About 750 000 Chinese people, mostly men, die from smoking each year. By the time that the young smokers of today reach middle or old age the number will have increased to three million. If current smoking patterns persist tobacco will kill 100 million of the 0.3 billion males now aged 0-29. These figures are more like those from astronomy than medicine. They emerge from two huge studies of smoking in China that are important not only for their public health message but also for their highly innovatory epidemiology (pp 1411 and 1423).
They provide, as Alan Lopez observes (p 1399), the first nationwide evidence of tobacco’s effects in a developing country. Of the four million tobacco related deaths expected worldwide in 2000, half will occur in rich and half in poor countries. By 2030 almost three quarters of the 10 million deaths will occur in the developing world.
Matched against this huge problem, the problem of the supply of doctors in the British NHS seems small—but it is no less real. It is surprisingly difficult to get reliable data on the medical workforce, but two papers we publish today show that about 80% of British doctors are working in the NHS nearly 20 years after graduation—and there is no indication that more doctors are dropping out (pp 1425 and 1429). The proportion of doctors entering general practice is falling and more of those who do enter are women, many of whom work part time. These figures explain the staffing crisis in general practice, which is happening just as many experienced general practitioners are needed to run the new primary care groups (p 1459).
The problem of nurse understaffing of wards in the NHS might be described as medium sized, but Clare Hamon provides a powerful account of the inhumane care that can result (p 1463). A friend died after 12 days in hospital during which he was exposed to other men dying in the ward in horribly undignified ways. A complaint produced the response that: “The ward sister and the manager of patient consumer affairs agreed that the events we described fell below acceptable standards of human decency, but were likely to be repeated time and time again.” This “rationing by dilution” is probably the commonest form of rationing in the NHS.
Hugh McKenna, a professor of nursing, worries that nurses are being systematically downgraded in the NHS and other healthcare systems (p 1403). He identifies a vicious circle whereby low numbers of registered nurses lead to poor quality of care, which leads to high stress and low morale; this in turn leads to high sickness rates, a shortage of nurses, and poor quality of care. The overwork of junior doctors was noticed and “fixed,” says McKenna, but nurses are too often blamed rather than supported.