188
radiotherapy. We can hope for an increase in local curerates in patients with fairly advanced tumours and with a safe and reliable technique this could then be applied to earlier tumours with great likelihood of improved long term result. In certain sites it may be possible to spare patients from extensive surgery, now required because of unsatisfactory results from radiotherapy. In other situations where radiotherapy is successful, but at a risk of considerable morbidity, we can hope to maintain the local cure-rate, but with fewer operations and deaths because of morbidity. At this time, extended fields for radiotherapy can only be used successfully in the management of tumours of high radiosensitivity. The good results which follow such radiotherapy in seminoma of the testis and in Hodgkin’s disease illustrate this dramatically. If the resistance of the hypoxic tumour cell can be overcome, it might be possible, in the common carcinomas and sarcomas, to extend the fields for radiotherapy to include large areas containing known or occult metastases and, with well-tolerated radiation doses, to eradicate tumour from wide areas and so give benefit to many patients. Palliation may also be achieved with greater ease and
efficiency. It is possible that some combination of heavy-particle therapy, hyperbaric oxygen, and chemical agents might be used where there is a high degree of radioresistance due to hypoxia. However, the attraction of the chemical agent is that it may be used in all radiotherapy departand in the management of every further investment in apparatus. ments
R. H. T. is
a
case
without any
member of the Medical Research Council external
staff.
REFERENCES 1.
Churchill-Davidson, I., Sanger, C., Thomlinson, R. H. Lancet, 1955, i, 1091.
2. Churchill-Davidson, I., Foster, C. A., Wiernik, G., Collins, C. D., Pizey, N. C. D., Skeggs, D. B. L., Purser, P. R. Br. J. Radiol. 1966, 39, 321. 3. Phillips, D. L., Morris, S., Orr, J. S. Clin. Radiol. 1966, 17, 173. 4. Van Den Brenk, H. A. S. J. Am. med. Ass. 1971, 217, 948. 5. Watson, T. A., Banerjee, P. Can. Ass. Radiol. 1969, 20, 132. 6. Wildermuth, O., Warner, G. A., Marty, R. Radiology, 1969, 93, 1149. 7. Henk, J. M., Kunkler, P. B., Smith, C. W. Proc. 2nd A.E.R. Congr. 1972, p. 2.
McEwan, J. Br. J. Radiol. 1972, 45, 395. Plenk, H. P. Am. J. Roentgenol. 1972, 114, 152. Chang, C. H., Conley, J. J., Herbert, C. ibid. 1973, 117, 509. Dische, S. Br. J. Radiol. 1974, 47, 99. 12. Watson, E. R., Morris, S., Halnan, K. F. Unpublished. 13. Cade, I. S., McEwan, J. B. Cancer, 1967, 20, 817. 14. Dische, S. Br. J. Radiol. 1973, 46, 13. 15. Fletcher, G. H. Personal communication. 16. Milne, N., Hill, R. P., Bush, R. S. Radiology, 1973, 106, 663. 17. Howes, A. E., Page, A., Fowler, J. F. Br. J. Radiol. 1971, 45, 250. 18. Thomlinson, R. H. in Proceedings of Carmel Conference on Time and Dose Relationship in Radiation Biology as Applied to Radiotherapy; Brookhaven natn. Lab. Rep. 1969, no. 50203, p. 242. 19. Fowler, J. F., Sheldon, P. W., Denekamp, J., Field, S. B. Int. J. Radiat. Oncol. Biol. Phys. (in the press). 20. Catterall, M., Sutherland, I., Bewley, D. K. Br. med. J. 1975, ii, 653. 21. Kligerman, M. M. Atomikernergie, (in the press). 22. Adams, G. E. Br. med. Bull. 1973, 29, 48. 23. Adams, G. E., Dewey, D. L. Biochem. Biophys. Res. Comm. 1963, 12, 473. 24. Chapman, J. D., Webb, R. G., Borsa, J. Int. J. Radiat. Biol. 1971, 19, 561. 25. Adams, G. E., Asquith, J. C., Dewey, D. L., Foster, J. L., Michael, B. D., Willson, R. L. ibid. 1971, 19, 575. 26. Chapman, J. D., Reuvers, A. P., Borsa, J., Petkau, A., McCalla, D. R. Cancer Res. 1972, 32, 2616. 27. Asquith, J. C., Foster, J. L., Willson, R. L., Ings, R., McFadzean, J. A. Br. J. Radiol. 1974, 47, 474. 28. Asquith, J. C., Watts, M. E., Patel, K., Smithen, C. E., Adams, G. E. Radiat. Res. 1974, 60, 108. 29. Denekamp, J., Michael, B. D. Nature new Biol. 1972, 239, 21. 30. Adams, G. E., Asquith, J. C., Watts, M. E., Smithen, C. E. ibid. 1972, 239,
8. 9. 10. 11.
