WORLD HEALTH REPORT
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196 Evaluating Everyman’s Portfolio AN account of the activities of the Department of Health and Social Security in health services research and development, published this weeks is a notable piece of private enterprise by the publishers, the Nuffield Provincial Hospitals Trust. Why the details of such an important public activity, which absorbs a wide range of resources costing nearly six million pounds a year, have not been set out publicly before now may seem surprising, but it would be churlish to be ungrateful for the opportunity now to study the roots of what could well be important future health service policies. The list of current grants which takes up a third of the book is an eye-opener for its variety, range, and cost (see p. 207). Perhaps the most surprising omission is the absence of any essay on research into the application of computers to medicine-a subject the direction and control of which lie largely in the hands of the D.H.S.S. This par- ticular activity has an unhappy history, and, without some hard thinking about its relation to information systems for clinical service, research, and manage- ment, its outcome is unlikely to be any more satis- factory. The book poses general questions, some of which are raised by Mr. GORDON McLACHLAN, Secretary of the Trust, in an editorial. Mr. McLACHLAN refers to the mechanisms for appraising applications and for monitoring the programmes and quality of research, and the follow-up and implementation of research results; but other issues are of even greater importance. Should a Department of State be responsible for initiating and managing pure research as distinct from applied research for its own adminis- trative purposes ? The position of the Research Councils is believed to be under scrutiny, not only by the Council for Scientific Policy, but also by Lord ROTHSCHILD’S team which was brought into being on the initiative of Downing Street. The style of the present Government suggests that, through the application of management principles, it will seek to secure the fullest possible return on investment. In such an ambience research must be related to executive action: hence the prima-facie case for a general tidying-up and centralisation under the De- partment responsible for Health Services. Yet the evidence of Portfolio for Health suggests a developing programme in search of a policy, rather than the reverse. Thus the volume bears no token of a firm coherent policy keyed to objectives, against which results can be measured. Partly this is inevitable. The nature of research in medical care (especially since it has been welded to " development " as a kind of action research) is such that its effectiveness 1. Portfolio for Health: the Role and Programme of the D.H.S.S. in Health Services Research. Edited by GORDON MCLACHLAN. London: Oxford University Press for Nuffield Provincial Hospitals Trust. 1971. Pp. 300. £3. is not speedily evident. Consequently it requires some elasticity in management and not a little optimism in its sponsors. Hitherto private founda- tions have had a large part in funding research. They have been prepared to take risks, and probably they would not lay claim to a high return on their total outlay. But with Government funds already dwarfing those from the foundations, these are at risk of being left to support the second-rate, and they will inevitably reconsider their roles. In this latest publication, the Trust has pointed the way to a monitoring role, which if fearlessly assumed may prove vital. But all the major funding bodies, whether independent, or Research Councils, or operated by Departments of State, will still need to take risks and cast their bread upon the waters- a dictum which may not altogether accord with the leanings of the present Government. No-one can doubt that the D.H.S.S. must have its own funds for research. The real question is where the various kinds of research should be pursued. This theme is taken up by Mr. McLACHLAN, who distinguishes between research for the Department’s own purposes and that concerned with protecting the public, and appeals to the D.H.S.S. to support an independent body dedicated to monitoring of quality of care and to protecting the public. There is little doubt that there are questions which in the public interest should be investigated independently; and there is equally little doubt that this volume will provoke debate on the funding and control of medical research in its various forms. WORLD HEALTH REPORT The latest W.H.O. report in the series on the world health situation is invaluable as a historical rather than as a contemporary account, since it refers to the four years from 1965 to 1968. This selective survey of the world situation depends on reports from some member States and associate members, so there are notable omissions, since nothing can be said about China or other non-member countries, such as the German Democratic Republic. 2 There are other omissions, particularly in Africa; for example, there are no comprehensive reports from some of the East African countries. No attempt is made to make a clinical diagnosis of the state of the world’s health: the aim is rather to draw up a balance-sheet between the apparent needs and known resources in different regions. Changes in the world health situation are governed more by the resources available than by the hazards to health. Although the report deals with a period which ended 1. 4th Report on World Health Situation, 1965-68. Off. Rec. Wld. Hlth Org. 1971, no. 192. Obtainable from P.O. Box 569, London S.E.1, American Public Health Association, Inc., 1015 Eighteenth Street N.W., Washington D.C. 20036, and other W.H.O. sales agents. £2.40. 2. See Lancet, 1971, i, 1114.
