LETTERS
TO THE
EDITOR
251
logical Association Convention, May 5, 1973, p. 97. 12. Funkenstein, D. H. : Medical Students, Medical Schools
and Society During Three Eras. In Coombs and Vincent (eds.): Psychological Aspects of Medical Training. Springfield, Ill.: Charles C Thomas, 1971. 13. Johnson, D. A., Kerr, D., Pyeritz, R. E., Quevedo-Grado,
S., and Rivera, R. : Program in biosocial medicine. Harvard Med. Alum. Bull., 48:20, 1973. 14. Virchow, R.: Die Einheitsbestrebunger in der
wissen-shaftlichen Medizin. Gesammelte Abhandlungen
aus dem Gebiet der #{246}ffentlichen Medizin und der Seuchenlehre. Berlin, 1879.
Dr. Nathan’s
Assumptions
Attacked
To THE EDITOR:
David C. Nathan’s commentary (Pediatrics, 52:768, 1973) on problems of delivery of health care suggests that the ra-tional application of scientific methods which have been so successful in the biomedical research area to the problems of the delivery of health services to our population, will pro-duce comparable achievements in this new arena.
Nathan may well be correct in his faith in the research process. However, he also seems to believe that persons en-gaged in research possess talent (“the cream”) which is equi-potential in all areas. Thus the same person, who has been most productive in developing new thoughts on how potassi-um moves in and out of red cells, is best able to develop new thoughts on the delivery of primary care.
It is this latter assumption which I wish to question. What
evidence suggests that the attributes of successful clinicians, students of health care, sociologists, or biomedical research-ers, are all the same? Without professing expertise myself, I venture to suggest that what little evidence is available
might more support the opposite hypothesis.
What if I propose that we pull out our senior public health and hospital medical staff clinicians, who have reached a stage in their careers when they are no longer truly excited by clinical practice. Administrative duties pull them away
from their office for progressively longer periods of time. Is there not a moment when it is clear to all that younger men
might best be appointed to replace them, while they move
toward a period of retraining which would enable them to provide expert leadership, in the complex area of biomedical research?
I for one, would feel much more comfortable seeing a man
who is capable ofunderstanding the problems of the delivery of health care in New York City, studying the rate at which potassium enters the red cell, than the reverse.
Dr. Nathan’s naivet#{233}with respect to problems outside the hematology laboratory is matched only by his arrogance.
AYRUM L. KATCHER, M.D.
Director, Pediatric Services Hunterdon Medical Center Flemington, New Jersey
pediatrics as a response to house staff interests and also in re-sponse to the needs of the surrounding community. This in-terest in primary care is perhaps even more evident among medical students. Maintaining and further stimulating this interest is a challenge to all programs offering pediatric training.
Primary care must be recognized as a field with unique problems, solutions, and academic challenges. These may well not be encountered in a traditional career focusing on the research lat)oratory. To assume that one who has devoted a lifetime to research in molecular kinetics could, with rela-tive ease, assume a position of leadership in community-based programs is naive indeed. The laboratory milieu, with its precisely controlled variables and its generally compati-ble teams, is quite different from the world of health care de-livery, family dynamics, public health, and medical con-sumerism. We believe, as does Dr. Nathan, that valid re-search designs should be applied to community problems, but would argue that this approach could be better learned from sources other than the medical research laboratory.
The position of the laboratory, insulated from the
communi-ty, does not promote understanding of the problems of deliv-ery of primary care or investigation of same.
Community-oriented programs, since they serve a teach-ing function and in addition are called upon to develop new approaches in patient care, necessarily demand the very best leadership that pediatrics has to offer. This must include ju-nior members capable of original organization of health ser-vices, research, and stimulation of the interest present in house staff and medical students. It is to those who have had this continuing interest in the teaching and research aspects of primary care that we can look for leadership. In addition, physicians who have been closely involved in other areas of research and teaching may find primary patient care an area worthy of their best creative efforts and may serve as another resource for leadership in this field. Any physician involved
in this area, with its serious and difficult challenges, is aware that it demands great interest, energy, and originality, often in areas for which traditional medical education and re-search leave one unprepared.
We are hopeful that those who occupy positions of leader-ship in pediatrics and medical education will meet this chal-lenge better in the coming years.
Boston, Massachusetts
J
OEL BASS, M.D.DOROTHEA JOHNSON, RN.
