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Health care is facing critical challenges worldwide. The explosion in scientific knowledge, its costly application to medicine and health care, coupled with rapid population growth and changing disease profiles during this century, have led to intense debates on the design, structure, and funding of health care systems. No perfect solutions have been found and health care systems in many countries are both of a mixed nature and in unstable states of change. The challenge is unique in South Africa as it faces the task of establishing a cohesive social democracy in which its natural resources and human talent can be used to benefit all its people. This will call for genuine commitment to human rights and rapid expansion of the economy within an international market. Within this context, the choice of a health care system has significance for the social tranquility so necessary for progress. The provision of greater equality of access to health care is a potentially powerful way to foster the sense of solidarity in citizenship and community that is essential in South Africa in its transition toward a more just society. Because of the narrow time frame available for visible progress toward a stable and flourishing democracy, the challenge of health care reform is particularly acute in the new South Africa. The recent remarkable election process gives cause for optimism, however. Our present system of health care education, practice, and policy has many characteristics of the society in which it evolved. Undisputed high standards of medical education in the Western tradition, aspiration to high standards of patient care, remarkable "Old World" goodwill between doctors and patients of all races, some public health facilities as well as successful private medicine show one side of the coin. The ability to perform the world's first heart transplant in 1967 illustrates this. The other side of the coin is fragmentation and duplication of services, wide disparities in health and in access to health care (particularly in rural areas), the paucity of preventive, promotive, and rehabilitative services, (increasingly resented) paternalistic attitudes to patients, and until recently, dismissive attitudes toward African traditional medicine.(1) Three statistics illustrate the current disparities in health. First is the infant mortality rate, which ranges from 13 per 1000 live births in whites to 82 in blacks. Second, infectious diseases accounted for 12.9 percent of all deaths in blacks in 1988 as compared with 2.2 percent of deaths in whites. Third, the life expectancy at birth in the 1980s was fifty-five years and sixty-two years for black males and females, respectively, and sixty-seven years and seventy-four years for white males and females. Structurally, our current health service fits somewhere between the predominantly fee-for-service, managed care health care system in the United States and the (until recently) predominantly socialized, nonprofit system in the United Kingdom. Approximately 50 percent of health expenditure is in the private sector in which 50 percent of doctors work to serve 20 percent of the population covered by health insurance. The undesirability of either a fully privatized or totally socialized health care service is not the major dispute, but rather the balance between these two components. Neither Thomas McKeown's nor Leonard Sagan's concern that modern medicine plays only a modest role in improving population health, as distinct from the health of specific individuals, minimizes the impressive impacts of modern medicine on individual and collective well-being.(2) Rather, their analyses point to the need for more than an individualistic and reductionist medical approach to health and disease. The challenge of transforming our health care system is compounded by the profound legacy of apartheid in all aspects of life that influence health and disease.(3) Developing a health care system that offers fairer access to a range of services capable of promoting and protecting health in our new society will demand great intellectual honesty, a realistic view of what has been achieved elsewhere and of what can be achieved within a reasonable time frame in our economic and demographic context. …

EDITOR, - Tony Waterston and Anthony Zwimake some valid comments regarding apartheid's effect on health care in South Africa but deal superficially with several important points.1 The crucial difference between the National Medical and Dental Association's advocacy of so called selective support (more accurately interpreted as “selective boycott” as there is an element of coercion) and true selective support as advocated by me2 seems to have escaped them. Recent requests by the African National Congress for the removal of sanctions highlights understandable …

In Reply. —Unlike Dr Dommisse, who has been correctly critical of apartheid but also has built his writing career on this, I and many of my colleagues who have remained in South Africa have struggled not only against apartheid but also to retain and strengthen those institutions necessary for building a new and better South Africa. Being highly critical of apartheid and its effect on medicine and health care and also at the forefront with many white and black colleagues in integrating Groote Schuur Hospital under difficult conditions so that patients of today, as well as those of the future, could be shielded from apartheid policies, I feel no discomfort in opposing total academic boycott as vigorously as I have opposed apartheid. The humanitarian basis for our concern about apartheid and academic boycott is, we believe, more consistent with the international medical ethos than a rigid political approach. My argument

