suggestions of Drs. Dennis Kendel and George Gilmour, registrar and president of the College of Physicians and Surgeons of Saskatchewan, on how to provide a rural practice setting compatible with the evolving health care of the 1990s, as quoted by Houston, the role of undergraduate and postgraduate medical education for Saskatchewan graduates in the process of practice selection should be considered in view of the fact that Saskatchewan graduates make up a small minority of physicians practising in rural settings in Saskatchewan. Michael J. Rieder, MD 75 Pine Valley Dr. London, Ont.

References 1. Steinwald B, Steinwald C: The effect of preceptorship and rural training programs on physicians' practice location decisions. Med Care 1975; 13: 219-229 2. Willoughby TL, Arnold L, Calkins V: Personal characteristics and achievements of medical students from urban and nonurban areas. J Med Educ 198 1; 56: 717-726 3. Rabinowitz HK: A program to recruit and educate medical students to practice family medicine in underserved areas. JAMA 1983; 249: 1038-1041 4. Carter RG: The relation between personal characteristics of physicians and practice location in Manitoba. Can Med Assoc J 1987; 136: 366-368

Patients living near small hospitals in Saskatchewan may be grateful to Dr. Houston, who praises some of the work done in them, although his example was from Manitoba. Of course "the larger hospital 30 km down the road" has become more accessible. It can offer more service. However, the service is not necessarily what the patient is seeking. The larger hospital is mainly supported by patients living in the vicinity. The small hospital commands a special loyalty from local residents. This support is fortified by the knowledge that governments have been trying to close the small

hospitals for years. The affected community may find this attitude oppressive and dictatorial. The family farm is the heartbeat of Saskatchewan. Agriculture is a business that requires space, lots of space. This calls for a farming population that largely resides and works far more than 30 km from Saskatoon and Regina. Small hospitals in Saskatchewan are administered by committees that are highly selective about their doctors, and the doctors are highly selective about the work they attempt. The doctor in solo practice in a small hospital is highly visible and the subject of an intense, ongoing audit. He or she cannot avoid responsibility, because there is no one else to blame. In 1978 I went to a small hospital in Newfoundland for 3 weeks as a locum tenens. I stayed for 5 years. There was an establishment for two doctors, but for quite long periods I was on my own. The doctor on his or her own in a hospital consults, confers and has discussions with nurses. I found a fantastic level of teamwork. It was my privilege to observe closely, in a working relationship, the compassion, dedication and technical precision that are the spegial elements of the nursing profession in Canada.

such as Gravelbourg, Redvers and Shaunavon? And Melville and Langenburg? I agree with Dr. Jackson. From his experience in practice in one-doctor Saskatchewan towns (Frontier and Gull Lake) and three-doctor towns (Biggar and Rosetown) he knows whereof he speaks. Although political restraints may keep the government from closing most one-doctor hospitals, most, unfortunately, seem destined to be served by a neverending stream of foreign-trained doctors who stay for 6 months or 1 year each.

wan graduates tend to be attracted chiefly to towns in the northern part of the province. Traditionally there have been Saskatchewan graduates practising in Canora, Hudson Bay, Humboldt, Kindersley, LaRonge, Maidstone, Meadow Lake, Melfort, Nipawin, Rosetown, Rosthern, Tisdale, Wakaw and Wynyard. Why do they avoid the towns south of #1 Highway,

her comments on my letter she states: "Parker proposes a presumption against allowing the entry of HIV-antibody-positive people." I suggest she has misread my letter. Admissibility to Canada is a matter for legislators. As a physician I merely proposed that immigrants and refugees seeking entry to this country be HIV tested, for public health reasons. In

C. Stuart Houston, MD Professor Department of Medical Imaging University Hospital Saskatoon, Sask.

The case against HIV antibody testing of refugees and immigrants D

r~. Margaret A. Somer-

ville's response (Can Med Assoc J 1990; 142: 525526) to my letter (ibid: 524-525) concerning her article (Can Med Assoc J 1989; 141: 889-894) raises some points that require my clarification. Her article displays a flaw in logic. It proposes a case against Noel Jackson, MB, BS HIV antibody testing of refugees PO Box 369 and immigrants. The body of the Lockeport Medical Centre article, however, addresses an Lockeport, NS issue that is not necessarily contingent on her proposal: the ad[Dr. Houston responds:] missibility of HIV-positive people For unknown reasons Saskatche- to Canada. In the summation of

