epidemiology duncan memorial lecture public participation ... · 3journalofepidemiology...

3Journal of Epidemiology and Community Health 1995;49:348-353

Duncan memorial lecture

Public participation in health care quality

Lowell S Levin

With my presentation there will have been aneven dozen Duncan lecturers. It is ex-traordinary how the work and character ofWilliam Henry Duncan has caused the selectionof such a diverse array of themes. Each ofthe Duncan lectures, however, found in DrDuncan's work a strand ofcommon cause withtheir own interests. And I am no exception.Duncan knew from his experience with theauthorities, be they governmental or pro-fessional, that for public health to advance itmust build a public constituency of informedcitizens. The horrendous poverty of Liverpool,its crowded housing and lack ofsanitation were,of course, obvious to the middle class but thepowerful link ofsuch conditions with high levelsofmorbidity and mortality needed Dr Duncan'sdocumentation to build the basis for publicunderstanding of the public health preventionoption. This may have been the first time thata purposeful effort was made to enlist publicsupport for a specific public health action.

Since Duncan's day, of course, there hasbeen a steady increase in the encouragementof public participation in moving the publichealth agenda forward. Progress toward fullpublic participation has not, however, beenconstant or without professional/governmentalresistance. Sharon Arnstein, an American cit-izen health advocate, developed nearly 25 yearsago the so called "ladder of participation" thatdescribed eight levels of participation. Thesestarted with informing, consultation, and plac-ation and moved to three degrees of whatArnstein referred to as "citizen power" - part-nership, delegated power, and citizen control.'Clearly Dr Duncan climbed the first severalsteps on the ladder and was probably inclinedto seek public-professional partnership as well.But nearly a century had passed before seriousstrategic consideration was given to involvingthe public as partners in health planning, del-egating specific power of self determination inhealth care, or placing citizens in full controlof the health enterprise.We are presently a long way from the latter

and are still tentative about "partnership" andlay self determination in health. We in thehealth and related professions remain quitecaught up in the exclusivity of our "qual-ifications" in health matters and view withsuspicion the ability of ordinary citizens toprovide criticism or even to comprehend thecomplexities of health actions, be they at thepolitical or personal level. We are, at the same

time, absolutely convinced of the scientificmerit and wisdom of our professional expertise.Ordinary citizens have beliefs - we have know-ledge. This, despite mounting evidence ofpubliccompetence in health decision-making2 con-current with mounting evidence ofthe fallibilityof the medical and public health professions.3Of course, these two realities are not usually

juxtaposed, but professional critiques of thelay role in health have an undercurrent ofdefensiveness. The view is that the proponentsof the lay role, especially in personal care, arereacting critically to limitations of professionalcare.4 Perhaps. But what this points out is thediscomfort health professionals feel as they seethe erosion of their power as health and healthcare become increasingly social ideas wheremany voices and many resources want to havetheir contributions acknowledged.The popularisation of health does take its toll

on traditional roles, traditional constructions ofreality, and the egos invested in them. Is nothingsacred anymore, some ask? Does demo-cratisation know no bounds? Will the timecome when plebiscites will replace scientificinquiry to determine truth? Will citizen control,ending professional dominance,5 as we havegrown to know and cherish it, destroy healthgains already achieved? Or are we entering anew era of health development where layand professional collaboration, with full pro-fessional and public oversight will bring uscloser to the World Health Organization's ideal-istic goal of health for all? What is going onhere and where might it take us.

In my time with you this evening, I want torespond to these questions as they redefinehealth as common property, in its achievement,maintenance, and restoration. I cannot professan unbiased view of consumerism and health,because I could not get away with it for verylong anyway. Too many of my British col-leagues in the College of Health and thePatients' Association have shared panels orpodia with me as we challenged what in earlierdays we called the establishment. What savesyou (us) from my bias now is that I no longerhave to rely on impressions, anecdotes, andrhetoric.