A controlled, prospective study comparing streptokinase and heparin treatment has been completed in 51 patients presenting with acute proximal venous thrombosis of less than 8 days' clinical duration. Patients were studied by means of pre-treatment, post-treatment, 3- and 12-monthly phlebography and pulmonary perfusion scanning and were followed up at 3-monthly intervals. Of the 26 patients randomized to receive streptokinase, therapy was stopped in 3 because of complications. Phlebography 5 days after starting treatment showed 80–100 per cent lysis in 17 of the 23 patients who completed the course of streptokinase. Two patients later developed partial rethrombosis. One patient developed an asymptomatic pulmonary embolus during treatment. During follow-up (mean 19 months) only 1 of the 17 patients with 80–100 per cent lysis developed postphlebitic symptoms, 3 patients died of unrelated causes and 1 patient was lost to follow-up. In patients randomized to heparin therapy no significant lysis was achieved in any of the 25 patients and only 2 of these patients were found to have asymptomatic legs on follow-up. Two patients in this group died and autopsy confirmed massive pulmonary embolus during treatment. These data suggest that streptokinase is superior to heparin in the treatment of acute proximal venous thrombosis of less than 1 week's clinical duration especially if the thrombus is largely non-occlusive. It must be stressed that in order to avoid the bleeding complications of thrombolytic therapy, streptokinase must not be used within 10 days of major surgery, or even longer after vascular, neurosurgical or eye operations.

Summary An analysis of skin prick reactions in 500 consecutive patients referred for investigation and management of asthma showed that 240 patients had multiple positive reactions. Of these patients 46% had positive reactions to Aspergillus and they differed from patients with multiple positive reactions excluding Aspergillus by having onset of asthma at a younger age and being more atopic. Precipitins to Aspergillus were present in the serum of twenty-six of seventy-one consecutive patients in whom these were looked for. Thirteen of the patients with positive precipitins had chest radiograph shadows compatible with allergic bronchopulmonary aspergillosis (ABPA) and in eight of these there was sufficient evidence to make a diagnosis of ABPA. These results were obtained in a region where ABPA had never been previously recognized and they highlight the importance of routine skin prick testing with Aspergillus antigen and of awareness of ABPA in making this diagnosis.

Cochcrane, G. M., Prieto, F., Hickey, B., Benatar, S. R., and Clark, T. J. H. Thorax , 29 , 389-393. Early diagnosis of airways obstruction. Three simple tests, maximum expiratory flow volume curve, maximum expiratory volume time curve and `closing volume9, were used to detect early airways obstruction in 21 smokers. A high proportion had abnormal values for MEF 75% , MEF 50% , and FET (86%, 71%, and 62% respectively) with a relatively normal FEV 1 . There was a good correlation between tests of small airways obstruction obtained from the forced expiratory manoeuvre. The measurement of `closing volume9 (phase 4/VC%) was less satisfactory as there were difficulties with interpretation of the records in half of the studies. We conclude that the forced expiratory manoeuvre can be used to detect early airways obstruction as well as providing FEV 1 and vital capacity. The importance of early diagnosis of airways obstruction is not yet clear and further information is required about its natural history, and its relation to smoking habits and to the more advanced and less reversible stages of airways obstruction. It may be possible to use early detection to prevent the development of disabling chronic obstructive bronchitis.

