NEWS -& Political Review China's landmark tobacco law The Standing Committee of the 7th National People's Congress-China's highest legslative body-has just announced its approval of the country's first ever tobacco law, which will come into effect on 1 January 1992. A national prevalence survey carried out in 1984 among 519000 people alerted the Chinese governmnent to the fact that 61%'of men and 7% of women over the age of 15 smoked daily. There are now 300 million smokers in China and more and more young people are taking up the habit. The main effects of this in the rural population (where stroke and chronic respiratory disease are already the commonest causes of premature death) will not be seen until the next century, but among men living in towns lung cancer is already the commonest neoplastic cause of death and most cases are probably caused by tobacco. Present smoking patterns suggest that tobacco will become the largest single cause of death: among those now aged 0-19 in auspices of the Ministry of Public Health, China about 50 million will eventually, as the Chinese Academy of Preventive Medicine, adults, be killed by tobacco.' the World Health Organisation, and the China is the largest producer and consumer International Union Against Cancer. There of tobacco in the world. The transnational have been several important health education tobacco companies are back in China (ad- campaigns, and World No Tobacco Day mittedly, still with a small market share), and has been marked since 1988. In 1990 the they have a formidable history in Asia of government established the national Chinese denying the health evidence, selling higher Association on Smoking and Health to cotar cigarettes than the same brands in their' ordinate tobacco control activities throughout country of origin, advertising in ways long A second national prevalence survey banned in the United States or United King- China. is planned for 1992. dom, marketing cigarettes without the health But countries that rely on health education warnings required in the West, bringing the alone are not as successful in reducing use of American government to threaten trade tobacco as countries that combine health sanctions unless markets are opened to the education with tobacco control legislation. sale and advertising of American tobacco Thus the Chinese law is timely. products, and challenging responsible the law regulates many aspects of and effective health initiatives by Asian theChiefly, tobacco monopoly-cultivation, national governments. licensing, manufacture and distribution, This industry, which is losing sales in sales, import and export of tobacco products industrialised countries, has proclaimed that and machinery, crackdowns on smugglingChina is the prize for its profits in the twenty but it also includes several crucial provisions first century. An executive from Philip health: Morris, which makes Marlboro cigarettes, is .regarding * reduction of tar and other harmful subin print as stating, "No discussion of the tobacco industry in the year 2000 would be stances in cigarettes complete without addressing what may be * improved health education on the harmful the most important feature on the landscape, effects of smoking the China market. In every respect, China * bans and other controls on smoking on confounds the imagination" (World Tobacco public transport and in public places 1986 Sept:41). R J Reynolds, which makes Camel cigarettes, already has a large factory * advice for young people not to smoke and in Xiamen, and British-American Tobacco bans on smoking by elementary and high announced two weeks ago a large expansion school students * printing of tar levels and health warnings at its Southampton manufacturing plant to on cigarette packs supply foreign markets. Over the past decade China has initiated * bans on advertisements for tobacco on several conferences and workshops on television and radio and in newspapers and tobacco
control,
BMJ VOLUME 303
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17 AUGUST 1991
the
magazines.
This landmark law represents the first large step in legislative control of the health effects of tobacco in China. It is particularly important in that it may encourage other governments, especially in developing countries, to grasp more' firmly the political nettle of tobacco control.-JUDITH MACKAY, chairperson of WHO Technical Advisory Group on Tobacco or Health, and RICHARD PETO, chairperson of WHO Consultative Group on Statistical Aspects of Tobaccorelated Mortality
American Hospital Association calls for health reform In an interview last month at the American Hospital Association's annual convention in California the association's new president, Dick Davidson, talked about the main problems facing American hospitals. Mr Davidson said that medical services are increasingly demanded, but in too many cases people are unable to pay for them. Doctors, he warned, have to balance their commitment to their communities while keeping their institutions financially healthy so that they can continue to serve. Although Mr Davidson agrees that something must be done to reduce administrative waste in the American hospital system, he does not support current calls for funding by only the government or for a move towards a system such as Canada's. Instead, 381
Headlines AIDS conference boycott: William Waldegrave, the health secretary, has written to his American counterpart, Louis Sullivan, protesting about the continuing ban on entry to the US of people with HIV infection (8 June, p 1360). -Britain's researchers might boycott the international conference on AIDS to be held in Boston next year unless4the ban is lifted, he said.