23.
Points of View SURGICAL IMMUNOLOGY SURGICAL immunology is a phrase which can be used to bring together as a new specialty two surgical disciplines which use immunology in different ways-transplantation (in which the immune response is suppressed to allow allografts to function) and immunotherapy (in which the immune response is stimulated in an attempt to deal with tumours). The method. ologies of each and the training required are so similar that it is tempting to identify this already as a future surgical specialty and perhaps to plan for it. In detail, the two parts of the specialty as they exist at present are remarkably similar. In transplantation, a surgical procedure is carried out (organ transplant) and then the patient is immunosuppressed to allow the organ to be accepted and function. Periodic increases in the host’s immune response, rejection crises, have to be dealt with as they arise. In the immunotherapy of the future a preliminary surgical procedure will be carried out (e.g,, removal of a melanoma or a mastectomy), followed by a period of immunostimulation by agents such as B.c.G., Corynebacterium parvum or levamisole with or without chemotherapy, along the lines now well established in the leukaemias. My contention is that it is best that one group of surgeons specialise in both these disciplines rather than that the disciplines are allowed to diverge. The transplant surgeon is at present in a good position to proceed with a surgical immunology service. In Britain a few surgeons devote themselves entirely to transplantation and the rest have an interest in general or urological surgery, together with their transplant interests. These surgeons, therefore, walk from the transplant unit to visit their other patients in general or urology wards, many of whom have some form of malignancy. The transplant surgeon is well used to thinking in terms of measurement of cell-mediated immunity and the man agement of cytotoxic drugs and their complications, and it is thus rational for him to take up the embryonic surgical specialty of immunotherapy. Transplant surgeons are keen to measure depression of cell-mediated immunity, and the immunotherapist is keen also to measure increased cell-mediated immunity. It may also be that in the future immunotherapy will be combined with cytotoxic drug therapy, thus also reducing cell-mediated immunity periodically, and the transplant surgeon will be well aware of the dangers and usage of these drugs. The reported outbreaks of serum hepatitis on oncology units will forcibly remind the transplant surgeon of his own battle with this particular complication of dialysis in the transplant unit, and reinforce the common ground of the two specialties. Indeed the indication for immunopotentiation (cancer) is the complication of immunosuppression (for transplantation), and a similar homology may apply in immunosuppression for autoimmune disease.
Berry, R. J., Asquith, J. C. in Advances in Chemical Sensitisation; p. 25. International Atomic Energy Agency, Vienna, 1974. 32. Sheldon, P. W., Smith, A. M. Br. J. Cancer, 1975, 31, 81. 33. Foster, J. L., Willson, R. L. Br. J. Radiol. 1973, 46, 234. 34. Begg, A. C., Sheldon, P. W., Foster, J. L. ibid. 1974, 47, 399. 35. Rauth, A. M. Proc. 5th int. Congr. Radiat. Res. (in the press). 36. Deutsch, G., Foster, J. L., McFadzean, J. A., Parnell, M. Br. J. Cancer, 1975, 31, 75. 37. Urtasun, R. C., Chapman, J. D., Band, P., Rabin, H., Fryer, C., Sturmwind. J. Radiology, 1975, 117, 129. 38. See C. R. C. Gray Laboratory annual report 1975 for literature summary 39. Foster, J. L., Flockhart, I. R., Dische, S., Gray, A. J., Lenox-Smith, I. Smithen, C. E. Br. J. Cancer, 1975, 31, 679. 40. Gray, A. J., Dische, S., Adams, G. E., Flockhart, I. R., Foster, J. L Clin. Radiol. (in the press). 41. Dische, S., Zanelli, G. D. ibid. (in the press). 42. Dische, S., Gray, A. J., Zanelli, G. D. ibid. (in the press). 43. Thomlinson, R. H., Dische, S., Gray, A. J., Errington, L. M. ibid. (in the press).