Acid fast bacilli are seldom identified by direct staining of sputum smears in patients with miliary tuberculosis, so that delays in diagnosis are common. We report 41 patients with miliary tuberculosis who had negative sputum smears and who underwent bronchoscopy, bronchial brushing, and transbronchial biopsy. In two patients the procedure was repeated. A definitive diagnosis was obtained from bronchoscopy in 34 patients (83%). Bronchial brushings yielded Mycobacterium tuberculosis in 24 of 42 bronchoscopies (57%), 13 from direct smear and a further 11 from culture only. Transbronchial biopsies were diagnostic in 30 of 41 procedures (73%), 28 from histological appearances, one from direct smear of the biopsy specimen, and another exclusively from culture. A rapid diagnosis was established in most patients (27/34), either by direct smear of brushings or biopsy specimens only (5), by histological examination only (14), or by both direct smear of brushings and biopsy specimens only (5), by histological examination only (14), or by both direct smear of brushings and histological examination (8). The diagnosis was confirmed later in a further seven patients by culture of brushings or specimens; in five of these non-caseating granulomas were initially found by histological examination. Fibreoptic bronchoscopy is a valuable technique for rapidly establishing the diagnosis of miliary tuberculosis.

In four years' use of the flexible fibreoptic bronchoscope in diagnosing sputum-negative pulmonary tuberculosis, of 275 patients with tuberculosis suspected from chest radiographic appearances, 89 (32.4%) were shown to have active disease. In 60 (67.4%) of these patients the diagnosis was made from samples obtained through the fibreoptic bronchoscope (56 from bronchial brushings, four from transbronchial biopsy samples). Of the 56 positive bronchial brushings, 35 were positive on direct smear and 21 only on culture. Transbronchial biopsy exclusively accounted for only four of the 60 positive diagnoses. In the remaining 29 patients, the diagnosis was made from further sputum or biopsy specimens in 15, from the response to treatment in 12, and at necropsy in two. In six of 10 patients with military tuberculosis, bronchial brushings were positive on direct smear.

Thirty-nine asthmatic patients required mechanical ventilation (IPPV) for status asthmaticus over a seven and a half year period. We reviewed their clinical records with particular emphasis on the events leading to intermittent positive pressure ventilation (IPPV) and the long-term courses of those patients who survived IPPV. Long delays by patients before seeking medical attention, incomplete assessment of acute attacks, underuse of corticosteroids prior to admission and overuse of sedation were important factors often influencing the necessity for IPPV. Four patients died during IPPV. Of the 35 who survived, 32 were regularly followed in our Respiratory Clinic. Nine patients subsequently died, eight undoubtedly from asthma. Serial measurements of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV 1 ) were retrospectively analyzed to determine patterns of asthma. Of the 23 patients still alive, 14 have well controlled asthma, five have a pattern of persistent airflow obstruction, two have markedly labile asthma, and two have gradually deteriorating airflow obstruction. By contrast, seven patients who died sufficiently long after IPPV to enable categorization of their patterns showed either markedly labile asthma or gradually deteriorating airflow obstruction. None had relatively constant ventilatory function at either normal or suboptimal levels. We suggest that patterns of asthma are useful guides in detecting patients at high-risk. Patterns characterized by markedly labile asthma or gradually deteriorating airflow obstruction appear to be associated with an increased risk of sudden death from asthma.

1. Lung volumes and maximum expiratory flow volume (MEFV) curves were measured before and after exercise and after a bronchodilator in eight asthmatic children. 2. Exercise produced significant changes in all volumes and flow rates measured, but the most sensitive measurement was of flow rate at an absolute volume in the terminal portion of the forced vital capacity. Of the more simply obtained measurements maximal flow at 50% of the exhaled vital capacity was the most sensitive, but reductions in forced expiratory volume at 1 s and peak flow rate were almost as marked. 3. The marked reductions in flow rates at low lung volumes after exercise were accompanied by large increases in residual volume and a reduction in the slope of the MEFV curve. These changes suggest functional closure of some lung units and an increase in the time-constant of emptying of other units. 4. The response of flow to breathing helium—oxygen (79:21, v/v) was assessed in the dilated state (before exercise or after bronchodilator) and the constricted state (after exercise) in five of the subjects. 5. An increase in density-dependence of flow rates at all lung volumes during constriction is evidence that, despite the reduction in flow rates, convective acceleration and turbulent flow constitute a greater proportion of the total upstream resistance after exercise than before exercise. The implication is that the cross-sectional area at equal pressure points (EPP) is smaller after exercise than before exercise. This could result from either bronchoconstriction with no change in the location of EPP, or from progression of the EPP further upstream to a region where loss of airways or reduction in their diameter has rendered the total cross-sectional area considerably smaller than under normal circumstances.

