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He tells them everything order forzest us, including the sites of the primary and secondary tumours forzest 20 mg online, promises nothing but offers with confidence to do his best trusted 20mg forzest. They take their own temperatures and pulses, chart their own fluid intake and output and assess vomit and are responsible for fluid replacement. There was no doubt about their feeling for Dr Issels, 23 amounting to devotion at times. Some of his patients seem to us to have been grossly over-treated by drugs or radiation, the treatment having been continued or repeated only to make matters worse when reactions had been mistaken for signs of tumour activity. His supportive regime, without cytotoxic drugs for the first week in most cases, allows time for partial recovery from some of 25 these therapeutic disasters. He aims to put each patient in the best possible condition to combat his (sic) disease, which is admirable; but there is no evidence from our examination of the patients and their notes that it makes a significant 26 contribution to their survival. According to the report, Issels was not a charlatan, just a misguided foreign gentleman who was very kind to his patients. We sadly think, however, that he is misguided in his 27 beliefs and that the treatment peculiar to his clinic is ineffective. Issels was also criticised for not taking all the patients that came to him, regardless of whether they could afford the treatment or not. The paucity of the scientific and philosophical arguments contained in the report did not escape those who felt strongly that orthodox medicine had contributed little to cancer care. The publication of the report temporarily reduced the number of patients attending the Bavarian clinic and caused Issels an estimated loss of £150,000. In October 1972, Lord Shawcross, in a comment obviously related to cancer care, suggested the setting up of a committee to censor medical news and prevent the raising of false hopes and fears. Such a committee for lowering hope and eradicating panic had a peculiar ring of 1984 to it. He also had interests in the processed food and pharmaceutical industries, having been a director of Shell, Rank Hovis McDougall and Upjohn. Despite Lord Shawcross, journalists, relatives and patients still reported on the amazing regression of tumours at the Ringberg Clinic. Eight year old David Towse had gone to the Clinic after British doctors had given up on him in 1970. By the time he got there his cancer had spread from his neck to his brain and his legs. By 1973, however, the tumours had regressed completely and David was back in England playing football for his school. Reporting for the Daily Express, James Wilkinson spoke to three British patients at the clinic, all of whom said that British doctors had simply given up on them when their cancer was 31 diagnosed. In this interview Issels pointed out that British doctors were now refusing to continue the prescription of drugs, which he believed was important to the continued well-being of his patients after they left the clinic. Two years passed before Hodder were able to publish in England, by which time Issels had been forced to close his clinic in Bavaria. There has been a "cover up" done on the whole question of Dr Issels and his techniques. When Issels tried to recruit more staff, the orthodox medical bodies did everything possible to stop people applying for jobs. The administration of the clinic had become prey to a whole range of dirty tricks. Callers using false names and titles rang the clinic to get the names and telephone numbers of staff, who were then harassed. Medicines sent by post from the clinic to some 400 outpatients were taken from parcels and propaganda notes about quackery substituted. In September, Dr Smithers, the leader of the Co-ordinating Committee for Cancer Research team which had been to Bavaria, made clear his feelings about the closure of the clinic. For three years he ran a smaller but equally successful clinic, until in 1979 he had to close the residential building and continue only with outpatients. In 1980, Penny, her friends Pat Pilkington and Dr Alec Forbes — at that time a consultant physician at Plymouth General Hospital — set up a small self-help group for cancer sufferers. Penny Brohn brought to the group all her personal experience of fighting cancer with alternative therapies, and her experience of fighting her orthodox doctors. The demand was evident, people wanted a system of support and advice away from the hospitals and the alienating professionalism of orthodox doctors. Influenced by Issels and Gerson, the discussion in the early meetings centred upon the relationship between cancer and nutrition and the possible relationship between cancer and vitamin deficiencies. From the beginning, the Bristol Centre worked on the assumption that if the onset of cancer could be related to deficiencies in diet then there was some point, even when people had cancer, in trying to redress such deficiencies. Teaching stress control was obviously something which a small self-help group could do, and they began to work with relaxation techniques and meditation. Counsellors joined the group, so that people could talk about what was troubling them. In the early eighties, when Penny Brohn, Pat Pilkington and Alec Forbes began working, such ideas seemed revolutionary. The programmes, remarkable for their honesty, were probably the only independent review of alternative cancer treatment ever to be broadcast in Britain. He was told to take extreme care in pointing out that attendance at Bristol was not a substitute for orthodox medicine, but a complement. They show the very real continuity which exists in the tactics of the anti-health fraud lobby, The biggest bombshell came just before the programmes were to be transmitted. In the discussion programme, the anger and antagonism between orthodox and alternative cancer therapies were evident. On the other side speaking in favour of an alternative approach, were Brenda Kidman the author of the book, A 39 Gentle Way With Cancer and Dr Dick Richards. For some reason which was not made clear, an empty chair took the place of the third spokesperson on the side of alternative cancer care. The supporters of orthodoxy suggested that there was no evidence to support claims made in the films by practitioners at Bristol. Dr Dick Richards talked about the immune system and how therapies had to enhance the capacity of the immune system to help people overcome illness. The Centre felt that they had nothing to lose from having their work evaluated scientifically; such research might in fact lend authority to their practices. By 1985, the Bristol Cancer Help Centre had agreed to a research project which would measure the efficacy of the therapies used at Bristol. It grew quickly, buying an extensive and beautifully situated old building in Clifton, Bristol, which was converted into a peaceful residential care centre. Within sight of realisation, at Bristol, was that spiritually supportive environment, which she had not found until she travelled to Bavaria.