31.
189 But it is in training and research that the biggest dividends would be paid from an amalgamation of transplantation and immunotherapy. Immunotherapy is an embryonic science, full of exciting clinical promise. For these reasons immunotherapy requires infusion of new ideas and concepts which can only come from the laboratory training in basic immunology, a training which the transplant surgeons already have. Manipulation of the immune response, an understanding of the complex laboratory techniques needed, and experimental work involving immunology are familiar to transplant surgeons, as is the use of biological therapeutic agents such as antilymphocyte globulin for immunosuppression and C. parvum for immunopotentiation. It is little wonder that in basic immunology
laboratories, experiments often use both allografted non-maligas skin and kidney and transplantable indiscriminately in probing a simple question involving immune mechanisms. It would make good sense then for transplant surgeons, having spent a time in the laboratory disciplines of immunology, to apply their knowledge of immunology to both transplantation and to tumour therapy, and to cooperate in the design of clinical trials and the monitoring of immunotherapy. In surgical training, the marriage of immunotherapy with transplantation would be a happy one. After basic training, a period of time could be spent in an immunology laboratory,
nant
tissue such
tumours
devoted
to basic research; the surgeon could then return and take up an appointment with responsibilities for transplantation and immunotherapy. There is no conflict of interest in these disciplines. Only a recognition of their common ground can advance them both.
Transplant Unit, Western Infirmary, Glasgow G11 6NT.
D. N. H. HAMILTON
Round the World Thailand PATRONS AND CLIENTS
IN 1965 140 out of 262 new graduates from the medical schools of Thailand left for the United States soon after they had finished their internships.’ The export boom in medical manpower was on; and the promoters of charter flights were only too ready to put the doctors in the air. Eventually, the Thai Government could stand it no longer and today new medical graduates must spend at least three years in Thailand, working in Government hospitals and clinics. Their pay there is meagre compared with the attractions of private practice in Bangkok (or in the U.S.A.) and, when the three years are up, the Government is still faced with the difficulty of regulating the distribution of this manpower and discouraging the rush back to Bangkok, where half of the country’s doctors work. For this is a one-city nation of over 40 million people, 3 million of them in Bangkok, and the second city, Chiangmai, on the northern plateau, has only about 80 000 inhabitants. The provision of health care for the country dwellers is confused not only by the economics and logistics of manpower and resources but also by the old perversity of horses led to the water. It is one thing to distribute as widely as possible such services as the nation can muster: it is quite another to persuade the potential recipients to receive them. Many people still prefer to rely on the old support when they are ill’: the herbal-medicine practitioner, the priest, the traditional midwife, or the friend who knows the answer. Patients and their families will often seek (and pay for) this help long before they turn to the Government health centre or hospital. There is also a social gap between Government physicians and the rural community which is in process of being bridged. And effective organisation may be slow to evolve in a society with a tradition of centuries in the patron-client relationship of Buddhist cul1 Bryant, J. Health and
the
Developing
World. Ithaca and
London, 1969.
