians by bringing them together into genuine group and team practice, upgrade the quality of general practitioners' work and their status in the profession, and permit them to work for salaries like their more affluent specialist and consultant colleagues in the National Health Service. *
*
*
Important developments, occurring since our article was published and the above letters were sent to the Journal, have drastically changed the political framework of this discussion. Senator Kennedy has apparently given up the Kennedy-Corman bill for Health Security.3 It seems likely that a program dominated by the private insurance companies will be presented to Congress by the Carter Administration. Such legislation, if passed, may be expected to embody the regressive features of health insurance outlined in our paper. These events make it all the more necessary for the supporters of Health Security and of a National Health Service to work together for real instead of illusory changes in health care. This will require a thorough restructuring of the nation's health services. Milton Terris, MD Paul B. Cornely, MD Henry C. Daniels Lorin E. Kerr, MD
REFERENCES 1. Report of the APHA Task Force on Chile. Am. J. Pub. Health 67:71-73, 1977. 2. APHA Task Force on Chile. History of the Health Care System in Chile. Am. J. Pub. Health 67:31-36, 1977. 3. Kennedy and Carter Reach an Agreement on Health Insurance. The New York Times, April 7, 1978, p. A28.
Health Promotion-The Importance of Demedicalized and Active Approaches. In the November 1977 issue of the AJPH, Fielding' discusses a number of 686
the practical ways which professionals with what can be done in that regard, in responsible for public health should use particular what they can do. In Switzto bring their partners in the health care erland, an action-research program on system and other relevant groups in the the prevention of cardiovascular dissociety at large to dedicate more of ease, sponsored by the National Fund their time, effort, and other resources for Scientific Research, includes such a to promotion and prevention-oriented component.8 Medical students need to receive the corresponding training,9 so activities. Addressing the situation of indus- that they later on invest time to teach/ trialized countries, the cost-benefit ra- encourage their patients and demontios of what the medical profession strate to them measures/behaviors famost often thinks of in terms of pre- vorable to health, in particular "deventive work are sometimes not very medicalized" ones.10 While physicians are a crucial convincing. Statements of caution are increasingly expressed vis-a-vis routine group, all health personnel as well as check-ups and certain screening proce- decision-makers in other sectors of sodures, if not applied to an adequately ciety whose actions have a bearing on selected (high-risk) population.2-4 Pap the health of the community need to be smear programs, to take one example, given careful attention. One need only while they detect curable cervical can- to remember the discussions and concers and thus avoid human suffering frontations taking place in many counand deaths, cannot be said to be a tries about consumption of tobacco, alcohol, non-prescription drugs, about cheap way to do it.5' 6 As a public health officer in a coun- pollution, or the low priority given to a try where medicine is determinedly of a solidly built and regularly delivered free enterprise, fee-for-service, nature, school health education program (in the author of this note, in the economic Switzerland, the canton of Geneva only context alluded to above, has to answer has had generalized school health eduqueries from personal care delivering cation for several years). Along with the increased promocolleagues who are aware of the modest paying off potential of certain pre- tion of more "demedicalized" moves ventive measures, and discuss the justi- for the health of people, one should refication of the present "fashion" with main aware of a risk, however: faced promotion/prevention. Yet, one can with numerous difficulties, and ill-preunderline that these physicians usually pared at this time to get involved with think of (relatively expensive) measur- laymen in