Stanford president to resign: Donald Kennedy, president of Stanford University, California, has announced that he will retire next year to "banish ambiguity" about his position. His decision follows allegations of misuse of research funds at the university (6 April, p 807). GP targets met: Data collected last October from family health services authorities show that, on average, 88% of general practitioners in England reached targets for childhood immunisation and 91% for cervical cytology, as laid down in the general practice contract.
Minister to talk about morale: The Secretary of State for Health has agreed to meet consultants' leaders to discuss the findings of the survey conducted by BMA News Review into consultants' morale (15 June, p 1471).
New organisation against war: The Medical Campaign Against Nuclear Weapons and the Medical Association for Prevention of War will merge in 1992. The new organisation will create a channel for health professionals to extend their concerns beyond preventing war to help foster new concepts of health and global security. "Pindown" compensation: The families of more than 100 children subjected to behaviour modification, pindown, in four local authority children's homes (8 June, p 1359) have been offered up to £500 compensation for each day in detention.
NHS Supplies Authority: Sir Robin Buchanan, chairman of Wessex Regional Health Authority, will head the new special health authority that will, from 1 October, handle the £4bn the NHS spends annually on goods and equipment.
Merging authorities: North West Durham and Durham Health Authorities are to merge from 1 April 1992 and be known as North Durham Health Authority. The chairman will be Professor John Clarke, chairman of Durham Health Authority since 1990.
382
believes Mr Davidson, everyone should use a uniform system of hospital billing, which would reduce bureaucracy even in the current pluralistic system. Another big problem is the need to improve relationships between doctors and hospital staff. While hospital medical staff have an allegiance to their institutions, individual physicians are still free to work from their own private practices too. Doctors must learn to work more effectively together, focusing on improving community health, said Mr Davidson. But he acknowledged that. this was easy to say and a lot more complicated to do. Finally, referring to what he called the "medical arms race," Mr Davidson warned that not everybody can have the ultimate in medical technology. Local hospitals must collaborate with each other and look at the best way to use scarce resources. The convention was a grand affair and began with a;videotaped greeting from President George Bush, who was in Moscow. 1 ne uouege of 1-nyswzans presuaent may nave naa a But, despite the pizazz, everyone attending lucky escape seemed to have simple common aimsimproved access to care, cost control, and can identify related grandparents and grandreform of the American health care system children the findings could indeed reveal away from competition and towards collabo- the supposed grandparents, Edward IV and ration. -FRED CHARATAN, psychiatrist, Long Elizabeth Woodville. Edward IV's coffin was Island opened, apparently, in 1789 and would have to be reopened for the genetic examination. At home and abroad, church authorities are being invited to cooperate, and if the tests are successful they may provide a solid core of evidence for further investigation. GORDON WOLSTENHOLME, former Harveian librarian, Royal College of Physicians
The princes in the tower
The true fate of Edward and Richard, the two young princes who disappeared from the Tower of London in 1483, is under multidisciplinary review. "The greatest mystery in English history will be resolved by scientists," says Jack Leslau of the society the Friends of Thomas More. Scientists in the United Kingdom, Europe, and the United States will test Leslau's theory that the princes were in fact not murdered and that the story was a successful Tudor deception. According to Leslau, there is considerable evidence that Thomas More's hearsay story of Richard III having the princes killed was intended to lay a smokescreen over their continued existence. The story was corroborated by the court artist Hans Holbein. The princes married and raised families under false names and identities- Sir Edward Guildford and Dr John Clement. They were, in security agency jargon, "notional persons" (people who only apparently exist). Later, both princes were supported financially by their nephew Henry VIII. Sir Edward Guildford was appointed standard bearer and lord warden of the Cinque Ports and Dr John Clement became president of the College of Physicians. Efforts are now being made to obtain samples of tissue, and perhaps of hair, for DNA profiling from the remains of Sir Edward Guildford and his daughter Lady Jane, who are buried in the More chapel of Old Chelsea Church in London, and from Dr John Clement and his children, who are buried in Flanders. Because DNA profiling
Getting "serious" about population The Overseas Development Agency of the British government is putting population higher up its list of priorities. "We were," said Lynda Chalker, minister for overseas development, at a press conference last week, "slipping away from the challenge. Now we are facing it." Those who know that world population is growing faster than ever before and will increase by a further billion from the current 5 4 billion during the 1990s may well wonder why the British government didn't long ago make population an issue. But population is a difficult issue for politicians. "Because of the sensitivities involved," said Mrs Chalker in a speech to the all party parliamentary group on population and development in July, "many have chosen to ignore the issue or leave it to the few 'activists."' One problem is that many politiciansincluding some from developed countriesare keen to increase population in order to feed armies and markets and to keep ahead of their neighbours and potential enemies. Religious sensitivities are a huge barrier to an open debate on population, and politicians from poorer countries are often offended by those from richer countries lecturing them on population. This is particularly the case