JACQUELINE KIRBY, MSW
GEORGE A. LAMB, M.D.
J
ANICE C. LEVY, M.D.PAUL L. MCCARTHY, M.D.
CAROL ROBINs, M.D.
CYNTHIA Ross, RN.
Division of Community Child Health Children’s Hospital Medical Center
The
Guest
Speaker
Adds Some
Thoughts
Viewpoint
From
the Division
of Community
Child
Health
To THE EDiToR:
We read with interest Dr. Nathan’s comments on primary medical care (Pediatrics, 52:768, 1973), but feel compelled to add another viewpoint.
One of the striking changes occurring today in teaching hospitals and medical schools is an increased awareness of and interest in primary care. Some institutions, including our own, have created residencies and fellowships in ambulatory
To THE EDITOR:
I am greatly honored by your publication of my Blackfan
Lecture at Harvard on “Health Services in the Home.”
I also appreciate the notice given to the article by the
commentary from Dr. David Nathan.2
Dr. Nathan is certainly entitled to interpret my feelings
(“Be off” she states “with your ultrascience”) and I am
grate-ful to him for his interpretation. I was rather ashamed of my own moderation. But this was not what I stated.
I cannot discover where I “refused to lay the responsibility
of the development of an adequate system of maternal and
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252 LETTERS
TO THE
EDITOR
child health on the doorstep of a government agency.” I do in fact lay a great deal of blame on governments, international, national and local, for these particular inadequacies. But a great deal of government thought and planning can be and is affected by intellectual trends and enthusiasms. I had been asked to speak on the subject of “Health Services in the Home” not by any government agency but by one of the most distinguished of all intellectual centers and therefore I tried to make the most of a heaven-sent opportunity.
That great authority on international health, Dr. Karl Evang,3 says: “Politicians generally do not want direct con-tact with technically trained people” but introduce the “non-expert administrator” between themselves and the specialist. Dr. Evang says this procedure is “destructive. “ If
more doctors were prepared to evaluate what needs doing, how to do it, and how to reach the politicians in spite of ad-ministrators this “destruction” would diminish. A place such
as Harvard and its alumni can have a profound influence on national and international trends.
When Dr. Nathan says that I demand “a cadre of public health and primary care-oriented physicians together with highly trained public health nurses,” this is misleading. Seri-ously misleading. I repeatedly refer to nurses and their aides.
I believe in the possibility of starting with “a one-man team,” in training medical assistants and illiterate birth at-tendants. But I should have stressed the obvious fact that in order to make a primary care and supervision service
effec-tive in content and in extent, care must be given to the selec-tion, training by doing, and support of paramedical workers of all types and degrees. One of the main functions of highly trained physicians, nurses and midwives that is often omitted from their curricula is that of teacher, which is after all what “doctor” means. They must be prepared to teach and train their colleagues and co-workers, to adapt to existing condi-tions and to recognize priorities.
Dr. Nathan writes of students who are “naively cynical about the scientific basis of medicine.” Cynical yes, or bored with biochemistry and questionable priorities. But naive, not always. Just hungry for a little more common sense and re-search into application.
Medical practice demands both natural sciences and the humanities, and there should be a balance. I too have little confidence in the “biosocial curriculum.” Just as our “scien-tific basis” is established by clinical and laboratory observa-tion as well as book learning, so our humanities demand ob-servation and experience in wards and outpatients in homes and factories. Textbooks and lectures in sociology, psycholo-gy and demography are not enough.
The “naive cynicism” comes from many who would like to see a more logical distribution of resources. Dr. Nathan mdi-cates that faculty trained or “further trained” in scientific disciplines will provide the “correct amalgam of discipline, inquiry and excitement that will stimulate the student to think broadly and creatively.” But some feel that generalists can think as broadly and creatively as specialists. Some be-lieve that nutrition is not just biochemistry, and that health does not only depend on hospitals. “Rigid enquiry and firm standards” exist outside the institutions as well as inside. We all have to learn to weigh the imponderables.
Unless physicians and nurses in their training are educated to recognize all the factors, physical, mental and social, that affect and compromise the reaction of the body to disease, they may take it for granted that all patients live and feel as they do. Until one has worked in a disadvantaged or “for-eign” area it is impossible to imagine the conditions, the atti-tudes, complacency and despair, the ignorance and the fears that govern some people’s lives. It is impossible to imagine how absolute trivia can determine life and death as they do.
