By V. Norris. Lyon College.

Hasnan 1University of Malaya order singulair 10mg with visa, Department of Rehabilitation Medicine- Material and Methods: 22 year old man who had motor vehicle accident in Apr 2012 and sustained comminuted fracture T3 to T5 Faculty of Medicine order singulair 5 mg otc, Kuala Lumpur proven singulair 4 mg, Malaysia and subluxation T3/T4 discount singulair 4mg on-line. Material and Methods: We report a 64 years rehabilitation team at 3 years post injury and he remains as com- old gentleman who sustained hyperextension injury of neck. Prior to admission, prognosis cated with spinal cord edema at C3/C4 level resulted by spinal canal and expected functional outcome explained. Neurogenic shock on day one of injury was stabi- discussed and set before the admission. On third day post injury, he underwent was monitored using Spinal Cord Independence Measure. He choked on his Our patient showed marked improvement during his 3 weeks of meal after the surgery. Spinal Cord Independence Measure right palate elevation, tongue deviation to right on protrusion and scored 26/100 on admission and 65/100 upon discharge. Complication of aspiration sion: Rehabilitation is an essential treatment for any spinal cord pneumonia had hindered the rehabilitation progress for the follow- injured patient to achieve functional independence and improve ing week. Results: Recovery 517 of dysphagia was slow despite aggressive swallowing therapies, practicing of swallowing maneuvers and compensatory strategies. He gained some 1 2 3 4 3 motor recovery but still required maximal assistance in daily activi- A. The exact mechanism has 1University of Tsukuba, Department of Orthopedic Surgery- Faculty not been clearly defned. Researcher observed a trend toward re- of Medicine, Tsukuba City, Japan, 2University of Tsukuba, Division covery over 2 to 6 months after surgery. However, it takes longer in J Rehabil Med Suppl 55 Poster Abstracts 153 this case scenario. Bedside swallowing and neurological assessment 1Wakayama Medical University, Rehabilitation Medicine, Wakay- should be performed for all patients with acute cervical spinal cord ama, Japan injury and those who undergone anterior cervical spinal surgery. Moreover, we evaluated effects of even admitted because of osteoporotic fractures with spinal cord in- local heating and cooling in both sensory-intact and disturbance volvement. Results: In our studies, sympathetic speaking bone research societies should be used in this very special control of thermoregulatory responses were strikingly attenuated patient group. During mild cold stress, even a decrease in body core tempera- glucocorticoid-induced osteoporosis there are separate guidelines. Conclusion: In medication and if necessary further work up of secondary causes are summary, thermoregulatory responses via central nervous system initiated. Results: In terial and Methods: Twelve paraplegic persons were participated 1976 only 14% of the patients had nontraumatic spinal cord injury, in the study. The range in age, time after injury, neurologic level, in the frst six months of 2015 its part had been 58%. The protocol was approved by the ethics committees at the two participating institutions, and all 521 participants provided written informed consent. Pa- gor, Malaysia, 3University Malaya, Department of Rehabilitation tients may experience severe neuropathic pain, weakness, abnor- Medicine, Kuala Lumpur, Malaysia mal sensation, particularly in the hands. The maximum intensity for heat sensation was set up at eration, degenerative disc, muscle fatigue. There were 523 studies were in the 4, 2, and 1 stepping algorithm with null stimuli test. Thirty-three threshold was measured by averaging the results after giving 20 studies were screened on their abstracts, and 10 studies were eligible stimuli for 3 seconds, with 10-second intervals in between. Seven out of 10 studies showed a high prevalence ended when there was wrong response to 3 consecutive stimuli. Depression was found to be the Results: The thresholds for heat sensation in syringomyelia patient most common factor associated with fatigue as shown in 5 stud- are as described in the table below. Pain was found as the second most common factor associated myelopathy showed higher threshold for warm and cold sensation with fatigue, as shown in 3 studies. Fatigue may lead to depression in both upper extremities compared to the control subject. How- as shown in 2 studies, as well as a barrier to physical functioning ever, there is no difference of temperature sensation in traumatic as shown in 2 studies. Conclusion: There is a high prevalence of myelopathy patients between syringomyelia and non-syrinx. Depression and pain were the most clusion: The results showed that traumatic myelopathy results in common factors associated with fatigue. These may lead to depres- sensory defcit for temperature, but the syringomyelia itself does sion and limited physical function. Material and Methods: A retrospective descriptive study, Material and Methods: A population-based cohort study. Medical conducted at the physical medicine department of Sousse, including claim data analyzed in this study comprised 2152 incident cases of patient with spinal cord injury dating back at least 2 years. Incidence that half of the patients had depression score between 8 and 10 (doubt- rate of depression was