essential, but the equipment can be as simple as a standard gastroscope and an injection needle. If skill is not available locally then transferring high risk cases should be considered. Controlling bleeding endoscopically will be technically impossible in a few patients, but the savings in morbidity, mortality, and cost justify strenuous efforts to make such a service widely available. A recent review by a surgeon concluded that "conventional surgery for bleeding from peptic ulcers may become a rarity in the near future."3 In an increasing number of hospitals this is already the case. STEPHEN BOWN ICRF Professor of Laser Medicine and Surgery, National Medical Laser Centre, University College and Middlesex School of Medicine, London WC1E 6JJ 1 Sacks HS, Chalmers TC, Blum AL, Berrier J, Pagano D. Endoscopic hemostasis-an effective therapy for bleeding peptic ulcers. JAMA 1990;264:494-9. 2 Hunt PS, Francis JK, Hansky J, et al. Reduction in mortality from upper gastrointestinal haemorrhage. Medj.Aust 1983;ii:552-5. 3 Steele RIJC. Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage. Br J
Surg 1989;76:219-25. 4 Wheatley KE, Snyman JH, Brearlcy S, Keighlev MNlRB, lDykes P'W. Mortality in patients with bleeding peptic ulcers when those aged 60 or over are operated on carly. BfJ 1990;301:272. 5 Dronfield MW. MIedical or surgical treatment for haematemesis and melaena. J R Coll I'hysicians
Lond 1979;13:84-6. 6 Morris DL, Hawker PC, Brearley S, Simms M, Dvkes PW, Keighlev MRB. Optimal timing of' operation for bleeding peptic ulcer: a prospective randomised trial. B.J 1984;288:1277-80. 7 Jones PF, Johnston SJ, McEwan AB, Kyle J, Needham CD. Further haemorrhage after admission to hospital for gastrointestinal haemorrhage. BiM7 1973;iii:660-4. 8 Griffiths WIJ, Neumann DA, Welsh JD. The visible vessel as an indicator of a controlled or recurrent gastrointestinal hemorrhage. N Engli Med 1979;300: 1411-3. 9 Storev DW, Bown SG, Swain CP, Salmon PR, Kirkham JS, Northfield FC. Endoscopic prediction of recurrent bleeding in peptic ulcers. N Englj led 198 1;305:915-6. 10 Swain CI', Bown SG, Storey DW, Kirkham JS, Northficld TC, Salmon PR. Controlled trial of argon laser photocoagulation in bleeding peptic ulcer. ILancet 1981;ii: 1313-6.
11 Swaiin CP', Kirkham JS, Salmoni PR, Bown SG, Northfield 'I'C. Controlled trial of Ndl'AG laser photocoagulation in bleeding peptic ulcers. Lancet 1986;i: 1113-6. 12 Borman PC, Theodorou NA, Shuttleworth RD, Essel HP, Marks IN. Importance of hypovolaemic shock and endoscopic signs ot predicting recurrent haemorrhage from peptic ulcer: a prospective evaluation. BM] 1985;291:245-7. 13 Escourrou J, Frexinos J, Bommclaer G, Edouard R. Prospective randomised study of' YAG photocoagulation in gastrointestinal bleeding. In: Atsumi K, Nimsakul N, eds. Proceedings of laser Tokyo '81. Tokyo: Intergroup Corporation, 1981:25-30. 14 Ihre T, Johansson C, Seligson U, Torngren S. Endoscopic YA(G laser treatment in massive upper gastrointestinal bleeding. Scandj Gastroenterol 1981;16:633-40. 15 Krejs GJ?, Little KH, 'estergaard H, Hamilton JK, Spady DK PIolter DE. Laser photocoagulation for the treatment of acute peptic ulcer bleeding. N Engli Med 1987;316:1618-21. 16 MacLeod IA, Mills PR, MSackenzie JF, Joffe SN, Russell RI, Carter DC. NdYAG laser photocoagulation for major haemorrhage from peptic ulcer and single sessels: a single blind controlled study. B.M] 1983;286:345-8. 17 Trudeau W, Siepler JK, Ross K, Cornish D, Prindiville T. Endoscopic NdYAG laser photocoagulation of bleeding tilcers with visible vessels. Gastrointesi Endosc 1985;31:138. 18 Panes J, Vivcr J, Forne M, Garcia-Olivares E, Marco C, Garau J. Controlled trial of endoscopic sclcrosis in bleeding peptic ulcers. Iancet 1987;ii: 1292-4. 19 Fullarton GM\, Birnie GG, Macdonald A, Murray WR. Controlled trial of heater probe treatment in bleeding peptic ulcers. Br] Surg 1989;76:541. 20 Johnston JH, Sones JQ, Long BW, Posey LE. Comparison of heater probe and YAG laser in endoscopic treatment of major bleeding from peptic ulcers. GastrointestEndosc 1985;31:364-6. 21 Lin HJ, Lee FY, Kang WM, 'Tsai YT, Lee SD, Lee CH. Heat probe thermocoagulation and pure alcohol injection in massive peptic ulcer haemorrhage: a prospective, randomised controlled trial. Gut 1990;31:753-7. 