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I finally decided to study psychology at York University generic forzest 20 mg, which turned out to be science-based experimental psychology order 20 mg forzest visa, psychopharmacology and brain biochemistry! I had always been a member of the consciousness 2 movement purchase forzest 20 mg with amex, an extremely vocal one. It talked about the mind, body and spirit; it sold 10,000 copies in the first year. Within three years, the organisation was in deep financial trouble and went into liquidation. As well as carrying out research, it holds courses and meetings for the general public. It has been a difficult organisation to run, dependent on a continuous flow of students for its courses. Since 1984, the Institute has had around 80 students go through the process of training. We want to create a shift in the public consciousness away from the idea that as long as you eat a well-balanced diet, you get all the vitamins you need, and towards the idea that optimum nutrition is a dynamic process and many illnesses are the result of faulty nutrition. They said that if you change your diet and take vitamin and mineral supplements, it makes a lot of difference to your health and well-being. I lost a stone in weight very rapidly and never put it on again, my energy shot up, my number of hours sleeping went down, my skin cleared up and my headaches went. I was eating no wheat and virtually no meat, lots of fruit and vegetables, mainly raw, and a few vitamins and mineral supplements. Like many others in the field of nutrition, Holford was influenced by work on nutrition in America. Much of this work with nutritional programmes achieved better results in the treatment of various mental conditions than did drug treatments or psychotherapy. He was involved in studying the effect of chemicals and nutrients on the brain for something like fifty years. By his fifties he was treating mental dysfunction, mainly schizophrenia, with nutrients. Like many of those whose time has not yet arrived, Patrick Holford has become used to being isolated and marginalised and used to the continual rebuke that he is a crank. Having accepted that the prevalent social view is not his view, he has developed a certain insecurity that can look like diffidence. In a world which was utterly in conflict with his ideas, acceptance proved elusive. His first disappointment was an interview at Queen Elizabeth College, University of London, in 1982. It left him dispirited and pessimistic at his chances of finding a place where he could pursue nutrition without having to accommodate vested interests. In 1985 I made enquiries to do research into the clinical significance of hair mineral analysis. I applied to do this at Surrey University, in the Human Nutrition Department, which comes under the control of the Biochemistry Department. At the time when Holford applied to do his research, Professor Dickerson held the Chair in Nutrition at Surrey. He was able to work with a company that had an atomic absorption spectrophotometer, a complex and expensive piece of equipment which analyses and measures the mineral content of hair. His problems began when the laboratory he was working with was suddenly sold and its operations moved to Hull. He took a year off, postponing the research until he was better equipped to do it. At about that time, Professor Dickerson retired and Professor Vincent Marks took over as head of the Biochemistry Department. At the time Marks became head of the Biochemistry Department at Surrey, apart 7 from publicising sugar for the sugar industry he was involved in the development of melatonin, a pharmaceutical solution to jet lag. Almost as soon as Marks took over, he wrote me a letter, the long and the short of which was that I had a few weeks to come up with a thesis which included experimental data, following which would be a live examination. I wrote back and told Marks about the difficulties I had had, and that I was thin on experimental data because I had little access to analytical equipment. Holford found out later that Delves was opposed to alternative health therapies and such things as hair mineral analysis. Soon after this failure, Holford was offered a place in the Chemistry Department, working under Dr Neil Ward, a lecturer who was particularly interested in hair mineral analysis. By 1989 Holford had re-established the Institute for Optimum Nutrition, this time with stronger foundations. Even many of the most conservative old school nutritionists agree that there are certain categories of people who may need their diet supplemented with vitamins. Many doctors and therapists now believe that the health and nutritional status not only of the pregnant woman, but of both prospective parents for some time prior to conception, affect both the chances of conception and the health of any new-born child. The relatively recent understanding of the various ways in which the actions and nutritional status of the future parents affect the health of a child has led to a growth of practice in the field of pre-conceptual care. Allopathic medicine and orthodox doctors, though they may consider the more obvious agents of pre-conceptual damage, such as smoking and drinking, rarely consider the nutritional status of possible parents. For those doctors and practitioners who use nutritional status as a guide to health, pre-conceptual care is one of the most important areas of work. Dealing with the health of couples who