estimated with Poisson assumption, and ful depression) and anxiety scores over 10 (some anxious state). Conclusion: The spinal cord may be from the rehabilitation group treated for depression, representing an accompanied by restrictions on body, social and also psychological. The corresponding So the management of spinal cord injured patients should be multi- J Rehabil Med Suppl 55 Poster Abstracts 155 disciplinary. Furthermore, the physical, the psychological condition more intermittent catheter, 1 less incontinent. Compare results 1University of Ibadan, Department of Physiotherapy, Ibadan, Ni- with National results. All patients should be referred to Southport geria and put on National spinal Injuries database. The huge fnancial burden of treatment is borne by the patient, their 529 families and the society. Direct costs of in-patient and out-patient treatment over the frst year of injury were estimated. Estimated cost included costs of 1Universiti Teknologi Mara, Fisioterapi, Puncak Alam, Malaysia, hospital admission, diagnostic tests and procedures, surgical treat- 2Universiti Malaya Medical Centre, Rehab Medicine, Kuala Lum- ments, physiotherapy, drugs and non-drug items, nursing and cost pur, Malaysia of outpatient visits. The total cost of out-patient treatment patient, there has not been a careful systematic approach to support was N9, 611 975. In this narrative review, we used system- lowed by cost of routine consultations by neurosurgeons (28. Material and Methods: A compre- these costs were on routine specialist consultations by the neurosur- hensive systematic review strategies were conducted from electronic geons. This could be reduced by ensuring consultations on require- search engine from 1946 to 2015 to identify the relevant evidence ments rather than routine. Acknowledgement: Study supported by and literature of potential lower limb muscle strength effect from grant from the Medical Education Partnership Initiative in Nigeria. Dwerryhouse1 clusion: Even though there were numerous quasi-experimental stud- 1 ies, generally they implicated different style and method of research Broadgreen Hospital, Phoenix Cent Re for Rehabilitation, Liver- 2 including sample sizes and protocols. Thus, it is hard to conclude pool, United Kingdom, Cheshire and Merseyside Rehabilitation which protocols can be implicated in the clinical practice. Although Network, Rehabilitation Medicine, Liverpool, United Kingdom all the studies have shown positive changes in muscle fbers, the Introduction/Background: Phoenix Rehabilitation Unit opened Jun evidence still insuffcient.

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Fatigue and anxiety symptoms best 5 mg singulair, both psychic and somatic buy singulair 4mg, are said to be very common in depressed women order singulair 5 mg on line. However purchase 10 mg singulair visa, some authors find no difference in symptomatology between depressed men and women. It is usually stated that the evidence is against a direct aetiological connection between depression and the 1350 menopause ,(O’Shea, 2000b) although this important event can mean freedom for one woman and perceived loss of role for her sister (the same applies to conditions such as endometriosis). The latter are best measured shortly after menstruation (their lowest concentration is expected at this time) since levels may rise to premenopausal figures later (with highest recordings midway through the cycle). New onset and recurrence of major depression may be more likely at the perimenopause in women with a history of premenstrual syndrome or postpartum depression. Mood disorders in youth 1351 Depression is more likely in adolescence , especially in females, but is still not uncommon even in early childhood, when it is possibly commoner in boys. Depression before puberty may present as physical concerns, agitation/anxiety/phobia, or avoidance of other people. The depressed adolescent may show poor academic performance, feelings of not being listened to or of not being understood, antisocial or aggressive behaviour, negativism, restlessness, alcohol/substance abuse, or avoidance of other people. Subjective complaints of depression should be sought in childhood because the disorder may be missed if too much reliance is placed on parental information. Childhood depression is often comorbid with other psychiatric conditions such as phobic or conduct disorders. Social disadvantage, parental problems, cognitive difficulties, chronic medical problems (e. The children of depressed parents with so-called major depression have an increased risk of depression, which may come on early in life, and a variety of behavioural problems, such as drug abuse and accident-proneness. Having a biological parent who suffers from a severe or chronic depression is associated with future adaptational problems in their offspring. Depression in the mother is generally considered to be more strongly associated with increased psychopathology in the children than is depression in the father. However, depression in the father during the postnatal period can have adverse and persistent effects on the emotional and behavioural status of their children. In one study, compared with early onset unipolar depressives, early onset bipolar cases had experienced delayed language, social or motor development, delay being most marked in those who developed psychotic