Letter from. . . Chicago


Weak, vunerable, and insignificant-mere specks between nothingness and infinity-we live in a world that abounds with more big brothers than Prospero's island abounded with spirits. Among these big brothers some are elected, some appointed, some self appointed. They haunt every tree, every house. Some are nimble and kind; others mean and misshapen. Some, like Dr Illinois, are half man half computer, a programme designed to keep track of the state's
health. This big brother telephones 100 households each month and asks people questions about their bad habits. It has found that one in four Illinoisians admit that they are obese, one in three smokes, one in three has elevated blood pressure. About one in five will have taken more than five drinks on one occasion in the past month, and 12% take more than 56 drinks in a month. All this information and much more is then fed into an even bigger brother at the Center for Disease Control in Atlanta, which at the end of three years will compute, compare, and evaluate the health of the nation. 


The least intrusive big brothers are the census keepers and sociologists. These have determined that the world's population now stands at five billion. Defying the dire prognostications of Mr Malthus, we continue to multiply on this lush planet at an irrepressible rate. If all goes well we should be six billion by the year 2000, as we grow by 1-7% or 85 million or one Mexico each year. In the United States the population has now reached 240 million, plus one bronze lady of French descent who stands in New York harbour and has recently had a $60m facelift. Altogether, America's
population is increasing by 0 9% a year. It comprises 29 million blacks, 17 million classified somewhat arbitrarily as Hispanics, 500000 people serving in the armed forces, and about an equal number of doctors. About 27 million people live in California, which is the most populous state, followed by New York (17 7 million), Texas (16-6 million), and Pennsylvania (11 8 million). Florida, from 2-8 million in 1950, has grown to 116 million, surpassing Illinois, which is in sixth place with 11-5 million. Some 22% of Americans are under age 15, compared with 40% in many developing countries. An estimated 1F5 million Americans may be carriers of the acquired immune deficiency syndrome (AIDS). So far 30 000 have developed AIDS and about half of them have died.


Eligible widowers gobbled up

Yet overall Americans are now also dying each year in greater numbers than ever before. This is merely because people are living longer, so that the proportion of older people has increased. Some 28 million Americans are now over 65 years old, and 2'7 million are over 85 years, the so called "old, old people." Currently the mean life expectancy stands at 74-6 years, highest for white women (78-7 years), then black women (73-6 years), white men (71 7 years), and
black men (65 7 years). Women still outlive men, and probably always will, but the edge is narrowing as more women smoke and die from lung cancer and respiratory diseases. Indeed, lung cancer will soon replace breast cancer as the most common cause of death in women. But other forms of cancers have declined, and so has cardiovascular disease, so that in the past 15 years death rates for heart disease have decreased by a quarter and for stroke by a half.
Interestingly, the surplus of older women surviving confers an unexpected bonus on the surviving men, who have many single women to chose from. This is because there are only two surviving men over 65 for every three women of that age. Furthermore, while most of the women over 75 are widowed the men are mostly married. So the telephone starts ringing as soon as the wife dies, and most eligible widowers are gobbled up quickly. Many of the new liaisons end in marriage, but many old folks have grown wise and have prenuptial agreements to keep their assets separate. So much for census keepers and mere observers of the human comedy. 


Other big brothers are more intrusive. In Georgia they watch what people do in their bedrooms. Last year the United States supreme court took a narrow view and blessed this pastime by a narrow five to four majority, upholding Georgia's antisodomy law that punishes for up to 20 years in prison any act "involving the sex organs of one person and the mouth or anus of another." Yet while the appeal was that of two homosexual men arrested for acts committed privately at home it was noted that the law itself was not specifically directed against homosexuals but applied equally to heterosexuals and even married couples. Though rarely enforced, such antisodomy laws have existed in all states. Indeed, in 1960 an Indiana court sent a dentist to prison on the testimony of a policeman who had looked through the window into the bedroom.