CAN M ED ASSOC J 1990; 142 ( 11)

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like manner, my comments on the articles that I quoted referred to the efficacy of testing, not its philosophy. As for the article's substance, Somerville states in her reply to me that "6protection of public health is not a valid justification for excluding people with HIV from Canada". Two paragraphs later she states: "Because prospective immigrants with HIV are not per se a threat to public health they are comparable to persons with Huntington's chorea and other inherited conditions (which are also 'transmissible')." Somerville and I, it seems, are on completely different wavelengths, but, then, I have no legal qualifications and, despite her title, she has no medical qualifications. Somerville and her legal colleagues have made AIDS unique, requiring that medical practitioners obtain informed consent to test for it. Ironically these efforts have protected the disease rather than the public. Somerville does not seem to comprehend the difference between inherited transmissibility and infectivity. Protection of the public health does not seem to be a legal consideration. However, people promoting policies that disregard proven physiological principles of epidemic containment will not be considered blameless by succeeding generations, particularly AIDS victims. Sooner or later we will have to return to "John Snow and the handle of the Broad Street pump". James E. Parker, MB 303-2151 McCallum Rd. Abbotsford, BC

[Dr. Somerville responds.] Dr. Parker's logic is difficult to follow. Is he suggesting that the rules on inadmissibility to Canada on health grounds governing immigrants and refugees are different from those governing "the admissibility of HIV-positive people 1182

CAN MED ASSOCJ 1990: 142 (I 1)

to Canada"? If so, he is incorrect. The same sections of the Immigration Act of 1976 govern this matter for both groups. If we are not going to use the results of HIV antibody testing to influence our decisions on inadmissibility to Canada on medical grounds or possibly even to determine this, there is no justification at all for doing this testing on immigrants and refugees. Both legislators and public health physicians must work from an initial presumption. If, as Parker claims, he does not propose "a presumption against allowing the entry of HIV-antibody-positive people", then he must have adopted the opposite presumption (to which, of course, there may be exceptions), that such people should be allowed entry to Canada. In this case he and I are entirely on the same "wavelength", despite our different qualifications. Moreover, when one considers his initial serious disagreement with me, our ability to reach such concordance through correspondence in the pages of CMAJ could be seen as an excellent example of the benefits of transdisciplinary scholarship, which is nowhere more essential than in dealing with the complex issues raised by HIV infection and AIDS. It is a paradox that we have engaged in this form of scholarship when it seems that Parker is opposed in principle to

physicians working with people from outside medicine on what he views as purely medical matters. Parker is correct that the rules governing immigration, as with the rules governing all activities in our society, are "a matter for legislators". But under the provisions of the Immigration Act of 1976, inadmissibility to Canada on medical grounds is not, in day-to-day practice, such a matter. The legislature has delegated the power to decide this to a medical officer of health, provided this judgement is concurred in

by at least one other medical officer of health. It can even be argued that under the provisions of the act the minister of immigration cannot override decisions of medical officers of health in this respect. The word "transmissible" was within quotation marks in my response to indicate its out-of-theordinary use. In particular, this usage indicates that fruitful insights can be gained by comparing our approaches to situations involving on the one hand genetically (vertically) transmissible disease and on the other hand infectiously (horizontally) transmissible disease. Parker apparently did not understand this. The law on informed consent is clear: one must obtain informed consent to all medical interventions, including diagnostic. Interventions relating to AIDS are not, and I agree should not be, unique in this respect. To the event that the diatribe in the last paragraph of Parker's current letter is understandable, the approaches that seem to be espoused are counterproductive to containing the spread of HIV. Consequently, I am left with the strong feeling that I am thankful Parker is not in charge of formulating public policy on AIDS in Canada. Margaret A. Somerville, AM, AuA (Pharm), LLB, DCL Director McGill Centre for Medicine, Ethics and Law Montreal, PQ

Here's something to chew on I n a recent Vista column in CMAJ (1990; 142: 465) Dr. Douglas Waugh addresses the issue of tobacco use in our society. Most of his comments are very true. Tobacco addiction is a serious and difficult problem, and all

The case against HIV antibody testing of refugees and immigrants.

suggestions of Drs. Dennis Kendel and George Gilmour, registrar and president of the College of Physicians and Surgeons of Saskatchewan, on how to pro...
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