BMJ
VOLUME 303
17 AUGUST 1991
Ilt:.,;b|_-r:
when overpopulation is linked with destruction of the environment because politicians from developing countries are well aware that it is rich countries that are profligate in consuming energy and creating pollution. Finally, the issue of population is obviously tied up with individual freedom and sextopics that embarrass politicians. Doctors too, said Mrs Chalker, have stood in the way of initiatives on family planning: some because they have a vested interest in there being lots of births, others because they see family planning as a low status activity. Thus British politicians-like those from many other countries-have been too polite to make much of an issue that may destroy the earth. But now Mrs Chalker is taking "every opportunity to beat this particular drum." And the way to do it, she believes, is not talking about population control but, rather, giving couples the chance to choose. The evidence is that most people given access to reproductive health and family planning services will limit their families. Tony German from Action Aid quoted at the press conference an African woman saying: "If I have a fourth child the third will go naked." Yet more than 100 million couples worldwide have no access to contraceptives. The Overseas Development Agency has three guiding principles: firstly, individuals, particularly women, must be able to choose when to have children; secondly, there must be no coercion in family planning; and, thirdly, the quality and availability of family planning services must be improved. Mrs Chalker announced last week 15 new projects to strengthen Britain's population initiative. Yet Britain spends only about 1-5% of its overseas aid of £1-62bn on population initiatives while the International Planned Parenthood Federation recommends that 2% of aid should be spent on such projects. In addition, Britain spends about 0-31% of its gross national product on overseas aid while the United Nations recommends spending 0 7%.-RICHARD SMITH, BMJ
2F
E
_a - r
_
British-Soviet exchange
With the ending of the Cold War, barriers between Soviet and Western medicine are thawing. From September a scheme for The UK-USSR Medical Exchange Programme is exchange fellowships with the Soviet Union based at 9d Stanhope Road, London N6 5NE. will give doctors and nurses in Britain a chance to swap places with their Soviet counterparts. The UK-USSR Medical Exchange Programme, a registered charity, will coordinate fellowships from three different sources. The Royal Marsden Hospital in London is A quarter of Britain's 18 to 20 year olds had providing a place for a Soviet oncology nurse. sex with a new partner in the past year and With professional help from the Royal Col- did not take precautions against HIV infeclege of General Practitioners, Glaxo Eastern tion, according to a report from the Nielsen Europe Ltd is sponsoring an exchange fellow- Consumer Research Fieldforce. Half of the ship in primary health care with the Lenin- adults who were sexually active denied being grad Institute for Advanced Medical Studies. concerned-about catching HIV infection. The London School of Hygiene and Tropical The report, commissioned by the condom Medicine has also offered a brief course on manufacturer Durex, states that three public health at the institute. Lastly, the quarters of people worldwide who are HIV Wellcome Foundation is funding senior positive contracted the virus through heteroBritish specialists to visit a Soviet city and sexual contact. Over half of 5000 people identify the highest priorities for the exchange interviewed in Britain thought that the programme. government should do more to encourage In addition, the Ministry of Health of the safer sexual practices. Russian Federation, which is currently reThe report claims that there has been thinking health policy for the 100 million some progress towards taking precautions. population it serves, has agreed to a pro- Condoms have now overtaken oral contragramme of exchanges in mother and child ceptives as the most popular form of birth health, therapeutics, health care manage- control. A fifth of the 16 and 17 year olds ment, and economics. surveyed claimed to have used condoms At a meeting of the exchange programme specifically as a precaution against transmislast month Dr Richard Jack explained how sion of HIV. British members of the World Federation Only 2% of men reported to be embarrassed of Societies of Anaesthesia have also been by buying condoms. Over two thirds of men practising Anglo-Soviet cooperation. Dr thought that women should carry condoms. John Zorab, president of the federation, But over a third of those interviewed thought raised funds from several British sources to that only homosexuals and drug addicts were send speakers from five Western countries to at risk of HIV infection, and only 5% of the first Soviet Union refresher course in people insisted that their male partner wore a anaesthesiology. More than 400 anaesthetists condom. -LUISA DILLNER, BMJ attended from all parts of the Soviet Union. 1991 is available from LRC Products Most were under 40 and spoke excellent TheDurexReport Ltd, North Circular Road, London E8 8QA.