symptoms. Timko ea (2008) followed up the offspring of depressed parents for 23 years and found that they had an excess of depression and disability in adulthood. Treatment of depression to remission in the mother leads to decreased psychiatric symptoms and better functioning in offspring. For moderate to severe cases combined psychotherapy-medication is advocated with family/parental 1353 therapy/education as needed. Medication-placebo differences may be underestimated for severe depression in these trials. Nevertheless, medication studies suggest that 4 out of 10 cases do not respond to medication and that relapse following acute response is very common. Also, the natural history of depression is to remit eventually, with 7 out of 10 cases doing so by 72 weeks. Another reason why medication may not be very effective in childhood may be the high comorbidity levels, the latter not being responsive to antidepressant drugs. It is difficult to know if these discrepancies relate to clinical reality (including high non-compliance rates) or to problems inherent to statistical analysis (e. Cognitive therapy may not be as effective in severe as in ‘mild to moderate’ depression. Fristad ea (2009), in study involving children aged 8-12 years old with depression or bipolar disorder, compared the effects of adjunctive multifamily psychoeducational psychotherapy (8 x 90 minute 1353 However, whilst it is often stated that family discord is aetiologically influential in depressed youth, family therapy, at least in research, may add little. The findings of a Dresden (Germany) study by Beesdo ea (2009) of 3,021 community subjects aged 14-24 years at baseline and 21-34 years at third follow-up are shown in the box. Incidence and conversion of mood episodes/disorders in first 3 decades of life (Beesdo ea, 2009) Estimated cumulative incidence at age 33 years = 2. Mood disorders in the elderly Although reported figures vary greatly, about 15% or more of people over age 65 years have significant symptoms of depression, one-fifth or less of these having severe depression. According to Heok and Ho (2008) risk factors include poor health, brain injury, low B12 and folate, and raised plasma homocysteine levels. Depression is a risk factor for cardiovascular disease and for mortality in coronary heart disease. While some authors claim that depression becomes more common with increasing age, it appears that mania does not. Müller-Spahn and Hock (1994) listed the most frequent problems in this vulnerable group as social isolation, loss of important support systems, loss of autonomy due to psychiatric and physical illness and physical disability, inactivity consequent upon retirement, loss of reputation and finances, residence relocation, and severe insomnia. Older people are likely to be taking many different medications, and some of these (e. Depressed patients with heart disease are less likely to adhere to diet, exercise, and prescribed medication. However, in the elderly depressed there is a reduced white matter response to acetazolamide, i. Tiemeier ea, (2004) in a cross-sectional population-based Rotterdam study, found that atherosclerosis and depression are associated in the elderly. The more severe was extra-coronary atherosclerosis the higher was the prevalence of depression. There was a strong relationship of severe coronary and aortic calcifications with depressive disorders. White matter changes predate and are associated with late-life depressive symptoms. The consequences of missing the diagnosis (Müller-Spahn and Hock, 1994) are loss of quality of life, social isolation, increased mortality (suicide), increased vulnerability to certain diseases, admission to a nursing home, and a large financial burden. Depression is common in nursing homes, factors contributing to this being loss of independence and familiar surroundings, reduced contact with family and enjoyed activities, and physical disorders. In an Irish community dwelling sample of people aged 65 years and older Gallagher ea (2009) found that, compared to early-onset depression, among those with depression commencing at age 60 years or more (late onset) there was less likely to be a positive family history of depression, less reporting of prior hospital admission for depression, greater cognitive impairment, less feelings of guilt, and less thoughts that life was not worth living. Nevertheless, the authors could find no distinct profile of depressive symptoms that helped to distinguish early versus late onset cases at an individual level. Saez-Fonseca ea (2007) found that depressive pseudodementia in the elderly may be a harbinger of dementia with most cases having an established dementia 5 years later! A Dutch study of depression in people aged 55 years or more (Licht-Strunk ea, 2009) found a median duration of major depressive episode of 18 months; 35% recovered within a year, 60% within two years, and 68% within three years; and poor outcome was associated baseline depression severity, a family history of depression, and poorer physical functioning (the latter only improved if the patient recovered from depression). Elderly depressives spend significantly longer as in-patients than do their younger counterparts, they take longer to respond to treatment, and relapse is common. This is more likely if the patient is taking diuretic medication or has poor left ventricular function.