Summary Two cases of phlegmasia caerulea dolens with peripheral venous gangrene treated with streptokinase are presented. Both patients had excellent results, beyond expectation. The literature is reviewed and the symptomatology, aetiology, pathogenesis and current thoughts on treatment are discussed.

The invitation to describe briefly health and medical care in South Africa — a large country that has inhabitants with a wide range of socioeconomic, educational, and cultural backgrounds and that is torn apart by internal strife and internationally vilified for its immoral policies — is a daunting challenge. The policies of apartheid pervade and taint every aspect of life in this country, including all efforts and achievements of individuals and institutions toward eliminating racially discriminatory practices and delivering health care equitably. Apartheid is indefensible. It has had serious adverse effects on health and human dignity.1 2 3 This much is beyond . . .

Cochrane, G. M., Benatar, S. R., Davis, J., Collins, J. V., and Clark, T. J. H. (1974.) Thorax, 29, 172-178. Correlation between tests of small airway function. To compare and correlate tests of small airway function we have measured residual volume, frequency dependence of compliance, `closing volume9, maximal expiratory flow rate at 50% and 25% of vital capacity, maximal expiratory flow rate at 50% of total lung capacity, and forced expired time in 10 health non-smoking male subjects and 10 non-smoking asthmatics who on the day of the study had no symptoms of airway obstruction. There was no evidence to suggest that any one particular test was more sensitive than others in detecting the presence of small airways obstruction. The closest correlation was between maximal expiratory flow rate at both 25% of vital capacity and 50% of total lung capacity and the forced expired time. It is argued that a prolonged forced expired time in the presence of normal dynamic lung volumes may be the most easily applicable screening test for early small airways obstruction.

Exposure to grain dust may induce acute and chronic respiratory, nasal, and ocular symptoms. The prevalence of respiratory symptoms, atopic status, and lung function changes, as measured by pulmonary function tests (PFT) over the week in 582 grain mill workers and 153 control subjects not exposed to grain dust were studied in Cape Town. Atopic status, smoking habits, and baseline PFT did not differ significantly between grain workers and control subjects. Grain workers showed significant deterioration in lung function values over the week, with forced expiratory volume in one second declining on average by 4.8% compared with an increase of 3.3% in control subjects (p less than 0.001). Forced expiratory flow during the middle half of the forced vital capacity declined by 14.8% in grain workers and by 0.8% in control subjects (p less than 0.0001). Grain workers had significantly higher prevalences than did control subjects of regular cough (46 versus 30%), expectoration (35 versus 17%), wheeze (25 versus 11%), and watery eyes (25 versus 10%) (p less than 0.01 for all). These symptoms were not related to the duration of employment. A dose-response relationship, independent of smoking habits, was demonstrated between reported dust exposure and symptoms as well as between dust exposure and PFT. These results have important implications for the grain mill industry in South Africa where there is insufficient legislation and worker compensation.

Clear guidelines for the selection of patients with large pulmonary bullae and severely impaired lung function for surgery remain to be defined. Twenty-one such patients operated on between 1971 and 1977 are reviewed in an attempt to shed some light on this difficult problem. Four of six patients with preoperative hypercapnia survived and were improved by surgery. There was no mortality among the remaining 15 patients of whom 14 were improved symptomatically by surgery (with improvement in FEV1 and vital capacity in 9). Preoperative bronchograms were used to help identify patients suitable for surgery. The presence of bronchiectasis was predictive of postoperative complications. Better results were obtained in those patients in whom plication of bullectomy could be performed than in those requiring lobectomy.

