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Thus kamagra effervescent 100 mg visa erectile dysfunction generics, for example generic kamagra effervescent 100 mg fast delivery erectile dysfunction drugs viagra, the increase in average life expectancy to be gained from a 10 per cent reduction in the level of serum cholesterol in the population at large (a much vaunted target of the 1992 Health of the Nation White Paper, though dropped in the 1999 document) is between 2. However, even to achieve this degree of reduction in cholesterol would require either drastic dietary modification or long-term drug treatment (with its attendant side- effects). Now it is true that the fact that old people live longer does not necessarily mean that they suffer worse health. However, it is also true that there is a tendency for the prevalence of common chronic degenerative conditions— heart disease, stroke, cancer, osteoarthritis, diabetes, dementia—to increase with age. What is by no means clear is the contribution of the various preventive measures favoured by the government to improving the quality—as distinct from the duration—of people’s lives. Indeed it may well be the case that an old person’s enjoyment of a cigarette, a cream bun and a bottle of Guinness is more important to them than the extra few weeks they might spend in a life of miserable abstinence. A further aim of government public health policy is to ‘narrow the health gap’ between rich and poor by concentrating its efforts on improving the health of the ‘worst off in society’. Here is another paradox: the government and the medical profession have become more preoccupied with the relationship between inequality and health at a time when social differentials in health are less significant in real terms than ever before. No doubt it is true that people who are better off are healthier and that the poor are sicker. A vast edifice of epidemiological data has been erected in recent years substantiating these differentials in great detail in relation to every disease and health indicator. Yet the simple contrasts between the health gap that exists in Britain today and that between rich and poor in Victorian England, or that which still prevails between Western and Third World countries today, is enough to expose the lack of historical or social perspective of contemporary public health. Take infant mortality, one of the most intensively studied indices of population health. The persistent gap between the rate of infant deaths among rich and poor has been a particular focus of the new public health since the publication of the Black Report in 1980 (Black 1980; Townsend, Davidson 1992). The 1990 figures reveal that the number of babies whose fathers are classified as ‘unskilled workers’ (social class V) who die in the first year of life is 11. In other words, the infant mortality rate for the poor is nearly twice that among the rich. While there can be little doubt that the persistence of this differential is a pernicious effect of Britain’s class divided society, it is important to place it in a 4 INTRODUCTION wider context. The overall rate of infant deaths in 1990 was slightly less than 8, by 1996 it had fallen below 6. At the turn of the century the figure was around 150, by the Second World War it was still above 50; it did not fall below 20 until the 1960s (Halsey 1988) In some Third World countries today, the infant mortality rate remains comparable with that of Britain in the early decades of this century: for example, India—94, Bangladesh—114, Egypt—61, Mali—164 (Gray 1993:11). Infant mortality has fallen dramatically among all social classes in Britain in the course of the twentieth century. In 1922 infant mortality among unskilled workers was 97; for the children of professionals, the rate was 38 (Halsey 1988). Over the past 70 years, the rate has fallen to roughly the same extent — between 80 and 90 per cent—among both the richest and the poorest. The infant mortality rate among the poorest families today is similar to that of the richest in the 1970s. As new public health statisticians are well aware, it is possible, by carefully choosing your starting point and other manoeuvres, to reveal slight increases or decreases in class differentials in infant mortality. But what all such comparisons of mortality rates obscure is the dramatic decline in the absolute number of infant deaths. In 1990 the total number of babies dying in the first year of life in England and Wales was 3,390; in 1900 the figure was 142,912, in 1940 it was still higher by a factor of ten and in 1970 more than four times greater (OPCS 1990; Halsey 1988). The 1990 figure included 248 deaths among babies of parents in social class I and 243 in social class V (though the total number of babies born in this category was half that of class I). Though infant deaths may be relatively more common in poorer families, they are very uncommon in any section of society. A commonplace event within living memory in Britain, the death of an infant has now become a rarity. Furthermore many of these deaths result from conditions such as prematurity and congenital abnormalities, which are often difficult to prevent or treat, or are ‘cot deaths’, the causes of which are uncertain and preventive measures remain controversial. Again, it seems that the level of government and official medical intervention is out of all proportion to the scale of the problem. The more closely you examine the new public health the more strange its focus on problems of vanishing significance appears. Yet, despite the limited scope for preventing disease by changing lifestyle, campaigns endorsed by the government and the medical profession to alter individual behaviour have had a major impact on society over the past decade. Nobody capable of watching television 5 INTRODUCTION can now be in any doubt that smoking cigarettes, drinking alcohol, eating rich food and not taking enough exercise are not good for your health. These basic preoccupations have been supplemented and reinforced by numerous panics about other health dangers from HIV/Aids and BSE/CJD to sunlight, salmonella and listeria. The expanding range of medical intervention characterised as the medicalisation of life involves two inter-related processes. On the one hand, there is a tendency to expand the definition of disease to include a wide range of social and biological phenomena. Thus, for example, while the inclusion of crime within the medical framework remains controversial, the excessive consumption of alcohol or the use of illicit drugs are now widely accepted as medical problems.

