COMMUNITY HEALTH STUDIES VOLUME XII, NUMBER 2. 1988 REPETITION STRAIN INJURY AND PSYCHIATRY Denise Russell Department qf General Philosophy* Universit,. of Sjdnej,. 2006. Introduction Evidence is rapidly accumulating for the physical causation of RSI but, in the New South Wales context, a psychiatric perspective is strongly advocated by the psychiatrist, Dr Y. Lucire. The General Insurance Office (GIO) has been persuaded of the value of this approach and has used Dr Lucire as a consulting psychiatrist for RSI claims.’ The initial cost is high: $220-$350 for each patient examination and accompanying letter of expert opinion? but the GI0 is likely to save a great deal in the long run, as it is Dr Lucire’s view that compensation is actually detrimental to the health of ‘RSI’ sufferers. She is providing the GI0 with a medical justification for the non-payment of claims. If Dr Lucire’s position cannot be defended, then this is harsh punishment indeed for the injured workers. It may also have serious consequences for those people suffering from RSI out of the work force in that they may gain a false impression of themselves as psychiatrically disordered rather than physically injured and seek help accordingly. In addition, Dr Lucire claims that personality tests reveal the personality types that are vulnerable to ‘RSI’ and suggests that this information might be useful in private industry: “While personality testing might not be an appropriate means of screening for the Australian Public Service, there seems little doubt that private industry will take information in this area into account in its own employment procedures”.’ If her view is indefensible then much time, effort, money and anxiety will be wasted with such testing and some people will be denied employment without justification. In this paper, I look at Dr Lucires hypothesis and consider some problems with the evidence that she has provided. I have not entered into hypotheses concerning physical causation of RSI and claim only expertise, as a philosopher, in the logic of argumentation. Dr Lucire’s hypothesis: ‘RSI’ as psychogenic illness Dr L u c k expresses her hypothesis in slightly different ways in different papers but a common theme is the link that she posits between psychiatric and economic issues. For example: RUSSELL I34 ‘RSI’ is a“psychogenic illness. where symptoms of feared disease are acquired through the unconscious identification of a dependent group with an affected person and with the wish for the benefits thereby accrued. A shared tension associated with the work environment finds release in the development of pain”.J(This‘shared tension associated with the work environment’ is sometimes referred to as ‘conflict’.s) ‘RSI’ is an “occupation neurosis”. Its “spread is dependent on sight and hearing, and is suggestive of an epidemic of psychogenic iilness, where symptoms of feared disease are acquired through the unconscious identification of a dependent group with those so affected through a wish for the security accrued to them.’? Because of her belief that ‘RSI’ is a psychogenic illness, Dr Lucire claims that “it is not logical or scientific to speak of injury”. She goes on to state that “an employer is clearly liable for a work related injury. However when the so called ‘injury’ is not an injury, is not caused by work but isa manifestation of fear of work, or of mixed feelingsabout working or is simply not relevant to work, should that person be dipping into that same honey pot?“h To continue using the Iabel‘RSI’is, for Dr Lucire, itself a psychiatric problem: “‘RSI’ is NOT a diagnosis. RSI is a highly abnormal mode of classification . . . The application of an incorrect lapel is abnormal diagnosis behaviour.”7 “The new nomenclature, ‘RSI’ is in itself pathogenic”.” Critical evaluation of the evidence presented for this hypothesis Argumenr ,froni Analogv Dr Lucire states that in 1955 there was an illness affecting three hundred staff in London Hospital. No physical cause was isolated but a viral origin was postulated. Dr Lucire grants that it cannot be proved that there was no virus but concludes that there was an epidemic of psychogenic pseudo illness. In a parallel fashion, she claims that there have been many diagnoses made of ‘RSI’ yet no physical cause has been isolated. Hence it “is suggestive of an epidemic of psychogenic illness”.y There are at least two problems with this COMMUNITY HEALTH STUDIES
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COMMUNITY HEALTH STUDIES VOLUME X I I , NUMBER 2. 1988
REPETITION STRAIN INJURY AND PSYCHIATRY
Denise Russell
Department qf General Philosophy* Universit,. of Sjdnej,. 2006.
