373 age and may indicate that many patients had incipient macular degeneration rather than a chloroquine retinopathy, although another study has suggested that chloroquine therapy may be more hazardous in the elderly. 17 Other studies have shown that the total amount of drug received is the most important risk factor13 22 and we also found that there was a clear relationship between total dose of chloroquine and retinal changes, with 10% of those receiving a total dose of less than 200 g of chloroquine developing retinal changes as opposed to 50% of those receiving more than 600 g.
Public Health
MICRO-PROCESSORS, MACRO-ECONOMIC POLICY, AND PUBLIC HEALTH PETER DRAPER JOHN DENNIS JENNY GRIFFITHS JAMES PARTRIDGE JENNIE POPA
Some authors have commented on the irreversibility23 progression 24 of the retinopathy after discontinuing therapy and this has been a major argument against the use of chloroquine. We therefore re-examined all the patients who had discontinued chloroquine because of a suspected retinopathy. The visual acuity, fundal appearance, and visual fields were re-examined in all patients and some had a photostress test.
Unit for the
or
There was deterioration of visual acuity in only 1 patient (case 22) and this was associated with a bull’s-eye macula and a paracentral scotoma. This patient had received more chloroquine than any of the other patients who had a retinopathy and had also exceeded the daily recommended dose of 250 mg with a mean daily dose of 600 mg. There was regression of macular changes in the other 4 patients initially found to have bull’s-eye maculæ with 2 showing minor pigment changes (caseses 10, 21) and 2 with normal maculae (cases 1, 2). There was no progression of retinal changes in the 17 patients who initially showed mild pigmentary disturbance of the macula and, on later review, in 7 of these patients the maculae were thought to be normal. A delay in recovery time in excess of 40 s after a photostress test has been claimed to be a sensitive index of macular function25 but we could not show any dose correlation between the photostress test and fundal abnormalities. These results show that retinal changes due to chloroare dose-related and are reversible in the early stages; even patients who show the bull’s-eye maculae which are regarded as a feature of advanced chloroquine retinopathy may have reversible changes if visual acuity is normal and there are no visual-field defects.
quine
The risks associated with theuse of chloroquine in the of rheumatoid arthritis should be balanced against the risk of fatal marrow suppression or nephrotoxicity which may occur when drugs of similar effectiveness, such as gold or penicillamine, are used. This study indicates that the ocular hazards associated with long-term chloroquine therapy are low and does not support the view that chloroquine should be regarded as
Study of Health Policy, Department of
Community Medicine, Guy’s Hospital Medical School, London SE1 1YR
"In West Germany, where the micro-processor is known the ’job-killer’, a study by the electrical giant, Siemens, suggests that office employment could fall by 40 per cent by 1990-that, incidentally, is two million jobs." "It was in 1975 that British unemployment began its miserable march toward the plateau of 1.5 million. It has stayed there for a couple of years now, despite job creation schemes and temporary employment subsidies ... Both the Think Tank and the Manpower Services Commission _admit that rising unemployment is the expectation in the medium term (up to ten years)."-The Micro-electronic Revolution. TOM FORESTER, New Society, Nov. 16, 1978. as
Whether the optimists or the pessimists will be proved right about the impact of micro-processors on employment, it is remarkable how those involved in health care in Britain have remained apparently untouched by the public debates on unemployment and what to do about it. High levels of unemployment raise two broad issues in relation to health care: the damage (and, of course, any benefits) to health caused by involuntary unemployment and relative poverty; and the waste of potentially useful employment. First, is there any evidence of damage to health caused by unemployment? Probably the largest and most statistically elaborate inquiries into the effects of unemployment on health and other social indicators in different countries (including the U.K.) has been carried out by an American medical sociologist, Dr Harvey Brenner, and his colleagues of
treatment
obsolete.
6. Popert, A. J. Rheum. Rehab. 1976, 15, 235. 7. Hobbs, H., Calnan, C. Lancet, 1958, i, 1207. 8. Abels, D. J., O’Keefe, T. N., Smith, D., Gutow, R., Falls, H. F., Duff, I. F. Arthrt. Rheum. 1963, 6, 258. 9. Henkind, P., Rothfield, N. F. New Engl. J. Med. 1963, 269, 432. 10. Cambiaggi, A.Archs Ophthal. 1957, 57, 451. 11. Ellsworth, R., Zeller, R. ibid. 1961, 66, 269. 12. Hobbs, H. E., Eadie, S. P., Somerville, F. Br. J. Ophthal. 1961, 45, 284. 13. Scherbel, A. L., Mackenzie, A. H., Nousek, J. E., Atdjian, M. New Engl. J.
