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erythrocyte flexibility was observed in both patientsand normal controls. If erythrocyte flexibility wasthe only factor involved, why were some of the con-trols not similarly afflicted ? WARDLE, PIERCY, andANDERSONI0 earlier reported that plasma-fibrinogen above 400 mg/dl in diabetic patients wasassociated with onset of major cardiovascular com-plications within three years. The involvement offibrinogen again suggests that the blood viscosityin the microcirculation may contribute to the deve-

lopment of vascular lesions. A link between theseobservations has been reported by KNIGHT, RAM-PLING, and SIRS,11 who found that the flexibi-

lity of erythrocytes in blood from diabetic patientswas lower at high fibrinogen levels than in normalcontrols.12,13 Below a plasma-fibrinogen concentra-tion of 350 mg/dl, however, the plasma viscosityand erythrocyte flexibility are normal. The red-cellflexibility of patients with diabetes is independentof fibrinogen levels. This implies that in patientswith high fibrinogen levels, and corresponding in-creased plasma viscosity, the blood viscosity in themicrocirculation is abnormally high. In wholeblood, the viscosity in diabetics is also raised at lowshear rates, probably owing to the increased levelof plasma-globulins,14 and this would predispose tovenous thrombosis. The change in erythrocyte be-haviour in diabetes is unexplained; it does not seemto be influenced by treatment with drugs such asinsulin. Perhaps manipulation of the viscosity bycontrol of plasma-fibrinogen level will prove usefulin diabetic complications. Attempts with clofibratehave not so far been successful, but clofibrate hasother effects, and patients have not been selectedfor suitability by measurement of both fibrinogenand erythrocyte flexibility. No drug has beenshown unequivocally to increase erythrocyte flexi-bility, and work along these lines may be fruitful.

Barefoot Yes, Hotfoot No

,

THE barefoot-doctor approach to medical care inthe Third World has been widely accepted-inprinciple at least-by governments, health plan-ners, and aid agencies. The notion is good: indeed,how else could the rural poor get the benefits of

preventive medicine and simple effective treat-

ments ? Yet the eagerness with which such schemesare being promoted may actually put the barefoot-doctor concept at risk. Nowhere is this better seenthan in population control.

After the failure of the crash programmes of the1950s and 1960s, some agencies realised that theemerging primary-care schemes offered the best

10. Wardle, E., Piercy, D., Anderson, J. Postgrad. med. J. 1973, 49, 1.11. Knight, K., Rampling, M. W., Sirs, J. A. Biorheology (in the press).12. Rampling, M. W., Sirs, J. A. J. Physiol. Lond. 1972, 223, 199.13. Dupont, P., Sirs, J. A. Thrombosis and Hœmostasis (in the press).14. McMillan, D. E. J. clin. Invest. 1974, 53, 1071.

hope of bridging the gap between those wanting toprovide contraception and those who seemed awk-ward about receiving it. The International PlannedParenthood Federation and USAID vigorously sup-ported programmes in which primary-health-careworkers, distributed contraceptive pills, adminis-tered injectables, inserted intrauterine devices, andperformed male and female sterilisations. Pro-

grammes which had formerly struggled along onmeagre budgets found themselves plied with largefunds to finance rapid expansion.

But barefoot doctoring requires the acquisitionof new attitudes as well as new skills, and this takestime. Some of those workers at the scene of theaction are beginning to suspect that population sta-tistics-numbers rather than human need--counttoo highly in the thinking of their sponsors. Forexample, how are they to react when they read (ofa vasectomy camp in India): "Although gloves wereused, they are not necessary. If instruments are

carefully sterilised and a ’no touch’ technique is

used, bacteria from the hands cannot enter a vasec-tomy incision"?1 This may well be true; but so longas, in the aid-giving country, every wound isstitched with gloved hands, such phrases will havea hollow ring. Some of those experts who press foran all-out drive to train primary health workers insterilisation of women are similarly prepared to dis-pense with gloves; yet these paramedicals will beoperating, not on well-npurished westerners, but onwomen already weakened by childbirth, malnutri-tion, and anaemia; and such women are not goodsubjects for an experiment with gloveless surgery-especially when the operator has only rudimentaryknowledge of bacterial behaviour. We can safelyassume that, for every woman whose woundbecomes infected postoperatively, several potentialclients will stay away. Primary health workers arean enormous asset to family-planning services, butthey will remain so only if the organisers resist

over-rapid expansion and reduction of standards.Population experts have latched on to just oneaspect of the barefoot-doctor approach-that itcan be established and expanded rapidly, owing tothe short training of the workers. But much moreimportant, in the long run, is that the servicebecomes a permanent part of the village scene-unlike the sporadic forays of city doctors whichrepresent most of the villagers’ experience ofmodern medicine. Any type of contraception will bemore acceptable when provided by health workerswho are known in the village and who will be avail-able for advice in case of side-effects or complica-tions. The Lancet has already commented favoura-bly on the project in Bangladesh known as

Gonoshasthaya Kendra, where paramedicals pro-

1. Population Reports, series D, no. 2. Department of Medical and PublicAffairs, George Washington University Medical Center, 1975.