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Food effects quality 4mg singulair, drug interactions singulair 4mg mastercard, and bioequivalence stud- However singulair 4 mg discount, Japanese clinical trials show some differ- ies nowadays belong to this clinical pharmacology ences in their organization and methodological ap- phase buy discount singulair 4mg on-line, as well as pharmacokinetics in the elderly proaches, which are still in practice in spite of and studies in subjects with poor kidney or hepatic regulations requesting the application of inter- function. With regard to certain pharm- chairman, a senior leader in his speciality who acological or therapeutic classes, several specific is chosen by the pharmaceutical company. Each of the five or eight key investigators on urinary tract infections and on dysuria are to be will recommend several medical institutions, announced soon; other therapeutic fields should be public or private, where the investigators will covered in the coming years. In addition to these Japanese committee is supposed to write the clinical original guidances for clinical development, inter- protocol, to follow the study progress and to nationally harmonized guidelines are now imple- propose action when something wrong happen mented in Japan: (serious adverse events for instance), to decide whether to keep or reject a case report form. Clinical development has to progress step by approval by a customs officer with a Drug step, according to the general guidelines; after Import Report Slip (Form 12) and a copy of each phase, the steering committee of investi- the invoice. When the protocol is not available, gators decides whether the study results justify a certificate from the Inspection and Guidance whether or not to proceed to the next step. However, it gen- chemical name or symbol, the manufacturing erally takes a long time in Japan to modify code number, storage instructions and expiry such strong traditions, and they will probably date. Foreign data could be helpful to reduce the 6±8 effects, and directions for use and doses of the years necessary for clinical development in trial drug should not be mentioned on the drug Japan. Comparison of the main characteristics of clinical data, and tables of all numerical data the drug with those of similar drugs already generated during development. Physical and chemical characteris- safety is given, with a listing of all adverse tics, specifications and test methods, for the events as functions of age, sex, doses, disease bulk material and the pharmaceutical formula- severity, in- or outpatients, concomitant treat- tion(s). Pharmacokinetics in animals and units and terms should be appropriate, and foreign humans, on absorption, distribution, metabol- data must be filed in the original language, with an ism, and excretion. A proposed summary of the product character- drug, ¥534 900 ($4500) for a generic drug, ¥65 600 istics, clearly detailing contraindications, warn- ($560) for a quasi-drug or a cosmetic and ¥34 500 ings, and precautions for use. A hearing studies, a description of the facilities and equip- can take place after this preliminary review and ment, with photographs (if available) and an instructions are given to the pharmaceutical com- organigram of the personnel, in order to be pany to amend or complete the application. Besides new preclinical or clinical studies are requested general information on the product, the most im- for complementary information, to be replied portant entries are warnings, precautions and con- within a reasonable time frame. Of course, information on meas- assessed by the Central Pharmaceutical Affairs ures taken during the period should be added Council (the Adverse Reaction Committee) and (modification of the data sheet, etc. Eighteenth Century Like every despot of that period, Mithridates lived in fear of being assassinated by poisoning, in con- To few belongs the privilege of being credited with sequence of which he sought the universal antidote the invention of a medicinal formulation that to all poisons. He succeeded to the throne about 120 bc poisons individually, he evaluated them experimen- as a boy of 13 years, had received a Greek educa- tally on condemned criminals. Pompey instructed Flavius Fimbria and compelled to make peace with a freed slave, Lenaeus, to translate these writings Sulla, giving up all his conquests in Asia Minor, into Latin. It was said that by the value of these surrendering 70 war galleys and paying 2000 talents writings, Pompey did a greater service to the in reparations. Galen records that Galen, writing in the second century ad at a time Marcus Aurelius consumed the preparation within when he was physician to the Roman Emperor, 2 months of its being compounded without ill effect. Aetius (first century ad) stated