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By N. Tukash. Washington & Lee University.

These GPs clearly need some training in the more interventionist approach buy 100mg zenegra amex, which recommends immediate and long- term responses discount 100mg zenegra with amex. The immediate response is a series of measures that encourage the victim towards involving other agencies, most importantly the police and the courts. There is a general approval of the fact that the police have adopted a much more interventionist approach, setting up domestic violence units and being ready to enforce court orders against violent spouses or partners. It is striking, however, that in this era of evidence-based practice, no evidence is adduced that the intervention of the police and the criminal justice system provides effective protection for women. The tragic case of Vandana Patel, fatally stabbed by her husband inside the domestic violence unit of our local police station in Stoke Newington in 1991, indicates that the police cannot guarantee women’s security. One of the few critics of the feminist enthusiasm for a more coercive approach to domestic violence—American academic Jean Bethke Elshtain—notes that ‘scant attention gets paid to the danger that enhancing police prerogatives to intervene may lead to abuse of the society’s least powerful’ (Elshtain, 1998:174). The long-term consequence of GPs adopting a more pro-active approach to domestic violence is more insidious. It means opening up the personal realm of family life and relationships to professional interference on an unprecedented scale. The BMA report comments 124 THE PERSONAL IS THE MEDICAL that the doctor is in a particularly good position to intervene, because he or she does ‘not necessarily need to prove the existence of domestic violence…but instead needs to identify and acknowledge that domestic violence is occurring’ (BMA 1998:45). The doctor’s suspicion of violence is thus deemed to justify unleashing a comprehensive programme of intervention, possibly involving a wide range of local authority and voluntary organisations, as well as other health professionals. A popular model is the Domestic Abuse Intervention Project in Duluth, Minnesota, USA. This seeks through multi-agency working to transform a range of violent behaviour into non-violent or egalitarian behaviour, showing respect and trust, giving support, being honest and accountable, fairly negotiating, taking shared responsiblity, having economic partnership and responsible parenting. Whether or not this approach is effective in terms of deterring domestic violence, it carries the heavy cost of opening up the private sphere to public scrutiny and regulation in a way that is characteris-tic of authoritarian societies. Such an intrusion into the intimate life of the individual can only be profoundly damaging both for the individual and for society. Again Elshtain is alert to the oppressive consequences of domestic violence programmes: Mandated counselling, even behavioural conditioning of violent men, coupled with compulsory punishment, are common as part of the panoply of interim proposals, along with a refusal to think about potential abuses inherent in extending therapeutic powers and responsibilities to the state as part of its policing function. In the Canadian survey cited above, of the 21 reasons given by GPs for not identifying more cases of domestic violence, the two least common, were ‘it is not a medical matter’ and it’s ‘none of my business’. Though these may be the convictions of a minority, they point the way forward to a form of medical practice that treats illness rather than regulating behaviour and puts the autonomy of the 125 THE PERSONAL IS THE MEDICAL individual and the privacy of personal life before the imperatives of political correctness. The dangers of family support The key event in catalysing the transformation of general practice into an interventionist agency of social control was the election of the New Labour government in May 1997. A central theme of New Labour policy is the need for ‘joined-up solutions’ to ‘joined-up problems’. The government’s central preoccupation is with the fragmentation of society, most conspicuously expressed in the priority it gives to dealing with ‘social exclusion’. In response to the perceived problems of social disintegration it is keen to promote any manifestation of collectivity and to encourage any form of collaboration among agencies and professionals that might help to restore community and cohesion. The focus of the government’s public health programme—especially its flagship ‘health action zones’—is on promoting local networks, inter- agency working, flexibility in professional roles. The idea is to take advantage of the popularity of primary health care services (GPs, district nurses, midwives, etc. Given the fact that doctors and nurses have managed to retain much higher levels of popular approval than social workers and other professionals, it is not surprising to find that the GP surgery has been identified as a suitable focus for the strategy of promoting local networks. A Guardian/ICM poll in January 2000 asked people to grade various professionals (on a scale of 1–10) according to how they were ‘respected by people in general’: doctors came in at 8. At a time when other agencies—notably social services—are held in low regard, they appear to have devised a strategy of reorganising around primary health care, in the hope that this will increase their public acceptability. The development of initiatives in the sphere of primary care that involve collaboration with social workers, sometimes in voluntary organisations, around ‘family support’ is one consequence of the New Labour approach to social problems. One such scheme—the WellFamily Project—was piloted in Hackney and a number of other areas in the late 1990s and has been widely recommended as a model 126 THE PERSONAL IS THE MEDICAL for the primary care intervention in the family (Layzell, Graffy 1998; Goodhart et al. The project was developed by GPs working in collaboration with the Family Welfare Association, a voluntary organisation with roots in Victorian philanthropy. The FWA provided a ‘family support coordinator’, who was qualified as a health visitor and had undergone further training in ‘family therapy, solution-focused counselling and welfare rights’. Individu-als or families, considered to be in need of psychological, emotional or practical support were referred by the GPs in a group practice and were seen by the family support worker in the surgery. Some were seen only once and offered information and advice or referral to another agency.