_
.Xa
:.
__ A_
i I
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=_IS _l-: L | L ,., ,,, _ The lucky ones: 100 million couples have no access tolcontraceptives
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1991
English, and all were career anaesthetists. Dr Jack plans to recruit Soviet senior house officers and registrars in anaesthetics to work and train in the Oxford region. -STEWART BRITTEN, honorary secretary, UK-USSR Medical Exchange Programme
HIV? Not me
Dutch tobacco industry backs down In the winter of 1987 the Dutch tobacco industry brought a lawsuit against Stivoro (the Dutch Foundation on Smoking and Health), alleging thht it was misleading the public by warning that passive smoking was harmful to health (BMJ 1990;310:1061-2). The industry alleged that this conclusion was not supported by generally accepted scientific evidence despite the fact that the Dutch parliament had just passed a law based on such evidence that banned smoking in public buildings. At the end of October 1990 the district court of The Hague made an interim judgment. Stivoro was allowed to declare passive smoking to be harmful and was entitled to publicise Sir Richard Doll's conclusion to this effect in its campaign. The court asked, however, that before final judgment Stivoro 383
should supply the scientific evidence on which its campaign had been based. The tobacco industry appealed against this interim judgment, but in mid-December, before Stivoro had delivered the additional evidence, the industry tried to persuade the foundation to agree to the appeal being dropped. There were, however, conditions. Stivoro had to pay its own legal costs and had to agree not to use the story of the industry's climbdown in any publicity. Stivoro ignored this offer and instead, at the end of January this year, produced for the court the additional evidence requested. The foundation then informed the industry of its conditions for dropping the case-all legal costs had to be paid by the industry, Stivoro would be free to publicise the result of the case in any way it chose, and the tobacco industry would confirm a victory for Stivoro and would not imply that the foundation had yielded in any way to or done a deal with the industry. On 30 July the industry withdrew the case unconditionally and agreed to pay all costs. But the industry also put out a press release that implied that no judgment had been reached and that Stivoro had reached a settlement with the industry. It claimed that The Hague ruling "supports the opinion of manufacturers that present day scientific research does not lead to the unanimous conclusion that passive smoking is harmful." It further stated that "both parties arrived at the conclusion that carrying on with the lawsuit no longer serves a useful purpose." MARTIN RAW, writer and consultant on health, London
Interested in trust status? Of the 113 units that have applied to join the second wave of trusts, six were unsuccessful in the first wave (BMJ7 1990;301:1347). The six include St Thomas's Hospital, which has faced severe financial difficulties, and St Bartholomew's Hospital and Harefield Hospital. All the applications will be vetted by the accountants Coopers and Lybrand Deloitte, and the Secretary of State for Health will announce the successful applicants in the autumn. From April 1992, when the second wave of trusts start up, they will account for about 35% of the NHS budget and employ 285 000 people. St Mary's Hospital, Paddington, and King's College Hospital are applying for the first time, which means that six of the 11 central London teaching hospitals either are trusts or have applied to become trusts. Claiming this as one of the "great success stories of the reforms," the Parliamentary Secretary of Health, Stephen Dorrell, insisted that the department could not be criticised for not learning from past experience. Trust status moved away, he said, from the overcentralisation of management that had been introduced in the 1970s and restored flexibility and authority to local management teams.
