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in a letter to the New York Times after the licence was awarded. "There are only two, two-lane roads leading from the plant. There are inadequate shelters". The Massachusetts attorney general is still trying to persuade a judge to revoke the licence, but a decision may not be forthcoming for six months. For the US nuclear industry, Seabrook was essentially a pyrrhic victory. The legal quarrel with environmentalists and State authorities took nearly 20 years and bankrupted the operator. Disillusion in the trade is widespread. The business magazine, Forbes, calls the nuclear programme "the largest managerial disaster in US business history". Estimates of money wasted on investments and cost overruns reach US$100 billion. There have been no new starts since the scare over the partial core meltdown at Three Mile Island, Pennsylvania, in 1979. Utilities executives say there won’t be any, either, unless public opinion changes. There is not much chance of that. Elsewhere, for the most part, nuclear power is in retreat. Plans to expand have been delayed or scrapped in the UK, the Soviet Union, West Germany, Austria, Greece, Italy, Belgium, the Netherlands, Switzerland, Finland, and Sweden. "Only in France and Japan are there plans for expansion", says Christopher Flavin, of Worldwatch Institute in Washington. Flavin, author of Reassessing Nuclear Power: the Fallout from Chernobyl, estimates that there are now less than 100 nuclear plants under active construction worldwide, compared with more than 200 in 1983. "The world is slowly but surely moving away from nuclear power expansion", he says. wrote

J. B. Sibbison

Germany: Preventing cardiovascular disease A little incident encapsulated the Third National Bloodpressure Conference held last month in Heidelbergthe front page of the local newspaper reported on the long-serving mayor’s early and sudden resignation because of a serious heart condition discussed in depth a few pages later in the paper’s conference report. Diseases of the cardiovascular system are still the biggest killer in West Germany. The decline in mortality from these

diseases has been due

to

better and earlier

treatment

rather

prevention. A study of the inhabitants of Bremen presented at the conference showed quite clearly that the prevalence of the main risk factors for cardiovascular diseases--cigarette smoking, hypertension, and high cholesterol level-is increasing in the population. In the past five years the risk of acquiring a cardiovascular disease has risen by around 4% for men over forty, and by 7% for than

to

in the same age group. Although the West German population seems to be increasingly aware of the importance of the risk factors, and despite various small antismoking campaigns, people are reluctant to modify their lifestyles. The situation is even worse in East Germany, where morbidity and mortality from cardiovascular diseases are higher than in the West. One of the East German physicians at the conference in Heidelberg even said that health in his country had never been valued, since illness did not produce any major disadvantage in the socialist system. It is certainly true that people in East Germany have an excessive fat intake and that there is a shortage of public exercise facilities for most

Epidemiologists and doctors actively involved in prevention initiatives agree that a centrally organised campaign is badly needed. Two steps aimed at increasing prevention were introduced as part of last year’s health reforms, but they have not made any impact yet-there are not enough creative people with good ideas about how to use the money that health insurance companies have been advised to put aside for prevention; and neither the public nor the doctors have responded to the scheme which gives doctors additional payments for annual screening of patients older than 35. Various leagues and associations with similar aims are fighting lonely battles against cardiovascular disease. Little campaigns-to measure cholesterol, for example--are mainly initiated and financed by the pharmaceutical companies. One problem is that health initiatives can be supported by three different ministries in Bonn. There is no central management with a vision of how prevention and health in Germany should be. Therefore, some scientists and politicians hope that with the unification of Germany there will be a reorganisation of government ministries such that a single powerful health ministry-with a structure like that in East Germany today-will evolve. An important step on the long ladder towards prevention was taken in Heidelberg. The five most important medical organisations working for the prevention of cardiovascular diseases decided to formulate a common strategy. It was agreed that there should be effective health education for the population and more emphasis on preventive medicine during the training of medical students. It was furthermore recommended that a new national institute for research into cardiovascular diseases should be established. Its main task would be to coordinate activities in all areas, from research to prevention. East Berlin was suggested as a possible location, since it already has a big research institute for cardiovascular diseases. Environmental politics has become an important and generally welcomed issue. The hope that the same should apply to the prevention of disease was commonly expressed in Heidelberg. Ways of encouraging prevention were discussed-for example, lowering health insurance costs for those who go regularly for check-ups. Last but not least, legal changes were called for-for instance, a ban on smoking in all public rooms and the declaration of nutrient contents on food packaging. It seems clear, however, that nothing can be achieved unless politicians can be induced to support these ideas. Since round tables seem to be the answer for nearly everything these days, it was proposed to install one in Bonn for discussing prevention with doctors, chemists, health teachers, and politicians as participants.

Annette Tuffs

women

citizens.

