CAT 1992

Section - 1

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Section-2

Passage 1

The core of modern doctoring is diagnosis, treatment and prognosis. Most medical schools emphasize little else. Western doctors have been analyzing the wheezes and pains of their patients since the 17th century to identify the underlying disease of the cause of complaints. They did it well and good diagnosis became the hall mark of a good physician. They were less strong on treatment. But when sulphonamides were discovered in 1935 to treat certain bacterial infections, doctors found themselves with powerful new tools. The area of modern medicine was born. Today there is a ever-burgeoning array of complex diagnostic tests, and of pharmaceutical and surgical methods of treatment. Yet what impact has all this had on health?

Most observers ascribe recent improvements in health in rich countries to better living standards and changes in lifestyle. The World Health Organization cities the wide differences in health between Western and Eastern Europe. The two areas have similar pattern of diseases: heart disease, senile dementia, arthritis and cancer are the most common cause of sickness and death. Between 1947 and 1964, both parts of Europe saw general health improve , with the arrival of cleaner water, better sanitation and domestic refrigerators. Since the mid 1960s, however, E. European countries, notable Poland and Hungary, have seen mortality rates rise and life expectancy fall. Why? The WHO ascribes the divergence to differences in lifestyle-diet, smoking habits, alcohol, a sedentary way of life (factors associated with chronic and degenerative diseases) rather than differences in access in modern medical care.

In contrast, the huge sum now spent in the same of medical progress produce only marginal improvements in health. America devotes nearly 12% of its GNP to it high technology medicine, more than any other developed country. Yet, overall, Americans die younger, lose more babies and are at least as likely to suffer from chronic diseases. Some medical producers demonstrably do work: mending broken bones, the removable of cataracts, drugs for ulcers, vaccination, aspirin for headaches, antibiotics for bacterial infections, techniques that save new born babies, some organ transplant, yet the evidence is scant for many other common treatments. The coronary bypass, a common surgical technique, is usually to overcome the obstruction caused by a blood clot in arteries leading to the heart. Deprived of oxygen, tissues in the heart might otherwise die. Yet, according to a 1988 study conducted in Europe, coronary bypass surgery is beneficial only in the short term. A bypass patient who dies within five years has probably lasted longer than if he had simply taken drugs. But among those who get to or past five years, the drug-takers live longer than those who have surgery.

An American study completed in 1988 concluded that removing tissue from the prostate gland after the appearance of (non-cancerous) growth, but before the growths can do much damage, does not prolong life expectancy. Yet the operation was performed regularly and cost Medicare, the federally – subsidized system for the elderly, over $1 billion a year.

Though they have to go through extensive clinical trials, it is not always clear that drugs provide health benefits. According to Dr. Louise Russell, a professor of economics at Rutgers University, in New Jersey, although anti – cholesterol drugs have been shown in clinical trails to reduce the incidence of deaths due to coronary heart disease, in ordinary life there is no evidence that extend the individual drug taker’s life expectancy. Medical practice varies widely from one country to another. Each year in America about 60 of every 100,000 people have a coronary by-pass; In Britain about six Anti-diabetic drugs are far more commonly used in some European countries than others. One woman in five, in Britain, has a hysterectomy (removal of the womb) at some time during her life; In America and Denmark, seven out of ten do so.

Why? If coronary heart problems were far commoner in America than Britain, or diabetes in one part of Europe than another, such differences would be justified. But that is not so. Nor do American and Danish women become evidently healthier than British ones. It is the medical practice, not the pattern of illness or the outcome, that differs. Perhaps American patients expect their doctors to “do something” more urgently than British ones? Perhaps American doctors are readier to comply? Certainly the American medical fraternity grows richer as a result. No one else seems to have gained through such practices.

To add injury to insult, modern medical procedures may not be just of questionable worth but sometimes dangerous. Virtually all drugs have some adverse side-effects on some people. No surgical procedure is without risk. Treatments that prolong life can also promote sickness: the heart attack victim may be saved but survive disabled.

Attempts have been made to sort out this tangle. The “outcomes movement” born in America during the past decade, aims to lessen the use of inappropriate drugs and pointless surgery by reaching some medical consensus–which drug to give? whether to operate or medicate?–through better assessment of the outcome of treatments.

Ordinary clinical trials measure the safety and immediate efficacy of products or procedures. The outcomes enthusiasts try to measure and evaluate far wider consequences. Do patients actually feel better? What is the impact on life expectancy and other health statistics? And instead of relying on results from just a few thousand patients, the effect of treating tens of thousands are studied retrospectively. As an example of what this can turn up, the adverse side-effects associated with Opren, an anti-arthritis drug, were not spotted until it was widely used.