participative promotion and prevention undertakings, the health es which are: * "medicalized" (needing the in- care establishment might be tempted to volvement of a physician or at least use such an evolution as a pretext for minimizing its responsibility in making of some other health professional), * passive as far as the patient is con- adequate and comprehensive health services available to the whole popucerned, lation. Active tendencies from non* aiming at secondary prevention. On the background of the pro- health professionals could be taken to posals made by Dr. Fielding, it appears "explain"~the persistence of unsatisthus very important to put enough em- factory situations and gaps in health phasis on the less costly* primary pre- care or the slowness of change.1'1 12 Jean Martin, MD, MSPH, DTM vention and active health promotion Medecin cantonal adjoint (active for the individual concerned) in Service de la sante publique actions aimed at the public and (perCite-Devant 11, 1000 haps especially) in actions aimed at the Lausanne, Switzerland medical profession. Doctors, in Westem European countries in any case, badly need to become more familiar REFERENCES 1. Fielding JE: Health promotion-some *The least one can say, with L. W. Green, is "Primary prevention ... has seldom had investments proportional to its potential. "7
notions in search of a constituency. Am. J. Public Health, 67, 1082-1085, 1977. 2. Wilson JMG and Jungner G: The principles and practice of screening for dis-
AJPH July, 1978, Vol. 68, No. 7
LETTERS TO THE EDITOR ease. Public Health Papers, No. 34. Geneva: World Health Organization, 1968. 3. Rawson G: Multiphasic screening: Definition and assessment. Med. J. Austral., 2, 497-504, 1972. 4. Delachaux A: (ed.) Les examens medicaux preventifs. Medecine sociale et preventive by Sozial-und Praventivmedizin (Bern), 20, No. 3-4, 103-188, 1975. 5. Schweitzer SO: Cost effectiveness of early detection of disease. Health Services Research, 9/1, 22-32, 1974. 6. Delachaux A. et al. A propos du depistage des cancers gynecologiques-Aspects economiques et services rendus. Given at the Congress of the Swiss Society for Gynecology, June 1977 (in press). 7. Green LW: Determining the impact and effectiveness of health education as it relates to Federal policy. Report for the Office of the Deputy Assistant Secretary for Planning and Evaluation/ Health. Revised, April 30, 1976 (mimeographed), p. 52. 8. Junod B and Gutzwiller F: Programme national de recherche sur la prevention des maladies cardio-vasculaires. Medecine sociale et preventive by Sozial-und Praeventivmedizin (Bern), 22, 157-158, 1977, and personal communications. 9. Antonovsky A: Case study: Student selection in the School of Medicine, BenGurion University of the Negev. Dundee, Scotland, Association for Medical Education in Europe, 1976. 10. Martin J: The active patient-A necessary development. WHO Chronicle, 32, 1978 (forthcoming). 11. Levin LS, Katz AH and Holst E: Selfcare-Lay initiatives in health. New York: Prodist, 1976, 77-78. 12. Galanter RB: To the victim belongs the flaws (editorial). Am. J. Public Health, 67, 1025-1026, 1977.
Pride of Authorship As long-time subscribers and readers of your fine periodical, it was especially rewarding for me and my staff to see our publication, Family Planning in Rlural America, mentioned on page 177 of the February 1978 issue [Book Corner]. Although the content of the volume was expanded and edited by our staff members, Robert Wells and Jeanne Bille, we felt it only fair to notify you that the primary author and contributor was James L. Reitz, Area Manager for the Family Planning Council of Western Pa., Inc., and request that he be given the credit of author-
ship. Thank you again for your efforts to keep public health service staff up-toAJPH July, 1978, Vol. 68, No. 7
date, especially regarding our particular interest-family planning. Russell H. Richardson Director Regional Training Center for Family Planning Emory University School of Medicine Atlanta, GA Editor's Note: The Journal notes the omission and thanks Mr. Richardson for his letter. The name of James L. Reitz did not appear in the usual title page situation-but under acknowledgments-consequently we missed it.