ture which has eternally striven to avoid unpleasantness or confrontation: no-one likes to criticise; and a British-style community health council might find it hard going. But there are changes-as there must be for the wellbeing of a nation which, though it has escaped the disruptions of the aftermath of colonialism (to which Thailand never succumbed), lies buffered on the edge of countries lately torn by war. Hitherto economically robust, by virtue of much self-sufficiency in food, Thailand now has its share of the ills of inflation and it feels the mounting, insistent, and justified pressures of trade-unionism for greater social justice. The farmers’ representatives bowed politely the other day before the Prime Minister, Kukrit Pramoj (who leads a seemingly impossible middle-of-the-road coalition of 16 parties), when they came to see him about the poor price they were getting for their rice crop; but, however cordial the bowing, the message was plain. The clients were now looking to the patrons for action. The number of clients will increase. Family planning in Thailand made a systematic start on a large scale only in 1970 and it is still too early to say what, if any, has been the impact of the National Family Planning Project. The demographic aim is to reduce the annual rate of population growth from the 1970 figure of over 3% to 2.5% by the end of 1976. The estimated numbers are themselves full of uncertainties. For example, the censuses of 1947 and 1960 showed that, between those two dates, the population of Thailand rose steadily by about 3.2% a year. In the same period, however, figures for births registered gave an annual increase over 2% in only six of those years. Registration was not much of a guide, therefore, though the law is now being applied more firmly. An evaluation by a Thai-American team of the family-planning project reported last year that the distribution of manpower and equipment was uneven, "various operational units lacked interest and enthusiasm," and services were not being delivered widely enough outside the midwifery centres and second-class health centres (first-class health centres have doctors). Rumours of cancer caused by the intrauterine device were deterring women from accepting it; and public relations had proved inadequate in countering long-established attitudes to sterilisation. Abortion is illegal in Thailand. The main instrument of family planning is the pill, which, for most Thai women, is offered from provincial hospitals and health and midwifery centres. It may be supplied free to the most needy, but a charge of up to 5 baht (about 12p) can be charged for each cycle of pills. Charges were being levied erratically, the evaluation team said, and should be standardised. (To be counted as poor in Thailand and qualify for food subsidies for himself and his family, a wage-earner must at present be getting less than 2000 baht a month, about 12 a week.) For I.U.D. insertion the charge may not exceed 20 baht (50p); and for vasectomy the maximum is 50 baht and for tubal sterilisation 150 baht. The Thai Government’s contribution to the cost of the programme in 1972 was 15% of the total received for this purpose from sources outside the country (including the United States Agency for International Development, United Nations agencies, the Population Council, and the International Planned Parenthood Federation). As some of these benefactors have put a time limit on their contributions, the Government will find it impossible to sustain the impetus of
the campaign without providing a lot more money. Some money for Thailand, but not the right kind, was brought ashore the other day after it had been stuck in a strike-bound British freighter. By concession of union leaders in Bangkok, the money was unloaded, because insurance on it was running out. Hurried away to the vaults was the 260 million baht in notes printed in England by Thomas de la Rue & Co. A British contribution to inflation?
United States MALPRACTICE AND REFORM
Many physicians in southern California inaugurated the year with a declaration of dissatisfaction with the status quo. Their declaration was accompanied by a "slow-down", a new
radiotherapy. We can hope for an increase in local curerates in patients with fairly advanced tumours and with a safe and reliable technique this could then be applied to earlier tumours with great likelihood of improved long term result. In certain sites it may be possible to spare patients from extensive surgery, now required because of unsatisfactory results from radiotherapy. In other situations where radiotherapy is successful, but at a risk of considerable morbidity, we can hope to maintain the local cure-rate, but with fewer operations and deaths because of morbidity. At this time, extended fields for radiotherapy can only be used successfully in the management of tumours of high radiosensitivity. The good results which follow such radiotherapy in seminoma of the testis and in Hodgkin’s disease illustrate this dramatically. If the resistance of the hypoxic tumour cell can be overcome, it might be possible, in the common carcinomas and sarcomas, to extend the fields for radiotherapy to include large areas containing known or occult metastases and, with well-tolerated radiation doses, to eradicate tumour from wide areas and so give benefit to many patients. Palliation may also be achieved with greater ease and
efficiency. It is possible that some combination of heavy-particle therapy, hyperbaric oxygen, and chemical agents might be used where there is a high degree of radioresistance due to hypoxia. However, the attraction of the chemical agent is that it may be used in all radiotherapy departand in the management of every further investment in apparatus. ments
R. H. T. is
a
case
without any
member of the Medical Research Council external
staff.
REFERENCES 1.
Churchill-Davidson, I., Sanger, C., Thomlinson, R. H. Lancet, 1955, i, 1091.
2. Churchill-Davidson, I., Foster, C. A., Wiernik, G., Collins, C. D., Pizey, N. C. D., Skeggs, D. B. L., Purser, P. R. Br. J. Radiol. 1966, 39, 321. 3. Phillips, D. L., Morris, S., Orr, J. S. Clin. Radiol. 1966, 17, 173. 4. Van Den Brenk, H. A. S. J. Am. med. Ass. 1971, 217, 948. 5. Watson, T. A., Banerjee, P. Can. Ass. Radiol. 1969, 20, 132. 6. Wildermuth, O., Warner, G. A., Marty, R. Radiology, 1969, 93, 1149. 7. Henk, J. M., Kunkler, P. B., Smith, C. W. Proc. 2nd A.E.R. Congr. 1972, p. 2.
