57

Benson contends that surgery demands certain characteristics in doctor, including a high level of confidence and a lack of diffidence. These demands may, of course, be tragically mismatched with the expertise of doctors still in training.5 His implicit paradigm of doctor-as-hero may help to explain why the NCEPOD report" for 1990 still reports deficiencies highlighted 5 years ago: poor supervision of junior staff and surgeons operating outside their field of expertise have been recurrent difficulties. This poor supervision and inadequate training can also have disastrous consequences for the career of the doctor, as well as for the patient. These and other aspects of the junior doctors’ life have prompted calls for changes in the postgraduate registration year, with an emphasis on the reduction of junior doctors’ hours and improved training and education.’ Perhaps a more cautious approach to medicine and life, especially other peoples’, is to be encouraged in junior doctors rather than mocked. a

Department of Epidemiology and Public Health, University College and Middlesex Schools of Medicine, London WC1E 6EA, UK

NISH CHATURVEDI ALLYSON POLLOCK

1. Elliot DL, Girard DE. Gender and the emotional impact of internship. J Am Med Wom Assoc 1986; 4: 54-56. 2. Firth-Cozens J Emotional distress in junior house officers. BMJ 1987; 295; 533-36. 3. Firth-Cozens J. Sources of stress in women junior house officers. BMJ 1990; 301: 89-91. 4. Payne RL, Firth-Cozens J, eds. Stress in the health profession. Chichester: Wiley, 1987. 5. Dyer C. Manslaughter convictions for making mistakes. BMJ 1991; 303: 1218. 6. Nixon SJ. NCEPOD: revisiting perioperative mortality. BMJ 1992; 304: 1128-29. 7. Richards P. Educational improvement of the preregistration period of general clinical training. BMJ 1992; 304: 625-27.

European Bureau for Action 117, rue des Atrébates, B-1040 Bruxelles,

Blood donation

claims that the commercial industry can guarantee a controllable quality that the European blood-bank community cannot. I strongly object to this statement. The fractionation laboratories belonging to the non-profit-making blood transfusion services comply with the same quality requirements and good manufacturing practice as does the industry, and the exclusive use of voluntary, unpaid donors adds to the safety of the products.1 The quality assurance of plasma separated from whole-blood donations is more difficult than that from plasmapheresis, but there is no foundation to indicate that plasma from commercial centres is of higher quality than that of unpaid plasmapheresis donors. The EC is not yet self-sufficient for plasma products. The increased yields of factor VIII and the emergence of recombinant products help the Community to achieve its goal in that respect. Albumin remains a difficulty. Japan has taken measures to reduce the excessive use of albumin in that country. Europe should take similar action, in addition to active promotion of non-remunerated donations of blood and plasma. I am convinced that self-sufficiency based on voluntary and unpaid blood donors as expressed in the Directive 89/381/EEC is a realistic goal. Establishment of new commercial plasmapheresis centres and increasing the frequency of paid plasma donation is not necessary.

JUHANI LEIKOLA

1. Beal RW, van Aken WG. Gift or good? A contemporary examination of the voluntary and commercial aspects of blood donation. Vox Sang (in press).

EC oral snuff ban and Sweden SIR,-At the European Community (EC)

on

Smoking Prevention,

LUK JOOSSENS,

Belgium

SIR,-Dr Smit Sibinga comments on the European Community (EC) policy of self-sufficiency in blood and blood products, based on voluntary and non-remunerated donations (June 13, p 1485). He

Finnish Red Cross Blood Transfusion Service, 00310 Helsinki, Finland

resembling a food product.l In a report that the European Bureau for Action on Smoking Prevention (BASAP) undertook at the request of the EC in December, 1990,2 we concluded that the use of moist snuff causes cancer in man, addiction to nicotine, and is increasingly being targeted at young people (as can be seen in Sweden and the USA). Dr Fagerstrom and colleagues (April 11, p 935) criticise this Directive, citing the World Health Organisation’s report on smokeless tobacco3 which made clear distinctions between countries with different tobacco use traditions and did not recommend a ban of smokeless tobacco in those where the products are well established. However, as snuff consumption is not yet established in the twelve EC countries, the Commission was acting in line with the results of WHO’s working group which said that countries with no established smokeless tobacco habit should, as a matter of urgency, ban the manufacture, importation, sale, and promotion of smokeless tobacco products before they were introduced in the marketplace or became an established product. Moist snuff (especially that packaged in small tea-bags) is especially popular in Sweden, and its consumption is high among young people. However, the EC Directive was aimed at the twelve present members of the EC where oral snuff use is not yet established. Dispositions for Sweden may be negotiated separately within the framework of the European Economic Area negotiations. Finally, it should be pointed out that snuff in Europe is mainly produced by the Swedish company Svenska Tobak, which has been restructured and given a new name-Procordia United Brands Group. Fagerstrom works for Kabi Pharmacia, which is owned by Procordia, which in turn is mainly owned by the Swedish State.

Health Minister’s

Council of May 15, 1992, a Directive was adopted that will ban the

marketing, in the Community, of certain types of oral tobacco-ie, all products for oral use, apart from those intended to be smoked or chewed, made wholly or partly of tobacco, in powder or particulate form or in any combination of these forms, especially those presented in sachet portions, porous sachets, or in a form

Director

1. Council Directive 92/41/EEC of 15 May 1992 amending directive 89/622/EEC on the approximation of laws, regulations and administrative provisions of the Member States concerning the labelling of tobacco products. Offic J Eur Commun L158 of 11Tune 1992, p 30-33. 2. A new form of smokeless tobacco: moist snuff. European Bureau for Action on Smoking Prevention (BASP), December 1990. 3. World Health Organisation. Smokeless tobacco control. Report of a WHO study group. Tech Rep Ser 773, Geneva: WHO 1988.

Safer sex and

women

in Africa

SIR,-In your note on safer sex and women (April 25, p 1048) you consider why women in London are not responding to safer sex messages. There may be parallels with the situation in Africa. Despite the fact that there are as many women as men with AIDS in Africa, research has focused on the role of women as transmitters rather than as recipients of infection. The emphasis has been on the study of female prostitutes, who may be important in maintaining transmission but are only a proportion of all infected women.1 It has been suggested that this partly results from women being regarded as either bad (sexually promiscuous) and at risk or good and therefore not at risk.2 This view may underline health education campaigns that are restricted to advocating faithfulness, and which do not address the protection of individual women who are at risk of infection even if faithful because many of their husbands are or will become infectious.3 In a recent study in Rwanda, the prevalence of HIV infection among women who reported a single lifetime sexual partner was 21 %.4 Even an appropriate health education message is not guaranteed to change behaviour: women might not have adequate access to information, might not be able to perceive the risk in their own situation, and might not be in a position to alter their lifestyle or to negotiate successfully change of behaviour with their partners. Research has shown that some women have little access to information; some perceive condoms as having negative health effectsor as necessary only for prostitutes and promiscuous women.s Social and cultural norms may prevent women from perceiving risk in their personal situation: in the same study in Rwanda, 24% of the women who did not regard themselves as at risk (most of whom were in monogamous relationships) had already