Med. 1965, 273, 360
Reprint requests should be addressed
to
J. S.
M.
14. Arden, K. B., Kolb, J. Br. med. J. 1966, i, 270. 15. Nylander, U. Acta ophthal. 1967, suppl. 92, p. 5. 16. Percival, S. P. B., Meanock, I. Br. med. J. 1968, iii, 579. 17. Elman, A., Gullberg, R., Nilsson, E., Rendahl, I., Wachmeister, L. Scand.
J. Rheumat. 1976, 5, 161.
REFERENCES 18.
1 Freedman, A., Steinburg, V. L. Ann. rheum. Dis. 1960, 19, 243. 2 Popert, A. J., Meijers, K. A. E., Sharp, J., Bier, F. ibid. 1961, 20, 18. 3. Mainland, D., Sutcliffe, M. I. Bull. rheum. Dis. 1962, 12, 287. 4 Clins rheum Dis. 1975, 1, 2. S Brooks, P M., Watson Buchanan, W. in Recent Advances in Rheumatology pan 2) (edited by W. Watson Buchanan, W. Carson Dick); p. 59. Edin-
burgh, 1976.
Fuld, H. Lancet, 1959, ii, 617. 19. Kornzweig, A. L., Felstein, M., Schneider, J. Am. J. Ophthal. 1957, 44, 29. 20. Percival, S. P. B., Behman, J. Br. J. Ophthal. 1969, 53, 101. 21. Reed, H., Campbell, A. Can. med. Ass. J. 1962, 86, 176. 22. Nazik, R. A., Weinstock, F. J., Vignos, P. J. Am. J. Ophthal. 1964, 58, 774. 23. Mayer, W. ibid. 1962, 53, 769. 24. Okun, E., Gouras, P., Bernstein, H. N., Van Sallman, L. Archs Ophthal. 1963, 69, 59. 25. Carr, R. E., Henkind, P., Rothfield, N., Siegal, I. M. Am. J. Opthal. 1968, 66, 738.
374
Johns Hopkins University. In his report to the U.S. Congress, the key finding was that a 1% increase in the unemployment rate in the U.S. sustained over a period of six years "has been associated ... with increases of approximately 36,887 total deaths". Like the early work on smoking and bronchial carcinoma, Brenner’s studies reveal statistical associations which may or may not be borne out by further work. (A complex computer model is used to allow for the different time-lags between unemployment rates and death rates from cardiovascular An independent examination of the data would demand comparable epidemiological, statistical, and computing skills to those that have been deployed in the U.S. over a number of years. Such an independent examination does not yet appear to have been carried out.
disease, suicide, cirrhosis, &c.)
Health researchers-and their sponsors-may be stimulated to study the relationships between unemployment and health by the unlikely instrument of a television broadcast, since Granada’s World in Action has just broadcast a programme on Brenner’s work.2 (Brenner’s work was brought to the attention of British economists and others some years ago by the then Lombard columnist of the Financial Tirnes3). If Brenner’s statistical work were unsupported by other evidence, it would still be worth repeating independently and developing. In fact, three kinds of studies lend support to his findings and they strengthen the case for considering and combating the adverse effects of un-
employment. The
the effects on health of inthe prospective inquiries voluntary unemployment which follow workers from the trauma of being told that they are to lose their jobs (for example, when a factory is to be closed) through to their eventual re-employment or to their despairing of the possibility of such an outcome. These findings also suggest the mechanisms by which damage occurs. Unsurprisingly, in addition to psychological effects - (notably depression), blood-pressure and other indicators of stress tend to rise and remain high until the workers have settled into a new job.4 Secondly, studies of the psychological and physical effects of particularly stressful events5 (such as bereavement, marital breakdown, or changing job) also support Brenner’s conclusions, albeit somewhat indirectly. Thirdly, despite improved unemployment benefits and a small minority of "scroungers",6 unemployment is still typically associated with poverty and hence the mass of evidence about the higher morbidity and mortality levels of the poor is also relevant.7 most
direct work
on
are
As far as the waste of potentially useful employment is concerned, comments on health-service policy, whether governmental or non-governmental, typically ignore the possibility that the neglected sectors of care (such as the care of the mentally ill and the handicapped) might be improved by creating appropriate new posts. For example, the Government’s documents which proposed changes between acute and chronic sectors, and between hospital and community services, (the priorities document8 and The Way Forward9) seem unaware of the phenomenon of unemployment. It is as though the climate of opinion which broadly says "taxes are too high and public expenditure should be pegged if
it can’t be cut" has blocked nearly all thinking of additional resources for the N.H.S. Doctors and health workers of all kinds might at least occasionally be heard amongst those calling for more N.H.S. income not by raising tax levels but from collecting what is supposed to be collected and by curbing the tax avoidance industry. 10 Equally, those with an interest in health care might also be heard more often and more convincingly when bids are being made for public sector funds. At the moment, the public might be excused for thinking that it is only the police and the armed services who have claims to make.