wish to conceive is dealing with the very foundation of life. It is the circumstances of conception and the medical history of the two parents which will to a great extent lay the foundations for the life-long health complexes of the child. All the nutritional deficiencies and the chemical toxicities which affect the adult have an effect upon foetal development. Cigarette smoking, consumption of alcohol and chemical interventions such as the contraceptive pill have an effect on the nutritional status of the adult and therefore the baby. Work by Professor Michael Crawford of the Institute of Brain Chemistry and Human Nutrition, in London, has shown that poor nutritional status of the mother can result in low birth weight and small head circumference. Small head circumference can mean also that there are 2 disorders in brain development, ranging from brain damage to poor learning ability. Factors which are likely to affect congenital malformations of the foetus are deficiencies of protein, amino acid, essential fatty acid and an inadequate carbohydrate intake. Vitamin deficiencies, especially of B1 and B2, folic acid and vitamin A, can also tend to produce 4 congenital abnormalities, as can mineral deficiencies of, for example, zinc and manganese. It has, for example, been common until recently for doctors to automatically prescribe an iron supplement to pregnant women. Research now shows, however, that this supplement is likely to inhibit the absorption of zinc.

Some of those who claim to be healers and appear to have had success in heal­ ing can dramatically elevate enzyme activity in controlled experim ents order genuine forzest online. First order 20mg forzest with amex, as inform ation becomes available linking the processes o f care with patient outcomes purchase forzest 20mg otc, inform ation will be available to aid people in making choices about healers. Second, that same inform ation will make it possible to bar some prac­ titioners from practice at regional health centers, when it is clear that harm is being done to patients. T hird, com­ munities may also choose to bar some practitioners from association with neighborhood hospitals. T he argum ent is that the reform s I propose are hopelessly unrealistic because they are inconsistent with pre­ vailing social, political, and economic realities. In addition, it is argued that since some o f the proposals have m erit, they might be achieved step by step, particularly if appropriate incentives to change are utilized. It is true that change oc­ curs in this gradualist way, and some proposals, such as the regionalization of costly medical care equipm ent and ser­ vices, could be im plem ented without a titanic struggle. But if the reform s I propose are viewed as a whole, the conclusion is inescapable—a revolution is needed. If we start to think differently about health, the reform s will follow in due course. T he accumulation of “bits” o f data that do not fit the old predictions, or old explanations. T he fact that the change is preceded by widespread dissonance and is followed, when the transform ation takes place, by widespread change. T he change is very sudden and is consum m ated in a relatively short period o f time, contrasted with the “life” of the system which is replaced. The change is often in the direction of “simpli­ fication”; m ore simple explanations and practices. Finally, and m ore subtle, is the occurrence of interac­ tions “leaping” across the system level between the old sys­ tem and the new system in the process o f formation, which precede the transform ation. It is far from self-evident that medicine will change dramatically in the next few years, but there are enough signs and signals to make it a possibility. Finally, it will be argued that insufficient resources would be saved from the truncation of the existing medical care system to establish the program s that are proposed. This may be true in the initial conversion o f the system because of pending commitments and sunk costs, and because existing needs must be met before the long-range benefits of the new program s are experienced. If prevention works, the dem ands on a frozen and partially retreaded personal health care system will T he Obstacles 227 gradually lessen, perm itting reallocation of resources to new program s until some reasonable equilibrium is reached. It will also be argued that we will have enough revenue to preserve medicine and launch new program s as well. T he press o f existing social and domestic needs is so great that substantially more money will be dem anded. T he current system is likely to consume 10 percent or m ore o f the gross national prod­ uct by the year 2000. But even assuming that sufficient monies could be com m andeered, why should the existing system be preserved at the expense of am elioration o f other problems? As Ivan Illich has said: Each car w hich B razil puts on the road denies fifty people good tran sp o rtatio n by bus. Each m erchandized re frig e rato r reduces th e chance o f building a com m unity freezer. Every dollar spent in L atin A m erica on doctors a n d hospitals costs a h u n d re d lives. H ad each dollar been sp en t on providing safe d rin k in g w ater, a h u n d re d lives could have been saved. In the face o f sharp criticism o f medical care, a solution to the ills of the system is now being sought through the enactm ent o f a national health insurance program. Enactment o f a na­ 228 The Transform ations of Medicine tional