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Little also met After the establishment of his hospital buy zenegra 100mg fast delivery, Little Judson buy generic zenegra 100mg on line, with whom he discussed spinal curvature. He also began the elected honorary member of the medical societies teaching of orthopedic surgery. He notes were published in 1855—“Lectures on the died at Ryarsh, after a few days’ illness, on July Deformities of the Human Frame,” in which he 7, 1894. He unknown disease, affecting two brothers, together was tall, with brown hair, grey eyes, and regular with autopsy findings. He gave no name to the features; but early baldness gave him a venerable disease and his description of it escaped notice. By nature he was reserved and retir- But 13 years later, Duchenne described the same ing; but he held firmly to his convictions. In old malady and called it pseudo-hypertrophic muscu- age, increasing deafness did not alter his kindly lar paralysis. He married Elizabeth, the daughter of On October 2, 1861, before the Obstetrical Thomas Roff Tamplin, of Lewes, Sussex. Two of Society of London, he read a paper: “On the influ- their sons became surgeons. Louis Stromeyer ence of abnormal parturition, difficult labour, pre- Little was surgeon to the London Hospital until mature birth and asphyxia neonatorum on the he resigned and went to practice in China. Ernest mental and physical condition of the child, espe- Muirhead Little became honorary surgeon to the cially in relation to deformities. This paper, duced subcutaneous tenotomy to England—a published in 1862, in the third volume of Trans- landmark in the cure of cripples. He wrote the first actions of the Obstetrical Society,4 aroused wide- important book on orthopedic surgery—a publi- spread interest, and spastic paralysis of infants cation that stimulated scientific investigation. He wrote many established the first orthopedic hospital for the other papers and delivered many addresses. For study and treatment of disabilities of the limbs Timothy Holmes’ System of Surgery he wrote on and spine. Jones AR (1937) The Evolution of Orthopedic Aspects of In-knee (Genu Valgum)” was pub- Surgery in Great Britain. London, He visited Canada and the United States in Henry Frowde and Holder & Stoughton 3. Little WJ (1839) A Treatise on the Nature of Club 1878, saw McDonnell at McGill Medical School Foot and Analogous Distortions. Little WJ (1862) On the influence of abnormal par- saw the Governor-General, Lord Dufferin, who turition, difficult labour, premature birth and was one of his old patients. In New York he met asphyxia neonatorum, on the mental and physical 204 Who’s Who in Orthopedics condition of the child, especially in relation to defor- these departments. Transactions of the Obstetrical Society of work, Elmslie allotted him the by-no-means easy London 3:293 task of clearing out the crowd of old chronics that 5. Smart WAM (1944) Famous London Hospital Clin- was clogging the massage department. On his return to London, he obtained the post of house surgeon at the Hospital for Sick Children, Great Ormond Street, a hospital to which he gave devoted service for the rest of his life. He was later appointed medical superintendent of the hos- pital, a post he held for 2 years, during which he gained valuable general experience of sick chil- dren, including operative surgery for emergency cases. In 1926 he became surgical registrar, and before the end of the year was appointed to the honorary staff. Although his interest was always concentrated on the orthopedic work, he was not actually des- ignated orthopedic surgeon to the hospital until 20 years had elapsed. During his early training he had served as registrar at the Royal National Orthopedic Hospital, where he gained further general experience of orthopedic surgery. For several years he held the post of orthopedic surgeon to the Royal Northern Hospital, a post from which he resigned in 1948, and for a time Eric Ivan LLOYD he was consulting orthopedic surgeon to the 1892–1954 London County Council. Throughout these years, though he was acquiring an ever-increasing Eric Lloyd was born in 1892, the son of J. He was educated at always dragging him towards his young patients Leighton Park, Reading, a school of which he at the Children’s Hospital. In his youth he was a fine athlete he gave an endless amount of thought to the and was allotted a half-blue for the half-mile details of any operation he was called upon to while at the university. He published a useful article on the Bartholomew’s Hospital to complete his medical technique of operating on the knee joint.

