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involved-it is to do with standards of medical care.

Western doctors and patients are now accustomed to

standards which depend on a high doctor/patient ratio,and, in turn, on an abundant supply of willing doctorsfrom these same nations. Though planners tend to assumethat the requirements to meet medical needs are calculable,experience shows that affluence and an expanding economycreates its own spiral of demand-in particular, demand forincreasingly elaborate medical care, costly in technology,in drugs, and in medical skills. Machines and medicamentsare in ready supply, but doctors have to be imported tomake up the manpower shortfall. At the moment, the onlyplace to find them is in the developing countries-Ghana,to take but one example, already has more doctors workingoverseas than in Ghana itself.

Last year, delegates from the Pakistan Medical Associa-tion called on the World Medical Assembly to try to

persuade overseas graduates to return to their home

countries, where they are so urgently needed. The

W.M.A., reporting back to their assembly this year at

Amsterdam, confessed that they were helpless to do

anything about it.It is a difficult and complex problem. On the one hand,

any suggestion that immigrant doctors should return

whence they came could be misinterpreted as powellismin disguise. On the other hand, our services (and thisapplies to most of Europe and North America) cannot keepup with the exponential demand of our ever more expectantpublic except by importing these doctors. We havereached the paradoxical situation where doctors are in-duced to leave the sick nations to come to the healthy ones.The real problem is an economic one-the grossly unequalstandards of living in different parts of the world. As longas there is freedom to travel-and who would wish to denythis right ?-there will always be such a flow, like the windson the weather-forecast charts, from areas of poverty toareas of wealth.

Doctors, in fact, migrate for two main reasons-bettereconomic and living standards, and postgraduate education.Those who go for the second reason often stay on in theirhost country, sometimes for the money but more usuallybecause their newfound skills are unsuited to hospitaland staffing conditions at home. It would, of course, bepossible to improve postgraduate training in their homecountries, and indeed this is being done on an increasingscale; but, in general, travel to learn should be encouraged,not discouraged.There is perhaps another way of helping to redress the

balance-namely, by cutting our own demand for thesedoctors. In Britain a new health service is being plannedto cope with the felt needs of today-the demands of asociety which expects medical services of a high order.The various green and white planning papers, the reportson management and administration, follow each other inquick succession. Problems are dealt with in terms that

belong to the world of big business and are seen mostly asa matter of economics or cost-benefit. But surely there isanother factor: is it right that we, the " have " nations,should benefit at the expense of the " have-nots " ?Should we be planning the gilt on our own gingerbreadwhen others have not even enough bread, ginger or other-wise ? Is this the foundation on which we would wish ourbrave new health service to be built ? In other words, isanyone planning a very, very rapid increase in our ownoutput of doctors ? If there are such plans, nothing hasyet been heard of them. If not, it would seem of theutmost importance that this should be built into plans, ifnot for 1974, then at least for 1980. Some quick decisionsare called for, so that Britain will be able to go back tothe W.M.A. next year and report that we at any rate are

trying to do something about it.

In England Now

Those of us who think nothing is any longer surprisingstill have to learn. The proposal before the committee wasfor a trial comparing two "feminine deodorant" sprays(containing, respectively, high and low concentrations ofhexachlorophane) and a placebo. The study would berandomised, double-blind, and cross-over in design. Odourwas to be quantified on a numerical scale by observers whowould inhale deeply with their noses in close proximity tothe target organ at specified intervals. Inter-observervariation would be checked. Appropriate sample sizeswere estimated to allow for type-1 and type-2 errors withacceptable confidence limits, assuming a stipulated degreeof difference. The trial was unanimously voted down ongrounds of offence to human dignity and unnecessary risk,but we speculated about the possible findings if such a

study were to take place. The design seemed beyondcriticism on scientific grounds if bad luck would not leadto spuriously negative results. What, for example, if oneor more of the observers were to catch a cold ? Could they,depending on their sex and disposition, be biased by thephysical attributes of the experimental subjects ? Shouldthe observers undergo psychometric testing ? In the endwe felt that the real issue before the committee was notwhether to approve or disapprove of the study, but whetherto laugh or cry.

* * *

I am worried about my old labrador retriever’s pelt.The weather here in the States continues odd. We hadone of the coldest Octobers on record in these parts, andour records very nearly equal those of the Pilgrim Fathers.November to date has been warm and wet. My oldlabrador was born in Norfolk (England not Connecticut)and emigrated with us that warm summer years ago.A hot summer was followed by a mild fall, and what withthe various summers that no-one can explain to me (St.Luke’s, St. Martin’s, Indian, &c.) my labrador did notthink of growing a pelt for the winter before Christmas.As usual the festival was followed by bitterly cold weather,good subzero Fahrenheit stuff, in which she suffered

acutely. She got down to growing a quite magnificent pelt.By April she resembled a walking black hearth rug. Ofcourse that year winter blossomed immediately into summerand the snow disappeared in a heat-wave. So there was asudden moulting and everything in the house was coveredwith black dog hairs. It’s early November now and she,old dog as she is, still has on her summer pelt; the weathercan’t ease. How does one teach an old dog old tricks ?

* * *

One of our nurses, granddaughter of a get-well-cardmanufacturer, has designed some inscriptions for adhesivewound-dressings. My favourite, for hernia patients, is" Slow-fibroblasts at work ". Others include " No

entry", "Do not open until December 25th ", and" Scratch somewhere else ". On the back, the message isapplied in mirror lettering.

* * *

Those of us who are monoglot are in a weak position formaking jokes about other people’s use of language, buteveryone has his own favourite tale. I put forward for

trumping by fellow peripatetics the moment in the 17thInternational Congress on Occupational Health whenwhat the speaker described as " an emergency care

ambulance " was translated as " a mobile salvation unit ".