607

to more ethical debate about the case for
intervening
in the lives of individuals who are
clinically
well on
the basis of evidence which is
suggestive, associative,
but not
provenly
causative.
Again,
such evidence is
collective, grouped
and
averaged
but not
necessarily
pertinent
to the individual. This last
point
is
especially important.
All that is known from
epidemiology
and
group
studies which
depend
on
statistical
expression
of mean differences should be
emphasised
as
representing just that,
a mean difference
between
compared groups.
Identification of a
susceptible
individual has never
really
been achieved
except through
a
gross averaged
assessment of
accumulated risk
factors,
and MEADE and CHAKRA-
BARTl 29
point
out that " a
prediction
within a
high
risk
group
on the basis of
multiple
factors still
produces
incorrect forecasts more often than correct
ones ".
So what do we do ? It
may
be that total elimination
of risk factors at an
early stage
should be our
goal,
and that we should
accept
the
hotchpotch
of hard
evidence, suggestion,
and faith as our
guideline. 30
For those who have not the time to wait for
proof
there is much merit in the motto " Act
now,
think
later ". Advice to our
patients
must be reasonable
as well as
objective,
since
only
a
proportion
are future
beneficiaries-the rest
merely subjects.
The cure
should not be worse than the disease.
Smoking
is a
hazard to health and can be
positively discouraged.
Specifically
it increases the risks of heart-attack and
lung
cancer to a
degree
which is
unacceptable
for
many. Obesity
is bad for
general
health and can
legitimately
be attacked. Some
degree
of
physical
fitness is an aid to
general
health. Diets
high
in
animal fats cannot be said to be so
certainly
causative
of heart-disease that
they
should be vetoed-but
equally palatable
alternatives are sensible. It is fair
that life should be
enjoyed
and
rewarding,
and that
matters
governing
emotional
wellbeing
should be
consciously safeguarded.
And the
protection
all this
gives ?
We cannot
say.
The
important thing
is to
make a reasonable investment at a reasonable
price.
Perhaps
the
objective
interest and care in the
quality
of life will
provide
the best
guarantee against
a heart-
attack.
Conquest
of Malaria: the Art of the
Feasible
" We like
progress,
but it must commend itself
to the Common Sense of the
People."
SAMUEL
BuTLER’s comment on the Erewhonian common-
wealth,
where machines would be
acceptable only
if
they
do not become masters of
men,
shows a
remarkable
foresight
into some
aspects
of
today’s
world. It could
very
well be used as a
prefix
to a
report
29. Meade, T.
W., Chakrabarti, R.
Lancet, 1972, ii. 913.
30.
Turner, R., Ball, L. ibid. 1973, ii, 1137.
of the World Health
Organisation’s interregional
conference on Malaria Control in Countries Where
Time-Limited Eradication is
Impracticable
at Pre-
sent.
1
This
report incorporates
the collective
opinion
of
representatives
of 31 countries and
territories of
Africa,
the Middle
East,
and the
Western
Pacific,
who
gathered
in 1972 in Brazzaville.
In 1955 the World Health
Assembly adopted
the
principle
of
global
malaria
eradication,
2
and a
year
later its
concept
was defined as
"
the end of the
transmission of malaria and the elimination of the
reservoir of infective cases in a
campaign
limited in
time and carried out to such a
degree
of
perfection
that,
when it comes to an
end,
there is no
resumption
of transmission ".3 This definition stresses un-
ambiguously
the contrast between the " once-and-
for-all "
concept
of eradication and the indetermined
duration of malaria control. The
early
results of the
campaign, waged mainly
in
Europe, Asia,
and several
countries of the
Americas,
were remarkable. Within
ten
years
over 1000 million
people living
in the
originally
malarious
parts
of the world were relieved
of the enormous burden of this
disease,
and this was
often followed
by striking
socioeconomic advance.