Lay initiatives in personal health careSince the late 1970s there has been an extra-ordinarily productive research effort, largely inthe UK, USA, and Canada that documents the

Department ofEpidemiology andPublic Health,Division ofInternational Health,Yale UniversitySchool of Medicine,60 College Street,PO Box 3333,New Haven,Connecticut06510-8034, USAL S Levin

Presented at theUniversity of Liverpool7 December 1994

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extent and quality of lay initiatives in personalhealth care, social care, and most recently in theheretofore sacred domain of quality assurance.This is not to say that we have reached thepromised land of a full text on how any, muchless all, aspects of lay health actions perform,but the research agenda now clearly specifiesthe work yet to be done. We have a map andnow we have the financial support of gov-ernment who were previously reluctant to in-vest in an area of study some felt wasantiestablishment. After all, some argued, iflevels of self care are shown to be high, willthis not be an indication that government ser-vices have failed to meet needs? Or, as somethVd world observers cautioned, promoting layself care may be a "sinister" plot to avoidgovernment responsibility.6

Undoubtedly, some people in the in-dustrialised countries feel the same way.7 Inthis country, it was Dr John Fry who in effectsaid "nonsense" to all of the above; self care isthe base ofthe health care pyramid and essentialfor the efficacy of the overall health care sys-tem.8 A decade later John Last in his classicstudy of self care practices forced considerationof lay practices in "completing the clinical pic-ture in general practice".' Research began tobuild which documented the extent (Wil-liamson and Danaher,"' Pratt," Freer,'2 Elliot-Binns," Alpert, et al'4) and efficacy of lay selfcare practices (Zapka,'5 Knapp and Knapp,'6Litman, 17 Katz8).

Self care - a threat to the status quoIn 1975, what turned out to be a landmark orat least benchmark international symposium onthe "Role of the Individual in Primary HealthCare", sponsored jointly by the University ofCopenhagen and the University of California,Los Angeles was held in Copenhagen at theEuropean headquarters of the World HealthOrganization. The symposium took a hard lookat lay health care practices, clarified roles andfunctions, drew attention to relevant technicaland social issues, and identified priority re-search needs. But acceptance of the lay con-tribution to health and especially to medicalcare was a tough struggle. Nothing came easy.Indeed in my country, the government un-

dertook a study of lay medical care practiceswhich concluded that such practices rep-resented "rampant empiricism", antitheticalto the health and welfare of the Americanpeople.'9 Never mind that 80 to 95% of allillness episodes were selfcared for (and safely!).Never mind that 15 million people in the USAwere in a given census year members ofmutualaid groups. Twenty years ago my government,with the advice of health care authorities it isassumed, were seeking ways of stamping outthe unauthorised practice ofmedicine albeit selfdirected within the family. Those who proposedexpanding lay self care practices were viewednegatively by authorities, both governmental(regulatory) and professional (organised medi-cine). They were seen as promoting an "em-powerment strategy", a serious threat to thestatus quo. And indeed it was.

The women's health movement challengedmedical authority in the boldest and most cour-ageous of ways. Some women's clinics andeducation centres were shut down and theirpersonnel jailed for allegedly practising medi-cine without a license. These women weresaying "enough!" to what they perceived asabuses in the professional medical treatmentthey received. They dared to "go public" aboutthese abuses and arm women with the know-ledge and skills to take charge of their ownbodies. The do it yourself vaginal examinationusing a speculum became the symbol of theirstruggle.

Self protectionIn America, it was the women's health move-ment, and in particular The Women's HealthBook Collective in Boston,20 that firstbroadened the definition of self care to includeconcern for, and ways to protect oneself from,the hazards of professional medical services.Starkly put, women are seen by some healthprofessionals as a disease. Many normal physio-logical phenomena are converted to patho-logies, from puberty to birthing to menopause.Women are "exposed" to medical care five tosix times as much as are men. In the USA andCanada, nearly 60% of women will not reachtheir 65th birthday with an intact uterus! Caes-arean section rates hover around 25%. Mam-mography screening fails to meet knownepidemiological criteria for use. Ultrasound isexcessively used in pregnancy. And womenare overdosed with unnecessary regimen ofprescribed medications. One Canadian phys-ician summed it up:

"Over the last 16 years of medical practice,I have seen many women suffer needlesslybecause their doctors did not really listen tothem, told them that physically based com-plaints were all in their heads and treatednormal events in a women's life as if theywere diseases. Time and again I have seenwomen paying a heavy price for the carelessprescription of antibiotics, birth control pills,hormones, and tranquilizers."'2'In the United States, the relatively benign

self care consumer movement began to reflecta concern for the quality ofprofessional medicalcare and the personal skills required to be moreselfprotecting. The challenges to the hegemonyof medical professionals began to spread inthe mid-70s beyond the borders of women'sgroups. A major rise in public awareness of thehazard of medical care came through the 1975publication of Ivan Illich's severe critique ofmedicine as a source of multiple levels of iatro-genic complications. Many of you can recallthe furore this little volume created in medicalcircles. Illich's work and his persona becamean irresistible irritant. He hit a sensitive spotand opened public debate on a previously tabootopic: the fallibility of medicine. Who was thispriest who dared to expose the secrets ofpriestsof another calling? As a learned philosopherwith international standing, Illich could not bedismissed lightly. Perversely, the health pro-

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fessionals could not get enough of him. Timeand again he was asked to explain his positionat conferences and seminars of medical prac-titioners and academics. His views began, aswell, to attract the attention of lay voluntaryhealth groups. He broadened awareness of thelimits and hazards of medical care at physical,psychological, and socio-politicial levels.

End of the age of innocenceThe age of public innocence regarding medicalcare and its supporting institutions was comingto a close in America. Soon a plethora of bookson medicine's shortcomings began to maketheir way into the popular trade market. Themost successful in the USA was Dr Robert SMendelsohn's Confessions of a Medical Hereticin which the author ".... tells you how to guardyourself against the harmful impact upon yourlife of doctors, drugs and hospitals."22 A re-spected clinician, Mendelsohn was also chair-man of the Medical Licensing Committee forthe State of Illinois and a faculty member of theUniversity of Illinois School of Medicine. Hispublic testimony was a shock to the medicalcommunity. Some colleagues labelled him morea traitor than heretic. But public interest waskeen, quickly making Confessions a best seller.That same year (1979) Dr Richard Taylor,

a member of the Doctors' Reform Society inAustralia, wrote an equally audacious book,but a nonetheless meticulously documentedaccount of the adverse effects of medical care.His book, Medicine Out of Control, had as itssubtitle "the Anatomy of a Malignant Tech-nology".2' Now, Australians are a kind andgentle people not ordinarily given to hyperbole,much less to frontal attacks on respected socialinstitutions. But Taylor's critique seems to havestruck a responsive chord even among somegeneral practitioners who had reservationsabout medical specialists who they chargeddid not encourage patients to make informeddecisions regarding the appropriateness andsafety of high tech medical procedures.Another publicly oriented trade book, this

time by an Australian lawyer and journalist,concentrated its attack not only on the "hugehidden toll of medical malpractice in Australia,but also how the law enabled negligent andincompetent doctors to escape penalty ... [and]how medical defence organisations use an arrayof 'dirty tricks' to stifle legal action bypatients."21 Arguably biased as a lawyer, authorStephen Rice does seem to have done a carefuljob of documentation as if preparing a legalbrief. His work tapped another aspect of publicconcern about the quality of care issues: thebelief that the medical establishment is an im-penetrable club with little possibility for or-dinary citizens to gain access to performancedata on practitioners or institutional care. Suchrestricted access to quality of care informationdiminishes patients' capacity to make personalcare decisions as well as sound political judge-ments about medical care reform. With regardto patient access to information, one con-tributor to the Victorian (Australia) Law Re-form Commission's report on Informed Decisionsabout Medical Procedures wrote:

"Other doctors, however, still cling to thenotion that 'doctor knows best'! They believethat their patients expect the doctor to tellthem what to do, rather than to encouragethem to make their own informed decisions.Confronted by this attitude, patients are oftenconfused; they do not know what informationthey should be given, how to ask for it, orwhat they should do if they think that theyhave not been properly informed or suitablytreated. "25

Nor has the public been well informed aboutthe efficacy of the medical care system. Evenin medical care systems considered exemplary,such as Canada's, the overuse and sometimesmisuse of high tech procedures is com-monplace. Canadians are just now becomingaware of the reason for long waits for electivesurgery, long emergency room queues and otherapparent discrepancies between the image ofhaving the best system and the reality of a"rationed" service.26

