community health care—schumacher style

2
1114 lobacteria,18 should be borne in mind when colitis arises in artificially fed babies or in older people after antibiotic therapy. Vancomycin is said to be useful in colitis due to Cl. sordellii, causing disap- pearance of toxin from the stool. Metronidazole is beneficial against anaerobes elsewhere, but has not been evaluated in these types of colitis. An alterna- tive approach, as in the successful New Guinea work, is to treat patients with specific antisera; but this cannot be done without data on the causal organisms. Finally, the clostridium story re-empha- sises the similarities between, and interdependence of, human and veterinary medicine. Rapid recogni- tion of Cl. welchii type C as a cause of necrotising enteritis in New Guinea was due to the collabo- ration of research-workers with experience of both human and veterinary medicine. Community Health Care—Schumacher Style ERNST FRIEDRICH SCHUMACHER, economist and philosopher, died in September. He preferred to be thought of as a crank rather than as a guru. A crank, he said, is simply a small mechanism which is hand-operated, but it creates revolution. On Nov. 30, widely assorted friends and colleagues gather in Westminster Cathedral to honour his memory. Convinced that technology should be applied only in the mix required by a particular com- munity, in 1966 SCHUMACHER set up the Interme- diate Technology Development Group. Interme- diate technology is a concept implying progress at a rate which enhances rather than disrupts the wellbeing of people. Their work is made more effec- tive through low-cost, labour-intensive techniques geared to their own stage of development. I.T.D.G. promotes self-reliance rather than dependence on outside aid. Although ScHUMACHER began with the needs of the rural Third World mostly in mind, in the next decade he came to question material growth and consumption as proper measures of social progress elsewhere. His book, Small is Beau- tiful: a Study of Economics as if People Mattered,1 is a worldwide best-seller. How can SCHUMACHER’S ideas contribute to human health? Suppose some of his friends were now invited to set up a health-care system from scratch, how would they tackle it. Intermediate has now become appropriate tech- nology. It has evolved from the original concept of being a staging post in the journey towards modern- isation ; and the technology includes, not just bits of hardware, but the supplying of knowledge and extra skills to the minds and the hands of people. 18. Skirrow, M. B. Br. med. J. 1977, ii, 9. 1. Schumacher, E. F. Small is Beautiful: a Study of Economics as if People Mattered. London, 1973. As SIGERIST2 pointed out in 1941: "Health cannot be forced upon the people. It cannot be dispensed to the people. They must want it, and be prepared to do their share and to co-operate fully in what- ever program a country develops". ILLICH3,4 is re- iterating this dictum when he maintains that health is "something people do, not something people get". No health service starts with a blank slate; the people and their maladies are already there. They attach varying importance to their state of health. Few actually enjoy genuine ill-health, but many are unaware of, or choose to ignore, the level of health they could, attain given the appropriate means and guidance. At the moment there is little hope of any health-care service being perfected to the point where the "greater medical profession"s becomes redundant. But the demand on this expensive resource might be lessened if each and every person could take part in a new style of health service. To this everyone would contribute as well as receive. The intermediate-technology concept applied to medicine means the devising of a flexible system, capable of accommodating individual skills, vary- ing levels of knowledge and education, disparate resources, and a range of supportive technologies. All these would range from the very simplest to the most elaborate. Health is both an individual and a community affair. Choosing the correct size for a cqmmunity capable of making at least. some of the decisions about its own health care seems to be the key to success in introducing such a new style of health service. Small is Beautiful and SCHUMACHER’S other writings provide possible clues, and he cites ARISTOTLE: "To the size of states there is a limit, as there is to other things, plants, animals, imple- ments ; for none of these retain their natural power when they are too large or too small." ScHU- MACHER frequently emphasised how ARISTOTLE’S "critical size" is probably much smaller than most people in our mass societies are inclined to believe. People cluster in natural communities with indivi- dual characteristics. These communities can be recognised if common sense rather than bureaucra- tic convenience is the measure. It is possible to know individually several hundred people, to recognise their faces and their relationships with each other, perhaps even to remember their names. Gathered together, such a group can come to a con- sensus about who should be responsible for their health-related needs. These representatives, picked by the community, can then react directly with the people themselves, discussing solutions which the 2. Sigerist, H. E. Medicine and Human Welfare. New Haven, 1941. 3. Illich, I. Medical Nemesis—the Expropriation of Health. London, 1974. 4. Illich, I. Limits to Medicine: Medical Nemesis—the Expropriation of Health. London, 1976. 5. Fox, T. F. Lancet, 1956, ii, 779.

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Page 1: Community Health Care—Schumacher Style

1114

lobacteria,18 should be borne in mind when colitisarises in artificially fed babies or in older peopleafter antibiotic therapy. Vancomycin is said to beuseful in colitis due to Cl. sordellii, causing disap-pearance of toxin from the stool. Metronidazole isbeneficial against anaerobes elsewhere, but has notbeen evaluated in these types of colitis. An alterna-tive approach, as in the successful New Guineawork, is to treat patients with specific antisera; butthis cannot be done without data on the causalorganisms. Finally, the clostridium story re-empha-sises the similarities between, and interdependenceof, human and veterinary medicine. Rapid recogni-tion of Cl. welchii type C as a cause of necrotisingenteritis in New Guinea was due to the collabo-ration of research-workers with experience of bothhuman and veterinary medicine.