health insurance plan in the United States can proba­ bly be expected within the next few years. Although the plans differ in their approaches to the means of financing care, the total num ber o f federal and state dollars to be appropriated, and the nature and degree o f public regulation, they all have three things in common. First, all tend to build upon the existing delivery system, although many o f the plans propose further industrializa­ tion o f the system. Second, they share a failure to address a m ajor alternative to the existing delivery system—a national health service—along the lines o f the medical care systems in Great Britain and Sweden and some other W estern nations. And third, there is no recognition of the limitations of m edi­ cal care to engender health. And, irrespective of the argum ents for and against a national health service—the second o f the points—its viability in the United States is doubtful. T he reason why there has been no debate about the third point—the limits of medicine—m ust be sought outside the policy-making process. Observers and practitioners o f medi­ cal care have failed to grasp the implications o f the evidence. As a result, the burning issue of the day is national health insurance, not the end o f medicine. We have tolerated tiers of medical practice paralleling class structure and even have created classes o f medical untouchables. T heir logical exten­ sion has always been some form o f comprehensive national health insurance that would greatly expand public support of medical care while leaving the delivery system intact. The Obstacles 229 National health insurance was a m ajor issue in the 1972 presidential election, and the debate has continued in Con­ gress since then. Thus, the assault proposed against inequi­ table access to care in this country will be m ade with dollars rather than with structural reform. T he solution being ad­ vanced, despite differences in details, is to increase purchas­ ing power to a level that presumably would be relatively uniform throughout the population. But when m easured against the argum ents made here, the plans are all o f a piece. A nd failure to engage these issues will have two profound and irreversible conse­ quences. T he first is that m ajor expansion in the financing system will lock in the current system for delivery of care for the indefinite future. This is the pitfall o f the otherwise salutary means being taken to assault inequities in medical care through an expansion of purchasing power. T he issue m ust be so stated as to make it possible for those who wish to limit the scope o f the existing system to fix on that goal and not be deflected by the benefits that comprehensive health in­ surance will ostensibly provide. T he second is that underw riting the costs of medical care through a com prehensive health insurance plan will inevita­ bly result in even steeper escalations in the cost of care and a m ore disproportionate consum ption of the gross national product by medical care. Enoch Powell, based on his years of experience in adm inistering England’s health service (and leaving aside his animadversions on other subjects), has m arveled at the capacity o f patients to consume large doses 230 The Transformations of Medicine of care.

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Students Physical function; hazards of hospitalization; participate in ward rounds purchase forzest no prescription, the Infammatory Bowel health services research order 20mg forzest with visa. Experience in Management of diabetes; urinary incontinence; the use and interpretation in upper and lower tract community-based geriatrics generic 20mg forzest with visa. Areas of current research activity are New approaches to treating elderly patients at molecular and cell biologic approaches to intesti- home. Cayea (Director), Arwam, Barron, Bellantoni, ing to regulation of absorption and secretion by Boult, Boyd, Burton, Christmas, Colvin, Durso, intracellular intermediates. Stre- the palliative care consult service and geriatrics iff (Course Director), Brodsky, Dang, Emadi, Gel- consult service. Available all year; limited to 3 in the weekly clinical geriatrics rounds and semi- students per half-quarter. Clinical experience is nars which often include presentations by visiting supplemented by regularly scheduled conferences professors. Formal instruction is provided in the Each student may elect to emphasize one or more preparation and interpretation of blood and marrow slides, performance of bone marrow examination aspects of the program. Research Elective in Geriatric Medicine division’s collection of pathology specimens, teach- and Gerontology. Students Greenough, Leff, Leng, Oh, Simonsick, Walston, may also engage in an independent project. Clerkship in Clinical Hematology and Medi- Electives are available providing participation in cal Oncology. Senior elective in Hematology/Oncology in an aca- The Sol Goldman Student Award in Geriatric demically-oriented community hospital setting. A fund was established in 1986 by the dents will participate on the inpatient consultation Goldman family to honor the late Sol Goldman. Students will also see patients dent in the School of Medicine who is interested in in attendings’ offces and in the ambulatory che- the special health needs and issues of older adults. Participation in weekly Tumor One or two awards of $1,000 are given annually to Board and weekly conferences are encouraged. One-half