In 1961 Illinois was the first state to decriminalize private sex between consenting parties, and some 25 other states have since followed suit. But in upholding the Georgia statute the majority judges argued that the constitution conferred "no fundamental right on homosexuals to engage in sodomy," that laws regulating private conduct have "ancient roots," and that striking down antisodomy laws might prevent states from legislating against incest or child abuse. Yet dissenting judges opposed this invasion of privacy as not justified by one's distaste for homosexuality. One judge wondered if 20 years in prison did not also violate the constitution's eighth amendment forbidding cruel and unusual
punishment. The press likewise disagreed, shuddering at the thought of policemen entering people's bedrooms to regulate "the most private of human association," referring to John Stuart Mill's view that what causes no harm to a third party is no legitimate concern of government, and calling the decision "a gratuitous and petty ruling, and an offence to American society's maturing standards of individual dignity."


What influences sex crimes?

Other big brothers served on the attorney general's commission on pornography and decided after some wrangling that sexually violent magazines, books, and films could lead to rape and other crimes. This was contrary to a 1970 presidential commission that had reached the opposite conclusion and had urged the repeal of antipornography laws, to the consternation of President Nixon who ignored the recommendations. This time a conservative commission
produced a 200 page document that critics called more of a moral or religious pamphlet than a serious scientific document. In this the commissioners objected particularly to the scenario where a woman rejects a man's advances, is raped, then grows ecstatic, and begs for more. Such portrayal, they thought, would promote the rape myth and victimise women. They also agreed to condemn child pornography but were divided on the effects of mere nakedness and "pure sex." Then they rounded off the report with 92 recommendations on how government and private organisations could prevent the production and distribution of obscene material. But they aroused civil liberty groups by calling on private groups to band together and file complaints, monitor judges, pressure local prosecutors, and boycott or picket stores selling pornographic materials. Calling it a conservative witch hunt, critics thought that the commissioners had
exceeded their mandate in order to further their personal and religious views; and indignation rose to a pitch when it was shown that the commissioners had written on official paper to several retail stores threatening to publish their names if they did not stop selling certain magazines. Thus the report came to be viewed as an excuse for censorship and repression, the issue changing from pornography to liberty.


Another issue of interest to big brothers is regulating pregnancybenefits in the workplace. This subject has been confused ever since the 1964 Civil Rights Act forbidding discrimination on the basis of sex. But in 1976 the supreme court allowed discrimination in favour of pregnancy, and then congress passed a law that pregnant women must receive the same benefits as workers with comparable (nonpregnancy) "disabilities." In California-and also in nine other
states, including Illinois-the legislatures meanwhile passed laws requiring employers to grant pregnant women four months' unpaid leave (even if leaves are not granted for other disabilities) and obliging them to allow the women to return to their original jobs. It was this law that the employers challenged when a telephone receptionist sued because on returning from maternity leave she was assigned to a different position. In their claim that the state law violated the federal statute the employers were supported by the chamber of commerce and also, paradoxically, by women's groups fearing that making it too expensive to hire women would cause industry to hire more men. In what some called a confused ruling the supreme court upheld the Californian law, arguing that federal law forbade discrimination against but not in favour of women.  Probusiness groups, however, thought that the ruling would increase female unemployment in the nine states in question, even if congress were to act favourably on the proposal to grant unpaid "paternity" leave to men. But there was less controversy when in a separate decision the supreme court upheld a Missouri law that
denied unemployment compensation to women choosing not to return to work after their maternity leave. And many economists thought that in the long run everybody would- benefit if congress did not succumb to what they called the European disease of dictating working conditions.


"If we don't do it others will"