Introduction Evidence is rapidly accumulating for the physical
causation of RSI but, in the New South Wales context, a psychiatric perspective is strongly advocated by the psychiatrist, Dr Y. Lucire. The General Insurance Office (GIO) has been persuaded of the value of this approach and has used Dr Lucire as a consulting psychiatrist for RSI claims.’ The initial cost is high: $220-$350 for each patient examination and accompanying letter of expert opinion? but the G I 0 is likely to save a great deal in the long run, as it is Dr Lucire’s view that compensation is actually detrimental to the health of ‘RSI’ sufferers. She is providing the G I 0 with a medical justification for the non-payment of claims. If D r Lucire’s position cannot be defended, then this is harsh punishment indeed for the injured workers. It may also have serious consequences for those people suffering from RSI out of the work force in that they may gain a false impression of themselves as psychiatrically disordered rather than physically injured and seek help accordingly.
In addition, D r Lucire claims that personality tests reveal the personality types that are vulnerable to ‘RSI’ and suggests that this information might be useful in private industry:
“While personality testing might not be an appropriate means of screening for the Australian Public Service, there seems little doubt that private industry will take information in this area into account in its own employment procedures”.’ If her view is indefensible then much time, effort,
money and anxiety will be wasted with such testing and some people will be denied employment without justification.
In this paper, I look a t Dr Lucires hypothesis and consider some problems with the evidence that she has provided. I have not entered into hypotheses concerning physical causation of RSI and claim only expertise, as a philosopher, in the logic of argumentation.
Dr Lucire’s hypothesis: ‘RSI’ as psychogenic illness Dr L u c k expresses her hypothesis in slightly
different ways in different papers but a common theme is the link that she posits between psychiatric and economic issues. For example:
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‘RSI’ is a“psychogenic illness. where symptoms of feared disease are acquired through the unconscious identification of a dependent group with an affected person and with the wish for the benefits thereby accrued. A shared tension associated with the work environment finds release in the development of pain”.J(This‘shared tension associated with the work environment’ is sometimes referred to as ‘conflict’.s) ‘RSI’ is an “occupation neurosis”. Its “spread is dependent on sight and hearing, and is suggestive of an epidemic of psychogenic iilness, where symptoms of feared disease are acquired through the unconscious identification of a dependent group with those so affected through a wish for the security accrued to them.’? Because of her belief that ‘RSI’ is a psychogenic
illness, Dr Lucire claims that “it is not logical or scientific to speak of injury”. She goes on to state that “an employer is clearly liable for a work related injury. However when the so called ‘injury’ is not an injury, is not caused by work but isa manifestation of fear of work, or of mixed feelingsabout working or is simply not relevant to work, should that person be dipping into that same honey pot?“h
To continue using the Iabel‘RSI’is, for D r Lucire, itself a psychiatric problem: “‘RSI’ is NOT a diagnosis. RSI is a highly abnormal mode of classification . . . The application of an incorrect lapel is abnormal diagnosis behaviour.”7 “The new nomenclature, ‘RSI’ is in itself pathogenic”.”
Critical evaluation of the evidence presented for this hypothesis Argumenr ,froni Analogv
D r Lucire states that in 1955 there was an illness affecting three hundred staff in London Hospital. No physical cause was isolated but a viral origin was postulated. Dr Lucire grants that it cannot be proved that there was no virus but concludes that there was an epidemic of psychogenic pseudo illness. In a parallel fashion, she claims that there have been many diagnoses made of ‘RSI’ yet no physical cause has been isolated. Hence it “is suggestive of an epidemic of psychogenic illness”.y
There are a t least two problems with this
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argument. Firstly, the illness in 1955 was confined to a particular time and place, whereas ‘RSI’ is not so confined. Thus the analogy breaks down. Secondly, from the fact that physical causation has not been established, it cannot be concluded that the causation must be psychogenic. The physical cause(s) of AIDS and Multiple Sclerosis have not been established yet. this does not force us into the conclusion that the causation must be psychogenic. Indeed the correlations between RSI and the use of a skill or certain equipment strongly suggest physical causation. Dr Lucire’s reasoning would lead us to conclude that many diseases which are now recognized as physical were once in fuci psychological (when their cause was unknown). ?his amounts to a suggestion that the type of disease changes with changing knowledge.