Yet Dr. Arnold Epstein, of the Harvard Medical School, argues that, worthy as it may be, the outcomes movement is likely to have only a modest impact on medical practice. Effectiveness can be difficult to measure: patients can vary widely in their responses. In some, a given drug may relieve pain, in others not: is highly subjective. Many medical controversies will be hard to resolve because of data conflict.

And what of the promised heart-disease or cancer cures? Scientists accept that they are unlikely to find an answer to cancer, heart disease or degenerative brain illness for a long while yet. These diseases appear to be highly complex, triggered when a number of bodily functions go awry. No one pill or surgical procedure is likely to be the panacea. The doctors probably would do better looking at the patient’s diet and lifestyle before he becomes ill than giving him six pills for the six different bodily failure that are causing the illness once he has got it.

Nonetheless modern medicine remains entrenched. It is easier to pop pills than change a lifetime’’ habits. And there is always the hope of some new miracle cure -–or some individual miracle.

Computer technology has helped produce cameras so sensitive that they can detect the egg in the womb, to be extracted for test tube fertilization. Bio-materials have created an artificial heart that is expected to increase life expectancy among those fitted with one by an average of 54 months. Bio-technology has produced expensive new drugs for the treatment of cancer. Some have proved life-savers against some rare cancers; none has yet had a substantial impact on overall death rates due to cancer.

These innovations have vastly increased the demand and expectations of health care and pushed medical bills even higher – not lower, as was once hoped. Inevitably, governments, employers and insurers who finance health care have rebelled over the past decade against its astronomic costs, and have introduced budgets and rationing to curb them.

Just as inevitably, this limits access to health care: rich people get it more easily than poor ones. Some proposed solutions would mean no essential change, just better management of the current system. But others, mostly from American academics, go further, aiming to reduce the emphasis on modern medicine and its advance. Their trust is two headed:
(i) prevention is better – and might be cheaper – than cure; and
(ii) if you want high-tech, high-cost medicine, you (or your insurers, but not the public) must pay for it, especially when its value is uncertain.

Thus the finance of health-care systems, private or public, could be skewed to favour prevention rather than cure. Doctors would be reimbursed for preventive practices, whilst curative measures would be severely rationed. Today the skew is all the other way: Governments or insurers pay doctors to diagnose disease and prescribe treatment, but not to give advise on smoking or diet.

Most of the main chronic diseases are man-made. By reducing environmental pollution, screening for and treating biological risk indicators such as high blood pressure, providing vaccination and other such measures – above all, by changing people’s own behavior – within decades the incidence of these diseases could be much reduced. Governments could help by imposing ferocious “Sin taxes” on unhealthy products such as cigarettes, alcohol, maybe even fatty foods, to discourage consumption.

The trouble is that nobody knows precisely which changes – apart from stopping smoking – are really worth putting into effect, let alone how. It is clear that people whose blood pressure is brought down have a brighter future than if it stayed high; It is not clear that cholesterol screening and treatment are similarly valuable. Today’s view of what constitutes a good diet may be judged wrong tomorrow.

Much must change before any of these “caring” rather than “cure” schemes will get beyond the academic drawing-board. Nobody has yet been able to assemble a coherent preventive programme. Those countries that treat medicine as a social cost have been wary of moves to restrict public use of advanced and / or costly medical procedures, while leaving the rich to buy what they like. They fear that this would simply leave ordinary people with third-class medicine.

In any case, before fundamental change can come, society will have to recognize that modern medicine is an imprecise science that does not always work: and that questions of how much to spend on it, and how, should not be determined almost incidentally, by doctor’s medical preferences.

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Passage 2

Smith did not invent economics. Joseph Schumpter observed that “The Wealth of the Nations” did not contain “a single analytic idea, principle or method that was entirely new”. Smith’s achievement was to combine an encyclopaedic variety of insight, information and anecdote, and to distill from it a revolutionary doctrine. The resulting masterpiece is the most influential book about economics ever published. Remarkably, much of it speaks directly to questions that are still of pressing concern.

The pity is that Smith’s great book, like most classics (of 900 pages), is more quoted than read. All sides in today’s debates about economic policy have conspired to peddle a conveniently distorted version of its idea. If his spirit is still monitoring events, it will undoubtedly have celebrated the collapse of communism. But it must also long to meet the politicians who have taken charge of a fine reputation and not so fine profile. And put them right on one or two points.