that beyond will counter all three, and Galen claimed that to question the best remedy for venomous bites is this class belong mithridatium and galene. Paul of Aegina was the last of the physicians The preparation of galene was simple, in that its of the Byzantine culture to practice in Alexandria, ingredients were free of fractional measures. Avicenna vapor came out of the four small holes left in (980±1037 ad) approved of mithridatium as an the clay seal, dark and turgid, the heat had reached antidote to poisons, and Maimonides, a Jew born the vipers and they were cooked. Jerusalem, sent mithridatium or theriac to King At the final stage, the prescribed quantities of 55 Alfred the Great, who died on 26 October 899 herbs, previously prepared by various processes, (Stenton 1947). The document is in the desired cure, this was due to incorrect prepar- two parts or leechbooks; the first contains 88 chap- ation (perhaps with adulterated or poor quality ters and the second 67 chapters. Following them is a third book, consist- lay with the pharmacist who compounded the ing of 73 sections, written in the same hand, but mixture, the remedy lay in careful scrutiny of which is nevertheless a separate and additional manufacture, which should be in public. The Pepperers in the three leechbooks were obviously intended as twelfth century took over the distribution of manuals of instruction for the treatment of a var- imported drugs and spicery (which includes spices, iety of illnesses, injuries, and mental states, to- sugar, confections, and fruit). Interspersed with these remedies selves became intermingled with or perhaps suc- are sections dealing with rites, charms, and invoca- ceeded by the Grocers. Christian and residual heathen practices are possibly included the Apothecaries and the Spicers represented, the latter including Greek and Roman and forbade the mixing of wares of different quality traditions in addition to Germanic and Celtic folk- and price, the adulteration of bales of goods, or lore, which the Saxons had either brought with falsifying their weight by wetting. A most important gether with the emergent chemists and druggists, passage is contained in the second leechbook and founded the Pharmaceutical Society and became concerns King Alfred. It was not until 1607, how- Greek and Roman medical writers again became ever, that James I was to grant a Charter to the available in Italy, possibly via Spain or through the Grocers, who recognized the Apothecaries as a university at Salerno. The manufacture inspect the shops and their colleagues and bring of these theriacs took place in public, with much any who offended in the quality of their wares pomp and ceremony. In the reign of Elizabeth I, the making of of the Apothecaries and the defective wares were to theriac was entrusted to William Besse, an apoth- be burnt or otherwise destroyed. In 1625, three apothecaries made respect- and was corrected later in the reign of Queen Mary ively 160 lb, 50 lb and 40 lb of mithridatium when by an Act of 1553 (1 Mary sess 2 c. The official and of Poticarye Wares, Drugges and Compositions obligatory guide for the apothecaries of Florence according to the tenour of a Statue made in the was published in 1498 and is generally regarded as Two and Thirtieth yeare of the Reigne of the said late King Henry Eighth That it shall be lawfull for the first official pharmacopoeia in Europe in the Wardeins of the Grocers or one of them to go the modern sense, i. Other cities soon followed in the publication of obligatory formularies: Barcelona in 1535 (Concor- It is revealing that, whereas the penalty for refus- dia Pharmacolorum Barcinonesium); Nuremberg in ing to have wares examined was 100 shillings in 1546 (Dispensatorium Valerii Cordis). Henry was also deter- times that it became obvious that there was a need mined that the 1540 Statute would be obeyed and for such a pharmacopoeia or formulary. The streets were to be kept clean and 1767 and in the first three volumes, 1768±1785, he flushed with water, in order to purify the air, fires published 16 papers. Special physicians, attended by point that they had no connection with gout, apothecaries and surgeons, were appointed to which was the main and highly fashionable arth- carry this out. Heberden died in 1801 and plague that were recommended were London was buried in Windsor Parish Church, where there treacle, mithridatium, galene and diascordium, a is a memorial plaque to him and his son William confection prepared from water germander. The 1746 London Pharmacopoeia was the last in Doubts as to whether theriac and mithridatium which mithridatium and galene appear; they were were the universal panacea had been voiced by absent from the 1788 edition. These concerns to maintain the quality of investigate the efficacy of the compulsory