The Ourrw?w Argutiietir Dr Lucire makes the claim that:
“if diagnosed and treated with relevimt specificity, physical disorders go o n to normal recovery which is not the case with ‘RSI”’. From this, she concludes that ‘KSI’ is not a
p h y s i ca I d i s o r d e r . l o U n f o r t u n a t e I y , acc u rate diagnosis and treatment d o not always prevent people dying or living with permanent disability as a result of physical disorder. Measured irt logical terms this argument is very weak, yet it has been repeated in at least two other papers:
-- “Physical problems recover, whereas a neurosis will endure”. ‘RSl’endures, hence it cannot be a physical problem. I t must be a neurosis.lt
- - “Injuries d o recover; RSI ‘victims’often don’t.’’ So RSI is not an injury.’?
Argutnent from Natural History Dr Lucire asserts that the notion that RSI has a
local cause is supported by the relevant trade unions and is associated with an epidemic. (From the context, it seems that she is equating‘local cause’with ‘organic disorder’.) In an attempt to counter this view, she claims that the symptoms vary and have been classified in different ways: “attempts a t classification have included spasmodic and paralytic, tremulous and neuralgic, tremulous, spastic and ataxic, simple, progressive and dystonic, and painful and non-painful. But this natural history on its own would leave little room for doubt as to the hysterical nature of the disorder.”” (Emphasis added.)
This argument is a very weak one. The varying symptomatology could as easily point to varying local causation (organic disorder) as to hysterical disorders.
Argutnent ,from Observation of Golfers Dr Lucire argues as follows:
“The ‘yips’ in golfers is the main sporting variant [of RSI] and anyone who has seen Sam Snead or Ben Hogan swing a perfect practice shot followed by a jerky and somewhat spastic putt would find it difficult to postulate an organic mechanism fo r the phenomenon.”t: Why? There is n o law governing organic
mechanisms which says that they have to operate in a visibly consistent fashion in every instance. Also. acknowledging sporting variants seems out of linc with her hypothesis: where is the ‘dependent group’ that the golfer could be identified with!
Tl?i. Feniini.st Argunietit I l r Lucire points to the fact that most ‘KSI’
sufferers are women who are in a subordinate position. I f it is claimed that the woman is‘injured by uncontrollable forces’ then she simply becomes a victim. one of ‘an army of splinted soldiers’. powerless and dependent. Thus ‘The Injury Theory should rile Feminists’. If , on the other hand, thc disorder is regarded as functional, then, Dr Lucirc states, the woman is deemed capable of regaining control and of ‘getting a grip on her~e1f.I~ Dr Lucire uses this imagery in another place as well:
“If the interview [between doctor and RSI sufferer] covers relevant matters she will be made aware of all the forces which are pushing her towards the development of a psychogenic illness and she can, if she so decides get a grip on herself.”’s (Emphasis added.) There are several points here that deserve
comment. There is a growing amount of evidence that the forces implicated in RSI are controllable. including posture, sustained repetitive ac1ivity.a high degree of static muscle load in trunk, shoulders and arms, performance of work against gravityand use of excessive force.16 Secondly, if one is injured then there is a sense in which one is a victim but recognition of this is not anti-feminist; that is, it does not work against the interests of women. If the injury is recognized as such then measures can be taken to allow recovery, for example, rest. Changes can be made in the work situation to prevent injuries to other workers. If the injury is denied, then far worse consequences seem to follow. There is a wide body of agreement that if the injury is detected soon enough and the person rests then this will help to prevent further damage. Another bad consequence of denying the injury is that changes may not be made to the work place in order to prevent future injuries.16 Such consequences would be against the interests of women. So Dr Lucire has things the wrong way around. Of course part of her point is that if a physical injury is attributed to an RSI sufferer then this may prevent her from seeing the appropriateness of desirable psychiatric help. Indeed it might, but is
RUSSELL 135 COMMUNITY HEALTH STUDIES
that help really appropriate or desirable? In a comprehensive survey of the approaches to RS1 documented by the Australian Nat ional Occupational Health and Safety Commission (NOHSC), the psychiatric approach is included with the comment: "This theory has not been ~ubstantiated".'~ According to Brennan, author of the book entitled, 'R.S.I.*,"psychiatrists who hold the mass hysteria theory have no obvious success in treatment", 18
Dr Lucire is wrong in stating that the person is necessarily powerless and dependent. If she stays in the work situation, she may insist on modifications including rest periods, better designed equipment, better work place design. To help the sufferer outside the work place a wide range of aids to independent living have been suggested. Examples include stabilizing bowls with a pull-out board under the bench with holes cut in it to fit mixing bowls,cleaning teeth by holding the tooth-brush between thumb and palm or replacing buttons with Velcro squares.lY
Commenting on the claim that attention needs to be directed towards the injured worker's daity living activities such as vacuum cleaning, ironing, washing clothes, sewing, and washing, Dr Lucire says "It is beyond the realms of possibility that many of these activities can be affected by physical causes".20This is a very surprising comment in terms of everyday experience. What if the arms had been broken? Elsewhere she says of an RSI sufferer who is unable to d o housework that she is"like a Victorian cripple with the vapours? This is irrelevant.