Quite apart, however, from the overall size of public expenditure and the proportion that goes to the N.H.S. in comparison with other services, relating high unemployment to possible improvements in staffing levels in health care would actually involve very little additional expenditure. The point is that when all the costs are calculated for unemployment benefits, for the administrative costs of paying such benefits, for the lost payments of income tax and social security contributions, the additional money needed to provide employment instead of unemployment is modest." Basically, what would be needed would be a transfer of funds from the socialsecurity side of the D.H.S.S. to the health side. That would no doubt raise difficult problems for the Treasury - and one or two others-but not impossible problems. As the number of "health economists" employed in Britain grows (now at least 75) it might be thought that many of them would be working on these issues-the health implications of macro-economic policy. But to judge by publications and the kinds of papers that are presented at the lively twice-yearly meetings of the Health Economists’ Study Group, nothing could be further from the truth. The overwhelming focus of attention is on micro-economics: how given N.H.S. resources are deployed and how they might be deployed "more efficiently"-what is accurately described as health service economics. Is it not reasonable for community medicine, that part of medicine which is (or ought to be) specially concerned with the hostilities to health in the wider environment, to begin to work with health economists and others in order to develop a better understanding of the "hostile economic environment"? Perhaps understandably, the Chief Medical Officer12 does not yet seem ready to mention a high level of unemployment as constituting a hazard to health-even though it results in work for the N.H.S., if only in prescriptions for tranquillisers and hypnotics. With its interest in the organisation of health services, community medicine might also help to create additional socially useful posts in health care-an exciting prospect for the unemployed and perhaps for others. Quite apart from the specific and threatening problem of unemployment, there are other reasons why community medicine in particular and medicine in general might take a fresh look at the wider environment in which the public and the N.H.S. have to work. The essence of public health is the idea of human interdependence with the environment. In current jargon that would probably be called human ecology. As the need for ecological sanity in other matters makes itself more keenly felt (such as the need to use oil more wisely and
375 reduce oil and sulphur-dioxide pollution) it would hardly be appropriate for medicine as a learned profession to devote itself solely to "ministering to the victims of the environment." While some doctors have made
outstanding contributions to problems of population, resources, and pollution, it could hardly be argued that the profession as a whole has taken up the challenge of Canadian Minister of Health. 13 If all this seems heady stuff, medicine could do worse than start with a critical look at doctors’ attitudes to their own work. Medicine is hardly in a sound position to offer thoughtful comments to society about work and unemployment if its own work is still surrounded by confusion and muddle. Is it reasonable for the profession apparently to approve almost unlimited work for itself and to retain the image and the practices of the too busy doctor? The responsibilities of a caring profession have traditionally (and most would say rightly) largely ignored the common and rigid boundaries of "working hours", but how does such "judicious availability" square either with the rigidity of formal contracts or with the need for doctors, like other people, to have reasonable rest and recreation? We have argued that the lower labour needs of manufacturing industry should contribute to better conditions for staff and better a recent
Round the World
human relations in health care-which would be to the benefit of all. An imaginative and responsible discussion of the work of doctors in a changing world might be a solid contribution to the wider problems of work and economic policy. It would certainly provide an exemplary starting point. Micro-processors and macro-economic policies have profound implications for the organisation of health services ; and they also have equally profound implications for the human habitat-for public health. REFERENCES
Brenner, H. Estimating the Social Costs of National Economic Government Printing Office, Washington, 1976. 2. Granada TV: World in Action. Feb. 5, 1979. 3. Gordon Tether, C. Financial Times, Dec. 19, 1975. 1.