Today Smith is widely seen as intellectual champion of self-interest. This is a misconception. Smith saw no moral virtue in selfishness ; on the contrary he saw its dangers. Still less was he a defender of capital over labour (he talked of the capitalist’s “mean rapacity”), of the rising bourgeoisie over the common folk. His suspicion of self – interest and his regard for the people as a whole come through clearly in one of his best-known remarks: “People of the same trade often meet together, even have merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.”

Far from praising self-interest as a virtue, Smith merely observed it to be a driving economic force. In “The Wealth of Nations” he explained how this potentially destructive impulse is harnessed to the social good. What is to prevent greedy producers raising their prices until their customers can afford to pay no more? The answer is competition. If producers raise their prices too high, they create an opportunity for one or more among them to profit by charging less and thus selling more. In this way competition tames selfishness and regulates prices and quality. At the same time it regulates quantities. If buyers want more bread and less cheese, their demand enables bakers to charge more and obliges cheese-mongers to charge less. Profits in bread-making would rise and profits in cheese-making would fall; effort and capital would move from one task to the other.Through Smith’s eyes, it is possible to marvel afresh at this fabulously powerful mechanism and to relish, as he did, the paradox of private gain yielding social good. Only more so, for the transactions that deliver a modern manufactured good to its customer are infinitely more complicated than those described by Smith. In his day, remember, the factory was still a novel idea: manufacturing meant pins and coats.

Through Smith’s eyes, it is possible to marvel afresh at this fabulously powerful mechanism and to relish, as he did, the paradox of private gain yielding social good. Only more so, for the transactions that deliver a modern manufactured good to its customer are infinitely more complicated than those described by Smith. In his day, remember, the factory was still a novel idea: manufacturing meant pins and coats.

A modern car is made of raw materials that have been gathered from all over the world, combined into thousands of intermediate products, sub-assembled by scores of separate enterprises. The consumer need know nothing of all this, any more than the worker who tapped the rubber for the tyres knows or cares what its final use will be. Every transaction is voluntary. Self-interest and competition silently process staggering quantities of information and direct the flow of good. Services, capital and labour – just as in Smith’s much simpler world. Far-sighted as he was, he would surely have been impressed. Mind you, modern man has also discovered something else. With great effort and ingenuity, and the systematic denial of personal liberty, governments can supplant self-interest and competition, and replace the invisible hand of market forces with collective endeavour and a visible input- output table. The result is a five-year waiting list for Trabants.

Because Smith was convinced that the market would, literally, deliver the goods, he wanted it, by and large, left alone. He said that governments should confine themselves to three main tasks: defending the people from the “violence and invasion of other independent societies”, protecting every member of society from the “injustice or oppression of every other member of it”; and providing “certain public works and certain public institutions, which it can never be for the interest of any individual, or small number of individuals, to erect and maintain.”

Each of these jobs arises because the market in some ways fails. In the first two cases-collective defence and the administration of justice - the failure is the so-called free-rider problem. People disguise what they are willing to pay for a service that must be provided to everybody or not at all; they want to consume it and let others meet the cost. However the third job the provision of “certain public works and certain public institutions” goes much wider. Indeed, to modern minds, it threatens to be all encompassing. It recognizes not only the free-rider problem but also other species of market failure notably, the effects of private transactions on third parties, or “externalities”. Smith has in mind roads, public education, and help for the destitute. As it turned out, millions of teachers, nurses, firemen, postmen, rubbish collectors, bus drivers and 57,000 varieties of civil servant have since marched through this opening.

Smith’s thinking already seems to permit a great deal of government intervention. Add some modern economics and the floodgates open. For instance, theorists have shown that if just one price in an economy is different from price under competition, efficiency may require other every price to be somewhat distorted as well. Less government intervention, it seems to follow, cannot be assumed to be better. Competition itself has changed out of recognition. Modern economies, it is said, are driven not by countless small producers, but by handful of giant enterprises and monopolistic trade unions. And the rapid pace of industrial change has made the externality of pollution for more obvious than before. Smith, admittedly, is a bit thin on global warming.

Above all, many have forgotten something than Smith saw clearly: that every advantage granted by government to one part of the economy puts the rest at a disadvantage. Accordingly, he talked not of “intervention” -a too-neutral word-but of “preference” and “restraint”. Modern governments offer preference as though it costs nothing: the beneficiaries demand it as of right.