The Epidemiological Argument The epidemiological argument put by Dr Lucire
runs a s follows: if 'RSI' is a work related injury then one would expect to find similar levels of incidence of 'RSI' in similar jobs. Yet this is not found. "At present time incidence of symptoms of keyboard RSI varies from nil to 40 per cent, while apparently other factors are constant".2*
There is a crucial, unsupported phrase in this argument: uvhile apparently other factors are constant. How does she know that? Were the chairs used the same? Were the positions of the hands on the keyboards the same? Was the desk height matched? Were the keyboards all the same type? Did all the workers have the same rest breaks? Were they all working at the same speed? The statistic in such reports means almost nothing if details are not provided about the situations which are supposedly matched.
The 'Australia only' Argument Another argument that Dr Lucire puts forward
for the psychogenic origin of 'RSI' is that it is "currently running in epidemic form in Australia only. "23
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Recently this claim has been examined and found to be false. Brennan cites illustrations from the nineteenth century to the present day in France, England, U.S.S.R., China, U.S.A., Finland and Japan.24 In a chapter on the internationalexperience *
of RSI, the NOHSC Report mentioned above gives further evidence of RSI in Japan, Sweden, Norway, Finland, Switzerland, Germany, the United States, Canada and Great Britain, with details on the investigative committees that have been established indicating the widespread concern about RSI.25
The claim that RSI is only a current problem is disputed by the studies that Brennan refers to and the NOHSC Report claims that"the first evidence of an awareness of these injuries in Australia appeared in 1961".2" Also in the local context, Judge Ray Burke, who has been involved in the Australian Workers Compensation Court since 1947, says there have been injuries as long as he can recall. Perhaps the phenomenon is more visible now as it is on the increase with the introduction of new technology and perhaps the users of this technology are more vocal than previous RSI sufferers.
The Conflict Argument A key part of 'RSI' according to Dr Lucire is
conflict. This conflict is partially, if dysfunctionally, solved by the symptoms, symbolically expressed by them and kept out of cons~iousness .~~ These conflicts are almost universally about work.*" Conflict is a key factor in psychogenic illness. Hence RSI is a psychogenic illness.2'
I would like to consider this issue in two stages: conflict before RS1 is experienced; and conflict when RSI is experienced. If it could be shown that people who go on to suffer from RSI have, prior to that time, more conflict than other people, then that would not prove that the conflict was an integral part of RSI. It could be a factor predisposing development of RSI understood as a physical injury in the same way as, say, a tendency to be reckless might predispose one to physical injury or it might be completely unrelated. But all this is very hypothetical as it has not been shown that RSI sufferers have more conflict prior to developing RSI than others. How could information on this be gathered? Dr Lucire claims that the conflict is "kept out of consciousness". Could the collection of information on this issue amount to anything more than a guess about levels of conflict in different groups? Also, given the complexities of modern living and modern work experiences, the stresses and demands, it would be a rare individual indeed who experienced no conflict about anything.
If it did turn out that people who suffer from RSI have more conflict than others then that also would not prove that RSI is a psychogenic illness. The
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conflict may be easily explicable in terrns of wanting o r needing t o keep a job, play a sport or garden, etcetera, and experiencing pain while doing so.
Psychological testing and RSI The arguments presented by Dr Lucire for the
psychogenic hypothesis are seriously flawed, from my perspective as a logician. In addition, valid questions may be raised about practices that are associated with her theoretical approach, such as personality testing. I will discuss briefly the main test used to expose certain problems that arise independently of the RSI theories, as it is often assumed that these tests are unproblematic.