Meanwhile big brothers are invading the health care playing fields in droves in defiance of all Malthusian formulations. Leading the pack is the Joint Commission on Accreditation of Hospitals, now ready to carry out ongoing reviews of illnesses, procedures, and operations in all hospitals. Acting under its usual motto "if we don't do it others will" the commission was stung into action at least in part by a much criticised federal report releasing hospital mortality rates without taking into consideration local conditions, patient mix, and severity of illness. Also watching are the state medical boards, which in response to earlier complaints of leniency have lately disciplined more doctors than ever before. Helped by certain changes in state laws they acted in one year on complaints against some 2000 doctors, causing their licences to be revoked, suspended, or restricted, placing them on probation or reprimanding them. Government officials were pleased but thought more should be done about the 5% of doctors-believed to be impaired, drunk, incompetent, or senile- who should not be allowed to practise or should have their privileges restricted. An almost equal proportion of psychiatrists, according to one survey, have had sexual relations with their patients, but some questioned the reliability of this report-both as overstating or understating the problem. Some psychiatrists, however, claimed that such relations were therapeutically beneficial, and one third said that the contact had been initiated by the patient. Also in the big brother business are the peer review organisations (PROs), mandated by the federal government
to oversee the practice of medicine and now facing extended duties. Soon they will be expected to conduct second surgical opinion programmes, review ambulatory surgery, health maintenance organisations, quality of care in hospitals, and specifically all cases readmitted within one month, as well as denying Medicare payment for substandard medical care. Then we have the Food and Drug Administration, restricting the use of the non-steroidal antiinflammatory
drug suprofen for causing flank pain and uricosuria; and university research committees are increasingly concerned about new instances of research fraud, fabrication of data, and falsification of results.


Yet even the politicians are now under scrutiny, as shown by the recent award of the Nobel prize to James Buchanan. His public choice theory, which applies marketplace principles to politics, argues that politicians in a democracy are motivated in their decisions more by self interest than by altruism, statesmanship, or national interest. According to his model political parties and bureaucrats constantly react to the wishes of the individual voters, coalitions, and special interest groups, often spending excessively unless kept in check by certain rules. Though regarded by some as stating the obvious, this formulation has apparently not been studied systematically before. It may thus represent a new way of looking at the behaviour of self interest groups in a variety of systems, in government, in smaller groups, and even in the family. It might also find application in hospitals, especially when it comes to allocating resources, setting priorities, sharing facilities, starting new programmes, or setting out to plan a new hospital facility.

A woman in her 30s has a two year history of grand mal epileptic fits in the premenstrual phase; she has premenstrual syndrome with classic symptoms in this week. What treatment is advised?


Menstrual exacerbation of epilepsy ("catamenial epilepsy") was first described 100 years ago, the usual pattern being an increase in fits around the time of the menses. Endocrine investigations in women and animals show
that oestrogen increases the frequency of seizures but progesterone protects against them, and it has been suggested that the cyclical pattern of catamenial epilepsy is due to a reduction of fits during the luteal phase of the
cycle. 1-' According to a recent report from England, clobazam 20 or 30 mg a day given for 10 days around menstruation is an effective treatment for catamenial epilepsy, and tolerance to this regimen does not occur.4 In
America medroxyprogesterone acetate, given either by mouth or parenterally, has been used with some success in women with intractable epilepsy and has been suggested but not yet evaluated as a treatment for catamenial
epilepsy.5 Oophorectomy may produce a cure but not always. i It is not clear how often catamenial epilepsy occurs in conjunction with the premenstrual syndrome. The cause of the premenstrual syndrome is unknown, though
many theories have been proposed, and no single remedy is reliably effective in every case, though both benzodiazepines and progestogens are among the many suggested treatments.6-JAMES OWEN DRIFE, 'senior lecturer in
obstetrics and gynaecology, Leicester.


1 Newmark ME, Penry JK. Catamenial epilepsy: a review. Epilepsia 1980;21:281-300.
2 Backstrom T. Epileptic seizures in women related to plasma estrogen and progesterone during the menstrual cycle. Acta NeurolScand 1976; 54: 321-47.
3 Laidlaw J. Catamenial epilepsy. Lancet 1956; ii: 1235-7.
4 Feely M, Gibson J. Intermittent clobazam for catamenial epilepsy: tolerance avoided. J7 Neurol NeurosurgPsychiat 1984; 47: 1279-82.
5 Mattson RH, Cramer JA, Caldwell BV, Siconolfi BC. Treatment of seizures with medroxyprogesterone acetate: preliminary report. Neurology 1984; 34: 1255-8.
6 O'Brien PMS. The premenstrual syndrome: a review of the present status of therapy. Drugs 1982; 24: 140-51.