All the 113 units had applied because of a
384
paperwork on which the secretary of state made his decision would remain confidential, Mr Dorrell insisted. All remaining directly managed units have now been invited to express an interest in joining the third wave by 16 September. The month's survey for the Independent disagreed successful applicants will become trusts from that the reforms would lead to a better health April 1993. The Labour party has criticised these service. And in a ballot organised earlier this month by the BMA's Brighton Division actions, complaining that consultation on the general practitioners were overwhelmingly trusts has been a sham. Creating more trusts, opposed to the health authority's plan for the Labour complains, is the first step towards community and mental health services to privatising the health service. The chairman become a self governing trust (the services of the BMA council, Jeremy Lee-Potter, said appear among the applications in the second that a second wave should have been deferred until all the lessons had been learnt from the wave). The minister was asked about the value of problems still faced by hospitals and general public consultation when little note was practitioners in the first wave. The associataken of it. Public opinion, he replied, was tion, he said, shared the concern of the House one of the factors to be taken into account of Commons health committee about the first when applications were considered, but "the wave and would welcome an opportunity to most important [factor] is the quality of scrutinise the applications in the second management." He believed that staff who wave. opposed the concept were now seeing the * An independent study by Newchurch and benefits in the first wave. What about openness of the trusts' business Company Limited, NHS Trust Briefing No 3, plans? The secretary of state has already found that most trusts had increased patient announced that from next April trusts will activity and reduced waiting lists. According have to publish their plans for the following to the study, which was largely based on year and produce an annual report accounting interviews with the chief executives of just for the previous year's expenditure (3 August, over half of the first wave of trusts -57 trusts p 316). Until the successful applicants were have been in operation since 1 April-most announced later this year the trusts would trusts believed that they were on target not be able to produce business plans, but the financially. -LINDA BEECHAM, B.W] local decision; there had been no compulsion from the centre, Mr Dorrell assured last week's press conference. This flies in the face of the ballots among doctors and the public about the popularity of the trusts. For example, half the people polled in last
BMJ VOLUME 303
17 AUGUST 1991
control,
BMJ VOLUME 303
principally
under
17 AUGUST 1991
the
magazines.
This landmark law represents the first large step in legislative control of the health effects of tobacco in China. It is particularly important in that it may encourage other governments, especially in developing countries, to grasp more' firmly the political nettle of tobacco control.-JUDITH MACKAY, chairperson of WHO Technical Advisory Group on Tobacco or Health, and RICHARD PETO, chairperson of WHO Consultative Group on Statistical Aspects of Tobaccorelated Mortality
American Hospital Association calls for health reform In an interview last month at the American Hospital Association's annual convention in California the association's new president, Dick Davidson, talked about the main problems facing American hospitals. Mr Davidson said that medical services are increasingly demanded, but in too many cases people are unable to pay for them. Doctors, he warned, have to balance their commitment to their communities while keeping their institutions financially healthy so that they can continue to serve. Although Mr Davidson agrees that something must be done to reduce administrative waste in the American hospital system, he does not support current calls for funding by only the government or for a move towards a system such as Canada's. Instead, 381
Headlines AIDS conference boycott: William Waldegrave, the health secretary, has written to his American counterpart, Louis Sullivan, protesting about the continuing ban on entry to the US of people with HIV infection (8 June, p 1360). -Britain's researchers might boycott the international conference on AIDS to be held in Boston next year unless4the ban is lifted, he said.
Stanford president to resign: Donald Kennedy, president of Stanford University, California, has announced that he will retire next year to "banish ambiguity" about his position. His decision follows allegations of misuse of research funds at the university (6 April, p 807). GP targets met: Data collected last October from family health services authorities show that, on average, 88% of general practitioners in England reached targets for childhood immunisation and 91% for cervical cytology, as laid down in the general practice contract.
Minister to talk about morale: The Secretary of State for Health has agreed to meet consultants' leaders to discuss the findings of the survey conducted by BMA News Review into consultants' morale (15 June, p 1471).
New organisation against war: The Medical Campaign Against Nuclear Weapons and the Medical Association for Prevention of War will merge in 1992. The new organisation will create a channel for health professionals to extend their concerns beyond preventing war to help foster new concepts of health and global security. "Pindown" compensation: The families of more than 100 children subjected to behaviour modification, pindown, in four local authority children's homes (8 June, p 1359) have been offered up to £500 compensation for each day in detention.
NHS Supplies Authority: Sir Robin Buchanan, chairman of Wessex Regional Health Authority, will head the new special health authority that will, from 1 October, handle the £4bn the NHS spends annually on goods and equipment.
Merging authorities: North West Durham and Durham Health Authorities are to merge from 1 April 1992 and be known as North Durham Health Authority. The chairman will be Professor John Clarke, chairman of Durham Health Authority since 1990.
