56
Euthanasia SIR,-In a recent commentary, I and J. Duddington, barrister at law,’ examined the medical and legal implications of the Voluntary Euthanasia Society’s advanced directive, which provides inter alia for the withdrawal of food and fluid and alleviation of resultant symptoms by analgesics.2 This was to be the means of death for those who had become incompetent from feared indignity, senility, or severe distress. In a report from Switzerland, Neeser et al3 relate the effects of a thirst and hunger strike by a prisoner protesting against solitary confinement. After thirteen days without fluid or food, he was still lucid but in great pain. Those of us who have seen death in newborn babies from unrelieved duodenal obstruction will not easily forget the extremes of dehydration, jaundice, and cerebral damage that precede death. For an account of starvation in a classic paper Capt P. Mollison4 describes the acute and long-term mental anguish of the victims of the Belsen concentration camp. This anguish continued long after the prisoners had been liberated. The suggestion in the Society’s document that such deaths could ever be easy, the classic meaning of euthanasia, is gravely misleading. Death by morphine overdose is proposed, but its effectiveness in relieving the pangs of thirst especially in the non-debilitated is uncertain. The toxic effects, especially nausea and vomiting are, however, well known. This needs to be drawn to the attention of those who sign the document. This point seems not to be appreciated by the British Medical Association Council, whose recent statement on advanced directives supported the withdrawal of food and fluids.5 An attempt to make advanced directives enforcable lies behind a draft Bill6 that is supported by a group of Peers and Members of Parliament. The penalties for non-compliance include a two-year prison sentence and an unlimited fine. There should be deep concern in the profession
at
such radical proposals,
Worcester Royal Infirmary, Castle Street Branch, Worcester WR1 3AS, UK
A. P. COLE
1. Cole AP, Duddington J. Advanced directives. Catholic Med Q 1992; XLII: 14-19. 2. Voluntary Euthanasia Society. Advanced Directive 2. Section 2. London: VES, 1991. 3. Neeser M, Ruedin P, Restellini JP. Thirst strike: hypernatraemia and acute pre-renal failure m a prisoner who refused to drink. BMJ 1992; 304: 1352. 4. Mollison P. Observation on cases of starvation at Belsen. BMJ 1946; i: 4-8. 5. British Medical Association. Statement on advanced directives. London: BMA, 1992. 6. Medical treatment (Advanced Directives) Bill. Copies from Alert, London SW3 4GS.
SIR,-Many people in Sweden support the right to use active euthanasia in patients with severe incurable diseases and who want to die. I have suggested, in much debated articles published in the Swedish Medical Journal,l that these patients, when capable of rational judgment, could choose to stop eating and drinking. In clinical work it has often been noted that old and sick people tolerate starvation and dehydration poorly. Death can be expected to take place fairly quickly, with little suffering. Hunger in acute starvation is usually rather mild, and thirst is reduced in old people deprived of water.2 Dehydration may even be a "comfort measure" in the terminal stages of various diseases.3 It is commonly believed that death by starvation is horrible, and the reaction to my first article was very strong. In their review about the effects of withdrawing tube feeding from patients with profound chronic brain injuries, Ahronheim and Gasner4 found the word starvation especially provocative: "Withdrawing artificial feeding and hydration from debilitated patients does not result in gruesome, cruel, and violent death. The sloganism of starvation must cease". I report an old patient with moderate vascular brain damage. He was an 84-year-old retired businessman with severe hemiplegia after two strokes (of brainstem type). Speech and other intellectual functions were well preserved, and he had no signs of heart disease. He lived in comfort but found his life hopeless and degrading. He wanted help to die through active euthanasia (of the Dutch type). Because this was impossible he decided-after reading about my articles and consultation with his doctor-to starve and to stop drinking (apart from small amounts of water to moisten his mouth). He died peacefully, without any signs of pain or suffering, after two
weeks.
This patient was old, sick, and weak, but he was not in the terminal stage of his disease; some doctors may believe, in accordance with their duty to preserve life, that he should have been fed artificially when dehydration and starvation resulted in depression of consciousness. The patient is, however, protected by the Tokyo declaration (accepted by the World Medical Assembly, 1975). Although this applies to prisoners, everybody should have the same rights: "Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgement concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed
artificially. The decision as to the capacity of the prisoner to form such a judgement should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner". The patient reported here was certainy capable of rational judgment and wanted to shorten his life. He saw that starvation was his only alternative to active euthanasia. The Tokyo declaration protects the rights of the patient, but it also protects the doctor. The doctor must inform the patient of the essential medical facts and give good medical care, but his duties are otherwise limited to those specified in the declaration. Young and strong patients also can, if capable of unimpaired judgment, end their suffering by refusal of nourishment, but the consequences are more difficult to predict than in old and weak patients. Skeppargatan 73, 11530 Stockholm, Sweden
BORIS SILFVERSKIÖLD
1. Silfverskiöld B. Ratten att svälta och dö i livets slutskede. Läkartidningen 1990; 87: 2438, 3322. 2. Phillips PA, Rolls BJ, Ledingham GGG, et al. Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 1984; 311: 753-59. 3. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 1988; 43: 84-88. 4. Ahronheim JC, Gasner MR. The sloganism of starvation. Lancet 1990; 335: 278-79.