Countless patients revered him; Lord Nuffield financed his concept of an 337 Who’s Who in Orthopedics that attracted him to the work of Lange and Vulpius on tendon transplantation in infantile paralysis discount kamagra effervescent 100 mg broccoli causes erectile dysfunction. Studies of Tendon Repair Tubby was appointed senior demonstrator of physiology at Guy’s Hospital and while occupy- ing this post he carried out important researches on tendon repair order kamagra effervescent 100 mg with visa erectile dysfunction 60, employing new staining methods he had learnt from Beneke of Brunswick. The Achilles tendons of full-grown rabbits were divided with antiseptic precautions, the punctures being protected with gauze. The animals were killed at intervals from 3 days up to 33 weeks, one at 13 months after tenotomy. His observations on the microscopic sections were reported in 1892 in the Pathological Society’s Alfred Herbert TUBBY Transcations and Guy’s Hospital Reports. In 1894, he was elected assistant surgeon to Alfred Herbert Tubby played a leading part in the Westminster Hospital and 4 years later became development of orthopedic surgery, particularly surgeon, an appointment he held for 30 years. He during its transition from the period of tenotomy was given charge of the orthopedic department and appliances to that of open operative correc- and lectured on clinical and orthopedic surgery. He also served as dean of the medical school, an He derived from South Country yeoman stock office in which his keen business instincts were and was born on May 23, 1862, the son of Alfred of value to the administration of the hospital. He Tubby, a corn merchant living in Great Titchfield was also consulting surgeon to the Hospital for Street, London, and his wife Frances, née Roe. Alfred was educated at Christ’s Hospital, then in Newgate Street, London, where he had as British Orthopedic Society schoolfellow F. Smith, who was to become Tubby’s colleague on the staff of the National In 1894, Tubby was elected joint secretary of the Orthopedic Hospital and a well-known physician newly formed British Orthopedic Society, whose to the London Hospital; author of a standard avowed object was the advancement of orthope- work on medical jurisprudence. This body came into being after an years was consulting surgeon, governor and informal discussion between a group of surgeons almoner to Christ’s Hospital. On leaving the interested in the surgery of deformities, who met Bluecoat School, he proceeded to Guy’s Hospital, at Bristol during the annual meeting of the British where he distinguished himself as a prizeman, Medical Association. Meetings were held in qualifying in 1884 as a member of the Royal London or a provincial center, the program con- 3 College of Surgeons. At the final medical exami- sisting of clinical demonstrations, papers and nations of London University in 1887, he won the discussions. Thus on May 24, 1895, the Society gold medal in medicine and the gold medal in visited the Royal Infirmary and Southern Hospi- surgery, besides gaining honors in anatomy, tal, Liverpool; at the Medical Institution Robert materia medica and forensic medicine; the same Jones introduced a discussion on the treatment of year he became a fellow of the Royal College of intractable talipes equinovarus, demonstrating a Surgeons. He proceeded to the degree of Master remarkable number of patients cured of this stub- of Surgery in 1890. But the Society lasted only for at Halle and Leipzig; it was this German training about 4 years; it published three slender volumes 338 Who’s Who in Orthopedics of its transactions, which serve as a permanent 1898, was one by T. Openshaw on tendon record of an early effort to bring orthopedic sur- transplantation. The Society was a forerunner of the British Orthopedic Association and in one way Collaboration with Sir Robert Jones was more fortunate than its greater successor in that all its gathered grain was brought together In 1903, A. Tubby collaborated with Robert into its own storehouse, whereas the Association Jones in publishing a book on Modern Methods unwillingly scattered its harvest for many years in the Surgery of Paralysis. The many indications for tendon Important Publications transplantation and its technique were described. Their treatment of spastic paralysis was an inno- In 