382
believes Mr Davidson, everyone should use a uniform system of hospital billing, which would reduce bureaucracy even in the current pluralistic system. Another big problem is the need to improve relationships between doctors and hospital staff. While hospital medical staff have an allegiance to their institutions, individual physicians are still free to work from their own private practices too. Doctors must learn to work more effectively together, focusing on improving community health, said Mr Davidson. But he acknowledged that. this was easy to say and a lot more complicated to do. Finally, referring to what he called the "medical arms race," Mr Davidson warned that not everybody can have the ultimate in medical technology. Local hospitals must collaborate with each other and look at the best way to use scarce resources. The convention was a grand affair and began with a;videotaped greeting from President George Bush, who was in Moscow. 1 ne uouege of 1-nyswzans presuaent may nave naa a But, despite the pizazz, everyone attending lucky escape seemed to have simple common aimsimproved access to care, cost control, and can identify related grandparents and grandreform of the American health care system children the findings could indeed reveal away from competition and towards collabo- the supposed grandparents, Edward IV and ration. -FRED CHARATAN, psychiatrist, Long Elizabeth Woodville. Edward IV's coffin was Island opened, apparently, in 1789 and would have to be reopened for the genetic examination. At home and abroad, church authorities are being invited to cooperate, and if the tests are successful they may provide a solid core of evidence for further investigation. GORDON WOLSTENHOLME, former Harveian librarian, Royal College of Physicians
The princes in the tower
The true fate of Edward and Richard, the two young princes who disappeared from the Tower of London in 1483, is under multidisciplinary review. "The greatest mystery in English history will be resolved by scientists," says Jack Leslau of the society the Friends of Thomas More. Scientists in the United Kingdom, Europe, and the United States will test Leslau's theory that the princes were in fact not murdered and that the story was a successful Tudor deception. According to Leslau, there is considerable evidence that Thomas More's hearsay story of Richard III having the princes killed was intended to lay a smokescreen over their continued existence. The story was corroborated by the court artist Hans Holbein. The princes married and raised families under false names and identities- Sir Edward Guildford and Dr John Clement. They were, in security agency jargon, "notional persons" (people who only apparently exist). Later, both princes were supported financially by their nephew Henry VIII. Sir Edward Guildford was appointed standard bearer and lord warden of the Cinque Ports and Dr John Clement became president of the College of Physicians. Efforts are now being made to obtain samples of tissue, and perhaps of hair, for DNA profiling from the remains of Sir Edward Guildford and his daughter Lady Jane, who are buried in the More chapel of Old Chelsea Church in London, and from Dr John Clement and his children, who are buried in Flanders. Because DNA profiling
Getting "serious" about population The Overseas Development Agency of the British government is putting population higher up its list of priorities. "We were," said Lynda Chalker, minister for overseas development, at a press conference last week, "slipping away from the challenge. Now we are facing it." Those who know that world population is growing faster than ever before and will increase by a further billion from the current 5 4 billion during the 1990s may well wonder why the British government didn't long ago make population an issue. But population is a difficult issue for politicians. "Because of the sensitivities involved," said Mrs Chalker in a speech to the all party parliamentary group on population and development in July, "many have chosen to ignore the issue or leave it to the few 'activists."' One problem is that many politiciansincluding some from developed countriesare keen to increase population in order to feed armies and markets and to keep ahead of their neighbours and potential enemies. Religious sensitivities are a huge barrier to an open debate on population, and politicians from poorer countries are often offended by those from richer countries lecturing them on population. This is particularly the case
BMJ
VOLUME 303
17 AUGUST 1991
Ilt:.,;b|_-r:
when overpopulation is linked with destruction of the environment because politicians from developing countries are well aware that it is rich countries that are profligate in consuming energy and creating pollution. Finally, the issue of population is obviously tied up with individual freedom and sextopics that embarrass politicians. Doctors too, said Mrs Chalker, have stood in the way of initiatives on family planning: some because they have a vested interest in there being lots of births, others because they see family planning as a low status activity. Thus British politicians-like those from many other countries-have been too polite to make much of an issue that may destroy the earth. But now Mrs Chalker is taking "every opportunity to beat this particular drum." And the way to do it, she believes, is not talking about population control but, rather, giving couples the chance to choose. The evidence is that most people given access to reproductive health and family planning services will limit their families. Tony German from Action Aid quoted at the press conference an African woman saying: "If I have a fourth child the third will go naked." Yet more than 100 million couples worldwide have no access to contraceptives. The Overseas Development Agency has three guiding principles: firstly, individuals, particularly women, must be able to choose when to have children; secondly, there must be no coercion in family planning; and, thirdly, the quality and availability of family planning services must be improved. Mrs Chalker announced last week 15 new projects to strengthen Britain's population initiative. Yet Britain spends only about 1-5% of its overseas aid of £1-62bn on population initiatives while the International Planned Parenthood Federation recommends that 2% of aid should be spent on such projects. In addition, Britain spends about 0-31% of its gross national product on overseas aid while the United Nations recommends spending 0 7%.-RICHARD SMITH, BMJ
2F
E
_a - r
_
British-Soviet exchange
With the ending of the Cold War, barriers between Soviet and Western medicine are thawing. From September a scheme for The UK-USSR Medical Exchange Programme is exchange fellowships with the Soviet Union based at 9d Stanhope Road, London N6 5NE. will give doctors and nurses in Britain a chance to swap places with their Soviet counterparts. The UK-USSR Medical Exchange Programme, a registered charity, will coordinate fellowships from three different sources. The Royal Marsden Hospital in London is A quarter of Britain's 18 to 20 year olds had providing a place for a Soviet oncology nurse. sex with a new partner in the past year and With professional help from the Royal Col- did not take precautions against HIV infeclege of General Practitioners, Glaxo Eastern tion, according to a report from the Nielsen Europe Ltd is sponsoring an exchange fellow- Consumer Research Fieldforce. Half of the ship in primary health care with the Lenin- adults who were sexually active denied being grad Institute for Advanced Medical Studies. concerned-about catching HIV infection. The London School of Hygiene and Tropical The report, commissioned by the condom Medicine has also offered a brief course on manufacturer Durex, states that three public health at the institute. Lastly, the quarters of people worldwide who are HIV Wellcome Foundation is funding senior positive contracted the virus through heteroBritish specialists to visit a Soviet city and sexual contact. Over half of 5000 people identify the highest priorities for the exchange interviewed in Britain thought that the programme. government should do more to encourage In addition, the Ministry of Health of the safer sexual practices. Russian Federation, which is currently reThe report claims that there has been thinking health policy for the 100 million some progress towards taking precautions. population it serves, has agreed to a pro- Condoms have now overtaken oral contragramme of exchanges in mother and child ceptives as the most popular form of birth health, therapeutics, health care manage- control. A fifth of the 16 and 17 year olds ment, and economics. surveyed claimed to have used condoms At a meeting of the exchange programme specifically as a precaution against transmislast month Dr Richard Jack explained how sion of HIV. British members of the World Federation Only 2% of men reported to be embarrassed of Societies of Anaesthesia have also been by buying condoms. Over two thirds of men practising Anglo-Soviet cooperation. Dr thought that women should carry condoms. John Zorab, president of the federation, But over a third of those interviewed thought raised funds from several British sources to that only homosexuals and drug addicts were send speakers from five Western countries to at risk of HIV infection, and only 5% of the first Soviet Union refresher course in people insisted that their male partner wore a anaesthesiology. More than 400 anaesthetists condom. -LUISA DILLNER, BMJ attended from all parts of the Soviet Union. 1991 is available from LRC Products Most were under 40 and spoke excellent TheDurexReport Ltd, North Circular Road, London E8 8QA.
_
.Xa
:.
