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Medicine and Books

A handsome book, rather handsomely priced, this was planned and begun by the late Dr John Baldwin, who was director of the Oxford Record Linkage Study (ORLS), itself the brainchild of Donald Acheson. After Baldwin's death his colleagues saw the book as a memorial as much as a consolidated record of the enterprise. Only part of it is original; 15 of the 20 chapters are reprints of papers published between 1965 and 1983. The five new chapters are found in part I (Theory and methodology) and in part III (Implications). Part II (Applications) is an anthology. The foreword (by Doll) and introduction (by Acheson) describe the origins of computerised record linkage. They reflect the initial enthusiasms and the perceived potential of supplanting tedious and error prone manual processes with electronic technology. Newcombe's reprinted paper (1967) on efficient record linking methods and two new chapters on the practicalities of application outline the scientific basis. They are well worth reading. By contrast, the "applications" induce a sense ofdisappointment. None ofthese papers is unworthy ofa place yet the whole offers little beyond the sum of its parts. There is no indication of the size of the field from which the selection was made, nor of the rationale for inclusion. Those who remember the early, roughly produced products of the ORLS will notice that old friends are missing. Whatever happened to the study of treated fractures of the neck of the femur, linked with death notifications in the following year? It showed to an astonished profession how unsuccessful their successful treatments sometimes were, and the impact of such pioneering investigations might now be difficult to recapture. The anthology also leaves the reader with ill resolved questions. What was discovered? What was disproved? What new approaches did the new tool stimulate? How did it prove its worth? Fox, Goldblat, and Adelstein, for example, present some of the findings from the longitudinal study by the Office of Population Censuses and Surveys. Its establishment and the analysis presented here are a technical tour de force. Yet beyond confirming that mobility and mortality are related it would be difficult to assert that our understanding of health and sickness was greatly enhanced. The study of mortality in women asbestos workers (Newhouse et al) is more directly related to predefined aetiological and preventive questions; yet it was based on a follow up of only 900 women and its success owes more to the ingenuity and manual dexterity of clerical workers than to electronic file handling technique. The high risks of pneumonia after discharge from hospital (Fedson and Baldwin) certainly did depend on large scale longitudinal record linkage, and the study tackled the practical issue of whether to vaccinate against pneumococcal infection. But it leaves the reader still asking whether the risk is higher among discharged patients than among those never admitted, and the recommendation to vaccinate has never been widely applied. And so on; as the sequence unfolds the discomforts persist. Baldwin's final chapter on "Future directions" is interesting. Here we find an enthusiastic exponent and proponent of a new technology nevertheless thoroughly capable of making a dispassionate appraisal. He remarks that "even the convinced reader will experience a sense of unease ... no dramatic discoveries ... have caught the imagination of the medical profession, much less of the general public or of the administrative powers"; and "except in scientific applications, progress seems to have been slow and patchy." Discussing the obstacles to progress, he quotes many: lack of resources; a rapidly changing technology; economic and ethical misconceptions; the non-awareness of clinical and academic staff; unwelcome revelations of the inadequacies of current record keeping systems; long latent intervals between initiating events and outcomes; and the low proportionate yields of prospective studies. He moves on towards a prognosis and a prescription for the future, but here the argument falters. The diagnosis itselfwas insufficiently exact. What, among these multiple obstructions, were the true critical blocks? Can they be removed? Is the critical constraint a question of resources, a question of technical feasibility, or a question of commitment to developing the theoretical basis of preventive medicine and measuring the true outcomes of therapeutic medicine? The issue is not resolved. Is it perhaps that the uncontrolled growth of the scientific approach in areas traditionally governed by wishful thinking is still a pill too hard to swallow?