Transcript of WORLD HEALTH REPORT
196
Evaluating Everyman’s PortfolioAN account of the activities of the Department of
Health and Social Security in health services researchand development, published this weeks is a notablepiece of private enterprise by the publishers, theNuffield Provincial Hospitals Trust. Why the detailsof such an important public activity, which absorbsa wide range of resources costing nearly six millionpounds a year, have not been set out publicly beforenow may seem surprising, but it would be churlishto be ungrateful for the opportunity now to studythe roots of what could well be important futurehealth service policies. The list of current grantswhich takes up a third of the book is an eye-openerfor its variety, range, and cost (see p. 207). Perhapsthe most surprising omission is the absence of anyessay on research into the application of computers tomedicine-a subject the direction and control of whichlie largely in the hands of the D.H.S.S. This par-ticular activity has an unhappy history, and, withoutsome hard thinking about its relation to informationsystems for clinical service, research, and manage-ment, its outcome is unlikely to be any more satis-factory.The book poses general questions, some of which
are raised by Mr. GORDON McLACHLAN, Secretaryof the Trust, in an editorial. Mr. McLACHLANrefers to the mechanisms for appraising applicationsand for monitoring the programmes and quality ofresearch, and the follow-up and implementation ofresearch results; but other issues are of even greaterimportance. Should a Department of State be
responsible for initiating and managing pure researchas distinct from applied research for its own adminis-trative purposes ? The position of the ResearchCouncils is believed to be under scrutiny, not onlyby the Council for Scientific Policy, but also byLord ROTHSCHILD’S team which was brought intobeing on the initiative of Downing Street. The styleof the present Government suggests that, through theapplication of management principles, it will seekto secure the fullest possible return on investment.In such an ambience research must be related toexecutive action: hence the prima-facie case for ageneral tidying-up and centralisation under the De-partment responsible for Health Services. Yet theevidence of Portfolio for Health suggests a developingprogramme in search of a policy, rather than thereverse. Thus the volume bears no token of a firmcoherent policy keyed to objectives, against whichresults can be measured. Partly this is inevitable.The nature of research in medical care (especiallysince it has been welded to " development " as a
kind of action research) is such that its effectiveness
1. Portfolio for Health: the Role and Programme of the D.H.S.S. inHealth Services Research. Edited by GORDON MCLACHLAN.London: Oxford University Press for Nuffield Provincial HospitalsTrust. 1971. Pp. 300. £3.
is not speedily evident. Consequently it requiressome elasticity in management and not a little
optimism in its sponsors. Hitherto private founda-tions have had a large part in funding research.They have been prepared to take risks, and probablythey would not lay claim to a high return on theirtotal outlay. But with Government funds alreadydwarfing those from the foundations, these are atrisk of being left to support the second-rate, andthey will inevitably reconsider their roles. In thislatest publication, the Trust has pointed the way to amonitoring role, which if fearlessly assumed mayprove vital. But all the major funding bodies,whether independent, or Research Councils, or
operated by Departments of State, will still need totake risks and cast their bread upon the waters-a dictum which may not altogether accord with theleanings of the present Government. No-one candoubt that the D.H.S.S. must have its own fundsfor research. The real question is where the variouskinds of research should be pursued. This theme istaken up by Mr. McLACHLAN, who distinguishesbetween research for the Department’s own purposesand that concerned with protecting the public, andappeals to the D.H.S.S. to support an independentbody dedicated to monitoring of quality of care andto protecting the public. There is little doubt thatthere are questions which in the public interestshould be investigated independently; and there is
equally little doubt that this volume will provokedebate on the funding and control of medical researchin its various forms.
WORLD HEALTH REPORT
The latest W.H.O. report in the series on theworld health situation is invaluable as a historicalrather than as a contemporary account, since it refersto the four years from 1965 to 1968. This selective
survey of the world situation depends on reports fromsome member States and associate members, so thereare notable omissions, since nothing can be said aboutChina or other non-member countries, such as theGerman Democratic Republic. 2 There are other
omissions, particularly in Africa; for example, thereare no comprehensive reports from some of the EastAfrican countries.
No attempt is made to make a clinical diagnosis ofthe state of the world’s health: the aim is rather todraw up a balance-sheet between the apparent needsand known resources in different regions. Changes inthe world health situation are governed more by theresources available than by the hazards to health.
Although the report deals with a period which ended
1. 4th Report on World Health Situation, 1965-68. Off. Rec. Wld.Hlth Org. 1971, no. 192. Obtainable from P.O. Box 569, LondonS.E.1, American Public Health Association, Inc., 1015 EighteenthStreet N.W., Washington D.C. 20036, and other W.H.O. salesagents. £2.40.
2. See Lancet, 1971, i, 1114.
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three years ago, it has something important to sayabout the trends of communicable disease and popula-tion. Perhaps the most significant is the recognition ofthe combined impact of malnutrition and infectionsin the causes of death in infancy. The death-rate belowthe age of five represents a major distinguishingfactor between the health of those in the developed andthe developing world.