1896, Tubby published a book entitled Defor- vation; little had been attempted for this type of mities: a Treatise on Orthopedic Surgery. It was based mainly on the experience the in abduction, to be followed by re-education author had gained at the National Orthopedic walking exercises. By these procedures they were Hospital and the Evelina Hospital for Sick Chil- able to get these patients walking and capable of dren. For the spastic pronated hand, the the lavish number of illustrations produced, 200 pronator radii teres was converted into a supina- were original. But he cast his net widely in order tor by detaching its insertion, with periosteum, to gather the thinking and practice of surgeons in passing it through the interosseous membrane, America and on the Continent. The work was an behind the radius and reattaching it to the outer authoritative presentation of orthopedic surgery side of the bone. Flexor carpi ulnaris was trans- as understood in the closing years of the nine- planted into extensor carpi ulnaris and flexor carpi teenth century; it revealed how great had been its radialis into the radial extensors. Little in 1839 published his sometimes combined with tendon transplantation classic A Treatise on Club-Foot and the Nature of in patients with infantile paralysis; more often Analogous Distortions. They had per- branch of surgery had still to reach maturity; a formed over 100 such operations. The publication passage in the preface of his book makes strange of this work in 1903 was a distinct landmark in reading: “The practice of Orthopedic Surgery in the progress of orthopedic surgery. England does not include all phases of diseases of In 1912, Tubby published a new edition of bones and joints such as tuberculous ostitis and his textbook with the ominous title Deformities arthritis of the hip and knee, on what grounds it Including Diseases of the Bones and Joints. He had been formed by Nicoladani in 1882, when he attached obliged to rewrite the whole work and to arrange the peronei to the tendo achillis in a patient with the various subjects according to their etiology talipes calcaneus. In 1892, Parish and Drobnik and pathology rather than on a regional classifi- independently applied the same method to other cation as in the previous edition.

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He made the words “orthopedic surgery” and Massachusetts purchase kamagra effervescent 100mg online impotence vacuum device, and with ambitious energy buy 100mg kamagra effervescent otc erectile dysfunction pump treatment, Albert “progress” almost synonymous, and he ranks also followed courses there, meanwhile having among those who laid the foundation for ortho- garnered a Peabody scholarship. Key had begun of his time on that scholarship to undertake some fundamental research early in his career and never hematological investigations. He continued his work attracted to hematology during his first year in along these lines and always correlated his medical school and was particularly interested in research work with the clinical approach. In spite of his multitudinous duties at the His endeavors in this field were successful, and Shriners’ Hospital, his enormous ability for work he published two important papers: “Studies on enabled him to make outstanding contributions Erythrocytes with Especial Reference to Reticu- in experimental and clinical studies. During this lum, Polychromatophilia and Mitochondria” and period, “The Reformation of Synovial Membrane “Lead Studies. Blood Changes in Lead Poi- in the Knees of Rabbits After Synovectomy,” soning in Rabbits with Especial Reference to the “The Mechanisms Involved in the Removal of Stippled Cells. Fluid of Normal Joints” were among his out- In 1921 he became instructor in applied phys- standing works. The Reactions of Joints to In 1924, it was the aim of the National Advi- Mild Irritants” and “The Pathogenic Properties of sory Board of the Shriners’ Hospitals for Crippled Organisms Obtained from Joints in Chronic Children to have their institutions throughout the Arthritis. His results were the investigation of the cause, prevention, and published under the titles “Experimental Arthri- treatment of crippling conditions in childhood. Key was appointed director of research for all Defects in the Articular Cartilage” and “Trau- the Shriners’ Hospitals, with headquarters in St. Childhood,” “The Non-Tuberculous Hip in have had the opportunity to observe Dr. Adolescence,” and “Some Diag- research, to become familiar with his ability as nostic Problems in the Hip in Early Life. Key wrote an article on brittle bones students, and to be stimulated by his keen inter- and blue sclera, which he termed “hereditary est in the clinical problems of crippled children. More than bones, and joints, in a case studied from the clin- simply a colleague, Albert became my friend, and ical, roentgenographic, and laboratory aspects. Furthermore, he became his thesis for membership in the American Ortho- interested in the School of the Ozarks. He contributed two sections, a small Missouri school whose interests were one on “Idiopathic Bone Fragility (Osteopsathy- directed mainly toward the education of under- rosis)” and the other “Fractures and Dislocations privileged children. Key endowed of the Extremities” as part of Graham’s Surgical a likely scholar with a fellowship. Immersed though he was in serious work, his The integrity of his publications, as of all his love and zest for sports always managed to shine work, is and will remain beyond question. I shall never forget the fishing trips fessionally and socially, Albert believed in and we took together in California, Idaho, Oregon, lived the truth. There was never a dull 1928, he made an English translation of Normal moment, due to his unfailing good humor, his and Pathological Physiology of Bone, from the ready wit, and his joy in seeing others catch more original French by Leriche and Policard. His ability to start a conversation mount the difficulties of a foreign language. He had as broad a his flair for absolute truth, Albert replied, “Avec knowledge of orthopedic surgery and of general le dictionnaire. He was extremely He became associated with the Washington kind and modest to the point where, when asked University School of Medicine in 1926 as associ- to give a paper or make some other presentation, ate in clinical orthopedics; in 1927, he was he willingly shared his honor with one of his col- appointed assistant professor of clinical orthope- leagues; in fact, he often turned the whole matter dics and, in 1931, head of the division of to the other man’s credit. He had a prodigious memory, arduous, often when they were finished, some- especially for the minutiae in orthopedic litera- times as late as five in the afternoon, his terrific ture. His presence at any function, social or drive compelled him to begin work on some medical, was practically a guarantee of its project of his own. He was an active member of Theta Nu cal and analytical mind had full scope. He was Epsilon, Gamma Alpha, Alpha Omega Alpha fra- full of intellectual curiosity. His original ideas were never-ending, Clinical Orthopedics at Washington University in and he pursued not one, but many simultaneously. Louis and head of the Division of Orthopedics, Once he stated that he had decided long before a position he held until his death. Among them was the excellent book one, a person might be slowed down and thus The Management of Fractures, Dislocations, and spend years to finish it. In Cowdry’s Special His own drive was a great stimulus to those Cytology he described synovial membranes, with whom he worked. He found time to contribute to advance his younger men and associates into to The Practitioners Library of Medicine and positions at the school and toward membership in Surgery, Military Surgical Manual of the orthopedic societies. Several times he said that he National Research Council, Clinics, Instructional hoped some day his younger men would be Course Lectures of The American Academy of among the leaders in orthopedic surgery. He was Orthopedic Surgeons, Lewis’Practice of Surgery, totally unselfish, both with his time and his A Textbook of Surgery by American Authors, money. He made private loans to those who Bancroft and Murray’s Surgical Treatment of the needed them, and it is known that he paid the Motor-Skeletal System, Ghormlley’s Orthopedic 173 Who’s Who in Orthopedics Surgery, Cirzrrgia de L’rgezzcia, Cole’s Opera- These meetings were held at the time of those tive Technic and Clinical Orthopedics. Among his of the Congress of the American College of many articles that have appeared in scientific Surgeons.