McEwan, J. Br. J. Radiol. 1972, 45, 395. Plenk, H. P. Am. J. Roentgenol. 1972, 114, 152. Chang, C. H., Conley, J. J., Herbert, C. ibid. 1973, 117, 509. Dische, S. Br. J. Radiol. 1974, 47, 99. 12. Watson, E. R., Morris, S., Halnan, K. F. Unpublished. 13. Cade, I. S., McEwan, J. B. Cancer, 1967, 20, 817. 14. Dische, S. Br. J. Radiol. 1973, 46, 13. 15. Fletcher, G. H. Personal communication. 16. Milne, N., Hill, R. P., Bush, R. S. Radiology, 1973, 106, 663. 17. Howes, A. E., Page, A., Fowler, J. F. Br. J. Radiol. 1971, 45, 250. 18. Thomlinson, R. H. in Proceedings of Carmel Conference on Time and Dose Relationship in Radiation Biology as Applied to Radiotherapy; Brookhaven natn. Lab. Rep. 1969, no. 50203, p. 242. 19. Fowler, J. F., Sheldon, P. W., Denekamp, J., Field, S. B. Int. J. Radiat. Oncol. Biol. Phys. (in the press). 20. Catterall, M., Sutherland, I., Bewley, D. K. Br. med. J. 1975, ii, 653. 21. Kligerman, M. M. Atomikernergie, (in the press). 22. Adams, G. E. Br. med. Bull. 1973, 29, 48. 23. Adams, G. E., Dewey, D. L. Biochem. Biophys. Res. Comm. 1963, 12, 473. 24. Chapman, J. D., Webb, R. G., Borsa, J. Int. J. Radiat. Biol. 1971, 19, 561. 25. Adams, G. E., Asquith, J. C., Dewey, D. L., Foster, J. L., Michael, B. D., Willson, R. L. ibid. 1971, 19, 575. 26. Chapman, J. D., Reuvers, A. P., Borsa, J., Petkau, A., McCalla, D. R. Cancer Res. 1972, 32, 2616. 27. Asquith, J. C., Foster, J. L., Willson, R. L., Ings, R., McFadzean, J. A. Br. J. Radiol. 1974, 47, 474. 28. Asquith, J. C., Watts, M. E., Patel, K., Smithen, C. E., Adams, G. E. Radiat. Res. 1974, 60, 108. 29. Denekamp, J., Michael, B. D. Nature new Biol. 1972, 239, 21. 30. Adams, G. E., Asquith, J. C., Watts, M. E., Smithen, C. E. ibid. 1972, 239,
8. 9. 10. 11.
23.
Points of View SURGICAL IMMUNOLOGY SURGICAL immunology is a phrase which can be used to bring together as a new specialty two surgical disciplines which use immunology in different ways-transplantation (in which the immune response is suppressed to allow allografts to function) and immunotherapy (in which the immune response is stimulated in an attempt to deal with tumours). The method. ologies of each and the training required are so similar that it is tempting to identify this already as a future surgical specialty and perhaps to plan for it. In detail, the two parts of the specialty as they exist at present are remarkably similar. In transplantation, a surgical procedure is carried out (organ transplant) and then the patient is immunosuppressed to allow the organ to be accepted and function. Periodic increases in the host’s immune response, rejection crises, have to be dealt with as they arise. In the immunotherapy of the future a preliminary surgical procedure will be carried out (e.g,, removal of a melanoma or a mastectomy), followed by a period of immunostimulation by agents such as B.c.G., Corynebacterium parvum or levamisole with or without chemotherapy, along the lines now well established in the leukaemias. My contention is that it is best that one group of surgeons specialise in both these disciplines rather than that the disciplines are allowed to diverge. The transplant surgeon is at present in a good position to proceed with a surgical immunology service. In Britain a few surgeons devote themselves entirely to transplantation and the rest have an interest in general or urological surgery, together with their transplant interests. These surgeons, therefore, walk from the transplant unit to visit their other patients in general or urology wards, many of whom have some form of malignancy. The transplant surgeon is well used to thinking in terms of measurement of cell-mediated immunity and the man agement of cytotoxic drugs and their complications, and it is thus rational for him to take up the embryonic surgical specialty of immunotherapy. Transplant surgeons are keen to measure depression of cell-mediated immunity, and the immunotherapist is keen also to measure increased cell-mediated immunity. It may also be that in the future immunotherapy will be combined with cytotoxic drug therapy, thus also reducing cell-mediated immunity periodically, and the transplant surgeon will be well aware of the dangers and usage of these drugs. The reported outbreaks of serum hepatitis on oncology units will forcibly remind the transplant surgeon of his own battle with this particular complication of dialysis in the transplant unit, and reinforce the common ground of the two specialties. Indeed the indication for immunopotentiation (cancer) is the complication of immunosuppression (for transplantation), and a similar homology may apply in immunosuppression for autoimmune disease.