963

vide general health care as well as contraception.2 2On p. 946 this week a report from this centrerecords experience with the injectable contracep-tive, depot medroxyprogesterone. Loss to follow-upwas almost nil and continuation-rates were higherthan one might expect in view of the formidableside-effects. This contrasts with reports3,4 fromThailand which recorded fewer side-effects withthis agent but considerable loss to follow-up. Presum-ably, many of the women who disappeared wereunwilling to return after experiencing unpleasantside-effects. Until contraceptives improve, womenwill need constant access to advice and support. The

Bangladesh workers argue fiercely against the

speed-and-numbers approach.Barefoot-doctor programmes depend on large

numbers of workers with little education and ashort practical training. They must be enthusiasticand conscientious. In addition, they must acceptthe limits of their knowledge and skill. When ascheme expands too quickly, well-motivated candi-dates become scarce, teaching and supervision aredelegated, and standards are diluted. In the train-ing of paramedical workers, the emphasis is on par-ticular procedures which must be followed to theletter. Decisions on what can be jettisoned andwhat must be preserved cannot be reached in haste.Unless primary-care workers are carefully trainedand perform their work skilfully and conscien-tiously, the whole concept is at risk. The popula-tion statistics are indeed horrifying, but the solu-tion does not lie in crash programmes promisingquick results; the need is for a humane approach,and a measure of patience.

EXERCISE FOR DEEP-VENOUS THROMBOSIS

How should a deep venous thrombosis be treated? Inthe current enthusiasm for prevention the matter hasbeen almost lost to view. The standard treatment is bedrest and anticoagulation, but the duration of rest andthe type and duration of anticoagulation are still contro-versial. Now some work from New York raises the ques-tion of whether rest is necessary at all and employs anovel method of anticoagulation. Stillman et al 5 treatedall their D.v.T. patients, except those with accompanying-fever or leucocytosis, at home with self-administeredsubcutaneous heparin, elastic stockings, and a pro-gramme of exercise. (Those patients who had a systemicdisturbance as well as local signs were admitted to hospi-tal for anticoagulation and later transferred to thehome regimen.) Venography was performed in only 119of the 407 patients, and since this investigation is essen-tial for accurate diagnosis6 (except in patients being

2 Lancet, 1976, i, 26.3 McDaniel, E B. Paper read at International Planned Parenthood Federation

meeting, April 26, 1976.4 IPPF. med.Bull. 1975, 9, no. 1.5 Stillman, R. M., Chapa, L., Stark, M. L., Malik, L. N., Keates, J. R. W.,

Sawyer, P N. Surgery Gynec. Obstet. 1977, 145, 193.6 Tibbutt, D. A. D M. thesis, University of Oxford, 1976.

screened with 1211-fibrinogen) the satisfactory resultsthat are claimed should be treated with caution.

Nevertheless, the technique of ambulant anticoagulationcertainly deserves further investigation.

Heparin, 20 000 u, was given subcutaneously into theabdominal fat-pad and the bleeding-time was apparentlyprolonged beyond 20 minutes for the next 24 hours,although the frequency of administration is not stated.(10 000 u heparin subcutaneously has been shown in thepast to give heparin levels within the therapeutic rangefor 12 hours, and self-administration for up to 10 weekshas proved satisfactory in women with placental insuffi-,ciency.7) In the New York study some patients continuedto give themselves heparin for many years, but whetherthis is necessary or has any advantages over conven-tional oral anticoagulation is impossible to say. Prolong-ing oral anticoagulation beyond six weeks is probablynecessary only in patients with recurrent thrombosis,pulmonary embolism, or a persistent predisposingcause 8 Only 9 patients had any abnormal bleeding whileon subcutaneous heparin and the bleeding alwaysstopped when heparin was withdrawn. As regardshaemorrhagic complications, therefore, this type of anti-coagulation compares favourably with long-term oralanticoagulation.9The exercise programme included daily walking and

swimming, with a hot bath. Probably this aspect of thetreatment is more.important than the anticoagulation,since muscular exercise and heat both stimulate fibrino-

lysis 10,11 and exercise increases blood-flow. Certainly smalluntreated calf thrombi lyse more rapidly if the patientis taking exercise.12Few of the patients in the New Yorkstudy were lost to follow-up and there were only sevenconfirmed episodes of pulmonary embolism, none fatal.On this evidence, exercise does not seem to dislodgethrombi. These ideas ought to be further investigated.Many patients would be saved a lot of misery, andhealth services a lot of money, if they were shown to becorrect.

JOINING UP THE LOWER GUT

SURGEONS fuss about technique, and rightly so

because the best of bedside manners and the finest of

postoperative care is as naught by comparison with get-ting the cutting and sewing right. (A live patient is anessential preliminary to exercising the finer points ofsocial interaction.) There are aspects of surgical tech-nique which defy the analysis which would enable us todistinguish the adequate from the inadequate surgeon.Even the best technique can fail when the operator lackstouch or judgment. That individual surgical flair andthe fruits of long experience remain paramount is noexcuse for not seeking better surgical methods. An essen-tial preliminary is demonstration that current practice isinadequate. Goligher and his colleagues’ did a great ser-vice by pointing out that colo-rectal anastomosis is

7. Bonnar, J., Denson, K. W. E., Biggs, R. Lancet, 1972, ii, 539.8. Sullivan, E. F. Med. J. Aust. 1972, ii, 1104.9. Pastor, B. H., Resnick, M. E., Rodman, T. J. Am. med. Ass. 1962, 180, 747.

10. Cash, J. D., Woodfield, D. G. Br. med. J. 1968, ii, 658.11. Britton, B. J., Hawkey, C. Peele, M., Kaye, J., Irving, M. H. ibid. 1974, ii,

139.12. Flanc, C., Kakkar, V. V., Clarke, M. B. Lancet, 1969, i, 477.1. Goligher, J. C., Graham, W. G., De Dombal, F. T. Br. J. Surg. 1970, 57,

109.