cell-to-cell interaction, communication and signal transduction. Apposition of an antigen-presenting cell with a CD4+ helper cell has a crucial role in activation of the cell-mediated immune system. Alteration in the lipid content of the cell membrane and the lipid environment in which the T lymphocytes interact can theoretically interfere with both activation of the cell-mediated immune system and signal transfer from one cell line to the other. This can compound the "state of anergy" observed in HIV infection.2 Thus Hinds' observations underscore the importance of nutrients as modulators of immune function in patients with HIV infection. Hardally R. Hegde, MD, FRCPC Clinical assistant professor Department of Pediatrics University of Calgary Alberta Children's Hospital Calgary, Alta.
References 1. Nunez EA: Modulation of cell-mediated immune response by steroids and free fatty acids in AIDS patients. A critical survey. Tumor Biol 1988; 9: 225-232 2. Hegde HR: Anergy and tuberculosis: introspection of a theory. Indian J Tuberc 1990; 37: 123-128
Generic drug companies are the winners T n he article "Patent-protection issue heats up again despite success of Bill
C-22" (Can Med Assoc J 1991; 145: 141-144), by Giles Gherson, was excellent, but I would have appreciated more hard numbers. The overall figure of 8.8% of revenue spent on research and development (R and D) in Canada is deceptive. The R and D bill is probably in the order of 40% to 60% for the brand-name drug companies but less than 4% for NOVEMBER 1, 1991
the generic producers. Given this enormous difference one would expect generic drugs to cost no more than 50% of the brand-name ones. In practice this is practically never the case: the difference is often as little as 10% to 15%. No one knows what the profit margins of the generic drug companies are, since practically none of them is listed publicly in the stock exchanges. One can only suspect that they must be huge. It is high time the government asked the generic drug companies to provide solidly audited balance sheets before giving them any more concessions. The shorter the patent period becomes, the more expensive the drugs. Brand-name drug companies know they have only a few years to recoup the cost of their research. The generic drug companies, whose costs do not rise since they do not do any R and D, simply jump on the bandwagon with a price that is just enough below the original price to capture the market - and their profits become even more huge! We should be urging our government and its representatives to examine the balance sheets of our generic drug companies very closely before passing laws that will make them richer still.
cannot be trusted to read scientific material interspersed with advertisements from drug companies without the danger of influence. I have tried having my receptionist remove the offending material, but then I miss the conclusion or references for an article of particular interest. Anyway, she is so busy cutting out any references to drug companies from the helpful patient literature, which I could not afford to produce myself, that she barely has time to answer the phone. I have hired a student to "brown bag" all my samples and write generic names on the bags. He is also dismantling my computerized drug evaluation system, on the basis of the quality of the fare provided by drug companies at their dinner evenings. This has all been very stressful, and I wonder if the Ethics Committee has thought of setting up a counselling phone line on which those of us who in our past ignorance have put ourselves at risk of influence may make our confessions and seek help and
Arnold J. Voth, MD 10106-11 1th Ave. Edmonton, Alta.
Stress and the ethical
I t is with regret that I inform the editors that I can no longer ethically read CMAJ. My consciousness has been raised by the recent ruling by the CMA's Ethics Committee that ethical physicians should not attend drug-
guidance. Alan J. Nixon, MD 207-2475 Bayswater St. Vancouver, BC
We are, of course, passing on your letter to the Ethics Committee, but we have also suggested to the Building Committee that confessionals be installed during renovations to CMA House. We hope that similar confessionals for ethically stressed physicians will be installed in each of the divisional offices. As a stopgap, my office is available for confessions of ethically stressed CMAJ readers on Saturdays from 9 to 12, by appointment only.
company-sponsored functions lest their judgement be clouded, influ- Bruce P. Squires, MD, PhD enced and distorted. I know that I Editor-in-chief, CMAJ CAN MED ASSOC J
1991; 145 (9)