Quality of medical careNow, in order to make clear the basis forthe growing public concern for the quality ofmedical care, I offer some aspects of the Am-erican experience. latrogenic complications arenot frivolous matters there. The table shows afew examples which will give some sense of themagnitude of the problem.27

I do not mean to suggest that Americanmedical care or medical care in other in-dustrialised countries is a disaster. But we can-not ignore that old aphorism: one third ofmedical encounters help, one third make thingsworse, and one third neither help or hurt.

Studies of the quality of medical care in theUnited States over the past 15 years, however,have shown no appreciable improvement in keyindicators such as rates ofnosocomial infection,medication errors, anaesthesia errors, un-necessary surgery (except the slight drop incaesarean sections), laboratory errors, and xray diagnostic errors. With accelerated use oftechnology there is further room for com-plications at the hands of inadequately trainedor supervised operators, as in the case oflaparoscopic surgery.29

Current strategies for quality control havenot obviously improved the situation. The com-bined efforts of hospital infections committees,surgical and medical audits, quality assurancereview boards, and medical licensing boardsdoes not seem to have contributed to a sig-nificant gradient of improvement. Even a newUSA government oversight programme thatattempts to track the movement ofincompetenthealth care providers has not been sufficient.Similarly, the USA system for reporting de-fective hospital equipment has had little effecton the use of such equipment. Governmenthospital accrediting agencies do review, inspect,and approve hospitals, but "in reality theseorganizations labor under inconsistent stand-ards and yield poor inspection results .... miss-ing two out of three quality-of-care problemsrelated to physicians' care in hospitals."30 So it

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The quality of medical care - some aspects of the US expenrence

* Only 10 to 20% of all procedures currently used in medical practice have been shown to be efficacious incontrolled trial (OTA 1978).

* The reporting of a procedure's overuse or obsolescence has a very slow impact on the practice of medicine(Rand Corporation/UCLA 1987).

* Nearly a quarter of all hospital admission and 15% of doctors' office visits are unnecessary; and 53% oftime spent in the hospital is medically unnecessary.

* Five-10% of American physicians are incompetent to practice medicine, not including those withincapacities such as drug abuse, alcoholism.

* Laboratory testing: approximately two thirds of tests are useless to irrelevant, with an overall 4% errorrate. In 1985 this error rate represented 140 million test results.

* Approximately 5% of patients in hospital, according to a 1984 Harvard study "sustained injuries thatresulted from their medical care and not the underlying disease". 1-35% was ascribed to medicalnegligence.28 This study, however, did not include a wide variety of treatment related injuries such asnosocomial infections, diagnostic errors, or unnecessary surgeries or unnecessary invasive testing.

* The nosocomial infection rate is now 5-10% of hospitalised patients.* The medication (hospital) error rate not using a unit-dose system averages 11-6% of medication

administrations.

* Five million surgical procedures are unnecessary (21% caesarean section rate).* Twenty two per cent of hysterectomies are unnecessary (mostly involving women under 40 years).

was inevitable that the public would perceivethat its health interests were not being ad-equately protected by the government and pro-fessional agencies and that public pressure forreform was necessary.

Lay health care is increasingAt the same time, the strong base of publicinterest in personal health action in the USAkeeps growing. Now there is increased accessto the technologies of medical care (note the 10billion dollar do it yourself medical equipmentindustry), greater access to effective medication(switch from prescribed to over the counterproducts), and above all a tremendous ac-celeration in health and medical informationvia books and magazines, electronic media (12TV doctors), and syndicated health columnsin the daily press. One estimate is that thereare over 7000 book titles in the general categoryof do it yourself medical care. The range ofsubjects runs from standard protocols text,3'dealing with common medical problems,3233selecting appropriate medications,34 to a pleth-ora of holistic and alternative medical texts.35There is also a modest literature on self pro-tection in medical care, although its appealis largely confined to a rather sophisticatedaudience. One of the earliest of these texts waswritten by a physician who was seeking toencourage a new kind of patient "... assertive,questioning, capable of making decisions thatare vital to his survival."36 The latest book,Whenyour Doctor Doesn 't Know Best, is subtitled"229 Errors Even the Best Doctors Make andHow to Protect Yourself'.37