health. Instead he confuses these same old issues; attempts to discredit international health professionals; and, perhaps worse of all, perpetuates the myths regarding the professional orientation of health planners. Mary T. Smith, MPH Research Analyst Center for Health Services Research School ofMedicine University of Southern California 2025 Zonal Avenue Los Angeles, CA 90033
REFERENCE
Re: Myths Revisited In the recent article, More Myths in International Health Planning' in the February issue, Roger England attacks some of the guidelines used to establish priorities for health programs and services in developing countries. He states that these frequently repeated models have gained "unjustified credibility" and have become oversimplified myths. Indeed, Mr. England's criticisms often lack their own credibility and, certainly, logic. For example, the myth of delivery of health services to rural versus urban areas is merely redefined in the article to be a struggle between urban poor and rural poor to receive all of the health resources. This magical mythical tour continues with Myth Number Two which bases its argument on the fact that international health specialists dismiss acute diarrheal disease as being "simply prevented and easily treated." Quotation marks surround the phrase, however, no source is cited. Was a poll taken of international health experts? Or is it a vague impression derived from a review of the literature? Ironically, the author advocates the need for "conceptual, systematic models" and "models which attempt a broad multi-sector overview" which is exactly the criticism leveled at the socalled "medical psuedoscientific Establishment" in perpetuating their myths. Mr. England does not offer any insight into the complex problems confronting international health professionals working for developing countries-nor does he contribute to the development of more acceptable parameters for the field of international
1. England R: More myths in international health planning (Commentary), Am J Public Health 68:153-159, 1978.
More on 'Myths in International Health Planning' In the February commentary "More Myths in International Health Planning," Mr. Roger England addresses the myth of "simple prevention and easy treatment." He points out the absurdity of telling fishing villagers that they must stay out of the water if they want to avoid schistosomiasis as an example of the limitation for the application of technical knowledge in the real world. I would like to point out that control of schistosomiasis has been approached by the introduction of sanitation and safe water supply. This has been addressed in Egypt,' South Africa,2' 3 Rhodesia,4 5 and St. Lucia.f With regard to the referral system, no data are offered to establish that "the hospital in the town receives very few referrals from rural areas." I question the correctness of this statement, which contradicts my informal observations in the Caribbean, Central America, and Africa. With regard to medical aides, Mr. England asserts that the supposed poor performance of many auxiliaries is due to temptations of corruption associated with low rates of pay. Again in my experience, auxiliaries can and often do provide valuable service in areas where no other medical care is available, may be well paid, and usually are honest and reliable. With regard to compulsory rural 687
centers that are now being developed in Britain are, we believe, a significant step forward toward a complete NHS which will end the isolation of general practitioners from specialist physicians by bringing them together into genuine group and team practice, upgrade the quality of general practitioners' work and their status in the profession, and permit them to work for salaries like their more affluent specialist and consultant colleagues in the National Health Service. *
*
*
Important developments, occurring since our article was published and the above letters were sent to the Journal, have drastically changed the political framework of this discussion. Senator Kennedy has apparently given up the Kennedy-Corman bill for Health Security.3 It seems likely that a program dominated by the private insurance companies will be presented to Congress by the Carter Administration. Such legislation, if passed, may be expected to embody the regressive features of health insurance outlined in our paper. These events make it all the more necessary for the supporters of Health Security and of a National Health Service to work together for real instead of illusory changes in health care. This will require a thorough restructuring of the nation's health services. Milton Terris, MD Paul B. Cornely, MD Henry C. Daniels Lorin E. Kerr, MD
REFERENCES 1. Report of the APHA Task Force on Chile. Am. J. Pub. Health 67:71-73, 1977. 2. APHA Task Force on Chile. History of the Health Care System in Chile. Am. J. Pub. Health 67:31-36, 1977. 3. Kennedy and Carter Reach an Agreement on Health Insurance. The New York Times, April 7, 1978, p. A28.
