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11 OCTOBER 1989: O~ Ca'7'7 NEW ZEALAND'MEDICA,LJOURNAll }' ') 539 presence: and found!that nalidiicic acid was contraindicated if there was history of'convulsive disorders. I di.uontinued'nalidizic acid and substituted cotrimoxazole. I am happ!y to reporv the child has been free of'convulsions for the last 5 weeks. Also there is a marked improvement in personality with no evidence of hyperactivity. I am unable to, predict whether the child will be free of convulsions and hyperactivity in the future. The lesson to be learnt from this experience is to listen to the oncerns and observations of parents. They are with the child all e time. We cannot remember the aide effects and c~ntraindications of drugs all the time. If in doubt don't be tlctant to refer to the text book even in the presence of patients. Th ' bud'get and certifying fitness for work The ' licy of a single benefit for people temporan'ly excluded from the "d work force is good. Many factors hinder rehabilitation and it `s unreal to pin it all on one. However the proposed greater mone rewards for long term sickness disability w171 put more press 'e on certifying doctors. I' personally find assessment of sicknes disability more difficultthan accident. When one is paid by the ' tient, one must do the best thing for that patient, who often in 'rprets this in purely financial terms. 1 find that patients, even one ' I have never seen before, often resent any attempt to reassess 'sabilit- - v. Patients will go to the doctor who takes the softest lin'. Clearll• the budget proposals will not work unless careful co ideration is given to the mechanism for determining who is fit r work: People eicluded from the paid work force for eight reasons: Lack of su ble employment. Very few people with long term disability are knable to do any sort of work. A caring;socoety would resen,e suitab jobs for the disabled. Certifying somebody fit for light w-ork is ile as sporting enthusiasts prefer these jobs too. We are wedded the concept of a forty hour working week. There would'be many vantages if twenty hour week employment were moregenerally. a'ab1e: For many attempting rehabilitation this would be a much kiore realistic initial goal: I am dismayed at tbe budget target of 1 000 unemployed by the end of 1992. It would be fairer to aim at 200 000 working only twenty hours a week. Only the totall' vdis bled! should be exduded'from the work force. Lack of training d skills. These are required for most jobs suitable for people 'th disability. Retraining is the key to rehabilitation. Care of other perso . Many are excluded from the paid work force by the needs ofch' dren and invalids. People often combine these responsibilities w'th paidlemployment but only if their health remains good;. Lack of motic.ation. I u ually find that this is better described as having given up hope. What use is rehabilitation if there is no job? Where a patient asbeen on high wages the job that follows is likely to be lower 'd. A major obstacle to rehabilitation would result from the pro se.d earnings related compensationn for long term sickness disa ` ity. Place of residence. People w have given up hope often attempt to make life bearable by mo , g to pleasant places. These are likelv to be remote from rehab 'tation facilities or employment opportunities. Others attempt relieve boredom by becoming itinerant. Congenital disabilities. illness. ccident. These last three are the only causes that come into the of expertise of the medical i profession: Even here we often the assistance of other disciplines. Seldom are medical co di.tions the sole causes of exclusion from the workforce. It' is impossible to aay wbetbeJ• rehabilitation is possible unless reha 7itation has been tried. I accept that certification by a d acting alone is the only practical way fon short term disabilit However I consider it unwise for these certificates to be ' newable indefinitely;, sometimes by a different doctor each ' . I propose that a time limit of say six months be set. After that. ' sessment should be by a multidisciplinary team, whose chief 'an is rehabl7itation. Patients should be reviewed annually. Even' the medical cause for exelusion from the workforce is unlik to improve, the nonmedical causes may, I consider it wrong taI cliaats that they are permanently useless: Bruce Mackereth, Mercury Ba Health Centre. Whrtunga. Passive smoking in New Zealand In replying:to my earlier letter (NZ Med J! 1989i 102: 448) Drs Kawachi an& Pearce (NZ Med Ji 1989: 102: 479) misunderstand some important issues. They suggest I have not grasped the purpose of' meta•analysis. because I' pointed out many of the studies of passive smoking and heart disease are very small. Nott so; I was making, it dear the overall' meta-analysis would be dominated by the two large studies; based on more deaths 118521 than the other five studies combined (22fi1: and that there were major doubts about the findings from both of these largeatudies. Drs Kaw-achi and Pearce seem to understand my criticisms of the Maryland study I11• but not my comment on the inconsistency of the two reports from Huayams'a study 12.31. Based on 14 years follow up and 406 heart disease deaths among female nonsmokers, Hirsyama lg) reported relative risks. standardised for age and occvpation, of 1. 0.97 and 1s03 according to whether the husband was lil a nonsmoker. (iil an exsmoker or, a smoker of 1-19 cigarettes a day, or (l'ti) a smoker of 20+ cigarettes a day. Based on 17 years follow up and an extra 88 deaths. Hirayama 13) reported relative risks, standardised for age, of 1, 1.10 and 1.30 for the same compariaona. If standardisation for. oocupation had no effect, it can be estimated that the relative risks for the last 3 years follow up would be 1„ 2.85 and 5.07; a magnitude of effect inconsistent with his previous results and also so large as to be totally implausible. If standardisation for occupation did have an effecL why did Hirayama not standardise for it in the later analysis? The heart disease data. which contribute largely to the estimated'bumber of deaths per year eaused'by passive smoking'. are very unconvincing. The American Cancer Society million person study has provided'the best evidence relating to apouse smoking and lung cancer hl iand'it is unfortunate no similar data on heart disease have ever been preseated. The study has far more deaths in nonsmokers than the Japanese or Maryland studies, and the quality of evidence is much superior. Drs Kew-achi and Pearce say they cannot specifically comment' on my elaim that misclassification of a proportion of smokers as nonsmokers might explain Ilie observe& association between passive smoking and lung cancer as two of my citations are to papers given at conferences. This overlooks all' the other references, one to a book (s) available since 1988 which contains all the essential material. I have forwarded each of them a complimentary copy:' Drs Kaw-achi and Pearce quote the remark of Hill ls) that consistencv, of an observation across different studies increases confidence in the belief that the association is causal. This ignores the possibility of a common source of bias affecting all the studies. Mi.,rlassif,cation of smoking habits is just such a bias. Measuring something 27 times with a faulty instrument is no better than measuring 13 times. What is needed is an accurate instrument. Until better studies are designed, estimates of deaths caused by passive smoking based on meta-analysis are likely to be seriously inaccurate. The views I express do not necessarily reflect those of the tobacco industry: Many organisations consult me, including some tobacco companies, but the views I express are always my own, and the only reason for expressing them is to promote scientific understanding of issues of which I have expert knowledge. Peter N Lee (Mrl:. PN Lee Statistics and Computing Ltd. Cedar Road. Sutton, Surrey SM2 5DA, UK. ' '-A _ n . '. 1..._ pr Ar_ f - _ t~_-r:~ht Law (lliti 17 L.S. GsA 1. H.1.~ a1.5.eAr DP. Cm.md Gw. Cb- E. H..rt dii..me.aR.titj ie mumakers hvmW wifL. moi- . Am JEpid®mi ]98a. ,127: 91b22'. t_ Hv.y.m..7..Am:eebe4 -w. d Mvy em4en b.v.. Y'i9hr n.kd k'.o9 oe~ • mdry hm J.p.n.. Br l4.d J 19f:: 282: 1!J-s.. & HsW.e. T. t..M uear . J bp.a .E.cu d nuviuon .edd p..vs -ba[9 l- Mi..ll. l[. Can.. P.,.da- t®9 ~ m.w .md p~uonN.. 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