But Smith went further than revealing the penalty in every preference. He also understood that ministers,like markets, fail. A great virtue of unfettered competition, he said, was that “the sovereign is completely discharged from a duty, in the attempting to perform which he must always be exposed to innumerable delusions, and for the proper performance of which no human wisdom or knowledge could ever be sufficient. “ Many of the reasons why markets fail are also reasons why governments fail at the same task. If the consumer refuses to reveal his preferences in a market setting, how are governments to discover them? All too often, moreover, government intervention is itself a cause of the market breaking down which becomes the reason for further rounds of intervention, and so on. In Britain think of tax preferences for housing, rent controls, planning, regulations; America think of tax preferences for borrowing, deposit insurance, leverage buy-outs, financial-market regulation.

In one crucial respect, Smith’s arguments are even more powerful now than in this day. Naturally, he favoured free trade to prevent market failure: “By means of glasses, hotbeds, and hotwalls, very good grapes can be raised in Scotland, and very good wine too can be made of them at about thirty times the expense for which at least equally good can be brought from foreign countries. Would it be a reasonable law to prohibit the importation of all foreign wines, merely to encourage the making of claret and burgundy in Scotland?” Two centuries later, free trade is not just a matter of the cheapest supply; it is also the best way to force producers that might otherwise be near-monopolies to compete. It is perfect folly to complain that today’s big companies render the invisible hand powerless, and to conclude that barriers to trade must go up: trade and competition need each other more than ever before.

Smith was a pragmatist. The principles he expounded on the proper role of government are flexible if anything, too flexible. They are a remainder that imperfect markets are usually cleverer than imperfect governments, but they cannot draw a line to separate good intervention from bad. If governments and voters could be guided by two Smithian precepts, however, the market system that has worked so well would work even better.

First, the competitive clash of self interest against self-interest, however imperfect, has built-in safeguards. Before governments exert their monopoly power to displace it, they must justify themselves. Let the burden of proof always be on them, Second, when preference or restraint are judged to be necessary, use market forces to apply them. Tariffs are better than quotas; taxes are better than bans or direct controls; allocating resources by price (e.g. in health or education) is better than allocating them by fiat, even if the services are then provided “free” (but never forget those inverted commas) to their consumers.

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Passage 3

Atmospheric jet streams were discovered towards the end of World War II by U.S. bomber pilots over Japan and by German reconnaissance aircraft over the Mediterranean. The World Meteorological Organization defines a jet stream as a strong, narrow air current that is concentrated along nearly horizontal axis in the upper troposphere or stratosphere (10 to 50 km altitude), characterized by wind motions that produce strong vertical lateral shearing action and featuring one of more velocity maximum. Normally a jet stream is thousands of kilometers long, hundreds of kilometers wide and several kilometers deep. The vertical wind shear is of the order of 5 to 10 m/sec per kilometer, and the lateral shear is of the order of 5 m/ sec per 100 km. An arbitrary lower limit of 30m/sec is assigned to the speed of the wind along the axis of a jet stream.

With abundant radio-sonic data now available over the Northern Hemisphere it is possible to map the jet streams in the upper troposphere (near 10 to 12 km) in their daily occurrence and variation and to forecast them reasonably well with numerical prediction techniques. Upper-air information from the Southern Hemisphere is still sparse. Constant-level balloons (the so-called GHOST balloons) and satellite information on temperature structure and characteristic cloud formations in the atmosphere are serving to close the data on the global jet stream distribution.

The strongest winds known in jet streams have been encountered over Japan, where speeds up to 500 km/ hr (close to 300 knots) occur. A persistent band of strong winds occurs during the winter season over this region, flowing from the southwest and leading tropical air northern India into juxtaposition with polar and arctic air from Siberia. A similar region of confluence of air masses with vastly different temperatures exists over the central and eastern United States, leading to a maximum frequency of occurrence of jet streams during winter and spring.

The main impact on weather and climate comes from two distinct jet stream system: the Polar - Front Jet Stream, which is associated with the air mass contracts (the fronts) of middle latitudes and which gives rise to the formation of squalls, storms, and cyclones in this latitude belt; and the Subtropical Jet Stream, which lies over the subtropical high-pressure belt, and which is characterized by predominant subsidence motions and, hence, with fair weather. During summer, a belt of strong easterly winds is found over Southeast Asia, India, the Arabian Sea, and tropical Africa, this tropical, easterly jet streams is tied in with the weather disturbances of the Indian and African summer monsoons and their heavy rainfalls.

Because of their strong winds, jet streams play an important role in the economy of air traffic. Head winds must be outlasted by extra fuel, which takes up useful cargo space. Clear air turbulence (CAT) is often associated with the strong vertical wind shears found in the jet stream region. It is a hazard to passenger and crew safety, and, because of the increased stresses on the air frame, it decreases the useful life of the aircraft.

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Passage 4

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Passage 5

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