Health Promotion-The Importance of Demedicalized and Active Approaches. In the November 1977 issue of the AJPH, Fielding' discusses a number of 686
the practical ways which professionals with what can be done in that regard, in responsible for public health should use particular what they can do. In Switzto bring their partners in the health care erland, an action-research program on system and other relevant groups in the the prevention of cardiovascular dissociety at large to dedicate more of ease, sponsored by the National Fund their time, effort, and other resources for Scientific Research, includes such a to promotion and prevention-oriented component.8 Medical students need to receive the corresponding training,9 so activities. Addressing the situation of indus- that they later on invest time to teach/ trialized countries, the cost-benefit ra- encourage their patients and demontios of what the medical profession strate to them measures/behaviors famost often thinks of in terms of pre- vorable to health, in particular "deventive work are sometimes not very medicalized" ones.10 While physicians are a crucial convincing. Statements of caution are increasingly expressed vis-a-vis routine group, all health personnel as well as check-ups and certain screening proce- decision-makers in other sectors of sodures, if not applied to an adequately ciety whose actions have a bearing on selected (high-risk) population.2-4 Pap the health of the community need to be smear programs, to take one example, given careful attention. One need only while they detect curable cervical can- to remember the discussions and concers and thus avoid human suffering frontations taking place in many counand deaths, cannot be said to be a tries about consumption of tobacco, alcohol, non-prescription drugs, about cheap way to do it.5' 6 As a public health officer in a coun- pollution, or the low priority given to a try where medicine is determinedly of a solidly built and regularly delivered free enterprise, fee-for-service, nature, school health education program (in the author of this note, in the economic Switzerland, the canton of Geneva only context alluded to above, has to answer has had generalized school health eduqueries from personal care delivering cation for several years). Along with the increased promocolleagues who are aware of the modest paying off potential of certain pre- tion of more "demedicalized" moves ventive measures, and discuss the justi- for the health of people, one should refication of the present "fashion" with main aware of a risk, however: faced promotion/prevention. Yet, one can with numerous difficulties, and ill-preunderline that these physicians usually pared at this time to get involved with think of (relatively expensive) measur- laymen in participative promotion and prevention undertakings, the health es which are: * "medicalized" (needing the in- care establishment might be tempted to volvement of a physician or at least use such an evolution as a pretext for minimizing its responsibility in making of some other health professional), * passive as far as the patient is con- adequate and comprehensive health services available to the whole popucerned, lation. Active tendencies from non* aiming at secondary prevention. On the background of the pro- health professionals could be taken to posals made by Dr. Fielding, it appears "explain"~the persistence of unsatisthus very important to put enough em- factory situations and gaps in health phasis on the less costly* primary pre- care or the slowness of change.1'1 12 Jean Martin, MD, MSPH, DTM vention and active health promotion Medecin cantonal adjoint (active for the individual concerned) in Service de la sante publique actions aimed at the public and (perCite-Devant 11, 1000 haps especially) in actions aimed at the Lausanne, Switzerland medical profession. Doctors, in Westem European countries in any case, badly need to become more familiar REFERENCES 1. Fielding JE: Health promotion-some *The least one can say, with L. W. Green, is "Primary prevention ... has seldom had investments proportional to its potential. "7
notions in search of a constituency. Am. J. Public Health, 67, 1082-1085, 1977. 2. Wilson JMG and Jungner G: The principles and practice of screening for dis-
AJPH July, 1978, Vol. 68, No. 7
LETTERS TO THE EDITOR ease. Public Health Papers, No. 34. Geneva: World Health Organization, 1968. 3. Rawson G: Multiphasic screening: Definition and assessment. Med. J. Austral., 2, 497-504, 1972. 4. Delachaux A: (ed.) Les examens medicaux preventifs. Medecine sociale et preventive by Sozial-und Praventivmedizin (Bern), 20, No. 3-4, 103-188, 1975. 5. Schweitzer SO: Cost effectiveness of early detection of disease. Health Services Research, 9/1, 22-32, 1974. 6. Delachaux A. et al. A propos du depistage des cancers gynecologiques-Aspects economiques et services rendus. Given at the Congress of the Swiss Society for Gynecology, June 1977 (in press). 7. Green LW: Determining the impact and effectiveness of health education as it relates to Federal policy. Report for the Office of the Deputy Assistant Secretary for Planning and Evaluation/ Health. Revised, April 30, 1976 (mimeographed), p. 52. 8. Junod B and Gutzwiller F: Programme national de recherche sur la prevention des maladies cardio-vasculaires. Medecine sociale et preventive by Sozial-und Praeventivmedizin (Bern), 22, 157-158, 1977, and personal communications. 9. Antonovsky A: Case study: Student selection in the School of Medicine, BenGurion University of the Negev. Dundee, Scotland, Association for Medical Education in Europe, 1976. 10. Martin J: The active patient-A necessary development. WHO Chronicle, 32, 1978 (forthcoming). 11. Levin LS, Katz AH and Holst E: Selfcare-Lay initiatives in health. New York: Prodist, 1976, 77-78. 12. Galanter RB: To the victim belongs the flaws (editorial). Am. J. Public Health, 67, 1025-1026, 1977.
