dining morbidity and mortality of
The Health Maintenance
cervical cancer, Cancer 34: 2018,
1974; Miller, A. et al. Mortality
from cancer of the uterus in Canada
and its relation to screening for
cancer of the cervix, Int. J. Cane.
17: 600, 1976. Such comparisons
are complicated by uncontrollable
factors, such as the recent upswing
of uterine cancer due to medical
use of estrogens to treat symptoms
of menopause in women: for ex-
ample, see: Weiss, N. et al. Increas-
ing incidence of endometrial cancer
in the United States. N. Engl. J.
Med. 294 (23): 1259-1262, 1976;
Antunes, C. et al. Endometrial can-
cer and estrogen use: report of a
large case-control study. N. Engl. J.
Med. 300 (1): 9-13, 1979.
33.OTA pages 48-50. The OTA sum-
mary of evidence in this case is
seriously flawed. They report only
the evidence of the Veterans Ad-
ministration Study, which showed
lowering of blood pressure, stroke
and kidney damage among hyper-
tensive men treated for short (3.3
years average) periods with anti-
hypertensive drugs, but no change
in coronary heart disease risk: Vete-
rans' Administration Cooperative
Study Group on Antihypertensive
Agents. Effects of treatment on
morbidity in hypertension: results
in patients with diastolic blood
pressures averaging 115 through
129 mm Hg. JAMA 202:1028-1034,
1967; Effects of treatment on mor-
bidity in hypertension. II. Results
in patients with diastolic blood
pressure averaging 115 through 134
mm Hg. JAMA 213: 1143-1152,
1970; Effects of treatment on mor-
bidity in hypertension. III. In-
fluence of age, diastolic pressure
and prior cardiovascular disease;
further analysis of side effects. Cir-
culation 45: 173-186, 1972. OTA
ignores reports showing increased
risk of coronary heart disease with
long-term (up to 8 years) admini-
stration of antihypertensive drugs;
for a review, see Robinson, S. Coro-
nary artery disease and antihyper-
tensive drugs. J. Clin. Pharmacol.
12: 123-126, 1973. This omission
is significant primarily because mass
prophylactic use of antihyperten-
sive drugs from adolescence is now
being widely advocated; for exam-
ple, see Stamler, J. et al. (ed.) The
Hypertension Handbook, Merck,
Sharpe and Dohme, West Point, Pa.,
1974. In addition, even under cur-
rent, more restricted conditions of
use, antihypertensive drug treat-
ment is only marginally cost effec-
tive: it returns only $1.25 in saved
medical costs of treating endstage
cardiovascular disorders for each
$1.00 invested in drug prophylaxis:
OTA, page 49. The main reason for
the small return is that coronary
heart disease is untouched and may
be increased by antihypertensive
medication.
34.OTA pages 33-36.
35.OTA pages 29-31.
36.OTA pages 51-52. Other methods
of broken limb support exist, and
may have less undesirable effects,
such as muscle atrophy, skin infec-
tions, etc.: Horn, J. Away With All
Pests, Monthly Review, New York,
1969.
37.OTA pages 52-53.
38.OTA pages 23-25.
39.The critique of*thei overuse of X-rays
is well known in medical literature.
For yet another recently emergent
example, see Favus, M. et al. Thy-
roid cancer occurring as a late con-
sequence of head-and-neck irradia-
tion. N. Engl. J. Med. 294 (19):
1019, 1025, 1976. This story is
particularly interesting because of
its possible wide consequences, be-
yond thyroid cancer alone. Since
the beginning of the 20th century,
an enlarged thymus in children was
baselessly considered pathological
by many scientistic doctors. At first
this condition was treated by surgi-
cal removal of the thymus, and
from the 1920's through the 1950's,
millions of infants and children
were treated by high-intensity X-ir-
radition to shrink the thymus. In
light of the present knowledge on
the essential role of the thymus in
cell mediated immunity, it can be
anticipated that these children
should develop immune-deficiency
diseases in later life. The very high
risk of thyroid cancers reported by
Favus et al. in previously irradiated
persons is perhaps only the tip of
the iceberg.
40.For an informative history, see
Sigerist, H. The Great Doctors,
Dover, New York, 1971.
41.Sigerist, op. cit. ref. 40, pages
215-16.
42.Shryock, R. The Development of
Modern Medicine Hafner, New
York, 1969.
43.Cochrane, A. Effectiveness and Ef-
ficiency Nuffield Provincial Hospi-
tals Trust, Burgess, London, 1972.
44.Paul, G., Tobias, L, and Holly, B.
Maintenance Psychotropic Drugs in
the presence of active treatment
programs: a "triple-blind" with-
drawal study with long term mental
patients. Arch. Gen. Psychiat. 27:
106-115, 1972.
45. See VA study, cited in reference 33.
The exact fraction excluded by pre-
selection against "placebo respon-
ders" was not reported in these
studies.
46.Medical World News, p. 7, Oct. 16,
1978.
/.Salmon, J.
Organization Strategy: a corporate
takeover of health services delivery.
International Journal of Health Ser-
vices 5(4): 609-624, 1975; Salmon,
J. Monopoly capital and its reorga-
nization of the health sector. Rev.
Rad. Pol. Econ. 8.125-133, Spring
1977.
J. Bunker, J. Surgical manpower:
a comparison of operations and sur-
geons in the United States and in
England and Wales N. Engl. J. Med.
282: 135, 1970; Bunker, J. and
Brown, B. The physician-patient as
an informed consumer of surgical
services N. Engl. J. Med. 290:
1051, 1974; Bunker, et al. (eds.)
Costs, Risks, and Bene fits of Surgery
Oxford University Press, New York,
1977; Bunker, J. Elective hysterec-
tomy: pro and con N. Engl. J. Med.
295: 264, 1976; Bunker, J. et al.
Surgical innovation and its evalua-
tion Science 200: 937, 1978;
Lewis, C. Variations in the inci-
dence of surgery N. Engl. J. Med.
281(16): 880-884, 1969.
>.Gaus, C.R. et al. Contrasts in HMO
and Fee-for-Service performance
Social Security Bulletin 39(5):
3-14, 1976.
.Berliner, H. A larger perspective on
the Flexner report International
Journal of Health Services 5(4):
573-592, 1975. For a review of
other work in this area, see Waitz-
kin, H. A Marxist view of medical
care Annals of Internal Medicine
89: 264-278, 1978.
..McKeown, T. The Modern Rise of
Population. Arnold, London, 1976;
McKeown, T. The Role of Medicine
Dream, Mirage, or Nemesis Nuffield,
Provincial Hospitals Trust, London,
1976; Scrimshaw, N. et al. Nutri-
tion and infection field study in
Guatemalan villages. 1959-64.
I. Study plan and experimental de-
sign. Arch. Environ. Health 14:
657-662, 1967; Scrimshaw, N. et al.
Nutrition and infection field study
in Guatemalan villages 1959-64.
V. Disease incidence among pre-
school children under natural
village conditions, with improved
diet and with medical and public
health services. Arch. Environ.
Health 16: 223-225, 1968; Scrim-
shaw, N. et al. Nutrition and infec-
tion field study in Guatemalan
villages 1959-64. IX. An evaluation
of medical, social and public health
benefits, with suggestions for future
field study. Arch. Environ. Health
18: 51-62, 1969; Scrimshaw, N. et
al. Interactions of nutrition and
infection. WHO Monogr. Ser. 57:
3-329, 1968.
.Eyer, J. Transitional medicine.
HMO 4: 180-204, 1978.