Pediatricians and their colleagues must above all be con-cerned with these trivia. The infant mortality rates in the USA, UK, Holland and Sweden were about 150 per 1,000 live births in 19(X). They are now about 20, 17, 14 and 12, respec-tively. This is mainly due to preventable diseases being pre-vented and treatable diseases treated. Some of this is by im-mitnizations. But the major causes of death and disease in disadvantaged areas are diarrheas, failure to thrive, worms,
respiratory diseases, prematurity and parental inadequacy.
It is essential to recognize these factors. Unless medical and paramedical workers are trained to recognize and correct these factors as they exist, much of the effort in “biomedical research training” may be wasted.
In some of the developing countries flO less than 50% of the total deaths are in children under 5 years compared with about 3% in Sweden. (Deaths under 1 year and births may be grossly under registered, so that the 0-5 mortality is more likely to be accurate than the IMR.)4 It is in the vulnerable groups that these common, “trivial” and preventable condi-tions do the most damage and are most ignored by govern-ments and by medical authorities. The countries with a high child mortality are those with a high birth rate. Quantities of
money and personnel are now being spent on family
plan-ning programs. Yet the F.P. authorities give little attention
to this correlation between the birth rate and the child mor-tality rates.
Dr. B. Berelson, President of the Population Council wrote “An Evaluation of the Effect of Population Control Programs.”3 He summarizes the methods by which birth control programs can be effective: (1) communication, (2) services, (3) incentives, (4) social institutions, (5) coercion. (This last is rightly rejected.) But there is no mention of the correlation between the declining child mortality rate and the declining birth rate. The existence, quality and duration
of mother and child health services receives not a mention.
Dr. Berelson refers to the events in China and says we need more faith and more “scientific analysis of relations between the social-medical inputs, and the demographic outcomes.” But he does not seem to give emphasis to the ease of
commu-nication in totalitarian structure, to the simplification and
distribution of medical care, or to the great emphasis on the care and education of children. The question is not either
family planning or family health. But it would seem to many
observers that family planning is most successfully
intro-duced when it is offered as one of the amenities of family health. It is certainly true of those programs in which the care of the vulnerable groups, the mothers and young
chil-dren have had the care according to their vulnerability. How much of existing resources is being spent on sophisti-cated methods of evaluation? How much of this is irrelevant?
Pediatrics, curative and preventive, physical, mental and
social, is a relatively new discipline. It has made enormous strides in this century and it is growing rapidly in scope as well as in strength. Care of mothers and children not only help to cure, prevent and modify disease, it can be an impor-tant factor in progress and in responsibility.
Pediatrics can use its power to influence politicians.
I would like to thank Dr. Nathan for his comments. There
is still room for improvement in the understanding of
prob-lems and in the delivery of health care. But resources in money and personnel are limited-pitifully limited in some parts of the world. We have to consider needs and resources and adaptations. It is only by looking carefully at priorities and at balance that we can expand. The universities have a great part to play in training workers as well as in advising
governments.
CII:ELY D. WILLIAMS, M.D.
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Boston, Massachusetts
Medical Center
LETTERS
TO THE
EDITOR
253
Neit’ Orleans, Louisiana
School of Public Health and Tropical Medicine
Tulane University
REFERENCES
1. Williams, C. D.: Health services in the home. Pediatrics,
52:773, 1973.
2. Nathan, D. :Primary medical care and medical research
training. Pediatrics, 52:768, 1973.
3. Evang K.: The politics of developing a national health policy.
J.
Nutr. Health Services, 3:331, 1973. 4. Casazza, L.J.,
and Williams, C. D.: Family health versusfamily planning. Lancet, March 31, 1973, p. 712.
5. Berelson, B.: The evaluation of the effect of population programs. Studies in Family Planning, January 1974, p. 1.
Dr. Nathan’s
Reply
to His Critics
To THE EcoTon:
Though the tone of some of the responses to my commen-tary is a bit more strident than I would hope to hear in a dis-ciission among colleagues, I must admit that some of the
crit-icisms are well taken.