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CONTENTS Preface vii Glossary of acronyms xii 1 Introduction 1 2 Health scares and moral panics 13 3 The regulation of lifestyle 35 4 Screening 55 5 The politics of health promotion 72 6 The expansion of health 96 7 The personal is the medical 118 8 The crisis of modern medicine 130 9 Conclusion 155 Bibliography 174 Index 188 v PREFACE On a bitterly cold February day in the winter of 1987 I had to break into the house of an elderly couple who had succumbed to a combination of infection and hypothermia generic kamagra effervescent 100mg fast delivery erectile dysfunction treatment costs. While I waited for the ambulance I found buy kamagra effervescent 100 mg lowest price impotence biking, unopened on the doormat, a copy of the government’s ‘Don’t Die of Ignorance’ leaflet which had been distributed to twenty-three million households as part of the campaign to alert the nation to the danger of Aids. Around half of these households contained either an old couple or an old person living alone. What was striking about the ‘worried well’ was not only the intensity of their anxiety about a rare disease that they had little chance of contracting, but the effect of the Aids publicity in making them question the way they conducted their personal life. Whether or not they were at risk of HIV, the Aids campaign put people under real pressure to conform to official guidelines regarding their most intimate relationships. The more I examined the Aids campaign the less it seemed to be a rational response to a new disease, and the more it seemed to be about the promotion of a new code of sexual behaviour. Not only were fears being needlessly inflamed, but this was being done to establish new norms of acceptable and appropriate behaviour. It was also supplemented by a systematic government drive to change personal behaviour in areas such as smoking, alcohol, diet and exercise through the 1992 Health of the Nation initiative, and by the promotion of mass cancer screening programmes targeted at women (cervical smears and mammograms). To an unprecedented degree, health became politicised at a time when the world of politics was itself undergoing a dramatic transformation. The end of the Cold War marked an end to the polarisations between East and West, labour and capital, left and right, that had dominated society for 150 years. The unchallenged ascendancy of the market meant that the scope for politics was increasingly restricted. Collective solutions to social problems had been discredited and there was a general disillusionment with ‘grand narratives’. One indication of the resulting ideological and political flux was the fact that the remnants of the left broadly endorsed the Conservative government’s Aids campaign (some criticising it for not going far enough), while some right-wingers challenged its scaremongering character (though a few hardliners demanded a more traditional anti- gay, anti-sex line). As someone who had always identified with the political left, the ending of the old order in the late 1980s led to some contradictory and disconcerting developments. In response to a series of setbacks at home and abroad, the left lowered its horizons and became increasingly moderate and defensive. The weakness of the British left had always been its tendency to confuse state intervention for socialism. In the past, however, the state had intervened in industry and services; now (as it tried to retreat from some of its earlier commitments) it stepped up its interference in personal and family life. The left’s endorsement of the government’s Aids campaign, following earlier feminist approval of the mass removal of children from parents suspected of sexual abuse in Cleveland, signalled the radical movement’s abandonment of its traditional principles of liberty and opposition to state coercion. While most conservative commentators loyally defended government policy, only a small group of free-market radicals was prepared to advance a, rather limited, defence of individual freedom against the authoritarian dynamic revealed in the government’s health policies (see Chapter 5). Until the early 1990s, politics and medical practice were distinct and separate spheres. Some doctors were politically active, but they viii PREFACE conducted these activities in parties, campaigns and organisations independent of their clinical work. No doubt, their political outlook influenced their style of practice, but most patients would have scarcely been aware of where to place their doctor on the political spectrum. Systematic government interference in health care has since eroded the boundary between politics and medicine, substantially changing the content of medical practice and creating new divisions among doctors. Thus, for example, the split between fundholding and non-fundholding GPs in the early 1990s loosely reflected party-political allegiances as well as the divide between, on the one hand, suburban and rural practices, and on the other, those in inner cities. Despondent at the wider demise of the left, radical doctors turned towards their workplaces and played an influential role in implementing the agenda of health promotion and disease prevention, and in popularising this approach among younger practitioners. Allowing themselves the occasional flicker of concern at the victimising character of official attempts at lifestyle modification, former radicals reassured themselves with the wishful thinking that it was still possible to turn the sow’s ear of coercive health promotion into the silk purse of community empowerment. Reflecting the wider exhaustion of the old order throughout Western society, an older generation of more conservative and traditional practitioners either capitulated to the new style or grumpily took early retirement. In 1987 I co-authored The Truth About The Aids Panic, challenging the way in which the ‘tombstones and icebergs’ campaign had grossly exaggerated the dangers of HIV infection in Britain, causing public alarm out of all proportion to the real risk (Fitzpatrick, Milligan 1987). Though the central argument of this book was rapidly vindicated by the limited character of the epidemic, it received an overwhelmingly hostile response, particularly from the left. Radical bookshops either refused to stock it or insisted on selling it with an inclusion warning potential readers that it might prove dangerous to their health. In public debates I was accused of encouraging genocide and there were demands that I should be struck off the medical register. My argument that safe sex was simply a new moral code for regulating sexual behaviour provoked particular animosity from those who took the campaign’s disavowal of moralism at face value. Not only does moralism not need a dog collar, in the 1990s it was all the more effective for being presented through the medium of the Terrence Higgins Trust, once aptly characterised as the Salvation Army without the brass band. Given the pressures of full-time general practice, intensified by the various government reforms and campaigns, this project took rather longer than intended and, in 1996. This was rejected by the Department of Health on the grounds that the proposed project was not ‘in the interests of medicine in a broad sense or otherwise in the interests of the NHS as a whole’.

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