Global health in the ’80s and ’90s The
Adults with cystic fibrosis Advances in the paediatric care of patients with cystic fibrosis mean that most affected individuals now survive to adult life. Some 2000 adults in the UK have cystic fibrosis, a figure that is increasing by about 100 patients every year. But many general practitioners and general physicians have little experience of the disease-a lack of awareness recognised by the Royal College of Physicians, which set up a working party to consider the special needs of adults with cystic fibrosis. The report of this working party’ recommends that each NHS region should have at least one cystic fibrosis centre with specialist medical and paramedical staff, and that Regional Health Authorities should be responsible for funding the clinical care of all patients with cystic fibrosis. These regional centres should ideally combine care for adults with that for children, and so coordinate the special needs of patients with cystic fibrosis throughout their lives-in liaison with general practitioners and local hospitals, and with supraregional centres, where more specialised care (such as may be provided. Regional cystic would also coordinate genetic services-including screening and counselling-and clinical research and audit. The report also recommends provision of 3-4 beds, preferably in single rooms, for every 50 patients and calls for standardisation of records for epidemiological analysis.
heart-lung transplantation) fibrosis
1 Royal College of Physicians. Cystic Fibrosis in Adults Recommendations for Care of Patients in the UK. London: Royal College of Physicians 1990. Pp 24. £6 00 (incl postage in UK). ISBN 1-873240120.
1980s were unfavourable years for many developing countries-only the newly industrialising economies in East and South-east Asia were able to just meet the United Nations target of 7 % annual output growth for the decade, while growth was negative in the least developed countries. Accompanying this decline was a drop in real health expenditure per head of population-an analysis of government expenditure for 57 countries showed that for the first half of the decade expenditure fell in nearly half of the African,
two-thirds of the Latin American, and one-third of the Asian countries. Real per head government expenditure on food subsidies also fell in eight of the ten countries for which suitable data could be found. The second half of the decade saw, in several countries, a slowing or a halting of the decline in infant mortality rates, and an increase in the incidence of malnutrition. UNICEF’s policy for the next decade is to meet basic human needs. The major issues requiring attention, says UNICEF, are the grinding poverty of their families, the degradation of their environment, and their lack of access to very rudimentary knowledge, skills, and resources to ensure their survival, development, and protection. UNICEF will retain its decentralised country programme approach, whereby country representatives have sufficient authority to respond to changing needs and government priorities. The economic difficulties that most countries faced in the ’80s and how health programmes were affected are also reflected in a book containing accounts of the experiences in fifteen countries,2 selected because their stage of development of primary health care was representative of their region. Development goals and strategies for children in the 1990s. A UNICEF policy review. New York: UNICEF. 1990. Pp 61. ISSN 1013-3194. 2. Achieving health for all by the year 2000. Midway reports of country experiences. Edited by E. Tanmo and A. Creese. Geneva: WHO 1990. Pp 262. SW Fr 46. ISBN 1.
Plasticisers in food A material of modem life that we take very much for granted is the thin, clear, flexible plastic film used for packaging foods-"cling film" as it has come to be known. Cling films are usually made from polyvinyl chloride (PVC) or vinylidine chloride (VDC) copolymers. To assist processing and give flexibility, cling films must contain plasticisers. The plasticisers used most widely in PVC cling films are di-2-ethylhexyl adipate (DEHA) and polymeric species (polyesters of dicarboxylic acids and dihydric alcohols), while acetyl tributyl citrate (ATBC) is commonly used in VDC co-polymer films. The hazards to human health from plasticisers leaching into food are little understood, and a UK government report’ urges caution in the use of cling film. Plasticisers can migrate into any food when in direct contact with cling film. As a consequence the report recommends that cling films should not be used in conventional ovens or for wrapping food or lining dishes for cooking in a microwave oven. Moreover, because plasticisers are soluble in fats, cling films should not be used to wrap food with a high fat content-eg, cheese. Because PVC films have been reformulated, with DEHA being replaced largely by polymeric species, the estimated maximum dietary intake per head of DEHA has fallen by almost half since 1987 to 8-2 mg per day (a figure that is highly unlikely to be reached in practice). Thus, there is now a 6000-fold margin between the estimated maximum dietary intake of DEHA and the dose that has produced cancer in mice. It is also unlikely that there are other adverse effects on health at this level of intake. ATBC-containing co-polymer films have a low permeability to moisture and oxygen. They are increasingly used for vacuum and controlled atmosphere packaging, for "boil-in-the-bag" meals, and, domestically, for microwave cooking. As a result, the estimated maximum intake of ATBC has risen since 1987 from 0 05 to 1 ’5 mg per day. The report does not consider that there are enough data available to assess the risks to human health from this level of intake and therefore "requires" to see toxicity data within two years. Although there does not seem to be any cause for alarm, provided cling films are used according to the guidelines in the report, it is disturbing that dietary intake of ATBC has been allowed to rise 30-fold without toxicity data first being made available. 1 Plasticisers. continuing surveillance. MAFF Food Surveillance Paper 30. London: HM
1990. Pp 52. £6 ISBN 0-11-242905-X
right to know in Japan
50-year-old nurse was told by her doctor that although he thought she had cancer of the gallbladder. Thinking her illness to be due to gallstones and hence unlikely to be fatal, the nurse refused surgery and stopped follow-up. By June, however, the cancer had spread to her liver and she died in December, 1983. Her family sued the hospital in negligence for failing to inform her of the true nature of her illness, so not allowing her to make an informed choice. The claim failed. Judge Kuniharu Ito held that it was up to the doctor to decide how much to explain because such disclosure can affect the recovery of the patient.1 The appeal has also been rejected. On Oct 31,1990, Judge Shigeo Ito, the presiding judge, held that the deceased woman and her doctor did not share "a relationship of mutual trust" that would In January, 1983, a she had gallstones,
have enabled him to disclose the true nature of her condition to her or members of her family.2 Since the deceased was herself a nurse, this lack of mutual trust seems especially hard to justify. Tradition ensures that Japanese doctors are educated to defend the paternalistic Confucian ideology of medical morality (known as Jin-Hyatus) and many people in Japan still think that obedience to their physician is mandatory.3 Eight out of ten doctors in Japan lie to their cancer patients; they prefer to give a diagnosis of a stomach ulcer, a vaginal cyst, or gallstones. One survey found that 30% of doctors would not tell a patient about cancer even if it were curable.2 The conspiracy of silence is to some extent fuelled by the patients themselves, who remain remarkably ignorant of the fact that many cancers can be treated if caught early. In Japan cancer remains unmentionable for most people, lay and medical. Furthermore, through superstition and ignorance, cancer is considered a stigma in
Japan. Whether the family will pursue their claim to the Supreme Court is uncertain. Last year’s statement by the government’s task force on truth telling for the terminally ill may prove an influencing factor for the Supreme Court, both in this case and in the likelihood of a change in the attitude of doctors and patients towards disclosure of