Community HealthCare—Schumacher Style

ERNST FRIEDRICH SCHUMACHER, economist andphilosopher, died in September. He preferred to bethought of as a crank rather than as a guru. Acrank, he said, is simply a small mechanism whichis hand-operated, but it creates revolution. On Nov.30, widely assorted friends and colleagues gather inWestminster Cathedral to honour his memory.

Convinced that technology should be appliedonly in the mix required by a particular com-munity, in 1966 SCHUMACHER set up the Interme-diate Technology Development Group. Interme-diate technology is a concept implying progress ata rate which enhances rather than disrupts thewellbeing of people. Their work is made more effec-tive through low-cost, labour-intensive techniquesgeared to their own stage of development. I.T.D.G.promotes self-reliance rather than dependence onoutside aid. Although ScHUMACHER began with theneeds of the rural Third World mostly in mind, inthe next decade he came to question material

growth and consumption as proper measures ofsocial progress elsewhere. His book, Small is Beau-tiful: a Study of Economics as if People Mattered,1is a worldwide best-seller. How can SCHUMACHER’Sideas contribute to human health? Suppose some ofhis friends were now invited to set up a health-care

system from scratch, how would they tackle it.Intermediate has now become appropriate tech-

nology. It has evolved from the original concept ofbeing a staging post in the journey towards modern-isation ; and the technology includes, not just bitsof hardware, but the supplying of knowledge andextra skills to the minds and the hands of people.

18. Skirrow, M. B. Br. med. J. 1977, ii, 9. 1. Schumacher, E. F. Small is Beautiful: a Study of Economics as if People

Mattered. London, 1973.

As SIGERIST2 pointed out in 1941: "Health cannotbe forced upon the people. It cannot be dispensedto the people. They must want it, and be preparedto do their share and to co-operate fully in what-ever program a country develops". ILLICH3,4 is re-iterating this dictum when he maintains that healthis "something people do, not something peopleget".No health service starts with a blank slate; the

people and their maladies are already there. Theyattach varying importance to their state of health.Few actually enjoy genuine ill-health, but many areunaware of, or choose to ignore, the level of healththey could, attain given the appropriate meansand guidance. At the moment there is little hope ofany health-care service being perfected to the pointwhere the "greater medical profession"s becomesredundant. But the demand on this expensiveresource might be lessened if each and every personcould take part in a new style of health service. Tothis everyone would contribute as well as receive.The intermediate-technology concept applied tomedicine means the devising of a flexible system,capable of accommodating individual skills, vary-ing levels of knowledge and education, disparateresources, and a range of supportive technologies.All these would range from the very simplest to themost elaborate.

Health is both an individual and a communityaffair. Choosing the correct size for a cqmmunitycapable of making at least. some of the decisionsabout its own health care seems to be the key tosuccess in introducing such a new style of healthservice. Small is Beautiful and SCHUMACHER’Sother writings provide possible clues, and he citesARISTOTLE: "To the size of states there is a limit, asthere is to other things, plants, animals, imple-ments ; for none of these retain their natural powerwhen they are too large or too small." ScHU-MACHER frequently emphasised how ARISTOTLE’S"critical size" is probably much smaller than mostpeople in our mass societies are inclined to believe.People cluster in natural communities with indivi-dual characteristics. These communities can berecognised if common sense rather than bureaucra-tic convenience is the measure. It is possible toknow individually several hundred people, to

recognise their faces and their relationships witheach other, perhaps even to remember their names.Gathered together, such a group can come to a con-sensus about who should be responsible for theirhealth-related needs. These representatives, pickedby the community, can then react directly with thepeople themselves, discussing solutions which the

2. Sigerist, H. E. Medicine and Human Welfare. New Haven, 1941.3. Illich, I. Medical Nemesis—the Expropriation of Health. London, 1974.4. Illich, I. Limits to Medicine: Medical Nemesis—the Expropriation of Health.

London, 1976.5. Fox, T. F. Lancet, 1956, ii, 779.