Pride of Authorship As long-time subscribers and readers of your fine periodical, it was especially rewarding for me and my staff to see our publication, Family Planning in Rlural America, mentioned on page 177 of the February 1978 issue [Book Corner]. Although the content of the volume was expanded and edited by our staff members, Robert Wells and Jeanne Bille, we felt it only fair to notify you that the primary author and contributor was James L. Reitz, Area Manager for the Family Planning Council of Western Pa., Inc., and request that he be given the credit of author-
ship. Thank you again for your efforts to keep public health service staff up-toAJPH July, 1978, Vol. 68, No. 7
date, especially regarding our particular interest-family planning. Russell H. Richardson Director Regional Training Center for Family Planning Emory University School of Medicine Atlanta, GA Editor's Note: The Journal notes the omission and thanks Mr. Richardson for his letter. The name of James L. Reitz did not appear in the usual title page situation-but under acknowledgments-consequently we missed it.
health. Instead he confuses these same old issues; attempts to discredit international health professionals; and, perhaps worse of all, perpetuates the myths regarding the professional orientation of health planners. Mary T. Smith, MPH Research Analyst Center for Health Services Research School ofMedicine University of Southern California 2025 Zonal Avenue Los Angeles, CA 90033
REFERENCE
Re: Myths Revisited In the recent article, More Myths in International Health Planning' in the February issue, Roger England attacks some of the guidelines used to establish priorities for health programs and services in developing countries. He states that these frequently repeated models have gained "unjustified credibility" and have become oversimplified myths. Indeed, Mr. England's criticisms often lack their own credibility and, certainly, logic. For example, the myth of delivery of health services to rural versus urban areas is merely redefined in the article to be a struggle between urban poor and rural poor to receive all of the health resources. This magical mythical tour continues with Myth Number Two which bases its argument on the fact that international health specialists dismiss acute diarrheal disease as being "simply prevented and easily treated." Quotation marks surround the phrase, however, no source is cited. Was a poll taken of international health experts? Or is it a vague impression derived from a review of the literature? Ironically, the author advocates the need for "conceptual, systematic models" and "models which attempt a broad multi-sector overview" which is exactly the criticism leveled at the socalled "medical psuedoscientific Establishment" in perpetuating their myths. Mr. England does not offer any insight into the complex problems confronting international health professionals working for developing countries-nor does he contribute to the development of more acceptable parameters for the field of international
1. England R: More myths in international health planning (Commentary), Am J Public Health 68:153-159, 1978.
More on 'Myths in International Health Planning' In the February commentary "More Myths in International Health Planning," Mr. Roger England addresses the myth of "simple prevention and easy treatment." He points out the absurdity of telling fishing villagers that they must stay out of the water if they want to avoid schistosomiasis as an example of the limitation for the application of technical knowledge in the real world. I would like to point out that control of schistosomiasis has been approached by the introduction of sanitation and safe water supply. This has been addressed in Egypt,' South Africa,2' 3 Rhodesia,4 5 and St. Lucia.f With regard to the referral system, no data are offered to establish that "the hospital in the town receives very few referrals from rural areas." I question the correctness of this statement, which contradicts my informal observations in the Caribbean, Central America, and Africa. With regard to medical aides, Mr. England asserts that the supposed poor performance of many auxiliaries is due to temptations of corruption associated with low rates of pay. Again in my experience, auxiliaries can and often do provide valuable service in areas where no other medical care is available, may be well paid, and usually are honest and reliable. With regard to compulsory rural 687