There are one or two points that require closer
examina-tion. First, it is not fair to blame the overgrowth of specialty
and research medicine on the department chairmen of the SOs. The facts are that organized medicine made certain that no hinds would be available to develop new primary care programs aside from traditional residency training
pro-grams. Only recently has opposition to health insurance
schemes of various kinds been somewhat muted. Thus the
only funds available to department chairmen were through the National Institutes of Health, and these were specifically restricted to research and specialty care. Thus did the uni-versity hospitals grow without firm relationship to the com-niunity hospitals that feed them, and we are left with a com-pletely unregulated and uncoordinated system.
Though Dr. Shiller and Dr. Katcher, and I am sure many
other critics, believe that I am trying to answer a complex
question with a very naive answer, I don’t think we are as far
apart as the temper of the language sounds. They are saying (and I agree) that one could never solve this problem merely by encouraging academic physicians into the primary medi-cal care group. Obviously what is needed is coordination of primary medical care deliverers, community hospitals and university hospitals as well as medical schools in a new part-nership with the government to solve this problem. I am merely saying that some of the specialists who are now
veer-ing away from specialty research pursuits could be very
vaIn-able in the organization of such a structure, and more inipor-tant, they could supply an analytic approach for students en-tering the field that would tend to maintain standards in the pathophysiology of disease (as well as the organization of treatment programs) of great importance in medical
educa-tion.
David Rutstein’s new book, Blueprintfor Medical Care, is a valuable monograph that reviews this subject far more co-herently than can a series ofcommentaries and letters. But at least this flurry has certainly livened the pages of the Journal,
and I hope that Dr. Sniith, who began the discussion, enjoys
the reading. He certainly deserves the pleasure after so many
years of leadership of a fine journal.
DAvin C. NATHAN, M.D.
Chief, Division of Hematology-Oncology Children’s Hospital
School
Problems
and Their
Causes
To THE EnITon:
In most respects Dr. Marcel Kinsbourne’s discussion of school problems was excellent,’ but he makes some state-ments which I feel should be reviewed critically.
His opening statement that “the great bulk of illiteracy in this country derives from socioeconomic adversity and cul-tural alienation that presents a primarily political rather than a medical challenge” (emphasis mine), though often made, confuses correlation and causation. Although illitera-cy can be correlated with low socioeconomic class, that does not necessarily mean that a poor socioeconomic status causes illiteracy (cfthe arguments regarding intelligence and social class). I would guess, on partial evidence, that the majority of underachievers in this country have problems due to the kinds of developmental disorders discussed in this article.
My second concern is with Dr. Kinsbourne’s discussion of the neurological basis for “developmental lag.” He states that the child who suffers some kind of trauma to the central nervous system sustains “. . .a failure of a normal timing of
development of the relevant function. The function which is involved will develop later and more slowly.” Studies of adults who had specific learning disability as children mdi-cate that many of the functions involved never do develop to the level to be expected on the basis of that adult’s intellec-tual function in other areas.2 Also there are cases of known brain damage sustained very early in life that result in very little or no measurable loss of function in later life. Some perceptual dysfunctions in children with specific learning disability and emotional characteristics of minimal brain dysfunction are indeed typical of younger children, but the pathophysiology ofthese “immaturities” is not at all certain. Also, if some such disorders are familial, they would be diffi-cult to explain as damage to a portion of the nervous system “that does not yet subserve any function.”
Finally, Dr. Kinsbourne discusses with considerable clar-ity the variability of intelligence. He states that intelligence, rather than a unitary phenomenon, is actually composed of many different kinds of intelligence and asks the reader to think of his own intellectual strengths and weaknesses as a
way of understanding this concept. When I speak before au-diences I find that this analogy, though easily made, may ob-scure a basic characteristic of specific learning disability. If we could accurately measure each of these different kinds of intelligence, I believe most people would fit somewhere along the bell-shaped curve usually generated when biologi-cal phenomena are measured, whereas children with specific learning disability would fall into a hump below the lower end of the curve: a bimodal distribution suggesting biologi-cal abnormality rather than normal variation. This impres-sion is certainly capable of being tested,3 though there are
many problems including the need to keep comparative groups standardized for “basic” intelligence.
ESTHER H. WENDER, M.D.
Department of Pediatrics
University of Utah Medical Center
50 North Medical Drive
Salt Lake City, Utah 84112
REFERENCES
1. Kinsbourne, M.: School problems. Pediatrics, 52:697, 1973.