22 Moreto M1, Zaballa M, Ibanez S, Setien F, Figa M. Efficacy of monopolar electrocoagulation in the treatment of bleeding gastric ulcers. Endoscopy 1987;19:54-6. 23 Freitas D, Donato A, Monteiro JG. Controlled trial of liquid monopolar electrocoagulation in bleeding peptic ulcers. Amjt Gastroenterol 1985;80:853-7. 24 Laine L. Multipolar electrocoagulation for the treatment of ulcers with non-bleeding visible vessels: a prospective, controlled study. Gastroenterologv 1988;94:A246. 25 Kernohan RM, Anderson JR, McKelvey STD, Kennedy TL. A controlled trial of bipolar electrocoagulation in patients with upper gastrointestinal bleeding. Brj Surg 1984;71:889-91. 26 Chung SCS, Leung JWC, Steele RJC, Crofts TJ, Li AKC. Endoscopic adrenaline injection for actively bleeding ulcers: a randomised trial. BMJ 1988;2%:1631-3. 27 Heldwein W, Lehnert P, Martinoff S, Loescchke K. Local epinephrine injection improves the therapeutic effect of NdYAG laser treatment of arterial peptic ulcer bleeding. Endoscopy 1988;20:2-4. 28 Rutgeerts P, s-an Trappen G, van Hootegem P, et al. NdYAG laser photocoagulation s multipolar electrocoagulation for the treatment of severely bleeding peptic ulcers: a randomised comparison. Gastrointest Etudosc 1987;33:199-202. 29 O'Keefe PA, Loizou LA, Grigg D, et al. Late follow up patients with peptic ulcer haemorrhage. Gut 1989;30:A 1488. 30 Harvey RF, Langman J S. The late results of medical and surgical treatment for bleeding duodenal ulcer. Q]Med 1970;39:539-547.
America worries about contagion Instead, it should provide some leadership The United States has postponed its decision about lifting its travel restrictions on foreigners with HIV infection, and a question mark hangs over next year's international AIDS conference in Boston.I Meanwhile, the patience of those waiting for the US to provide a lead in respecting the rights of those infected with HIV is wearing thin. Last year's boycott of the sixth international AIDS meeting in San Francisco was moderately successful. Next year more people may want to register their disapproval. If so they would seem to be on firm ground: none of the arguments so far given to support travel restrictions stand up to examination. For instance, the possibility that people would flock from Third World countries to the US for treatment seems unlikely. Given the costs of American medical care, any money that they had to spend on high quality treatment would go further almost anywhere else. The more primitive fear of contamination from outsidecertainly not unique to the US -may also explain some of the opposition to lifting restrictions. But Americans have no need to fear contamination from outside-rather the opposite. Nearly half the world's reported cases of AIDS come from the United States, and the average visitor there has a far greater risk of acquiring HIV from a native than vice versa. Taking sexual tourism and contaminated blood products into account, the US has been a net exporter of HIV. Some of the problems that arise with testing for HIV are
1418
relevant to travel restrictions. As Dr Jonathan Mann, the former director of the World Health Organisation's global programme on AIDS, has pointed out, visa restrictions penalise only those who have acted responsibly by having a test; those who do not know they are infected may enter the country freely.2 Inhabitants of the host country may be lulled into a false sense of security, believing that all foreigners allowed in are negative for HIV. Perhaps they are, but not everybody tells the truth and even those who have genuinely tested negative may later seroconvert or become infected. So why single out the US for criticism, when at least 50 other countries restrict the entry of people with HIV infection or AIDS and others are thinking of doing so?' The reason is that if the US wants to be taken seriously as the leader of the "new world order" it will have to provide leadership off as well as on the battlefield. So much of what is known of the science and management of AIDS has come from the US. When it comes to respecting the rights of people infected with HIV other countries should be able to look to the US for a good example. At present they can't. TONY DELAMOTHE Deputy Editor,
BMJ 1 Tanne JH. US decides not to lift AIDS ban. BMJ 1991;302:1360. 2 Groves 'r. US relaxes visa restrictions. BMJ 1990;300:1156. 3 Duckett M, Orkin A. HIV and travel. BMJ 1990;300:1676.
