Sir.—After 30 years' experience in the delivery of health and medical services to people of low economic resources, I found "Patterns of Primary Care That Create Dependency" by James and Ackerman1 and the comments on it most interesting.
James and Ackerman do provide an accurate description and evaluation of most public services. Dr Morris Green's observation (p 534) on overdependency in the private sector is also well established. Paternalism (or maternalism) is a more palatable word than colonialism to most of us.
Drs Julius B. Richmond and Milton Kotelchuck (pp 534-535) appeared to overlook James and Ackerman's concession to the appropriateness of paternalism in certain situations, clinging to the concept that "more is always better." While their approach is generally considered liberal philosophy, the number of patients continuing to be dependent on public financing belies success in liberating people to the real attributes of human dignity—self-esteem, independence, and