Currently the G I 0 (Australia’s major insurer) is insisting that people making claims for RSI complete two personality tests: An Illness Behaviour Questionnaire and the Minnesota Multiphasic Inventory (M MPI). As mentioned above, Dr Lucire has also recommended personality tests to screen for the likelihood of ‘RSI’ developing.
It is D r Lucire’s belief that certain results on these tests pick out the RSI personality type people who are more vulnerable than others to the development of this‘psychogenic illness’. “These are said to be compulsive paranoid and passively aggressive personality types”.’”
I f the psychogenic hypothesis is inadequately defended then such testing is a degrading ritual for the RSI sufferer. The MMPI has 566 questions which relate to many facets of one’s sexual, political, religious, emotional, social and occupational life. The person sitting for this test is asked to reveal the most intimate details of personal life. Most of us would see this as a n unjustifiable intrusion into our privacy. Of course we may choose to fabricate the answers and the likelihood that this would occur is very high given the low value that is commonly put on honesty in coercive situations - especially where one is required to answer so many questions. Some questions check to see that the person is answering consistently but it is possible to lie consistently. So that is no guide to truth.
The results of these tests indicate what the answerer did on the test, not why she did it. Even if there is no conscious fabrication, the answers may be a totally inaccurate reflection of the answerer’s personality because of an unconscious desire to present a false picture. Disinterest may distort results, too, in that the answerer may not read the question closely enough or may answer in a fairly random manner, sometimes honestly. sometimes not. Some people may be happy to respond honestly to some questions, such as Item 115: ‘1 believe in a life hereafter’ True or False?, but resent others and give a false reply: for example Item 149: ‘I used to keep a diary’ True or False‘? All of these factors
RUSSELL I37
should lead to scepticism about the value of such tests.
In addition, there are certain Americanisms which may put the answerer off answering correctly or may not even be understood, for example, Item 118: ‘In school 1 was sometimes sent to the principal for cutting up.’ True or False?
Finally there are problems inherent in the test, such a s subjectivity or vagueness. The following items for example, could have extremely variable interpretations: 239: ‘I have been disappointed in 1ove’True or False?; 163: ‘I d o not tire quickly’True or False?; 367 ‘I a m not afraid of fire’True o r False’!
Even if the psychogenic hypothesis proposed by Dr L.ucire has support, the use of the personality tests she recommends has to be questioned. But the psychogenic hypothesis has not been adequately supported so the continued use of these personality tests on RSI sufferers or to detect vulnerability for RSI is without foundation.
Concluding Comment Given the apparent logical flaws in Dr Lucire’s
arguments, it is surprising that they have had a f a v o u r a b l e r e c e p t i o n ( a l t h o u g h p e r h a p s understandable from the point of view of those whose economic interests are involved). It is, perhaps, a reflection of the power of psychiatry in modern western culture and a willingness to view more and more phenomena in psychiatric terrns (including criminal behaviour, unusual sexual preferences. developmental disabilities). I have tried to argue against this trend in other papers.?’
Nick Crofts, in the paper ‘RSI ~ How d o doctors know?’, points out the convenience of the victim-blaming approach. It allows us to “forget all about working conditions, poverty, unemployment and alienation, from work. In fact, you can well and truly divert attention from the injuries that unsafe work causes.”j* Economic interests are, of course. important in understanding employers’ reactions to RSI and they help to explain why for instance. the G I 0 continues to use the MMPI , with all its problems, a s a screening device to justify psychiatric referral and perhaps. non-payment of compensation claims.
Evan Willis argues that RSI should be viewed in the context of modern capitalism. a s a condition that has been inflicted upon workers because of excessive product iv i ty d e m a n d s a n d the consequent dehumanisation of work. He points optimistically to the rise in importance of the workers’ health movement in post-war Australian society and goes on to suggest that theconstraints on workconditions that will be introduced to help with RSI problems will be a counter to dehumanisation. He also anticipates certain broad developments of the
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politics of RSI, towards worker participation, work enrichment and industrial democracy? Although I view this as somewhat utopian. it is a refreshing alternative to the political direction of the psychiatric view of RSI.
References
I . See Appendix I . This is a copy of a letter sent by the G I 0 to a number of RSI sufferers who were referred to Dr Lucire.