Nevertheless,
with a few
exceptions,
there has been
little
progress
in the
tropical
core of the
geographical
distribution of malaria. The initial credo of malaria
eradication seems to have been
copied
from Silvius’s
declaration to Phoebe in As
you
Like It: " all made of
passion
and all made of
wishes,
all
adoration, duty
and observance ".
However,
a decade after the
official
launching
of the world-wide
programme
of
malaria eradication the World Health
Organisation
recognised
the obstacles that
lay
ahead. A
remarkably
frank and realistic assessment of the situation was
presented
before the 22nd World Health
Assembly.-1
This
report pointed
out
that, during
the first
decade,
too much confidence and
emphasis
was
placed
on
the use of residual insecticide
spraying
as the main
method of attack on the
anopheline
vector. On the
other
hand,
the
importance
of all the
administrative,
socioeconomic, financial,
and other factors so
prominent
in
tropical developing
countries was
underestimated.
5
Difficulties that had slowed the
early
advance of malaria eradication were
obvious,
yet many
countries with slender resources continued
rather
wearily
to fulfil their contractual
obligations.
Moreover,
technical obstacles arose in the
shape
of
insecticide resistance and
drug
resistance. When in
1969 the future
strategy
of malaria eradication under-
went its
painful reappraisal,
the need for an alterna-
tive to the unfulfilled dream was evident but the new
tactics were uncertain. The Brazzaville
report
provides
much
background
for a less ambitious but
1. Tech. Rep.
Ser. Wld Hlth
Org. no. 537, 1974.
2. World Health Organization, Proceedings
of the 8th World Health
Assembly. Off.
Rec. Wld Hlth Org. 1955, no. 63.
3. Tech. Rep.
Ser. Wld Hlth
Org.
no. 123.
4. Off.
Rec. Wld Hlth Org. no. 176, annex 13.
5. Bruce-Chwatt,
L. J. Bull. N.Y. Acad. Med. 1969, 45, 999.
608
more realistic
approach
to antimalarial activities in
tropical developing
countries.
In those
parts
of the world where endemic malaria
forms a sizeable
portion
of the still unsolved dilemma
of socioeconomic advance the effective
control,
let alone
eradication,
of this disease
depends
on im-
proved
distribution and
scope
of basic health ser-
vices. This in turn demands careful choice of
priorities.
The selection of the best and most eco-
nomic antimalarial
measures-including
residual
spraying, larvicides, chemotherapy,
and environmental
sanitation-must be based on local
epidemiology
of the disease.
Finally,
evaluation of the results of
control should be built into the
programme
and
carried out
by
a central
auditing authority.
The flaw
in this
component
of the
system
is that the
impact
of malaria on the
community
is little known in
countries where statistical data are
patchy
and
unreliable.
6
When it comes to the
question
of funds for malaria
control in
underprivileged countries,
the situation is
both
simple
and
grim.
The
expenditure
on malaria
eradication varies
considerably
from
country
to
country, but,
in the recent
past,
the mean lowest
costs were between U.S.$0.15 and 0.20
per person per
annum. This
figure
is now
considerably higher
since
the
selling price
of most insecticides doubled last
year.
Most of the
developing tropical
countries are
not able to
spend
more than U.S.1-2
per caput per
year
for all their combined health activities.
Many
of
these countries allocate an
average
of
U.S.$0-20 for
this overall
purpose.
The immense achievements of the
global
malaria
eradication
programme
must not be underestimated.
Today,
out of 1840 million
people
not less than 1350
million live in areas freed of this disease.