our
Correspondents
1atJan and Elsewhere CLIOQUINOL
AND S.M.O.N
Ix a judgment delivered on Nov. 14, 1978, the Fukuoka District Court declared Ciba-Geigy (Japan) Ltd., Takeda Chemical Industries Ltd., Tanabe Seiyaku Co., and the State of Japan legally responsible for the damage done by subacute myelo-optic neuropathy (s.M.o.N.). It ordered a total compensation of 3862 million yen (£9.66m) to be paid to 164 patients and relatives who brought the suit, equivalent to almost :60 000 each. The court found the causal relationship between s.M.o.N. and clioquinol indisputable. The chief judge, Yoshiomi Gondo, said that the Government had failed to check the safety of clioquinol as stipulated by the Drugs, Cosmetics and Medical Instrument Act, and that the harmful effect of the drug could have been foreseen in May, 1959. The court’s ruling was an even more substantial victory for the s.M.o.x. victims than the verdicts of the Kanazawa1 and Tokvo District Courts,2 because it accepted the claim of 4 pauents who did not submit doctors’ certificates showing that thev had taken clioquinol. This decision may lead to further action by an estimated 20 000 S.M.O.N. patients in Japan who have been unable to obtain proof that they took clioquinol. An editorial in Mainichi Daily News said: "the new judgment. which censures the producers and the state, will be
widely welcomed by HI trust m
the
the public, and will undoubtedly increase We must now watch closely to see how
courts.
quicklv the producers, the state and others concerned will euend relief to the sufferers in line with the new ruling and how honestly they will endeavour to eliminate the causes of drug-related diseases by strengthening the present medical policy". 1.
2.
Lancet, 1978, i, 1144 .
ibid. 1978, ii, 519.
U.S.
4. Kasl, S., Cobb, S. Int. J. Epidem. 1972, 1, 111. 5. Gunderson, E. K., Rahe, R. H. Life Stress and
Illness. Springfield, Illinois, 1974. 6. Report of the Committee on Abuse of Social Security Benefits, Cmnd 5228. H.M. Stationery Office, London, 1973. 7. Hart, N. Health and Inequality (in the press). 8. Priorities for Health and Personal Social Services in England. H.M. Stationery
Office, London, 1976.
9. The Way Forward. H.M. Stationery Office, London, 1977. 10. Outer Circle Policy Unit. Policing the Hidden Economy. London, 1978. 11. Mukherjee, S. There’s Work to be Done. Manpower Services Commission, H.M. Stationery Office, London, 1974. 12. Department of Health and Social Security. On the State of the Public Health for the Year 1977. H.M. Stationery Office, London, 1978. 13. Lalonde, M. Am. J. publ. Hlth, 1977, 67, 4
Tokyo group of lawyers who acted for S.M.o.N. patients organising "the Kyoto International Conference Against Drug Induced Sufferings" which is to be held from April 13 to 18. The conference is financed by the lawyers’ fees from settled S.M.O.N. cases. Doctors, lawyers, .medical authorities, consumer organisations, and politicians from many A
is
From
Policy.
now
countries have been invited. 16 cases of neurological damage by oxyquinolines were recently recorded in Sweden,3 where many doctors are still boycotting Ciba-Geigy as a protest against the continued sale of clioquinol round the world.4 The Swedish drug company Hassle (a subsidiary of Astra) has decided to end its marketing cooperation with Ciba-Geigy in Finland, Norway, and Sweden. In France Sandoz has withdrawn ’Intestopan’ (containing broxyquinoline) from the -market. A prescription is now required for each purchase of an oxyquinoline product; and the indications for "prophylactic use" and for "non-specific diarrhoea" have been deleted. India is often mentioned as a country where the medical authorities are convinced of the benefits and safety of clioquinol. The Indian Government, however, has now stopped the free sale to the public of ’Mexaform’, ’Entero-Vioform’, and over 100 similar drugs.6 On the other hand, Mr Arsenio Regala, of the Philippine Food and Drug Administration, last year stated that clioquinol-based drugs marketed as ’Entero-vioform’ or ‘Mexaform’ do not produce adverse effects in Filipinos because of their "genetic characteristics".’ Medical records of Government and private hospitals had shown no evidence of severe side-effects of the drug. Mr Regala said that the drug had been marketed for the past 15 years, and ill effects, if any, would have been reported to the F.D.A. already. He cited chloramphenicol as another example of a drug which has caused reactions in Americans, but is well tolerated in the Philippines. It is to be hoped that he is right. 3. Hansson, O. Lakartidningen, 1978, 75, 3064. 4. See Lancet, 1977, ii, 1219. 5. See Bernard, G., Griffith, R. W. ibid. 1977, i, 956.
