By E. Asaru. Illinois College.

The need was assumed to be finite and quantifiable panmycin 250 mg generic, the ballot box the best place to decide the total budget for health buy panmycin 500mg with mastercard, and doctors the only ones able to determine the resources that would satisfy the need of each patient. But need as assessed by medical practitioners has proved to be just as extensive in England as anywhere else. The fundamental hope for the success of the English health-care system lay in the belief in the ability of the English to ration supply. Until about 1972 they did so, in the opinion of an author who surveyed British health economics, "by means in their way almost as ruthless but generally held to be more acceptable than the ability to pay. But this stern commitment to equality prevented only those astounding misallocations for prestigious gadgetry which provided an easy starting point for public criticism in the United States. Since 1972 the Health Service in Britain has undergone a traumatic change, for complex economic and political reasons. The initial success of the Health Service and the present unique disarray in the system make predictions for the future impossible. Yet curiously, England is also one of the few industrialized countries where the life expectancy of adult males has not yet declined, though the chronic diseases of this group have already shown an increase similar to that observed a decade earlier across the Atlantic. The number of physicians and hospital days per capita seems to have doubled between 1960 and 1972, and costs to have increased by about 260 percent. The Russians, for instance, limit by decree mental disease requiring hospitalization: they allow only 10 percent of all hospital beds for such cases. The proportion of national wealth which is channeled to doctors and expended under their control varies from one nation to another and falls somewhere between one-tenth and one-twentieth of all available funds. Excepting only the money allocated for treatment of water supplies, 90 percent of all funds earmarked for health in developing countries is spent not for sanitation but for treatment of the sick. From 70 percent to 80 percent of the entire public health budget goes to the cure and care of individuals as opposed to public health services. All countries want hospitals, and many want them to have the most exotic modern equipment. The poorer the country, the higher the real cost of each item on their inventories. As to cost, the same is true of the physicians who are made to measure for these gadgets. The education of an open-heart surgeon represents a comparable capital investment, whether he comes from the Mexican school system or is the cousin of a Brazilian captain sent on a government scholarship to study in Hamburg. It is clearly a form of exploitation when four-fifths of the real cost of private clinics in poor Latin American countries is paid for by the taxes collected for medical education, public ambulances, and medical equipment. But the exploitation is no less in places where the public, through a national health service, assigns to physicians the sole power to decide who "needs" their kind of treatment, and then lavishes public support on those on whom they experiment or practice. Once President Frei of Chile had started on one palace for medical spectator-sports, his successor, Salvador Allende, was forced to promise three more. The prestige of a puny national team in the medical Olympics is used to intensify a nationwide addiction to therapeutic relationships that are pathogenic on a level much deeper than mere medical vandalism. Only in China at least, at first sight does the trend seem to run in the opposite direction: primary care is given by nonprofessional health technicians assisted by health apprentices who leave their regular jobs in the factory when they are called on to assist a member of their brigade. The achievements in the Chinese health sector during the late sixties have proved, perhaps definitively, a long- debated point: that almost all demonstrably effective technical health devices can be taken over within months and used competently by millions of ordinary people. Despite such successes, an orthodox commitment to Western dreams of reason in Marxist shape may now destroy what political virtue, combined with traditional pragmatism, has achieved. The bias towards technological progress and centralization is reflected already in the professional reaches of medical care. China possesses not only a paramedical system but also medical personnel whose educational standards are known to be of the highest order by their counterparts around the world, and which differ only marginally from those of other countries. Most investment during the last four years seems to have gone towards the further development of this extremely well qualified and highly orthodox medical profession, which is getting increasing authority to shape the over-all health goals of the nation. University-trained personnel instruct, supervise, and complement the locally elected healer. This ideologically fueled development of professional medicine in China will have to be consciously limited in the very near future if it is to remain a balancing complement rather than an obstacle to high-level self-care. But there is no reason to believe that cost increases in pharmaceutical, hospital, and professional medicine in China are less than in other countries. For the time being, however, it can be argued that in China modern medicine in rural districts was so scarce that recent increments contributed significantly to health levels and to increased equity in access to care. But the fundamental reason why these costly bureaucracies are health-denying lies not in their instrumental but in their symbolic function: they all stress delivery of repair and maintenance services for the human component of the megamachine,79 and criticism that proposes better and more equitable delivery only reinforces the social commitment to keep people at work in sickening jobs. The war between the proponents of unlimited national health insurance and those who stand up for national health maintenance, as well as the war between those defending and those attacking all private practice, shifts public attention from the damage done by doctors who protect a destructive social order to the fact that doctors do less than expected in defense of a consumer society. Beyond a certain point, what can produce money or what money can buy restricts the range of self-chosen "life.