Conference AIDS, San Francisco The Sixth International Conference on AIDS (June 20-24) began and ended with widely publicised demonstrations. San Francisco, the city that has suffered so much in the epidemic yet has still managed to provide innovative models for the care of patients infected with HIV, hosted a well-organised meeting that was the object of global controversy because of the immigration laws. Many

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boycotted the conference in protest, but unfortunately this act of solidarity with HIV-infected persons limited their access to the information presented. Journals and books by themselves cannot adequately convey the climate of the epidemic nor provide the interactions scientists

necessary to stimulate researchers. The decision of the International AIDS Society not to support any future

in countries with discriminatory and scientifically unsound immigration policies, including the planned 1992 meeting in Boston, is commendable. Perhaps the most sobering developments were in the of epidemiology and prevention, with the areas acknowledgment of the rapidly increasing global incidence of the virus. Studies in Asia have documented alarming HIV incidence rates in prostitutes-30% in Bombay and 44% in Changmai, Thailand. Equally sobering were the nosocomial rates in Eastern Europe, with reports from Romania of the paediatric exposure from microtransfusions and needles and from the Soviet Union of parenteral and sexual spread due to the lack of disposable or properly sterilised needles and of condoms. The USSR also reported a new route of spread from infants with stomatitis, infected in hospital, to their mothers during suckling; this observation

conferences

needs confirmation. Nosocomial factors may be

more

prevalent in Africa than previously reported. Also, studies among prostitutes in Kinshasa showed non-ulcerative sexually transmitted diseases as a risk factor for HIV infection. The update of the San Francisco cohort showed that AIDS had developed in 53% of the 489 men within 11 years. Of 341 evaluable men with an estimated seroconversion date before 1981, 66 (19%) had no signs or symptoms of HIV infection and approximately half had maintained a CD4 count of more than 500. Other studies suggested a levelling in the rate of AIDS cases, interpreted as a reflection of the effect of antiviral therapy, the decreased reporting of AIDS cases, and other unexplained factors. The age and disease status of the index case remain the greatest risk for progression, with the incubation in the western world now estimated at a median of 8-10 years with a mean of 11-12 years. The increased survival after diagnosis is thought to be due to prophylaxis against Pneumocystis carinii pneumonia (PCP) and treatment with zidovudine. In the basic sciences there has been further definition of the virus, highlighting the need for a three-dimensional model to understand the conformational complexities, especially of the regions near the C terminus of CD4. The V3 loop of gp 120, a highly variable area, may have a consensus sequence such that neutralising antibodies to 5-6 variants may be sufficient to neutralise 85% of the HIV strains in Europe and North America. The mechanism of latent infection was explored with reports of a provirus that can now be cultured. HIV in acute infection seems capable of rapid cell replication before a period of a slow growth that can erode the immune system during a time of latency before a recrudescence of rapid replication when the proportion of cells in the body increases. The source of HIV is still not known. Polymerase chain reaction technology has spread rapidly but applications outside the laboratory remain undetermined because of the high false-positive rate and lack of a reliable simple method. CD8 clones have been shown to inhibit HIV replication in vitro, and the putative role of cytotoxic CD8 cells and soluble factors in infection

reported. A very early indicator of immunodeficiency may be high levels of tumour necrosis factor released in the was

blood. There was optimism about a vaccine in the next decade, via new strategies and various recombinant techniques, which may be safer and more effective than a natural vaccine. Reports were presented on a vaccinia gpl60 vaccine, whole virus vaccines in macaques, and inactivated immunogen in combination with zidovudine. Issues for the 1990s are: can a vaccine protect against infection or should scientists be satisfied with a vaccine that protects against disease? When will it be safe to begin phase II/III vaccine studies, and in whom? Zidovudine remains the gold standard in the clinical arena, although the best time to begin therapy, the dose of the drug, and the duration of efficacy remain controversial. The various methods of detecting HIV resistance to zidovudine need standardisation to allow a true comparison of results. Although such resistance occurs in all stages of infection, it is less common in the symptomless disease and no reported study has had the statistical power to correlate resistance to zidovudine with clinical events. Reports of other antivirals, in combination or singly, are preliminary and new agents, including protease inhibitors, await phase I/II trials. The trial of aerosolised pentamidine versus co-trimoxazole in mild to moderate PCP showed no statistical difference at day 21, although the aerosolised treatment seemed to produce a slower response. In more severe disease the mortality remains over 20%, but may be reduced with the early use of steroids. Although the prophylaxis of PCP is well accepted, there was still no consensus on the best agent; arguments against the use of aerosolised pentamidine include poor penetration into the upper lobes, the development of blebs and cavities, the difficulties in diagnosis after prophylaxis because of low numbers and clumping of organisms, the increased risk of disseminated disease, and the striking question of cost effectiveness-aerosolised pentamidine costs ten times as much as daily co-trimoxazole. A new drug, BW566C80, may be an important agent for both toxoplasmosis and PCP. Prevention through global education and continued pressure on policy makers for scientifically sound government efforts was emphasised eloquently by many speakers. This epidemic has stressed our limited capacity to cope with health problems in a modem world and will continue to do so. Numerous reports suggested the urgent need for intensive education, especially of adolescents who do not perceive the risk but who are becoming sexually active at a younger age. This population is not reflected in the cohort studies used for health-care planning. Although there were encouraging data from needle sharing programmes, difficulties of maintaining commitment to safe sex and the need for reinforcement of education were

reported. Activitist groups have had a major role in the pace of AIDS research and policy. The red arm bands worn by delegates at the conference expressed their solidarity with the cause of the infected. A conference such as this reflects the commitment that thousands of scientists have to this epidemic, in all its aspects, and it is important that these meetings continue to take place in an atmosphere of creative and constructive exchange rather than confrontational frustration. The enemy is the virus. Karen Gelmon II

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I