6. Eastern Pharmacist, 1977, 20, 116. 7. Ang Mamimili (Quezon City), March,
1978, p. 50.
Public Health
MICRO-PROCESSORS, MACRO-ECONOMIC POLICY, AND PUBLIC HEALTH PETER DRAPER JOHN DENNIS JENNY GRIFFITHS JAMES PARTRIDGE JENNIE POPA
Some authors have commented on the irreversibility23 progression 24 of the retinopathy after discontinuing therapy and this has been a major argument against the use of chloroquine. We therefore re-examined all the patients who had discontinued chloroquine because of a suspected retinopathy. The visual acuity, fundal appearance, and visual fields were re-examined in all patients and some had a photostress test.
Unit for the
or
There was deterioration of visual acuity in only 1 patient (case 22) and this was associated with a bull’s-eye macula and a paracentral scotoma. This patient had received more chloroquine than any of the other patients who had a retinopathy and had also exceeded the daily recommended dose of 250 mg with a mean daily dose of 600 mg. There was regression of macular changes in the other 4 patients initially found to have bull’s-eye maculæ with 2 showing minor pigment changes (caseses 10, 21) and 2 with normal maculae (cases 1, 2). There was no progression of retinal changes in the 17 patients who initially showed mild pigmentary disturbance of the macula and, on later review, in 7 of these patients the maculae were thought to be normal. A delay in recovery time in excess of 40 s after a photostress test has been claimed to be a sensitive index of macular function25 but we could not show any dose correlation between the photostress test and fundal abnormalities. These results show that retinal changes due to chloroare dose-related and are reversible in the early stages; even patients who show the bull’s-eye maculae which are regarded as a feature of advanced chloroquine retinopathy may have reversible changes if visual acuity is normal and there are no visual-field defects.
quine
The risks associated with theuse of chloroquine in the of rheumatoid arthritis should be balanced against the risk of fatal marrow suppression or nephrotoxicity which may occur when drugs of similar effectiveness, such as gold or penicillamine, are used. This study indicates that the ocular hazards associated with long-term chloroquine therapy are low and does not support the view that chloroquine should be regarded as
Study of Health Policy, Department of
Community Medicine, Guy’s Hospital Medical School, London SE1 1YR
"In West Germany, where the micro-processor is known the ’job-killer’, a study by the electrical giant, Siemens, suggests that office employment could fall by 40 per cent by 1990-that, incidentally, is two million jobs." "It was in 1975 that British unemployment began its miserable march toward the plateau of 1.5 million. It has stayed there for a couple of years now, despite job creation schemes and temporary employment subsidies ... Both the Think Tank and the Manpower Services Commission _admit that rising unemployment is the expectation in the medium term (up to ten years)."-The Micro-electronic Revolution. TOM FORESTER, New Society, Nov. 16, 1978. as
Whether the optimists or the pessimists will be proved right about the impact of micro-processors on employment, it is remarkable how those involved in health care in Britain have remained apparently untouched by the public debates on unemployment and what to do about it. High levels of unemployment raise two broad issues in relation to health care: the damage (and, of course, any benefits) to health caused by involuntary unemployment and relative poverty; and the waste of potentially useful employment. First, is there any evidence of damage to health caused by unemployment? Probably the largest and most statistically elaborate inquiries into the effects of unemployment on health and other social indicators in different countries (including the U.K.) has been carried out by an American medical sociologist, Dr Harvey Brenner, and his colleagues of
treatment
obsolete.
6. Popert, A. J. Rheum. Rehab. 1976, 15, 235. 7. Hobbs, H., Calnan, C. Lancet, 1958, i, 1207. 8. Abels, D. J., O’Keefe, T. N., Smith, D., Gutow, R., Falls, H. F., Duff, I. F. Arthrt. Rheum. 1963, 6, 258. 9. Henkind, P., Rothfield, N. F. New Engl. J. Med. 1963, 269, 432. 10. Cambiaggi, A.Archs Ophthal. 1957, 57, 451. 11. Ellsworth, R., Zeller, R. ibid. 1961, 66, 269. 12. Hobbs, H. E., Eadie, S. P., Somerville, F. Br. J. Ophthal. 1961, 45, 284. 13. Scherbel, A. L., Mackenzie, A. H., Nousek, J. E., Atdjian, M. New Engl. J.