Physician-patient relationships and quarter or longer; limited to 4 students per half communication; respect, bioethics, healthcare quarter. Patient-provider communication in the hospital; Bartlett to discuss clinically oriented topics such agenda setting during the outpatient visit; as intraabdominal sepsis, pneumonia, antibiotics, patient-provider diagnostic concordance. Particular empha- Ambulatory care, prevention, and integrative sis is given to perioperative medicine and increas- medicine. The students evalu- effectiveness research including evidence ate the patients initially and then present the patient based review; advanced methods for using care problem(s) to the attending faculty and/or observational data; evaluation of diagnostic senior clinical fellows in internal medicine. Students tests; diabetes; venous thrombosis and blood follow the inpatients daily during their hospitaliza- disorders. Selected articles regarding assessment epidemiology; chronic disease in developing and consultation are provided. Students centered care; behavior change and also spend up to 2 1/2 days each week in the fac- psychosocial issues in primary care; innovations ulty ambulatory care clinic seeing patients with the in medical education; medical professionalism. Available four quar- Pharmaceutical outcomes research; drug safety; ters and summer (except July). Ambulatory care; medical education; community Students can serve as subinterns on one of the outreach. On most of Quality of life for cancer patients undergoing these services students work under the supervision treatment; coordination of care for cancer and tutelage of interns, residents, and the admitting survivors; patient-reported outcomes physician. On the hospitalist service, students work assessment; quality of medical care; cancer directly with the attending hospitalist physicians. Didactic ses- Medical education; preventive medicine; health sions with the course directors are also part of this outcomes. Advanced Clinical Clerkship in Internal Philosophical and empirical research in Medicine. Occupational epidemiology; cumulative trauma Prerequisite: Three years of medical school. Clinical topics in therapeutics to be covered Biomarkers of occupational diseases. Clinical Clerkship in Occupational Medi- internship and will demonstrate the rational appli- cine. Avail- cation of core pharmacologic principles with gen- able all year; one-half quarter or longer. By evaluating patients with suspected cess for a given clinical topic during the frst hour occupational illness, students will expand their of the sessions. In the fnal half hour, the guest skills in medical history, physical assessment and faculty will facilitate a practical case-oriented dis- differential diagnosis. The industrial setting from cussion with students to interactively solve a series which the patient came will be evaluated and haz- of clinical problems using the therapeutic tools just ards quantifed. Present principles underlying the drug develop- Students are invited to attend the regularly sched- ment process from discovery through pre-clinical to uled seminars and journal review sessions of the all clinical phases. Throughout the course See related courses in occupational medicine students develop, write, and present detailed drug offered by the Department of Environmental Health development plans and clinical protocols for new Sciences in the School of Public Health. One and one half hours for each lec- Qualitative analysis of drugs and metabolites in ture/discussion. Each topic is introduced with a teach-do- Chronic kidney disease; end stage kidney review sequence focusing on skill building exercis- disease. Clinical Pharmacology/Internal Medicine Hypertension; glomerular disase; electrolyte Elective. Students will join in review sessions Choi, Fine, Estrella, Myers, Scheel, Sperati, Tur- of questions posed to the Drug Information Center, ban, and Watnick. Clinical Pharmacology Division will be open to the Prerequisite: Medicine Core Clerkship. The student will be invited student with practical clinical work in nephrol- to attend the monthly Pharmacy and Therapeutics ogy including: diagnostic evaluations on inpatients; Committee meeting, and join the Hospital Phar- macologist and Drug Information Center staff in participation in hemodialysis and the management responding to questions and issues arising within of chronic kidney disease; management of renal the hospital. One-half quarter or lon- Critical care medicine; ventilator-induced lung ger by prior arrangement. One-half Disease activity and novel therapeutics of quarter or longer by arrangement. Raynaud’s phenomenon; scleroderma and Students participate in the clinical evaluation related disorders. Stu- * Bayview faculty dents may conduct short-term clinical or laboratory investigative projects. Students Evaluation and management of Sjogren’s will actively participate in the in-patient consultation syndrome; metabolic myopathies and gout. There will be signifcant opportunity for osteoarthritis; oral health in rheumatic diseases; one-on-one teaching. Advanced Clinical Clerkship in Medicine/ rheumatic diseases with emphasis on Sjogren’s Rheumatology. Patients with multi- Mechanisms of autoimmunity, especially system connective tissue disorders and infamma- myositis and scleroderma. Evaluation of exercise and phychological health Students will be taught the approach/evaluation in arthritis and fbromyalgia.

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