Surgical careers and female doctors SIR,-It was with utter amazement that I read Mr Benson’s views, (May 30, p 1361) on surgical careers for women. What hope is there for equal opportunities for women when they are up against such patronising bias? Perhaps if we were still in the 19th century it would be acceptable to describe women as diffident, lacking in confidence, and liable to panic, although I would argue that even then these traits would have applied to only a few women-but no longer. In the 1990s women are equally able and just as assertive, confident, and decisive as men, and a good deal more so than many-they have to be to overcome the widespread discrimination that exists. To say that generally women tolerate sleep deprivation less well than men is rubbish. Most mothers have spent countless sleepless nights caring for their fretful children and yet managed to carry out their daytime duties successfully. I accept the view that the review of junior doctors’ hours may well be because of the increased number of women in medicine-they are obviously not prepared to accept poor conditions of work and are willing to speak out and fight for improvements that are long overdue. Low Fold House, 98 Denby Lane,
Upper Denby, Huddersfield HD8 8TZ, UK
JUDITH A. BARDEN, Chairman, Women in the NHS Non-executive Group
seems to advocate discrimination against in surgery. His views may, however, be unintentionally useful in highlighting certain professional attitudes that have helped to ensure that the overall lot of junior doctors remains unchanged. His experience of house surgeons suggests that women respond poorly to sleep deprivation. Studies of both male and female junior doctors find similar levels of reported fatigue! and abnormally high emotional distress compared with other occupational groupS.2 Further investigation shows that women are more likely to be depressed than men, but the source of this higher prevalence is the conflict between family and career rather than overwork.3 A review of the copious publications suggests that women may be forced to choose certain careers because of discrimination.4
SIR,-Mr Benson
women
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
Euthanasia SIR,-In a recent commentary, I and J. Duddington, barrister at law,’ examined the medical and legal implications of the Voluntary Euthanasia Society’s advanced directive, which provides inter alia for the withdrawal of food and fluid and alleviation of resultant symptoms by analgesics.2 This was to be the means of death for those who had become incompetent from feared indignity, senility, or severe distress. In a report from Switzerland, Neeser et al3 relate the effects of a thirst and hunger strike by a prisoner protesting against solitary confinement. After thirteen days without fluid or food, he was still lucid but in great pain. Those of us who have seen death in newborn babies from unrelieved duodenal obstruction will not easily forget the extremes of dehydration, jaundice, and cerebral damage that precede death. For an account of starvation in a classic paper Capt P. Mollison4 describes the acute and long-term mental anguish of the victims of the Belsen concentration camp. This anguish continued long after the prisoners had been liberated. The suggestion in the Society’s document that such deaths could ever be easy, the classic meaning of euthanasia, is gravely misleading. Death by morphine overdose is proposed, but its effectiveness in relieving the pangs of thirst especially in the non-debilitated is uncertain. The toxic effects, especially nausea and vomiting are, however, well known. This needs to be drawn to the attention of those who sign the document. This point seems not to be appreciated by the British Medical Association Council, whose recent statement on advanced directives supported the withdrawal of food and fluids.5 An attempt to make advanced directives enforcable lies behind a draft Bill6 that is supported by a group of Peers and Members of Parliament. The penalties for non-compliance include a two-year prison sentence and an unlimited fine. There should be deep concern in the profession
at
such radical proposals,
Worcester Royal Infirmary, Castle Street Branch, Worcester WR1 3AS, UK
A. P. COLE
1. Cole AP, Duddington J. Advanced directives. Catholic Med Q 1992; XLII: 14-19. 2. Voluntary Euthanasia Society. Advanced Directive 2. Section 2. London: VES, 1991. 3. Neeser M, Ruedin P, Restellini JP. Thirst strike: hypernatraemia and acute pre-renal failure m a prisoner who refused to drink. BMJ 1992; 304: 1352. 4. Mollison P. Observation on cases of starvation at Belsen. BMJ 1946; i: 4-8. 5. British Medical Association. Statement on advanced directives. London: BMA, 1992. 6. Medical treatment (Advanced Directives) Bill. Copies from Alert, London SW3 4GS.