Page 2: Community Health Care—Schumacher Style

1115

community can itself implement, or solution!which may require outside help. Outside help wilcome at various levels-from the neighbourhoochealth centre with its team of full-time and parttime health professionals; from centres of medicaexcellence to which appropriate problems will bereferred. The community system would in someways be autonomous, but it would also be repre-sented at the levels of health and social-service

organisation where efficiency, rather than the wel-fare of individuals, so easily becomes the prime tar.get.Obviously such a style of health service, based

upon the self-reliance of little groups, will demandmuch goodwill and ingenuity both from health pro-fessionals and from the fiscal authorities. Health

professionals are understandably anxious aboutdilution of standards of care and their own accoun-tability. Much patience will be extended in findingways to share both knowledge and responsibilitysuitably, -to provide what PELLEGRIN06 callsallowable amounts of discretionary space. It willmean a demystification of medical technology andits attendant jargon, thus allowing ordinary peopleinto the inner shrines, and exposing the fallibilityof the professionals. But the building-up of such anintermediate level of health care, whereinthe power of the ordinary people is channelled fromthe periphery to mesh with expertise thrustingoutwards from the professional centre, could leadto the most comprehensive kind of communityhealth service, and if health professionals can sharetheir special knowledge with the community, thecommunity can surely share in the task of decidingwhich buck stops where. From new health-careschemes89 all over the world, the financial lessonseems to be that when people put their own penniesdirectly into a local exchequer for primary healthcare, they take a closer interest in the success ofthat health care. Back-up services will needback-up funding from a central source. But thecommunity appears to need control over some of itsown health spending, because the customer’s prior-ities do not always coincide with those of the shop-keeper. If a community is responsible for the costof meeting a suitable proportion of its immediatehealth needs, and if its primary-health-care fundruns out of money, the people will clearly have anincentive to take a closer look at what they canthemselves do to reduce unnecessary demands onthe community’s resources.Small size and flexibility seem essential and in-

terrelated factors. BLAKE’S "He who would do goodto another must do it in Minute Particulars:

6. Pellegrino, E. D. Paper given at the International Conference on Prioritiesfor the Use of Resources in Medicine. Bethesda (in the press).

7. Mahler, H. Lancet, 1975, ii, 829.8. ibid. 1973, i, 982.9. Newell, K. W. (editor) Health by the People; p. 206. World Health Organisa-

tion, Geneva, 1975.

General Good is the plea of the scoundrel, hypocrite& flatterer ."10 shows his appreciation of thedanger inherent in overlarge institutions. ScHU-MACHER advocated "the freedom of lots and lots ofsmall autonomous units"’ as being more relevantto real human needs. And J. B. S. HALDANEl2pointed out in 1927 that if a mouse falls down athousand-metre mineshaft, it dusts itself off at thebottom and gets on with its business, whereas alarger animal, such as an elephant, making thesame mistake simply explodes.

PRENATAL DIAGNOSIS OF DUCHENNEMUSCULAR DYSTROPHY

Duchenne muscular dystrophy is inherited as an

X-linked recessive trait which affects only boys and istransmitted by healthy female carriers. It is the com-monest X-linked disease in man, with an incidence ofabout 1 in 3000 male births. There is progressive musclewasting and weakness which begins around age 3 to 4and eventually leads to death usually by age 20. The dis-ease is particularly tragic because affected boys are oftenaware of the prognosis and there is no effective treat-ment. Thus the only approach is prevention throughgenetic counselling, which was considerably helped bythe discovery some 15 years ago that a proportion of car-riers have a raised level of serum-creatine-kinase

(S.C.K.). Until lately, however, a woman who judged herrisk of having an affected son to be unacceptably highhad no alternative other than family limitation. Nowa-days, with the advent of fetal sexing and selective abor-tion of male fetuses, such a woman can be told that herdaughter will not be affected though the child may ofcourse be a carrier. This is an unsatisfactory solutionbecause some of the aborted male fetuses will be normal.What is required is a reliable prenatal test for affectedmale fetuses. Affected boys have very high S.C.K. levelseven before there are symptoms, and probably frombirth. 1,2 Emery3 has shown that muscle histology isabnormal in a proportion of at-risk male fetuses, and atleast in one such specimen at 16 weeks’ gestation thesechanges were associated with a raised fetal S.C.K. level,though here the blood-sample was obtained post mortemby cardiac puncture.Mahoney and colleagues4 now record a very high plas-

ma-creatine-kinase level in fetal blood obtained by pla-cental aspiration from an at-risk male fetus at 20 weeks’gestation; and when the pregnancy was terminated, his-tological abnormalities of muscle were found, similar tothose reported by Emery. These and other5 observationstend to support the suggestion that a raised fetal S.C.K.may be a useful prenatal test for Duchenne musculardystrophy. However, corroberation is essential-par-

10. Blake, W. Jerusalem 3.1804-1820.11. Schumacher, E. F. People’s Power. National Council of Social Service, Lon-

don, 1974.12. Haldane, J. B. S. Possible Worlds and Other Essays; p. 18. London, 1927.1. Heyck, H., Laudahn, G., Carsten, P. M. Klin. Wschr. 1966, 44, 695.2. Beckmann, R., Scheuerbrandt, G. Kinderarzt, 1976, 7, 1267.3. Emery, A. E. H. Nature, 1977, 266, 472.4. Mahoney, M. J., Haseltine, F. P., Hobbins, J. C., Banker, B. Q., Caskey,

C. T., Golbus, M. S. New Engl. J. Med. 1977, 297, 968.5. Stengel-Rutkowski, L., Scheuerbrandt, G., Beckmann, R., Pongratz, D.

Lancet, 1977, i, 1359.