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tomore ethical debate about the case for interveningin the lives of individualswho are clinicallywell onthe basis of evidencewhich is suggestive, associative,but not provenly causative. Again, such evidence iscollective, grouped and averaged but not necessarilypertinent to the individual. This last point is

especially important. All that is known fromepidemiology and group studieswhich depend onstatistical expression ofmean differences should be

emphasised as representing just that, amean differencebetween compared groups. Identification of asusceptible individual has never really been achieved

except through a gross averaged assessment ofaccumulated risk factors, and MEADE and CHAKRA-BARTl 29 point out that " a predictionwithin a highrisk group on the basis of multiple factors still

produces incorrect forecastsmore often than correctones ".

Sowhat dowe do ? Itmay be that total elimination

of risk factors at an early stage should be our goal,and thatwe should accept the hotchpotch of hardevidence, suggestion, and faith as our guideline. 30For thosewho have not the time towait for proofthere ismuch merit in the motto " Act now, think

later ". Advice to our patientsmust be reasonableaswell as objective, since only a proportion are futurebeneficiaries-the rest merely subjects. The cureshould not beworse than the disease. Smoking is ahazard to health and can be positively discouraged.

Specificallyit increases the risks of heart-attack and

lung cancer to a degreewhich is unacceptable for

many. Obesity is bad for general health and canlegitimately be attacked. Some degree of physicalfitness is an aid to general health. Diets high inanimal fats cannot be said to be so certainly causativeof heart-disease that they should be vetoed-but

equally palatable alternatives are sensible. It is fairthat life should be enjoyed and rewarding, and thatmatters 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 qualityof lifewill provide the best guarantee against a heart-attack.

Conquest of Malaria: the Art of theFeasible

" We like progress, but itmust commend itself

to the Common Sense of the People." SAMUELBuTLERs comment on the Erewhonian common-

wealth,where machineswould be acceptable onlyif they do not become masters ofmen, shows aremarkable foresight into some aspects of todaysworld. It could verywell 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 Organisations interregionalconference 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 andterritories 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 conceptwas defined as"

the end of the

transmission of malaria and the elimination of the

reservoir of infective cases in a campaign limited intime and carried out to such a degree of perfectionthat,when it comes to an end, there is no resumptionof 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 severalcountries of the Americas,were remarkable. Withinten years over 1000 million people living in the

originally malarious parts of theworldwere relievedof the enormous burden of this disease, and thiswasoften followed by striking socioeconomic advance.Nevertheless,with a few exceptions, there has beenlittle progress in the tropical core of the geographicaldistribution of malaria. The initial credo of malaria

eradication seems to have been copied from Silviussdeclaration to Phoebe inAs you Like It: " allmade of

passionand allmade of

wishes,all

adoration, dutyand observance ". However, a decade after theofficial launching of theworld-wide programme ofmalaria eradication the World Health Organisationrecognised the obstacles that lay ahead.A remarkablyfrank and realistic assessment of the situationwas

presented before the 22nd World Health Assembly.-1This report pointed out that, during the first decade,toomuch confidence and emphasiswas placed onthe use of residual insecticide spraying as themainmethod of attack on the anopheline vector. On theother hand, the importance of all the administrative,

socioeconomic, financial, and other factors soprominent in tropical developing countries wasunderestimated.5 Difficulties that had slowed the

early advance of malaria eradicationwere obvious,yetmany countrieswith slender resources continued

ratherwearily to fulfil their contractual obligations.Moreover, technical obstacles arose in the shape ofinsecticide resistance and drug resistance. When in1969 the future strategy of malaria eradication under-

went its painful reappraisal, the need for an alterna-tive to the unfulfilled dreamwas evident but the new

tactics were uncertain. The Brazzaville report

providesmuch 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.