BMJ VOLUME 302
15 JUNE 1991
Surg 1989;76:219-25. 4 Wheatley KE, Snyman JH, Brearlcy S, Keighlev MNlRB, lDykes P'W. Mortality in patients with bleeding peptic ulcers when those aged 60 or over are operated on carly. BfJ 1990;301:272. 5 Dronfield MW. MIedical or surgical treatment for haematemesis and melaena. J R Coll I'hysicians
Lond 1979;13:84-6. 6 Morris DL, Hawker PC, Brearley S, Simms M, Dvkes PW, Keighlev MRB. Optimal timing of' operation for bleeding peptic ulcer: a prospective randomised trial. B.J 1984;288:1277-80. 7 Jones PF, Johnston SJ, McEwan AB, Kyle J, Needham CD. Further haemorrhage after admission to hospital for gastrointestinal haemorrhage. BiM7 1973;iii:660-4. 8 Griffiths WIJ, Neumann DA, Welsh JD. The visible vessel as an indicator of a controlled or recurrent gastrointestinal hemorrhage. N Engli Med 1979;300: 1411-3. 9 Storev DW, Bown SG, Swain CP, Salmon PR, Kirkham JS, Northfield FC. Endoscopic prediction of recurrent bleeding in peptic ulcers. N Englj led 198 1;305:915-6. 10 Swain CI', Bown SG, Storey DW, Kirkham JS, Northficld TC, Salmon PR. Controlled trial of argon laser photocoagulation in bleeding peptic ulcer. ILancet 1981;ii: 1313-6.
11 Swaiin CP', Kirkham JS, Salmoni PR, Bown SG, Northfield 'I'C. Controlled trial of Ndl'AG laser photocoagulation in bleeding peptic ulcers. Lancet 1986;i: 1113-6. 12 Borman PC, Theodorou NA, Shuttleworth RD, Essel HP, Marks IN. Importance of hypovolaemic shock and endoscopic signs ot predicting recurrent haemorrhage from peptic ulcer: a prospective evaluation. BM] 1985;291:245-7. 13 Escourrou J, Frexinos J, Bommclaer G, Edouard R. Prospective randomised study of' YAG photocoagulation in gastrointestinal bleeding. In: Atsumi K, Nimsakul N, eds. Proceedings of laser Tokyo '81. Tokyo: Intergroup Corporation, 1981:25-30. 14 Ihre T, Johansson C, Seligson U, Torngren S. Endoscopic YA(G laser treatment in massive upper gastrointestinal bleeding. Scandj Gastroenterol 1981;16:633-40. 15 Krejs GJ?, Little KH, 'estergaard H, Hamilton JK, Spady DK PIolter DE. Laser photocoagulation for the treatment of acute peptic ulcer bleeding. N Engli Med 1987;316:1618-21. 16 MacLeod IA, Mills PR, MSackenzie JF, Joffe SN, Russell RI, Carter DC. NdYAG laser photocoagulation for major haemorrhage from peptic ulcer and single sessels: a single blind controlled study. B.M] 1983;286:345-8. 17 Trudeau W, Siepler JK, Ross K, Cornish D, Prindiville T. Endoscopic NdYAG laser photocoagulation of bleeding tilcers with visible vessels. Gastrointesi Endosc 1985;31:138. 18 Panes J, Vivcr J, Forne M, Garcia-Olivares E, Marco C, Garau J. Controlled trial of endoscopic sclcrosis in bleeding peptic ulcers. Iancet 1987;ii: 1292-4. 19 Fullarton GM\, Birnie GG, Macdonald A, Murray WR. Controlled trial of heater probe treatment in bleeding peptic ulcers. Br] Surg 1989;76:541. 20 Johnston JH, Sones JQ, Long BW, Posey LE. Comparison of heater probe and YAG laser in endoscopic treatment of major bleeding from peptic ulcers. GastrointestEndosc 1985;31:364-6. 21 Lin HJ, Lee FY, Kang WM, 'Tsai YT, Lee SD, Lee CH. Heat probe thermocoagulation and pure alcohol injection in massive peptic ulcer haemorrhage: a prospective, randomised controlled trial. Gut 1990;31:753-7. 22 Moreto M1, Zaballa M, Ibanez S, Setien F, Figa M. Efficacy of monopolar electrocoagulation in the treatment of bleeding gastric ulcers. Endoscopy 1987;19:54-6. 23 Freitas D, Donato A, Monteiro JG. Controlled trial of liquid monopolar electrocoagulation in bleeding peptic ulcers. Amjt Gastroenterol 1985;80:853-7. 24 Laine L. Multipolar electrocoagulation for the treatment of ulcers with non-bleeding visible vessels: a prospective, controlled study. Gastroenterologv 1988;94:A246. 25 Kernohan RM, Anderson JR, McKelvey STD, Kennedy TL. A controlled trial of bipolar electrocoagulation in patients with upper gastrointestinal bleeding. Brj Surg 1984;71:889-91. 