The People's Medical SocietyAmerica is arguably the world's most con-sumerist and litigious society. Americans havea core mistrust of government and professionalassociations devoted to the well being of theirprofession. And, as noted earlier, the reverse istrue as well. American government agencies

and health professional organisations, with fewexceptions, were never keen on public em-

powerment in health. Professionals seem tohold all the cards. They are organised and,well financed, and influential with governmentauthorities. The public, on the other hand,while increasingly better informed about healthand medical care had no focal point for theirviews and priorities, until 1983 when America'sfirst national health consumer organisation wasformed. Well financed through a generous en-dowment by health book publisher, RodalePress, the People's Medical Society began lifewith a sophisticated strategy to enroll membersin every state. Eventually the People's MedicalSociety reached 115 000 members, to becomethe largest consumer health organisation inAmerica.The goal of the organisation is to improve

the quality of professional medical care throughincreasing public disclosure of relevant data;mobilising public political action at all levelsof government; empowering individuals to takeself protective action in the use of medical care;and investigating and reporting the competenceof health care providers and institutions. I shallgive only a few examples of the actions takenin these areas.The People's Medical Society has pro-

mulgated or vigorously supported laws re-quiring hospitals to disclose publicly androutinely data on nosocomial infection rates,rates of diagnostic and treatment errors, fre-quency of surgical procedures, caesarean sec-tion and hysterectomy rates, and the status ofmalpractice law suits against hospital healthcare personnel. With regard to political action,the society mounts highly focused membershipcommunications campaigns addressed at legis-lators. As many as 45 000 communicationson behalf (or opposed to) a piece of healthlegislation have been directed at legislators ina 48 hour period. These have been very effectivein expanding access to information, in tight-ening up serious penalties for medical mal-feasance, and in providing safeguards againstalcohol and drug impaired physicians.

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The society continues to press state gov-ernments to change from a physician licensuresystem to a certification system. This wouldinclude triannual written, oral, and practicaltesting of all physicians and certifying onlythose skills where competence is demonstrated.No more lifetime licenses would be issued.A certification approach would help assistpatients select practitioners according to spe-cific competencies, regardless of the specialitylabel.38 You can imagine the uproar this pro-posal is creating. On the other hand, duringthis tight budget period more and more le-gislatures are interested in saving the averageof $400.00 cost of incompetent care which isnow added to each hospital bill!

Central work of the societyThe central work of the society, however, con-centrates on individual empowerment. A phys-ician evaluation form is completed by membersafter each office visit and filed by the societyfor reference by other members. The evaluationcovers 20 aspects of the physician contact -for example waiting time, respect for patientintegrity and privacy, quality of explanationsprovided, suggestions for self care and pre-vention, encouraging second opinions, etc.Physicians are invited to subscribe to thePeople's Medical Society "Code of Good Prac-tice" which entitles them to be entered in thesociety's recommended list of physicians.

Quality control, it seems is most effective atthe point of medical contact. Members areencouraged when possible to take a relative orfriend along to the doctor, or otherwise taperecord the encounter for further review at aless stressful time. If the physician objects tothe presence of a friend or relative, or taperecording, members are advised to see anotherphysician, if this is feasible.The society helps members prepare for med-

ical encounters. Selfprotection guides are avail-able with such titles as Take this Book to theHospital wvith you,3 Take this Book to the Ob-stetrician with you,40 and Take this Book to theGynaecologist with you. 41 Several members re-ported that merely placing a copy ofthe hospitalbook at the bedside had a positive effect on thecare givers' attitudes and performance!The People's Medical Society undertakes

periodic assessments of hospitals through sur-veys of physicians and nurses practising in agiven catchment area. The results of their pref-erences and the rankings of hospitals are pub-lished widely and serve to remind the publicthat quality, as judged by people who shouldknow, varies among hospitals. It demonstratesthe importance of being selective, of increasingchoice.