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Avoidance Therapy Complete avoidance of an allergen results in a cure when there is only a single allergen cheap panmycin 250 mg amex. For this reason purchase panmycin 500mg overnight delivery, attempts should be made to minimize contact with any important allergen, regardless of what other mode of treatment is instituted. Allergic rhinitis associated with a household pet can be controlled completely by removing the pet from the home. If the patient is allergic to feathers, he or she should be advised to change the feather pillow to a Dacron pillow, or to cover the pillow with encasings. Mold-sensitive patients occasionally note their precipitation or aggravation of symptoms after ingestion of certain foods having a high mold content. Tips for patients with allergic rhinitis In most cases of allergic rhinitis, complete avoidance therapy is difficult, if not impossible, because aeroallergens are so widely distributed. Attempts to eradicate sources of pollen or molds have not proved to be significantly effective. In the case of house dust mite allergy, complete avoidance is not possible in most climates, but certain measures decrease the exposure to antigen. Instructions for a dust-control program also should be given to the patient with house dust mite sensitivity. The most practical program is to make the bedroom as dust free as possible, so that the patient may have the sleeping area as a controlled environment. The patient should wear a mask when house cleaning if such activity precipitates significant symptoms. These simple measures are often enough to enable the patient to have fewer and milder symptoms. Pharmacologic Therapy Antihistamines Antihistamines are the foundation of symptomatic therapy for allergic rhinitis and are most useful in controlling the symptoms of sneezing, rhinorrhea, and pruritus that occur in allergic rhinitis. They are less effective, however, against the nasal obstruction and eye symptoms in these patients. Antihistamines are compounds of varied chemical structures that have the property of antagonizing some of the actions of histamine ( 63). Activation of H1 receptors causes smooth muscle contraction, increases vascular permeability, increases the production of mucus, and activates sensory nerves to induce pruritus and reflexes such as sneezing ( 64). Activation of H2 receptors primarily causes gastric acid secretion and some vascular dilation and cutaneous flushing. The H3 receptors located on histaminergic nerve endings in brain tissue control the synthesis and release of histamine ( 65). They may also decrease histamine release from mast cells and release of proinflammatory tachykinins from unmyelinated C fibers in the airways. The antihistamines used in treating allergic rhinitis are directed against the H 1 receptors and thus are most effective in preventing histamine-induced capillary permeability. Many of the first-generation antihistamines also result in anticholinergic effects, which account for side effects such as blurred vision or dry mouth. Because so many are available, it is best to become familiar with selected antihistamines for use. In practice, clinical choice should be based on effectiveness of antihistaminic activity and the limitation of side effects. However, contrary to previous belief, pharmacologic tolerance to antihistamines does not occur, and poor compliance is considered to be a major factor in treatment failures (69). Thus, there is no rationale for the practice of rotating patients through the various pharmacologic classes of antihistamines. In general, elimination half-life values of antihistamines are shorter in children than older adults. Drowsiness in some patients with antihistamines is mild and temporary and may disappear after a few doses of the drug. Because patients exhibit marked variability in response to various antihistamines, individualization of dosage and frequency of administration are important. Recent studies have reported that these drugs may be administered less frequently than previously recommended because of the prolonged biologic actions of these medications in tissues ( 70,71). These drugs are usually tolerated by older patients, who may have benign prostatic hypertrophy or xerostomia as complicating medical problems. Because fatal cardiac arrhythmias occurred when terfenadine and astemizole were given concomitantly with erythromycin (macrolide antibiotics), imidazole antifungal agents (ketoconazole and itraconazole), or medications that inhibit the cytochrome P-450 system ( 71), these drugs have been removed from the United States market. This side effect has not been seen with fexofenadine (the active carboxylic acid metabolite of terfenadine). Loratadine has been reported to be 10 times less potent against central than peripheral H 1 receptors (79). In adults, a 10-mg dose is approved for treatment of seasonal allergic rhinitis, but higher doses may have greater bronchoprotective effects for histamine-induced bronchospasm.

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