__ A_
i I
_
=_IS _l-: L | L ,., ,,, _ The lucky ones: 100 million couples have no access tolcontraceptives
BMJ
VOLUME
303
17
AUGUST
1991
English, and all were career anaesthetists. Dr Jack plans to recruit Soviet senior house officers and registrars in anaesthetics to work and train in the Oxford region. -STEWART BRITTEN, honorary secretary, UK-USSR Medical Exchange Programme
HIV? Not me
Dutch tobacco industry backs down In the winter of 1987 the Dutch tobacco industry brought a lawsuit against Stivoro (the Dutch Foundation on Smoking and Health), alleging thht it was misleading the public by warning that passive smoking was harmful to health (BMJ 1990;310:1061-2). The industry alleged that this conclusion was not supported by generally accepted scientific evidence despite the fact that the Dutch parliament had just passed a law based on such evidence that banned smoking in public buildings. At the end of October 1990 the district court of The Hague made an interim judgment. Stivoro was allowed to declare passive smoking to be harmful and was entitled to publicise Sir Richard Doll's conclusion to this effect in its campaign. The court asked, however, that before final judgment Stivoro 383
should supply the scientific evidence on which its campaign had been based. The tobacco industry appealed against this interim judgment, but in mid-December, before Stivoro had delivered the additional evidence, the industry tried to persuade the foundation to agree to the appeal being dropped. There were, however, conditions. Stivoro had to pay its own legal costs and had to agree not to use the story of the industry's climbdown in any publicity. Stivoro ignored this offer and instead, at the end of January this year, produced for the court the additional evidence requested. The foundation then informed the industry of its conditions for dropping the case-all legal costs had to be paid by the industry, Stivoro would be free to publicise the result of the case in any way it chose, and the tobacco industry would confirm a victory for Stivoro and would not imply that the foundation had yielded in any way to or done a deal with the industry. On 30 July the industry withdrew the case unconditionally and agreed to pay all costs. But the industry also put out a press release that implied that no judgment had been reached and that Stivoro had reached a settlement with the industry. It claimed that The Hague ruling "supports the opinion of manufacturers that present day scientific research does not lead to the unanimous conclusion that passive smoking is harmful." It further stated that "both parties arrived at the conclusion that carrying on with the lawsuit no longer serves a useful purpose." MARTIN RAW, writer and consultant on health, London
Interested in trust status? Of the 113 units that have applied to join the second wave of trusts, six were unsuccessful in the first wave (BMJ7 1990;301:1347). The six include St Thomas's Hospital, which has faced severe financial difficulties, and St Bartholomew's Hospital and Harefield Hospital. All the applications will be vetted by the accountants Coopers and Lybrand Deloitte, and the Secretary of State for Health will announce the successful applicants in the autumn. From April 1992, when the second wave of trusts start up, they will account for about 35% of the NHS budget and employ 285 000 people. St Mary's Hospital, Paddington, and King's College Hospital are applying for the first time, which means that six of the 11 central London teaching hospitals either are trusts or have applied to become trusts. Claiming this as one of the "great success stories of the reforms," the Parliamentary Secretary of Health, Stephen Dorrell, insisted that the department could not be criticised for not learning from past experience. Trust status moved away, he said, from the overcentralisation of management that had been introduced in the 1970s and restored flexibility and authority to local management teams.
All the 113 units had applied because of a
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paperwork on which the secretary of state made his decision would remain confidential, Mr Dorrell insisted. All remaining directly managed units have now been invited to express an interest in joining the third wave by 16 September. The month's survey for the Independent disagreed successful applicants will become trusts from that the reforms would lead to a better health April 1993. The Labour party has criticised these service. And in a ballot organised earlier this month by the BMA's Brighton Division actions, complaining that consultation on the general practitioners were overwhelmingly trusts has been a sham. Creating more trusts, opposed to the health authority's plan for the Labour complains, is the first step towards community and mental health services to privatising the health service. The chairman become a self governing trust (the services of the BMA council, Jeremy Lee-Potter, said appear among the applications in the second that a second wave should have been deferred until all the lessons had been learnt from the wave). The minister was asked about the value of problems still faced by hospitals and general public consultation when little note was practitioners in the first wave. The associataken of it. Public opinion, he replied, was tion, he said, shared the concern of the House one of the factors to be taken into account of Commons health committee about the first when applications were considered, but "the wave and would welcome an opportunity to most important [factor] is the quality of scrutinise the applications in the second management." He believed that staff who wave. opposed the concept were now seeing the * An independent study by Newchurch and benefits in the first wave. What about openness of the trusts' business Company Limited, NHS Trust Briefing No 3, plans? The secretary of state has already found that most trusts had increased patient announced that from next April trusts will activity and reduced waiting lists. According have to publish their plans for the following to the study, which was largely based on year and produce an annual report accounting interviews with the chief executives of just for the previous year's expenditure (3 August, over half of the first wave of trusts -57 trusts p 316). Until the successful applicants were have been in operation since 1 April-most announced later this year the trusts would trusts believed that they were on target not be able to produce business plans, but the financially. -LINDA BEECHAM, B.W] local decision; there had been no compulsion from the centre, Mr Dorrell assured last week's press conference. This flies in the face of the ballots among doctors and the public about the popularity of the trusts. For example, half the people polled in last
BMJ VOLUME 303
17 AUGUST 1991