Med. 1965, 273, 360
Reprint requests should be addressed
to
J. S.
M.
14. Arden, K. B., Kolb, J. Br. med. J. 1966, i, 270. 15. Nylander, U. Acta ophthal. 1967, suppl. 92, p. 5. 16. Percival, S. P. B., Meanock, I. Br. med. J. 1968, iii, 579. 17. Elman, A., Gullberg, R., Nilsson, E., Rendahl, I., Wachmeister, L. Scand.
J. Rheumat. 1976, 5, 161.
REFERENCES 18.
1 Freedman, A., Steinburg, V. L. Ann. rheum. Dis. 1960, 19, 243. 2 Popert, A. J., Meijers, K. A. E., Sharp, J., Bier, F. ibid. 1961, 20, 18. 3. Mainland, D., Sutcliffe, M. I. Bull. rheum. Dis. 1962, 12, 287. 4 Clins rheum Dis. 1975, 1, 2. S Brooks, P M., Watson Buchanan, W. in Recent Advances in Rheumatology pan 2) (edited by W. Watson Buchanan, W. Carson Dick); p. 59. Edin-
burgh, 1976.
Fuld, H. Lancet, 1959, ii, 617. 19. Kornzweig, A. L., Felstein, M., Schneider, J. Am. J. Ophthal. 1957, 44, 29. 20. Percival, S. P. B., Behman, J. Br. J. Ophthal. 1969, 53, 101. 21. Reed, H., Campbell, A. Can. med. Ass. J. 1962, 86, 176. 22. Nazik, R. A., Weinstock, F. J., Vignos, P. J. Am. J. Ophthal. 1964, 58, 774. 23. Mayer, W. ibid. 1962, 53, 769. 24. Okun, E., Gouras, P., Bernstein, H. N., Van Sallman, L. Archs Ophthal. 1963, 69, 59. 25. Carr, R. E., Henkind, P., Rothfield, N., Siegal, I. M. Am. J. Opthal. 1968, 66, 738.
374
Johns Hopkins University. In his report to the U.S. Congress, the key finding was that a 1% increase in the unemployment rate in the U.S. sustained over a period of six years "has been associated ... with increases of approximately 36,887 total deaths". Like the early work on smoking and bronchial carcinoma, Brenner’s studies reveal statistical associations which may or may not be borne out by further work. (A complex computer model is used to allow for the different time-lags between unemployment rates and death rates from cardiovascular An independent examination of the data would demand comparable epidemiological, statistical, and computing skills to those that have been deployed in the U.S. over a number of years. Such an independent examination does not yet appear to have been carried out.
disease, suicide, cirrhosis, &c.)
Health researchers-and their sponsors-may be stimulated to study the relationships between unemployment and health by the unlikely instrument of a television broadcast, since Granada’s World in Action has just broadcast a programme on Brenner’s work.2 (Brenner’s work was brought to the attention of British economists and others some years ago by the then Lombard columnist of the Financial Tirnes3). If Brenner’s statistical work were unsupported by other evidence, it would still be worth repeating independently and developing. In fact, three kinds of studies lend support to his findings and they strengthen the case for considering and combating the adverse effects of un-
employment. The
the effects on health of inthe prospective inquiries voluntary unemployment which follow workers from the trauma of being told that they are to lose their jobs (for example, when a factory is to be closed) through to their eventual re-employment or to their despairing of the possibility of such an outcome. These findings also suggest the mechanisms by which damage occurs. Unsurprisingly, in addition to psychological effects - (notably depression), blood-pressure and other indicators of stress tend to rise and remain high until the workers have settled into a new job.4 Secondly, studies of the psychological and physical effects of particularly stressful events5 (such as bereavement, marital breakdown, or changing job) also support Brenner’s conclusions, albeit somewhat indirectly. Thirdly, despite improved unemployment benefits and a small minority of "scroungers",6 unemployment is still typically associated with poverty and hence the mass of evidence about the higher morbidity and mortality levels of the poor is also relevant.7 most
direct work
on
are
As far as the waste of potentially useful employment is concerned, comments on health-service policy, whether governmental or non-governmental, typically ignore the possibility that the neglected sectors of care (such as the care of the mentally ill and the handicapped) might be improved by creating appropriate new posts. For example, the Government’s documents which proposed changes between acute and chronic sectors, and between hospital and community services, (the priorities document8 and The Way Forward9) seem unaware of the phenomenon of unemployment. It is as though the climate of opinion which broadly says "taxes are too high and public expenditure should be pegged if
it can’t be cut" has blocked nearly all thinking of additional resources for the N.H.S. Doctors and health workers of all kinds might at least occasionally be heard amongst those calling for more N.H.S. income not by raising tax levels but from collecting what is supposed to be collected and by curbing the tax avoidance industry. 10 Equally, those with an interest in health care might also be heard more often and more convincingly when bids are being made for public sector funds. At the moment, the public might be excused for thinking that it is only the police and the armed services who have claims to make.