system, mithridatium and theriac led to the introduction of was concerned by a report by Dr Jonathan Hutch- strict controls over the quality of ingredients and inson, who gave an account of the transmission of blending. For example, the manufacture had to be syphilis in two patients by arm-to-arm inoculation done in public in Venice and the ingredients had to of the material from the pustule of one patient to be open to inspection. The use of calf lymph vaccine duced, which laid down standards, not only for did not become standard until 1893, when a com- mithridatium and theriac, but for other therapeutic mercially available preparation was introduced. Perhaps, in the final analysis, the con- Prior to this it had been impossible to standardize tribution of mithridatium and theriac to modern the material used for vaccination. The first British work in medicine, pharmacy, chemistry, and nat- Pharmacopoeia was published in 1864 (the 1958 ural history, suggested in its first volume in 1799: and 1993 editions were published by the Health Ministers on the recommendations of the Medi-... Compulsory vaccination against smallpox was es- Chloroform was first used as an anesthetic in tablished by the Vaccination Act of 1853 after the 1847 and, as its use increased, it was found that report compiled by the Epidemiological Society on occasionally people died unexpectedly during the the state of vaccination following the first Vaccin- induction of anesthesia. The 1840 Act had provided free pointed a committee to investigate this and the vaccination for the poor to be administered by the final report was published in 1880. This Select Committee reported in 1914, but Substances Act), but it may be noted here that World War I intervened and all the proposed legis- this was a foretaste of control of advertisement lation was shelved. That the administration of the law of the product was known, highly toxic impurities governing the advertisement and sale of patent, could only be detected by biological testing.

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Most o f us generic 4mg singulair free shipping, since we live and work in artificial environm ents discount singulair 5 mg fast delivery, are constantly exposed to artificial light order singulair 10 mg with visa. But the principal them e in John O ttt’s Health and Light65 is that natural light is healthier singulair 4mg for sale. Ott gets to this conclusion through some studies; unfortunately, few are rigorously empirical. In one of the m ore thorough studies, Ott investigated the influence o f wave lengths of light on spontaneous tum or developm ent in C3H mice. For example, he reports on a poten­ tial relationship between the use of full-spectrum lighting —rarely used in commerce today—and the contraction of flu: During the winter of 1968-1969 a serious outbreak of Hong Kong flu swept the country. The Health Department reported 5 percent of Sarasota County—or 6,000 people—sick with the flu at one time. Employee illness caused the temporary closing of one supermarket, a social club, and the shutdown of two areas of the Sarasota Memorial Hos­ pital because sixty-one nurses were out with the flu. Obrig Laboratories, located just north of Sarasota, is one of the largest manufacturers of contact lenses and has approximately one hundred employees. During the entire flu epidemic not one employee was absent because of any flu type ailment, according to Philip Salvatori, Chairman of the Board. Obrig Laboratories was the first to design a new building using full-spectrum lighting and ultraviolet-transmitting plastic panes throughout the entire office and factory areas. The added ultraviolet seemed to tie in closely with the results noted at the “Well of the Sea” restaurant in Chicago. Salvatori also mentioned that the Obrig employees had not been given any mass inoculation against the Hong Kong flu, although some individuals may have received shots from their private physi­ cians. If the preservation o f perishables is possible in pyramids and cyclical frequencies of light and sound affect man, the implications for health are enormous. Today, the physician’s arm am entarium is limited to sharp instrum ents, pills, and cryptic advice. Professor Gavraud could have swallowed hundreds of pills and had a frontal lobotomy and still felt ill. How many infrasounds pulse through the average hospital stuffed with sophisticated apparatus? Hos­ pitals and physicians do not concern themselves with sound and light because they perceive different problems and un­ dertake different missions. But that is the point: They pro­ vide medical care, and only incidentally does that result in health. Much of the research on interconnectedness is inexplica­ ble; we have done little work so far, and we consequently know very little. But this much is clear: Explanations of hum an life in parochial and mechanistic term s will have to be modified, if not abandoned. Aside from the mysticism that always dances at the edge of accepted knowledge, we have generally con­ structed explanations o f how things work out o f our material and social environm ent. T he spirituality of Michelangelo is soaring, but at the same time earthbound, as if the gods were etched into an im perm eable um brella just 174 The Climate for Medicine a few miles above us. O ur demonic and spiritual imagery —our religious expressions—have been decidedly an- thropocentric. O ur sense of oneness with the rest o f our world and beyond has been truncated; and correspondingly, our sense of reality has been tragically limited. It is common in economic theory to refer to “externalities” in the production of material goods. But in the conven­ tional view, while there can be too many products and un­ fortunately byproducts in the form o f externalities as well, it is not generally thought that services generate externalities. Services—health care, legal advice, education, welfare, and social aides—are designed to sup­ port those whose lack of material or hum an resources ren­ ders them vulnerable to the depredations of a competitive culture. In this sense services are society’s answer to the failure to ensure economic equality—equality o f opportunity is the catchword. Equality is possible only if services can be delivered to ensure that the “disadvantaged” have a fighting chance. Given this conceptualization of services, it follows that as long as there are those who rem ain in need, services cannot be overproduced. This is a highly controversial issue and one that deserves far m ore sophisticated treatm ent than I can give it here. T here Medicine, Society, and Culture 175 are instances o f “benefits”: the child who learns to read, the m other who “grows” when her children are placed in a day care program , and the family that utilizes “well-baby” care. But in the aggregate and in the long run there is doubt that services accomplish the purposes for which they were de­ signed. In education, for example, a string o f m ajor studies, including the Coleman report and Inequality by Christopher Jencks and others,67 dem onstrate that schooling fails to achieve one of its m ajor purposes—the economic success of its graduates. T he Coleman and Jencks studies are sur­ rounded by controversy, but their conclusions have yet to be refuted. T here are few who do not think that the current welfare services system is a shambles. T he failure of welfare reform is not testimony to the strength o f the current welfare system, but rather to the political troglodytes who have opposed change. T he point is that while some may benefit, services are not always unm itigated blessings. T he original purpose of services was to create a climate where the vulner­ able could become self-sufficient. But the opposite has occurred—services have created and now maintain millions in dependency. While education has paved the way to material rewards for many, many others lack the most basic survival skills. These include those who simply did not and could not learn, as well as those whose need for skills did not match what the schools were selling. In 176 The Climate for Medicine all service sectors, large, complex, expensive, and unwieldy bureaucracies have prospered and grown at the expense of those in need. For this reason dependency and need cannot disappear—they are necessary functional attributes of a ser­ vice economy. If all o f the criminal statutes on the books in the United States were repealed tomorrow, save one, almost any one, the next day roughly the same num ber of people would be snared for the one crime as may otherwise have been apprehended for the hundreds of crimes now on the books. Services create their own dem and, and if that de­ m and is greater than it should be, then those services are overproduced. Much of this analysis is indebted to Ivan Illich, who first in Deschooling Society,66 but m ore trenchantly in Tools for Conviviality,69 develops the thesis of overproduction. In simple form his argum ent is that the institutions of medicine pursue their own objectives—security, growth, stability, and income—and as such must create widespread dependency on the part of a consuming public. This necessarily results in stripping the tools for health from the people and restricting their use to those who have been certified. Illich charac­ terizes medicine’s aggrandizem ent by alluding to two water­ sheds: the first in 1913 when it first began to borrow from the scientific m ethod, and the second in 1955 when it first became clear that medicine created new forms of disease —iatrogenic disorders—in its frenzied efforts to cure.

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