Berry, R. J., Asquith, J. C. in Advances in Chemical Sensitisation; p. 25. International Atomic Energy Agency, Vienna, 1974. 32. Sheldon, P. W., Smith, A. M. Br. J. Cancer, 1975, 31, 81. 33. Foster, J. L., Willson, R. L. Br. J. Radiol. 1973, 46, 234. 34. Begg, A. C., Sheldon, P. W., Foster, J. L. ibid. 1974, 47, 399. 35. Rauth, A. M. Proc. 5th int. Congr. Radiat. Res. (in the press). 36. Deutsch, G., Foster, J. L., McFadzean, J. A., Parnell, M. Br. J. Cancer, 1975, 31, 75. 37. Urtasun, R. C., Chapman, J. D., Band, P., Rabin, H., Fryer, C., Sturmwind. J. Radiology, 1975, 117, 129. 38. See C. R. C. Gray Laboratory annual report 1975 for literature summary 39. Foster, J. L., Flockhart, I. R., Dische, S., Gray, A. J., Lenox-Smith, I. Smithen, C. E. Br. J. Cancer, 1975, 31, 679. 40. Gray, A. J., Dische, S., Adams, G. E., Flockhart, I. R., Foster, J. L Clin. Radiol. (in the press). 41. Dische, S., Zanelli, G. D. ibid. (in the press). 42. Dische, S., Gray, A. J., Zanelli, G. D. ibid. (in the press). 43. Thomlinson, R. H., Dische, S., Gray, A. J., Errington, L. M. ibid. (in the press).
31.
189 But it is in training and research that the biggest dividends would be paid from an amalgamation of transplantation and immunotherapy. Immunotherapy is an embryonic science, full of exciting clinical promise. For these reasons immunotherapy requires infusion of new ideas and concepts which can only come from the laboratory training in basic immunology, a training which the transplant surgeons already have. Manipulation of the immune response, an understanding of the complex laboratory techniques needed, and experimental work involving immunology are familiar to transplant surgeons, as is the use of biological therapeutic agents such as antilymphocyte globulin for immunosuppression and C. parvum for immunopotentiation. It is little wonder that in basic immunology
laboratories, experiments often use both allografted non-maligas skin and kidney and transplantable indiscriminately in probing a simple question involving immune mechanisms. It would make good sense then for transplant surgeons, having spent a time in the laboratory disciplines of immunology, to apply their knowledge of immunology to both transplantation and to tumour therapy, and to cooperate in the design of clinical trials and the monitoring of immunotherapy. In surgical training, the marriage of immunotherapy with transplantation would be a happy one. After basic training, a period of time could be spent in an immunology laboratory,
nant
tissue such
tumours
devoted
to basic research; the surgeon could then return and take up an appointment with responsibilities for transplantation and immunotherapy. There is no conflict of interest in these disciplines. Only a recognition of their common ground can advance them both.
Transplant Unit, Western Infirmary, Glasgow G11 6NT.