SIR,-Many people in Sweden support the right to use active euthanasia in patients with severe incurable diseases and who want to die. I have suggested, in much debated articles published in the Swedish Medical Journal,l that these patients, when capable of rational judgment, could choose to stop eating and drinking. In clinical work it has often been noted that old and sick people tolerate starvation and dehydration poorly. Death can be expected to take place fairly quickly, with little suffering. Hunger in acute starvation is usually rather mild, and thirst is reduced in old people deprived of water.2 Dehydration may even be a "comfort measure" in the terminal stages of various diseases.3 It is commonly believed that death by starvation is horrible, and the reaction to my first article was very strong. In their review about the effects of withdrawing tube feeding from patients with profound chronic brain injuries, Ahronheim and Gasner4 found the word starvation especially provocative: "Withdrawing artificial feeding and hydration from debilitated patients does not result in gruesome, cruel, and violent death. The sloganism of starvation must cease". I report an old patient with moderate vascular brain damage. He was an 84-year-old retired businessman with severe hemiplegia after two strokes (of brainstem type). Speech and other intellectual functions were well preserved, and he had no signs of heart disease. He lived in comfort but found his life hopeless and degrading. He wanted help to die through active euthanasia (of the Dutch type). Because this was impossible he decided-after reading about my articles and consultation with his doctor-to starve and to stop drinking (apart from small amounts of water to moisten his mouth). He died peacefully, without any signs of pain or suffering, after two
weeks.
This patient was old, sick, and weak, but he was not in the terminal stage of his disease; some doctors may believe, in accordance with their duty to preserve life, that he should have been fed artificially when dehydration and starvation resulted in depression of consciousness. The patient is, however, protected by the Tokyo declaration (accepted by the World Medical Assembly, 1975). Although this applies to prisoners, everybody should have the same rights: "Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgement concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed
artificially. The decision as to the capacity of the prisoner to form such a judgement should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner". The patient reported here was certainy capable of rational judgment and wanted to shorten his life. He saw that starvation was his only alternative to active euthanasia. The Tokyo declaration protects the rights of the patient, but it also protects the doctor. The doctor must inform the patient of the essential medical facts and give good medical care, but his duties are otherwise limited to those specified in the declaration. Young and strong patients also can, if capable of unimpaired judgment, end their suffering by refusal of nourishment, but the consequences are more difficult to predict than in old and weak patients. Skeppargatan 73, 11530 Stockholm, Sweden
BORIS SILFVERSKIÖLD
1. Silfverskiöld B. Ratten att svälta och dö i livets slutskede. Läkartidningen 1990; 87: 2438, 3322. 2. Phillips PA, Rolls BJ, Ledingham GGG, et al. Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 1984; 311: 753-59. 3. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 1988; 43: 84-88. 4. Ahronheim JC, Gasner MR. The sloganism of starvation. Lancet 1990; 335: 278-79.
Surgical careers and female doctors SIR,-It was with utter amazement that I read Mr Benson’s views, (May 30, p 1361) on surgical careers for women. What hope is there for equal opportunities for women when they are up against such patronising bias? Perhaps if we were still in the 19th century it would be acceptable to describe women as diffident, lacking in confidence, and liable to panic, although I would argue that even then these traits would have applied to only a few women-but no longer. In the 1990s women are equally able and just as assertive, confident, and decisive as men, and a good deal more so than many-they have to be to overcome the widespread discrimination that exists. To say that generally women tolerate sleep deprivation less well than men is rubbish. Most mothers have spent countless sleepless nights caring for their fretful children and yet managed to carry out their daytime duties successfully. I accept the view that the review of junior doctors’ hours may well be because of the increased number of women in medicine-they are obviously not prepared to accept poor conditions of work and are willing to speak out and fight for improvements that are long overdue. Low Fold House, 98 Denby Lane,
Upper Denby, Huddersfield HD8 8TZ, UK
JUDITH A. BARDEN, Chairman, Women in the NHS Non-executive Group
seems to advocate discrimination against in surgery. His views may, however, be unintentionally useful in highlighting certain professional attitudes that have helped to ensure that the overall lot of junior doctors remains unchanged. His experience of house surgeons suggests that women respond poorly to sleep deprivation. Studies of both male and female junior doctors find similar levels of reported fatigue! and abnormally high emotional distress compared with other occupational groupS.2 Further investigation shows that women are more likely to be depressed than men, but the source of this higher prevalence is the conflict between family and career rather than overwork.3 A review of the copious publications suggests that women may be forced to choose certain careers because of discrimination.4
SIR,-Mr Benson
women
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