Serum angiotensin converting enzyme (SACE), despite certain limitations, has been found to be a useful adjunct to the diagnosis, assessment of disease activity, and management of sarcoidosis. The spectrofluorimetric assay was used to measure SACE in 50 normal controls, 76 patients with tuberculosis (42 pulmonary, 16 lymphatic and 18 military cases), 20 patients with cryptogenic fibrosing alveolitis, 50 patients with silicosis, three patients with extrinsic allergic alveolitis, 10 patients with Crohn's disease, two patients with Gaucher's disease, and 128 patients with sarcoidosis on 303 occasions (144 during periods judged as clinically active and 189 inactive). Our results show a normal range (mean +/- 2SD) of 19-54 nmol/ml/min. The false positive rate is 2 per cent in normal controls, 9.2 per cent in tuberculosis (38.9 per cent in military but 0 per cent in the other forms), 48 per cent in silicosis, 100 per cent in Gaucher's disease, and 0 per cent in the other diseases. The sensitivity, specificity, positive and negative predictive values were 58.1, 83.8, 83.8 and 58.1 per cent respectively. The sensitivity rose to 85.9 per cent if only those samples taken from patients in whom sarcoidosis was suspected on initial presentation were included, and 92.1 per cent if only those with clinically active sarcoidosis were included. The sensitivity of SACE as a diagnostic test in sarcoidosis is thus influenced by the relative frequency of active and inactive sarcoidosis. The specificity is influenced by the prevalence of military tuberculosis and silicosis, but is uninfluenced by other common varieties of interstitial lung disease such as cryptogenic fibrosing alveolitis and extrinsic allergic alveolitis, or by other non-pulmonary granulomatous disease. There was no correlation of the SACE level with age, sex, population group, associated other illness or duration of sarcoidosis. Statistically, SACE levels were significantly higher in patients with Types II and III chest radiographs as compared to Type I and 0, and also in those with additional clinically evident extra-thoracic disease e.g. in lymph node, eye and especially multiple systems. SACE also reflected clinical activity with levels being statistically significantly greater in those patients assessed as having active disease, although 7.9 per cent of these had normal levels. Our observations indicate that SACE levels correlate well with disease activity longitudinally, both in relation to spontaneous remission and steroid therapy, and are thus helpful in patient management.

Health care issues such as the availability of medical services, access to health care according to ability to pay, geography, and racial discrimination, segregation of public hospitals, allocation of resources and facilities, occupational health care, and the physician patient relationship are discussed within the context of the political, economic, and psychosocial forces of South Africa.

The concept of "virtual shunt" is presented as a practical means for determining the optimal inspired oxygen concentration for patients with hypoxaemia due to pulmonary venous admixture. The approach permits a reduction in the number of blood-gas analyses needed. Its limitations have been explored and its validity assessed from a series of 44 observations made on 4 patients.

1. Rapid intravenous (i.v.) infusions of saline were administered to five healthy male volunteers. Measurements were made of static and dynamic lung volumes, ‘closing volume’ and pulmonary compliance before and after infusion; all measurements were made in the seated upright position. 2. Following a 1 litre infusion small decreases occurred in static and dynamic lung volumes in all studies and were associated in each case with an increase in ‘closing volume’. ‘Closing volume’ returned to normal within 1 h of the infusion. 3. After 2 litre infusions more marked decreases in all lung volumes occurred and were associated with variable changes in ‘closing volume’. The pattern of change varied between individual subjects and this is thought to reflect differences in localization within the lungs of the effects of the saline load in different subjects. 4. After 2 litre infusions static compliance was decreased in all subjects during the first 10–15 min. Changes in dynamic compliance showed marked individual variation.

Eight cases of fat embolism have been seen during a 15-month period. Of these, three died and five survived. Pulmonary-function tests performed in three of the surviving patients have shown a complete return to normal of pulmonary function. The importance of early recognition and correction of hypoxaemia is emphasized, with special reference to the cases seen. Controversial aspects of the syndrome, including the source of the embolic fat, its pathophysiological effects, and the treatment are discussed with reference to the literature. Attention is drawn to the observation that late internal fixation procedures on the fractured bones can be undertaken safely.