D. N. H. HAMILTON
Round the World Thailand PATRONS AND CLIENTS
IN 1965 140 out of 262 new graduates from the medical schools of Thailand left for the United States soon after they had finished their internships.’ The export boom in medical manpower was on; and the promoters of charter flights were only too ready to put the doctors in the air. Eventually, the Thai Government could stand it no longer and today new medical graduates must spend at least three years in Thailand, working in Government hospitals and clinics. Their pay there is meagre compared with the attractions of private practice in Bangkok (or in the U.S.A.) and, when the three years are up, the Government is still faced with the difficulty of regulating the distribution of this manpower and discouraging the rush back to Bangkok, where half of the country’s doctors work. For this is a one-city nation of over 40 million people, 3 million of them in Bangkok, and the second city, Chiangmai, on the northern plateau, has only about 80 000 inhabitants. The provision of health care for the country dwellers is confused not only by the economics and logistics of manpower and resources but also by the old perversity of horses led to the water. It is one thing to distribute as widely as possible such services as the nation can muster: it is quite another to persuade the potential recipients to receive them. Many people still prefer to rely on the old support when they are ill’: the herbal-medicine practitioner, the priest, the traditional midwife, or the friend who knows the answer. Patients and their families will often seek (and pay for) this help long before they turn to the Government health centre or hospital. There is also a social gap between Government physicians and the rural community which is in process of being bridged. And effective organisation may be slow to evolve in a society with a tradition of centuries in the patron-client relationship of Buddhist cul1 Bryant, J. Health and
the
Developing
World. Ithaca and
London, 1969.
ture which has eternally striven to avoid unpleasantness or confrontation: no-one likes to criticise; and a British-style community health council might find it hard going. But there are changes-as there must be for the wellbeing of a nation which, though it has escaped the disruptions of the aftermath of colonialism (to which Thailand never succumbed), lies buffered on the edge of countries lately torn by war. Hitherto economically robust, by virtue of much self-sufficiency in food, Thailand now has its share of the ills of inflation and it feels the mounting, insistent, and justified pressures of trade-unionism for greater social justice. The farmers’ representatives bowed politely the other day before the Prime Minister, Kukrit Pramoj (who leads a seemingly impossible middle-of-the-road coalition of 16 parties), when they came to see him about the poor price they were getting for their rice crop; but, however cordial the bowing, the message was plain. The clients were now looking to the patrons for action. The number of clients will increase. Family planning in Thailand made a systematic start on a large scale only in 1970 and it is still too early to say what, if any, has been the impact of the National Family Planning Project. The demographic aim is to reduce the annual rate of population growth from the 1970 figure of over 3% to 2.5% by the end of 1976. The estimated numbers are themselves full of uncertainties. For example, the censuses of 1947 and 1960 showed that, between those two dates, the population of Thailand rose steadily by about 3.2% a year. In the same period, however, figures for births registered gave an annual increase over 2% in only six of those years. Registration was not much of a guide, therefore, though the law is now being applied more firmly. An evaluation by a Thai-American team of the family-planning project reported last year that the distribution of manpower and equipment was uneven, "various operational units lacked interest and enthusiasm," and services were not being delivered widely enough outside the midwifery centres and second-class health centres (first-class health centres have doctors). Rumours of cancer caused by the intrauterine device were deterring women from accepting it; and public relations had proved inadequate in countering long-established attitudes to sterilisation. Abortion is illegal in Thailand. The main instrument of family planning is the pill, which, for most Thai women, is offered from provincial hospitals and health and midwifery centres. It may be supplied free to the most needy, but a charge of up to 5 baht (about 12p) can be charged for each cycle of pills. Charges were being levied erratically, the evaluation team said, and should be standardised. (To be counted as poor in Thailand and qualify for food subsidies for himself and his family, a wage-earner must at present be getting less than 2000 baht a month, about 12 a week.) For I.U.D. insertion the charge may not exceed 20 baht (50p); and for vasectomy the maximum is 50 baht and for tubal sterilisation 150 baht. The Thai Government’s contribution to the cost of the programme in 1972 was 15% of the total received for this purpose from sources outside the country (including the United States Agency for International Development, United Nations agencies, the Population Council, and the International Planned Parenthood Federation). As some of these benefactors have put a time limit on their contributions, the Government will find it impossible to sustain the impetus of
the campaign without providing a lot more money. Some money for Thailand, but not the right kind, was brought ashore the other day after it had been stuck in a strike-bound British freighter. By concession of union leaders in Bangkok, the money was unloaded, because insurance on it was running out. Hurried away to the vaults was the 260 million baht in notes printed in England by Thomas de la Rue & Co. A British contribution to inflation?
United States MALPRACTICE AND REFORM
Many physicians in southern California inaugurated the year with a declaration of dissatisfaction with the status quo. Their declaration was accompanied by a "slow-down", a new