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Likewise buy zenegra 100 mg otc, inclusion would remove the barriers of cost and improve access to informa- tion about these approaches to health and healing buy discount zenegra 100 mg online. Finally, inclusion of alternative and complementary therapies within Medicare would show that health policymakers are responsive to the needs and desires of Canadians (WHO 2000). Furthermore, integration of allopathic with alternative healing approaches and inclusion of alternative therapies within Medicare would enable the people who took part in this research to address health problems for which they found no redress prior to their participation in alternative forms of healing. Finally, given these informants’ alternative model of health’s emphases on prevention, and its orientation towards chronic conditions, integration of alternative and allopathic healing paradigms would also positively affect population health and enable the Canadian health care system to better cope with the incidence of chronic illness. Notwithstanding these positive consequences, it is important to consider the ways in which integration of alternative and allopathic healing ideology or inclusion of alternative therapies within mainstream health care provision may not necessarily be entirely desirable. For instance, Glik (1988:1205) argues that “Attempts to ‘medicalize’ healing practices by employing them in clinical contexts may rob these practices of their effectiveness. Such standardization would result in reduced efficacy of alternative therapies according to these informants’ alternative model of healing, under which Conclusion | 121 the effectiveness of a therapy is due in part to individualized treatment regimes. In particular, it would likely divest their alternative model of health of its power to heal the self, one that lies in their perception of the distinc- tiveness of their alternative definition of health from biomedical under- standings. Inclusion of these therapies within Medicare would also interfere with how the people I spoke with use alternative therapies by constraining their ability to self-prescribe, experiment, and dabble in alternative therapies, as these approaches to health and healing would then be subject to the same gate- keeping practices as allopathic interventions. Furthermore, to the extent to which inclusion depends on scientific evidence of efficacy and medically rational explanation, some alternative or complementary therapies that “work” may remain “unproven. It is noteworthy, therefore, that many of the therapies used by these informants, including those they found most effective, are not found amongst those endorsed by the Western medical community. Finally, among the potential negative consequences of the efforts of alternative practitioners to become regulated professionals is that they may no longer have the power to challenge institutionalized biomedicine. Furthermore, the integration of alternative and allopathic approaches could rob the former of its ability to serve as a catalyst for innovation within mainstream health care provision. In Stambolovic’s (1996:603) words, “it is so important to nurture heresy’s imperfection, [especially] those parts that leave room for inquiry and change. Due care should also be taken that regulation of alternative therapies reflect these individuals’ desire to take control of their healing 122 | Using Alternative Therapies: A Qualitative Analysis process, which they accomplish, in part, through the freedom to experiment with alternative therapies. For example, in discussing a proposed bill that would include Vitamin C under the controlled substances act, Nora told me this: If they outlawed alternative medicine, would you stop using it? Would you strategize around how to get access to things that will become illegal...? I’d break the law if it was against the law because I think my health is my business and because it might be that my whole life or my whole being depended on that. It has to do with my health, so I really do think that when the state interferes and things like that it is never about protection; it’s about control. Similarly, where assessing the safety of these therapies is concerned, policy- makers should note that “the truth is that most therapies have direct risks and side effects” (Ernst 1997:43, emphasis mine). For example, in response to the headline: Patient Dies of Alternative Cancer Remedy, in the British Medical Journal (Gottlieb 2001), Lade (2000:1491) wrote as follows: “Why not make a headline such as: 10 000 people died from complications of cancer this week even though they had the standard conventional treatment. Therefore, Health Canada would do better to broaden its scope to address the safety of all interventions, whether alternative or allopathic, rather than focus exclusively on the safety of alternative therapies (Balon et al. In addition, regarding the efficacy of these therapies, policymakers need to widen the boundaries of what is considered valid evidence of the effectivene- ss of a therapy to include more than just methods consistent with the natural science model. However, placebos have been shown to be associated with considerable response rates among patients with active disease. This proves that therapies lacking obvious scientific bases for effecting disease improvement may nonetheless work. Therefore, Health Canada would be wise to adopt an approach such as that advocated by a small minority of authors who suggest the benefits of using more than one type of evidence. For example, Barton (2000:256) suggests a “flexible approach in which randomised controlled trials and observation studies have complementary roles,” and White and Ernst (2001:112) allow that uncontrolled clinical trials can be used “as ‘pilot’ or ‘feasibility’ studies to guide subsequent controlled research. From the perspective of the lay user of alternative therapies, greater weight is accorded to lay referral systems and individual experiences of efficacy over medical referral and expert validation in lay participation in these forms of health care (Low 2001b; Kacperek 1997; Boon et al. In general, the conceptual models of assessing efficacy employed by lay people are complex; they are made up of different combinations of elements of both alternative and allopathic healing ideol- ogy, and in these models, lay people assign greater weight to the role of subjective perceptions—over positivistic measures—in establishing the effectiveness of a therapy (Low 2001b). Moreover, lay people show a relative lack of interest in why something works (Low 2001b), suggesting a greater concern with outcomes than with mechanisms of action. A primary concern with outcomes is consistent with the current vogue in evidence-based medicine.

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