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more realistic approach to antimalarial activities in

tropical developing countries.In those parts of theworldwhere endemic malaria

forms a sizeable portion of the still unsolved dilemmaof socioeconomic advance the effective control,let alone eradication, of this disease depends on im-

proveddistribution and

scopeof basic health ser-

vices. This in turn demands careful choice of

priorities. The selection of the best andmost eco-nomic antimalarial measures-including residual

spraying, larvicides, chemotherapy, and environmentalsanitation-must be based on local epidemiologyof the disease. Finally, evaluation of the results ofcontrol should be built into the programme and

carried out by a central auditing authority. The flawin this component of the system is that the impactof malaria on the community is little known incountries where statistical data are patchy andunreliable.6

When it comes to the question of funds for malariacontrol in underprivileged countries, the situation isboth simple and grim. The expenditure on malariaeradication varies considerably from country to

country, but, in the recent past, themean lowestcostswere between U.S.$0.15 and 0.20 per person perannum. This figure is now considerably higher sincethe selling price ofmost insecticides doubled last

year. Most of the developing tropical countries arenot able to spendmore than U.S.1-2 per caput peryear for all their combined health activities. Many ofthese countries allocate an

averageof

U.S.$0-20for

this overall purpose.The immense achievements of the global malaria

eradication programmemust not be underestimated.

Today, out of 1840 million people not less than 1350million live in areas freed of this disease. Havingundergone some modifications to give it greaterflexibility,8 the principle of malaria eradication issound and the programme should continuewherever

the conditions are favourable. But malaria of various

degrees of endemicity remains and even shows some

resurgence inmany areas inhabited by some 490million

people.9 Clearly,malaria-controlmethods

must be improved through applied research, and

developing countries will have to brace themselvesfor a coordinated and decisive effort to control majorcommunicable diseases and to provide better generalhealth services in rural areas. Other steps are not

less important-rapid advance of agricultural andindustrial techniques, acceptance of an appropriatepolicy of family planning, and recognition of the fullsocial status ofwomen. But such an enormous task of

social engineering requires a large amount of inter-national assistance. The first decade of developmentso

loudlyheralded

bythe 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 thesecond decade produce better results in terms of

quality of human life on this our one and onlyworld ?

A NURSE PRACTITIONER

CAN a nurse,with additional training, do the jobof a general practitioner ? A randomised controlled

trial, bearing on this question, is reported fromCanada.1 " The results demonstrate that a nurse

practitioner can provide first-contact primary clinicalcare as safely and effectively,with asmuch satisfactionto patients, as a family physician. The successful

ability of the nurse practitioner to function alone in67 per cent of all patient visits andwithout demon-strable detriment to the patients has particularlyimportant implications in planning of health-caredelivery for regionswhere family physicians are inshort supply."

This trial is clearly important in relation to medical

manpower shortage in parts of NorthAmericawherethere are no doctorswithin reach orwhere a small

number of them are overloaded. It is relevant also

to poorer countrieswhich cannot afford fully traineddoctors in sufficient quantity. In Britain, too, thereare underdoctored areaswhere list sizes are too bigto permit the highest standards of practice; moreover,the average consultation time in general practice forthewhole country is sixminutes.

2Although this

figure, being an average, does not preclude somemuch longer consultations,most people judge it tobe too short. The introduction of a nurse into a

practice, without special training, can increase the

consultation time by 15-27 %.3

Additional trainingof a nurse might increase the doctors consultationtime even more.A consumer survey4 suggests thatthis increasewould bewelcomed by patients, par-ticularly thosewith nervous problems.

But this trial raises amore fundamental question.If the nurseswith additional trainingwere able to doa general practitioners work, were the doctors towhom theywere attached (both trained in the 1950s)overtrained for their job ? Farmore pertinently-whyarewe advocating a large increase in training for

general practice, if the findings of this trial are valid ?A closer andmore critical look is needed. What tasks

did thesenurses

carry out ? Whatwas

the nature andamount of their training ?" The graduating nurse practitioners are qualified to

become not physicians assistants, but co-practitioners,sharing the family physicians responsibility for continuingcare of patients. The nurse practitioner learns to evaluateeach patients presenting problems and to choose fromthree possible courses of action: providing specific treat-ment : providing reassurance alone, without specifictreatment: or referring the patient to the associatedphysician, to another clinician, or to an appropriate serviceagency."

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 fromGeneral Practice no. 16. Royal College of General Practitioners,1973.

3. The Practice Nurse. Reports from General Practice no. 10. RoyalCollege of General Practitioners, 1968.

4. Which ? January, 1974, p. 4.