Quite apart, however, from the overall size of public expenditure and the proportion that goes to the N.H.S. in comparison with other services, relating high unemployment to possible improvements in staffing levels in health care would actually involve very little additional expenditure. The point is that when all the costs are calculated for unemployment benefits, for the administrative costs of paying such benefits, for the lost payments of income tax and social security contributions, the additional money needed to provide employment instead of unemployment is modest." Basically, what would be needed would be a transfer of funds from the socialsecurity side of the D.H.S.S. to the health side. That would no doubt raise difficult problems for the Treasury - and one or two others-but not impossible problems. As the number of "health economists" employed in Britain grows (now at least 75) it might be thought that many of them would be working on these issues-the health implications of macro-economic policy. But to judge by publications and the kinds of papers that are presented at the lively twice-yearly meetings of the Health Economists’ Study Group, nothing could be further from the truth. The overwhelming focus of attention is on micro-economics: how given N.H.S. resources are deployed and how they might be deployed "more efficiently"-what is accurately described as health service economics. Is it not reasonable for community medicine, that part of medicine which is (or ought to be) specially concerned with the hostilities to health in the wider environment, to begin to work with health economists and others in order to develop a better understanding of the "hostile economic environment"? Perhaps understandably, the Chief Medical Officer12 does not yet seem ready to mention a high level of unemployment as constituting a hazard to health-even though it results in work for the N.H.S., if only in prescriptions for tranquillisers and hypnotics. With its interest in the organisation of health services, community medicine might also help to create additional socially useful posts in health care-an exciting prospect for the unemployed and perhaps for others. Quite apart from the specific and threatening problem of unemployment, there are other reasons why community medicine in particular and medicine in general might take a fresh look at the wider environment in which the public and the N.H.S. have to work. The essence of public health is the idea of human interdependence with the environment. In current jargon that would probably be called human ecology. As the need for ecological sanity in other matters makes itself more keenly felt (such as the need to use oil more wisely and
375 reduce oil and sulphur-dioxide pollution) it would hardly be appropriate for medicine as a learned profession to devote itself solely to "ministering to the victims of the environment." While some doctors have made
outstanding contributions to problems of population, resources, and pollution, it could hardly be argued that the profession as a whole has taken up the challenge of Canadian Minister of Health. 13 If all this seems heady stuff, medicine could do worse than start with a critical look at doctors’ attitudes to their own work. Medicine is hardly in a sound position to offer thoughtful comments to society about work and unemployment if its own work is still surrounded by confusion and muddle. Is it reasonable for the profession apparently to approve almost unlimited work for itself and to retain the image and the practices of the too busy doctor? The responsibilities of a caring profession have traditionally (and most would say rightly) largely ignored the common and rigid boundaries of "working hours", but how does such "judicious availability" square either with the rigidity of formal contracts or with the need for doctors, like other people, to have reasonable rest and recreation? We have argued that the lower labour needs of manufacturing industry should contribute to better conditions for staff and better a recent
Round the World
human relations in health care-which would be to the benefit of all. An imaginative and responsible discussion of the work of doctors in a changing world might be a solid contribution to the wider problems of work and economic policy. It would certainly provide an exemplary starting point. Micro-processors and macro-economic policies have profound implications for the organisation of health services ; and they also have equally profound implications for the human habitat-for public health. REFERENCES
Brenner, H. Estimating the Social Costs of National Economic Government Printing Office, Washington, 1976. 2. Granada TV: World in Action. Feb. 5, 1979. 3. Gordon Tether, C. Financial Times, Dec. 19, 1975. 1.