Having
undergone
some modifications to
give
it
greater
flexibility,8
the
principle
of malaria eradication is
sound and the
programme
should continue wherever
the conditions are favourable. But malaria of various
degrees
of
endemicity
remains and even shows some
resurgence
in
many
areas inhabited
by
some 490
million
people.9 Clearly,
malaria-control methods
must be
improved through applied research,
and
developing
countries will have to brace themselves
for a coordinated and decisive effort to control
major
communicable diseases and to
provide
better
general
health services in rural areas. Other
steps
are not
less
important-rapid
advance of
agricultural
and
industrial
techniques, acceptance
of an
appropriate
policy
of
family planning,
and
recognition
of the full
social status of women. But such an enormous task of
social
engineering requires
a
large
amount of inter-
national assistance. The first decade of
development
so
loudly
heralded
by
the United Nations has been
6. Lancet, 1970, i, 598.
7. Lepes, T. Proc. IX int. Congr. trop.
Med. Malar. 1973, Abstr.
1,
p. 308.
8. Tech.
Rep.
Ser. Wld Hlth
Org. 1971,
no. 467.
9. WHO Chron. 1974, 27, 516.
to a
large
extent " a
study
in frustration ". Will the
second decade
produce
better results in terms of
quality
of human life on this our one and
only
world ?
A NURSE PRACTITIONER
CAN a
nurse,
with additional
training,
do the
job
of a
general practitioner ?
A randomised controlled
trial, bearing
on this
question,
is
reported
from
Canada.
1
" The results demonstrate that a nurse
practitioner
can
provide
first-contact
primary
clinical
care as
safely
and
effectively,
with as much satisfaction
to
patients,
as a
family physician.
The successful
ability
of the nurse
practitioner
to function alone in
67
per
cent of all
patient
visits and without demon-
strable detriment to the
patients
has
particularly
important implications
in
planning
of health-care
delivery
for
regions
where
family physicians
are in
short
supply."
This trial is
clearly important
in relation to medical
manpower shortage
in
parts
of North America where
there are no doctors within reach or where a small
number of them are overloaded. It is relevant also
to
poorer
countries which cannot afford
fully
trained
doctors in sufficient
quantity.
In
Britain, too,
there
are underdoctored areas where list sizes are too
big
to
permit
the
highest
standards of
practice; moreover,
the
average
consultation time in
general practice
for
the whole
country
is six minutes.
2
Although
this
figure, being
an
average,
does not
preclude
some
much
longer consultations,
most
people judge
it to
be too short. The introduction of a nurse into a
practice,
without
special training,
can increase the
consultation time
by 15-27 %.
3
Additional
training
of a nurse
might
increase the doctor’s consultation
time even more. A consumer
survey 4 suggests
that
this increase would be welcomed
by patients, par-
ticularly
those with nervous
problems.
But this trial raises a more fundamental
question.
If the nurses with additional
training
were able to do
a
general practitioner’s work,
were the doctors to
whom
they
were attached
(both
trained in the
1950s)
overtrained for their
job ?
Far more
pertinently-why
are we
advocating
a
large
increase in
training
for
general practice,
if the
findings
of this trial are valid ?
A closer and more critical look is needed. What tasks
did these nurses
carry
out ? What was the nature and
amount of their
training ?
" The
graduating
nurse
practitioners
are
qualified
to
become not
physicians’ assistants,
but
co-practitioners,
sharing
the
family physician’s responsibility
for
continuing
care of
patients.
The nurse
practitioner
learns to evaluate
each
patient’s presenting problems
and to choose from
three
possible
courses of action:
providing specific
treat-
ment :
providing
reassurance
alone,
without
specific
treatment: or
referring
the
patient
to the associated
physician,
to another
clinician,
or to an
appropriate
service
agency."
1.
Spitzer,
W. O., Sackett, D. L., Sibley, J. C., Roberts, R. S., Gent,
M., Kergin,
D.
J., Hackett, B. C., Olynich, A. New
Engl. J.
Med.
1974, 290,
251.
2. Present State and Future Needs of General Practice.
Reports
from
General Practice no. 16.
Royal College
of General Practitioners,
1973.
3. The Practice Nurse. Reports from General Practice no. 10. Royal
College of General Practitioners, 1968.
4. Which ? January, 1974, p. 4.