The report, the fourth since the series began in 1954,includes for the first time chapters on manpower,education, and training, emphasising their increasingimportance. On the whole, with a few notable excep-tions, little change has been recorded in the incidence ofdisease, particularly in areas where communicabledisease is still dominant. Success has been remarkablewith malaria and with smallpox; and indeed theworldwide decline in smallpox makes it certain thatroutine infant vaccination will now be abandoned inBritain and elsewhere. But negligible progress hasbeen achieved against schistosomiasis and some of thehelminthic infections. As far as the developed coun-tries are concerned, the health services remain pre-occupied with the chronic and degenerative diseasesof ageing populations. With an increased world
population of 250 million between 1965 and 1968,most of this increase has been in developing countries.One significant fact is the increase in the proportionof young people in the populations of developing areasand the proportion of old people in the developed world.This must have a profound effect on the methods ofdelivering medical care in various parts of the worldand the structure of the health service. It seems
apparent that the application of mass immunisationprogrammes for children in developing areas can becarried out by personnel quite different from thosewho care for the degenerative diseases of middle andold age. The Director General of W.H.O. has referredto the balanced health team, composed of full profes-sionals and auxiliaries, as a feature of this approachto community medicine.
Not all countries have supplied details of Govern-ment health expenditure, but in many countriesthere has been a considerable increase in the pro-portion of money spent on health. Korea, for example,has more than doubled the amount spent, whereasthe United Kingdom and the United States haveincreased their expenditure by about 40%. A fewcountries have suffered economic setbacks and havenot advanced. Expenditure on health in Ghana hasbeen reduced, so that in 1968 it was 14% less thanin 1964.
The record has more than historic value. In termsof global distribution of resources applied to worldhealth needs, it provides a ready means of assessingwhere and to what extent technical assistance is neces-
sary. Some of the facts recorded demonstrate whereability lies to marshal resources to the best advantage,as well as indicating the size of the gap between whatcan be done and what needs to be done. It is good tonote that W.H.O. has received the World HealthAssembly’s authority to provide supplementary state-ments every two years, which will enhance the practicalimportance of this type of reporting.
HARD FACTS ON SOFT DRUGS
MucH of present concern, both national and inter-national, about drug abuse tends to centre on the non-medical use of self-injected drugs taken by an ex-panding youthful population, predominantly male,who use drugs, initially at least, for their subjectivepleasurable effects. But it is being realised, perhapsrather late in the day by some, that this is merely ahighly illuminated part of the spectrum of drugmisuse which covers a much wider population. Blum 1commented: " Drug dependency occurs paradoxic-ally, both more often and less often than seems com-monly expected; more often in that there is hiddendependency on barbiturates and tranquillisers ", lessoften " in the sense that particular drugs previouslythought to be almost inevitably dependency producing,heroin for example, are by no means that. Depen-dency ... depends on the quality of the person and hisenvironment as well as the way a drug acts on thebody
Isbell and Chrusciel I provide a comprehensivereview of the abuse potential of a wide range of drugs,including not only those with seemingly impeccablemedical credentials but also those more exotic sub-stances, mainly hallucinogenic, which have capturedthe imagination of some and stimulated the moralfervour of others. Their monograph presents techni-cal data on 253 psychoactive drugs and herbs which" possess the capacity " to produce central-nervousstimulation, depression, or hallucinations, or to
produce distortions in perception, thinking, or judg-ment and which may induce drug dependency.These substances are classified in five main categories:C.N.S. depressants, C.N.S. stimulants, hallucinogens,crude plant drugs, and precursors. Certain categoriesare further subdivided-such as sedatives into 13and stimulants into 4. In the depressant (sedative)group are listed 66 diureides (barbiturates), 5 mono-ureides, 22 chloral derivatives, 7 piperidinedionederivatives, including glutethimide, and 15 benzo-
diazepines, including oxazepam, nitrazepam, diaze-
pam, and chlordiazepoxide. 20 are listed as miscel-laneous. The total ofc.N.s. depressants is, in fact, 158.All the barbiturates are classified as dependencyproducing; and of 92 non-barbiturate sedatives, 59carry clear evidence of dependence liability. Of the40 stimulants listed, 23 show definite evidence of
dependence liability. The remaining substances areeither hallucinogens or their precursors. Dependenceon hallucinogens is less easy to define, though changesin life style after long-term use of hallucinogens seemto be an alarming consequence.
Listing substances in this factual way and tabulatingthem under headings which indicate symptoms of
intoxication, tolerance, dependence, and so on, is a
sobering reminder of the extent of the availability ofdependence-producing drugs, many of which mayreadily be prescribed. In the case of barbiturates,where physical and psychological dependence potential
1. Blum, R. M. Drugs, Dangerous Behaviour, and Social Policy.Narcotics and Drug Abuse; appendix A 3, pp. 64-79. Task ForceReport. President’s Commission on Law Enforcement andAdministration of Justice. Washington, 1967.
2. Isbell, H., Chrusciel, T. L. Bull. Wld Hlth Org. suppl. 43, 1970.