3. Lucire Y. Submission to the Task Force on ' Repetition Strain Injury' in the Australian Public Service. Oct. 1985.
4. Lucire Y. Neurosis in an Occupational Setting. Unpublished paper, p. 5.
5. Lucire Y. Neurosis in the Workplace. Med J
6. Lucire Y. What the Community Can Do About Epidemic Conversion. Address given to the seminar: RSI: Medical Mythology, 1985, p. 4.
7. Ibid, pp. 1-2. 8. Lucire Y. RSI - A Pathogenic Diagnosis.
9. Lucire, Neurosis in an Occupational . . . Op.
AUSI 1986; 145: 323-327.
Unpublished paper, p. 1.
Cit. pp. I , 2, 5. 10. Ibid, p. 3. I I . Lucire, What the Community.. . Op. Cit. p. 7. 12. Lucire, Submission,. . Op. Cit. p. I I . 13. Lucire, Neurosis in an Occupational . . . Op.
14. Ibid, p. 9. 15. Lucire, What the Cornmunit-v . . . Op. Cit. p. 8.
(Emphasis added.) 16. National Occupational Health and Safety
Commission: Repetition Strain Injury (RSI) A Report and Model Code of Practice. Australian Government Publishing Service, Canberra, 1986.
Cit. p. 6. (Emphasis added).
17. Ibid, p. 5. 18. Brennan, Op. Cit. p. 83. 19. Workers' Health Centre, Information Leaflet,
No. 6, Home Hints for Sufferers of Overuse Injuries, July, 1981; Newsletter of the Tenosynovitis Assoc., No. 6; Western Region Health Centre, Repetition Injury Clinic,'Living
with the problem', Jan. 1983. (All available from Workers' Health Centre, 27 John St., Lidcombe, 2141).
20. Lucire, Submission . . . Op. Cit. p. 7. 21. Lucire, What the Cornrnunitj~ . . . Op. Cit. p. 5 . 22. Lucire, Submission . . . Op. Cit. (Unnumbered
23. Lucire, Neurosis in an Oi.cupaIiona1 . . . Op.
24. Brennan, Op. Cit. pp. 40-47. 25. NOHSC Report, pp. 10- 19. 26. Ibid, p. 21. 27. Lucire, Neurosis in an Occupational . . . Op.
Cit. p. 3. 28. Lucire, What the Cotnmunitj'.. . Op. Cit. p. 5. ;
Submission . . . Op. Cit. (Unnumbered page). 29. Lucire, Neurosis in an Occupational ... Op.
page). 31. Russell D. Who is Mad'? Social Alternatives
1982; 2:4. Russell D. Madness Revisited, Social A1ternatiw.s 1983; 3:2. Russell D. Making Criminals Mad, Australian .!.eft Revie&* 1985; 92. Russell D. Some Philosophical Problems of Psychiatric Diagnosis, Methodology and Science 1985; 19: I . Russell D. Psychiatric Diagnosis and the Oppression of Women, Part I The International Journal qf Social P.%j.chiatry, 1985; 31:4. Russell D. Psychiatric Diagnosis and the Oppression of Women, Part 2. Women and Therapy 1986; 5:4.
32. Crofts N. 'RSI ~ How Do Doctors Know?' New Docror 1986; 40:14.
33. Willis E. RSI as a social process, Community Health Stud 1986; 10:213-21.
RUSSELL I38 COMMUNITY HEALTH STUDIES
APPENDIX
'CITY REGIONAL CENTRE TI0 GEORGE S?REEr. SYDNEY TELEPHONE (02) 21777oOo P.O. BOX K W . HAYMARKET.
I n regard to your r e c e n t c o n s u l t a t i o n w i t h our appointed Pr Y Lucirr your complaint nas been passed on to our Department of n e d i c d S e r v i c e s . c' roms that were g i v e n to you Tor cocopletlon. hn l l l n e s s Behaviour h e s t l o n a i r e an9 a Uinnesota Mu1 t i p h a s i c Invenmry.
Xovever our Office i s c u r r e n t l y avliting
Further compensrtion has been approved s u b j e c t to the satisfactooy complet ion of these foms.
I t would be appreciated i f . y o u c o u l d a t t e n d to t h i s matter urgent ly .
Yours F a i t f u l l s
.- J .EICHIE WORKERS COHPEPISATIOI CLAIMS
R U S S E L L 139 C O M M I I N I T Y HEALTH STUDIES