Public participation in assuring quality ofmedical care in the USA has become seriousbusiness, tough and unrelenting in its process ofdiscovery and demands for reform. It uncoversunpleasant facts about the real work of medicalcare and urgently challenges government andprofessionals to take action now. When it wasseen, for example from the records of medicallicensing boards in the 50 American states that

only a tiny portion of malpractising physiciansare censured, much less barred from practice,the People's Medical Society began a campaignto make all membership on medical licensureand examining boards exclusively lay - no phys-icians - and to move to a jury system whereexpert medical and scientific witnesses couldbe heard. Lay representation also is being ar-gued for on hospital medical and surgical auditteams. These are seen as necessary remediesin an environment where there is not now anybuilt in system for public accountability.

The style of confrontationYou might have guessed that the style of thePeople's Medical Society is irreverent and pro-vocative. This style, in itself, serves to com-municate that it is alright, legal, ethical, andpossible to criticise sacred cows openly and tochallenge the conspiracy of silence within thehealth professions. Anger is a healthy emotionand fear of retribution is far less a threat to aperson's well being that passivity in the face ofdoubtful medical competence. Those messagesseem to be taking hold in an America wheremedical care was the last holdout against con-sumerism.

I am told by friends in Europe and Canadathat a confrontational style is typically Am-erican. It would not work elsewhere, they say.Perhaps not. But one way or the other, theissues of information disclosure, equity, ac-countability, and empowerment will have to beaddressed everywhere if we wish to achievethe promotion of health as envisioned in theDeclaration of Alma Ata and in the WorldHealth Organization's Ottawa Charter.42 Aninitiative is now being considered in Hungaryto organise a panEuropean association ofhealthconsumer organisations. Countries of centraland eastern Europe and the newly independentstates of the former Soviet Union present apropitious opportunity to develop a consumervoice in health. The optimistic view is that suchan innovation can take root in this period oftransition, where suspicion of government andauthority in general runs high and the strategiesof democracy are still novel and inviting.

The futureAs chair ofthe board of directors of the People'sMedical Society, and at the same time a long-time member ofthe public health establishment(and an academic at that!), I am well awarethat an agenda of nihilism, doctor bashing, andgeneral antiestablishmentism would be shallow,self serving, and ultimately counterproductive.We must avoid replacing one tyranny withanother. This can be accomplished by con-tinuing to expand the partners in dialogueamong public interest groups and the healthprofessions where the partnership is mutuallyrespectful. We should not misconstrue or beembarrassed by the passion in the voices oneither side.

William Henry Duncan was nothing if he wasnot courageous. He took on the establishmentwith strong and persistent pressure. And he

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knew the value of a public constituency tomove the political agenda.Were he with us today, I believe he would

be as undaunted in pursuit of solutions toproblems from within the health professionsand health system as he was in pursuit ofproblems within the community. He had toconvince people of the environmental threat,its causes and its remedies, in the face of otherbeliefs and social priorities. I doubt he wouldtolerate any obstacle, not even his own pro-fessional identity, to bringing people around toa reasoned solution. We could use a little ofthat courage today in public health to evaluateour contribution to health on a full continuumfrom -1 to + 1. Promoting health as Hip-pocrates emphasised, starts with doing no

harm. Not a bad idea.

1 Arnstein S, as quoted in Schiller PL, Steckler A, DawsonL, Patton F. Participatory planning in community healtheducation. Oakland, CA Third party Publishing Company:1987:20-21.

2 Carlson R, Newman B, eds. Issues and trends in health. St.Louis: CV Mosby, 1987.

3 Skrabanek P, McCormick J. Follies and fallacies in medicine.Buffalo, NY: Prometheus Books, 1990.

4 Round table discussions. World Health Forum. 1981;2(2):191-201.

5 Friedson E. Professional dominance: The social structure ofmedical care. New York: Atherton Press, 1970.

6 Deria A. Self-Care puts the onus on the people themselves.World Health Forum 1981;12(2):194.

7 Katz AH, Levin LS. Self-care is not a solipsistic trap: Areply to critics. Int3JHealth Serv 1980;10:329-36.

8 Fry J. Self-care, its place in the total health care system. Areport by an independent working party. London: Guy'sHospital, 1973:15.