our
Correspondents
1atJan and Elsewhere CLIOQUINOL
AND S.M.O.N
Ix a judgment delivered on Nov. 14, 1978, the Fukuoka District Court declared Ciba-Geigy (Japan) Ltd., Takeda Chemical Industries Ltd., Tanabe Seiyaku Co., and the State of Japan legally responsible for the damage done by subacute myelo-optic neuropathy (s.M.o.N.). It ordered a total compensation of 3862 million yen (£9.66m) to be paid to 164 patients and relatives who brought the suit, equivalent to almost :60 000 each. The court found the causal relationship between s.M.o.N. and clioquinol indisputable. The chief judge, Yoshiomi Gondo, said that the Government had failed to check the safety of clioquinol as stipulated by the Drugs, Cosmetics and Medical Instrument Act, and that the harmful effect of the drug could have been foreseen in May, 1959. The court’s ruling was an even more substantial victory for the s.M.o.x. victims than the verdicts of the Kanazawa1 and Tokvo District Courts,2 because it accepted the claim of 4 pauents who did not submit doctors’ certificates showing that thev had taken clioquinol. This decision may lead to further action by an estimated 20 000 S.M.O.N. patients in Japan who have been unable to obtain proof that they took clioquinol. An editorial in Mainichi Daily News said: "the new judgment. which censures the producers and the state, will be
widely welcomed by HI trust m
the
the public, and will undoubtedly increase We must now watch closely to see how
courts.
quicklv the producers, the state and others concerned will euend relief to the sufferers in line with the new ruling and how honestly they will endeavour to eliminate the causes of drug-related diseases by strengthening the present medical policy". 1.
2.
Lancet, 1978, i, 1144 .
ibid. 1978, ii, 519.
U.S.
4. Kasl, S., Cobb, S. Int. J. Epidem. 1972, 1, 111. 5. Gunderson, E. K., Rahe, R. H. Life Stress and
Illness. Springfield, Illinois, 1974. 6. Report of the Committee on Abuse of Social Security Benefits, Cmnd 5228. H.M. Stationery Office, London, 1973. 7. Hart, N. Health and Inequality (in the press). 8. Priorities for Health and Personal Social Services in England. H.M. Stationery
Office, London, 1976.
9. The Way Forward. H.M. Stationery Office, London, 1977. 10. Outer Circle Policy Unit. Policing the Hidden Economy. London, 1978. 11. Mukherjee, S. There’s Work to be Done. Manpower Services Commission, H.M. Stationery Office, London, 1974. 12. Department of Health and Social Security. On the State of the Public Health for the Year 1977. H.M. Stationery Office, London, 1978. 13. Lalonde, M. Am. J. publ. Hlth, 1977, 67, 4
Tokyo group of lawyers who acted for S.M.o.N. patients organising "the Kyoto International Conference Against Drug Induced Sufferings" which is to be held from April 13 to 18. The conference is financed by the lawyers’ fees from settled S.M.O.N. cases. Doctors, lawyers, .medical authorities, consumer organisations, and politicians from many A
is
From
Policy.
now
countries have been invited. 16 cases of neurological damage by oxyquinolines were recently recorded in Sweden,3 where many doctors are still boycotting Ciba-Geigy as a protest against the continued sale of clioquinol round the world.4 The Swedish drug company Hassle (a subsidiary of Astra) has decided to end its marketing cooperation with Ciba-Geigy in Finland, Norway, and Sweden. In France Sandoz has withdrawn ’Intestopan’ (containing broxyquinoline) from the -market. A prescription is now required for each purchase of an oxyquinoline product; and the indications for "prophylactic use" and for "non-specific diarrhoea" have been deleted. India is often mentioned as a country where the medical authorities are convinced of the benefits and safety of clioquinol. The Indian Government, however, has now stopped the free sale to the public of ’Mexaform’, ’Entero-Vioform’, and over 100 similar drugs.6 On the other hand, Mr Arsenio Regala, of the Philippine Food and Drug Administration, last year stated that clioquinol-based drugs marketed as ’Entero-vioform’ or ‘Mexaform’ do not produce adverse effects in Filipinos because of their "genetic characteristics".’ Medical records of Government and private hospitals had shown no evidence of severe side-effects of the drug. Mr Regala said that the drug had been marketed for the past 15 years, and ill effects, if any, would have been reported to the F.D.A. already. He cited chloramphenicol as another example of a drug which has caused reactions in Americans, but is well tolerated in the Philippines. It is to be hoped that he is right. 3. Hansson, O. Lakartidningen, 1978, 75, 3064. 4. See Lancet, 1977, ii, 1219. 5. See Bernard, G., Griffith, R. W. ibid. 1977, i, 956.
6. Eastern Pharmacist, 1977, 20, 116. 7. Ang Mamimili (Quezon City), March,
1978, p. 50.