26 Chung SCS, Leung JWC, Steele RJC, Crofts TJ, Li AKC. Endoscopic adrenaline injection for actively bleeding ulcers: a randomised trial. BMJ 1988;2%:1631-3. 27 Heldwein W, Lehnert P, Martinoff S, Loescchke K. Local epinephrine injection improves the therapeutic effect of NdYAG laser treatment of arterial peptic ulcer bleeding. Endoscopy 1988;20:2-4. 28 Rutgeerts P, s-an Trappen G, van Hootegem P, et al. NdYAG laser photocoagulation s multipolar electrocoagulation for the treatment of severely bleeding peptic ulcers: a randomised comparison. Gastrointest Etudosc 1987;33:199-202. 29 O'Keefe PA, Loizou LA, Grigg D, et al. Late follow up patients with peptic ulcer haemorrhage. Gut 1989;30:A 1488. 30 Harvey RF, Langman J S. The late results of medical and surgical treatment for bleeding duodenal ulcer. Q]Med 1970;39:539-547.
America worries about contagion Instead, it should provide some leadership The United States has postponed its decision about lifting its travel restrictions on foreigners with HIV infection, and a question mark hangs over next year's international AIDS conference in Boston.I Meanwhile, the patience of those waiting for the US to provide a lead in respecting the rights of those infected with HIV is wearing thin. Last year's boycott of the sixth international AIDS meeting in San Francisco was moderately successful. Next year more people may want to register their disapproval. If so they would seem to be on firm ground: none of the arguments so far given to support travel restrictions stand up to examination. For instance, the possibility that people would flock from Third World countries to the US for treatment seems unlikely. Given the costs of American medical care, any money that they had to spend on high quality treatment would go further almost anywhere else. The more primitive fear of contamination from outsidecertainly not unique to the US -may also explain some of the opposition to lifting restrictions. But Americans have no need to fear contamination from outside-rather the opposite. Nearly half the world's reported cases of AIDS come from the United States, and the average visitor there has a far greater risk of acquiring HIV from a native than vice versa. Taking sexual tourism and contaminated blood products into account, the US has been a net exporter of HIV. Some of the problems that arise with testing for HIV are
1418
relevant to travel restrictions. As Dr Jonathan Mann, the former director of the World Health Organisation's global programme on AIDS, has pointed out, visa restrictions penalise only those who have acted responsibly by having a test; those who do not know they are infected may enter the country freely.2 Inhabitants of the host country may be lulled into a false sense of security, believing that all foreigners allowed in are negative for HIV. Perhaps they are, but not everybody tells the truth and even those who have genuinely tested negative may later seroconvert or become infected. So why single out the US for criticism, when at least 50 other countries restrict the entry of people with HIV infection or AIDS and others are thinking of doing so?' The reason is that if the US wants to be taken seriously as the leader of the "new world order" it will have to provide leadership off as well as on the battlefield. So much of what is known of the science and management of AIDS has come from the US. When it comes to respecting the rights of people infected with HIV other countries should be able to look to the US for a good example. At present they can't. TONY DELAMOTHE Deputy Editor,
BMJ 1 Tanne JH. US decides not to lift AIDS ban. BMJ 1991;302:1360. 2 Groves 'r. US relaxes visa restrictions. BMJ 1990;300:1156. 3 Duckett M, Orkin A. HIV and travel. BMJ 1990;300:1676.
BMJ VOLUME 302
15 JUNE 1991