9 Last J. The iceberg: Completing the clinical picture ingeneral practice. Lancet 1963;ii:28-31.

10 Williamson JD, Danaher K. Self-care in health. LondonCroom-Helm, 1978.

11 Pratt L. The significance of the family in medication. journalof Comparative Family Studies. 1973;4: 13-31.

12 Freer CB. Self-care a health diary study. Med Care 1980;18:853-61.

13 Elliott Binns CP. An analysis of lay medicine. J7R Coll GP1973;23:255-64.

14 Alpert JJ, Kosa J, Haggerty RI. A month of illness andhealth care among low income families; Public Health Rep1972;82: 1004-12.

15 Zapka J, Averill BW. Self-care for colds: A cost effectivealternative to upper respiratory infection management.Am _7 Public Health 1979;69:814-16.

16 Knapp DA, Knapp DE. Dccision-making and self-med-ication: preliminary findings. Ami7 Hospital Pharm 1972;29: 1004-12.

17 Litman TJ. The family as a basic unit in health and medicalcare: A social-behavioral overview. Soc Sci Med 1974;53:495-519.

18 Katz HP, Clancy RR. Accuracy of home throat cultureprogram: A study of parent participation in health care.Pediatrics 1974;53:687-9 1.

19 National Analysts Inc. A study ofhealth practices and opiniolns.Springfield, VA: National Technical Information Service,US Department of Commerce; 1972, 343.

20 The Boston's Women's Health Book Collective. Our bodzes,ourselves. New York: Simon and Schuster, 1971.

21 Carolyn De Marco. Medical malpractice. In: Hinks KM,ed. Misdiagnosis: women as a disease. Allentown: People'sMedical Society, 1994:59.

22 Mendelsohn RS. Confessions of a miedical heretic. Chicago:Warner Books, 1979.

23 Taylor R. Medicine out of control. Melbourne: Sun Books,1979.

24 Rice S. Somne doctors make you sick. Auckland: Angus andRobertson, 1988.

25 Skene Dust jacket: You, your doctor and law. Oxford Uni-versity Press, Melbourne, 1990:IX.

26 Rachlis M, Kusher C. Second opinion. Toronto; Collins,1989.

27 Inlander C, Levin LS, Weiner E. Medicine on trial. NewYork: Prentice Hall Press, 1988:308.

28 Center for Medical Consumers. Health Facts. 1990;XV(132): 1.

29 Altman LK. Standard training in laparoscopy found in-adequate. New York Times. Dec 14, 1993:C3.

30 Anonymous. Quality of care in the hospital. People's MedicalSociety Newsletter 1992; 11:1.

31 Vickery DM, Fries JF. Take care of yourself. Reading, MA:Addison-Wesley Publishing Company, 1986.

32 Simons A, Hasselbring B, Castleman M. Before you call thedoctor. New York: Fawcett Columbine, 1992.

33 Howell M. Healing at home. Boston: Beacon Press, 1978.34 Graedon J, Graedon T. Graedon's best medicine: from herbal

remedies to high tech Rx breakthroughs. New York: BantamBooks, 1991.

35 Pelletier KR. Holistic medicine: Fromn stress to optimunm health.New York: Delacorte Press, 1979.

36 Belsky MS, Gross L. How to choose and use your doctor. NewYork: Arbor House, 1975, jacket.

37 Podell RN. When your doctor doesn't know best. New York:Simon and Schuster, 1994.

38 Andrews L. Deregulating doctors. Allentown, PA: People'sMedical Society, 1986.

39 Inlander CB, Weiner E. Take this book to the hospital withyou. New York: Pantheon Books, 1991.

40 Morales K, Inlander CB. Take this book to the obstetricianwith you. Reading, MA: Addison-Wesley Publishing Inc,1991.

41 Maleskey G, Inlander CB. Take this book to the gynecologisttcirh you. Reading, MA: Addison-Wesley Publishing Inc,1991.

42 Ottawa charter for heath promotion. World Health Or-ganization, Health and Welfare Canada, CanadianPublic Health Association, No. 17-21, Ottawa, Canada,1986.

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