1388

Preventing disease, 1990s style

Many health hazards, such as the availability of alcohol andtobacco, the growing volume of road traffic, social deprivation ininner cities, unemployment, and homelessness, are beyond thecapacity of clinical medicine to alter. So what is the role of the doctorin preventive medicine these days? Principally to educate and advisepatients about healthy lifestyles, says a report from the RoyalCollege of Physicians.1 Individuals can reduce their chances ofcontracting disease if they have the knowledge and incentive todo so.

Diseases of the circulatory system and cancer are still the biggestkillers, accounting for 70% of all deaths. So an important aim forhospital doctors and general practitioners is to encourage their

patients to stop smoking-the cause of a quarter of coronary heartdisease deaths as well as 90% of lung cancer deaths and

three-quarters of deaths from chronic obstructive lung disease.Deaths from alcohol, another target for prevention, are hard toquantify, but heavy consumption can affect virtually any organsystem in the body and do much social damage besides. Diet isanother area for medical intervention, because the main effects of anunhealthy diet-obesity and high serum cholesterol levels-add tothe number of deaths from ischaemic heart disease and cancer inaddition to being associated with diabetes and arthritis.

Since preventive medicine is directed mainly at apparentlyhealthy people preventive strategies can sometimes turn a personwho feels well into someone who feels ill-a vaccine may causeunwanted side-effects or a false-positive screening test result maycause needless arxiety-and so the report emphasises that thedoctor needs to be certain that the balance is in favour of a givenintervention. He should also do all he can to ensure that the patientunderstands the risks and benefits.More than other preventive measure, screening is likely to harm

some of the well people tested, says the report. Many establishedscreening programmes, it suggests, are of uncertain benefit andunknown cost. Routine screening for toxoplasmosis and

cytomegalovirus infection in pregnancy is questionable, and so areneonatal screening for congenital dislocation of the hip anddetection of glue ear in childhood. Research into the effectiveness ofgeneral surveillance of child growth and development is a highpriority, the report says. It also questions the cost-effectiveness ofscreening apparently healthy people for hypertension and highplasma cholesterol levels.

In its recommendations the report gives priority to legislativemeans of control in areas such as smoking, alcohol consumption,and accidents, where, it says, preventive strategies could be mostpowerful and benefits greatest.The report draws attention to disease prevention in children and

the elderly and the prevention of infectious diseases, accidents, andoccupational diseases. It does not consider mental illness or theavoidance of inherited disease. The latter was reviewed in a Collegereport two years ago.2

1. Preventive medicine: a report of a working party of the Royal College of Physicians.London: Royal College of Physicians, 1991. Pp 212 ISBN 1873240325.

2. Prenatal diagnosis and genetic screening: community and service implications. RoyalCollege of Physicians, 1989.

Harassing people having sex

History rarely repeats itself as often as it does in family planning.A quarter of a century ago the Brook Advisory Centres were accusedof promoting promiscuity by offering contraception to theunmarried. Indeed, Lady Helen Brook set the centres up becausethe Family Planning Association (FPA) itself was divided on thisissue. Today, government and non-governmental organisationsrecognise that an overwhelming majority of people engage inpremarital sex and that counselling and contraceptive advice areessential if unintended pregnancies and abortions are to be reduced.

In Northern Ireland, however, the battle is still being fought. In1989, 73% of teenage births in Northern Ireland were to theunmarried and one in three of all births in Belfast were outside

marriage. Dr Gabriel Scally, director of public health for the

Eastern Health Board in Belfast, among others, has encouragedBrook, and a clinic is expected to open early in 1992. The FPA hasno clinic in Belfast, and no other specialist services exist to care forthe reproductive health of young people.The prospect of a clinic has aroused a hornet’s nest of opposition.

Protestant and Catholic groups, who are at loggerheads over mostissues, are united in opposing the clinic. The Society for theProtection of Unborn Children, Life, and Family and YouthConcern are threatening to picket any new centre, and two potentiallandlords have already backed down and refused to rent space.Kathleen McQuaid and Betty Gibson, two of the protest leaders,are threatening to harass young people attending the two sessions aweek planned by the centre. The plans are rather like those used bythe American anti-abortion movement-the protesters will askclients "to change their minds". It would seem that when historyrepeats itself it sometimes does so with an extra, nasty twist.

In England Now

Middle age reminds one of its presence in unexpected ways. Forme it was at a recent international conference, when the

unexpectedly autumnal feel of a lovely continental city should havebeen a warning. Twenty years ago one took pride in membership ofa specialty at the leading edge of medicine, able to offer its patientsthe best of high-technology treatment, including organreplacement. New ideas were discussed into the small hours overmany bottles of wine, and we rarely reconvened before the morningcoffee break. Now my specialty appears to be reducible to a fewimmunological formulae or cytogenetic fragments that I can

scarcely comprehend. Some colleages, now past the time when theywould be readily at the bedside of a sick patient, have become moredetached and aloof and obviously cultivating the gravitas that isrequired for election to high office in professional societies. The"accompanying persons" are the saddest reminder of how timeshave changed. In days gone by they were called wives (or spouses),and we all grew up together sharing hopes and friendship. Manymarriages and relationships survive, and both partners havematured into graceful (though portly) middle age; but othercolleagues now come alone or arrive with new and youngercompanions. The most dispiriting change, however, is my inabilityto keep up with the social programme: I doze during its morerelaxing moments (and in the scientific presentations) but amunable to sleep at night. So here I am writing melancholic anddyspeptic pieces such as this while impatiently waiting for a furtherdose of angst at the day’s first session.

International Diary

1991

A conference entitled Evaluating the Clinical Significance of DrugChirality is to take place in London on Dec 4-5: Katerina Georgluou,ROSTRUM, Lewis House, 1 Mildmay Road, Romford, Essex RM7 7DA,UK (0708 745042/768194).

1992

A Singapore-San Francisco advanced course in Infectious Disease willtake place in Singapore on Feb 13-16: Communication Consultants, 336Smith Street #06-302, New Bridge Centre, Singapore 0105 (65-2279811).

The first of the Dead Sea conferences on the Interaction BetweenWestern and Eastern Medicines is Israel has been rescheduled for March1-6, 1992: Secretariat, Dead Sea Conferences, PO Box 50006, Tel Aviv61500, Israel (03-654571).

International Mediterranean conference on Endocrine Disorders inThalassemia is to be held in Cosenza on May 7-9: Scientific Secretary, SAndo’, Cattedra di Fisiopatologia Endocrina, Dip Biologia Cellulare, 87030Rende, Cosenza, Italy (0039-984 401275/401302).