accepted that most systemic metastases are haematogenous de novo and that simpler means of locoregional control are equally successful.3 The most effective adjuvant treatment is likely to be systemic agents such as fluorouracil and levamisole,4 although a significant survival advantage associated with postoperative infusion of fluorouracil into the portal vein has been found, reaching a 60% reduction in the odds of death.' Other groups have repeated this study and confirmed the reduced mortality but found it to be of smaller magnitude; many of these studies, however, were unable to show any reduction in the incidence of hepatic metastases-presumably the improved survival arose from systemic effects of the fluorouracil.6 The benefits of portal vein infusion are being reassessed in the axis trial of the United Kingdom Coordinating Committee for Cancer Research; the flexibility of the trial's design could perhaps accommodate a desire by the surgeon to resect small lesions before portal vein infusion.7 STEPHEN WHITAKER
Section of Radiotherapy, Institute of Cancer Research, Sutton, Surrey SM2 5NG 1 Allen-Mersh TG. Improving survival after large bowel cancer. BMJ 1991;303:595-6. (14 September.) 2 Palmer M, Petrelli NJ, Herrera L. No treatment option for liver metastases from colorectal adenocarcinoma. Dis Colon Rectum 1989;32:698-701. 3 Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, ct al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engly Med 1981;305:6-1 1. 4 Metzger U. Adjuvant therapy for colon and rectal cancer-NIH consensus development conference. Eur J Cancer 1990;26: 755-62. 5 Taylor I, Machin D, Mullee M, Trotter G, Cooke T, West C. A randomised controlled trial of adjuvant portal vein cytotoxic perfusion in colorectal cancer. BrJ Surg 1985;72:359-63. 6 Slesin ML, Gray R. Adjuvant therapy for cancer of the colon. BMVJ 1991;302:1100-1. (11 May.) 7 James RD. 'Axis': a new type of cancer trial. Clin Oncol 1990;2: 125-9.
makes it unlikely that their natural course can be observed ethically as the polyp-cancer relation is widely accepted. It is, unfortunately, simplistic to call for an "urgent ... randomised controlled trial of polypectomy" as Reasbeck has calculated that, even in high risk subjects, matched groups of 7000 patients would be needed to show a reduction in mortality from cancer.5 Studying patients with an average risk would avoid the ethical problems of not subjecting the control group to colonoscopy, but the numbers in each group would need to be increased at least threefold (to allow for decreased compliance as well as a lower yield). A society like ours must surely wish to identify those at risk of such a common and potentially preventable cancer, and (except for surgery in certain cases) polypectomy is currently our only weapon for reducing that risk. Epidemiologists may wish to debate available data, but surely the commonly held view that polyps present a golden opportunity to prevent cancer should remain the basis for surveillance. To denigrate colonic polypectomy in blanket fashion in a general medical journal is unreasonably nihilistic and clinically misleading. C B WILLIAMS I C TALBOT W S ATKIN St Mark's Hospital for Diseases of the Rectum and Colon, London ECIV 2PS
SIR,-The central theme of the editorial by Drs Allyson M Pollock and Philip Quirke is that the value of polypectomy as a means of preventing colorectal cancer is unproved and by implication perhaps not worth while.' From their armchair viewpoint, however, the authors contribute little other than "knocking copy." They challenge the "inevitability of the adenomacarcinoma sequence," but no one has ever claimed this. Morson emphasised that only a small proportion ofcolorectal adenomas progress to carcinoma.2 About 30% of the population have an adenoma by the age of 60, but the lifetime risk of colorectal cancer is only about 3%, which suggests that only 10% with adenomas develop cancer in their lifetime. A minimum of five genetic changes are required for the formation of a colorectal cancer; fewer changes are required for the development of an adenoma.3 Larger adenomas seem to have more genetic abnormalities, which fits with the clinical observation of their greater likelihood of containing cancer. Most adenomas are small, and it is indeed problematic to predict which could become malignant. From the observation by Muto et al that 40% of villous adenomas already had a focus of malignancy by the time of excision,4 however, Drs Pollock and Quirke incorrectly conclude that the remaining 60% would never progress to cancer. They also state that "only 46% of polyps more than 2 cm will contain an invasive focus"; this figure, based on Muto et al's surgical series,4 is probably an exaggeration, but the incidence is still exceedingly high. We do not know how to identify those adenomas that will grow, but the ease of endoscopic removal
BMJ VOLUME 303
12 OCTOBER 1991
MALCOLM H GOUGH
Chairman, Federation of Surgical Specialty Associations, Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU BERNARD F RIBEIRO
Honorary Secretary, Association of Surgeons of Great Britain and Ireland, London WC2A 3PN
1 Pollock AM, Quirke P. Adenoma screening and colorectal cancer. BMJ 1991;303:3-4. (6 July.) 2 Morson B. The polyp-cancer sequence in the large bowel. Proc R Soc Med 1974;67:451-7. 3 Fearon ER, Vogelstein B. A genetic model for colorectal tumorigenesis. Cell 1990;61:759-67. 4 Muto T, Bussey HJR, Morson BC. The evolution of cancer of the colon and rectum. Cancer 1975;36:2251-70. 5 Reasbeck PG. Colorectal cancer: the case for endoscopic screening. BrJSurg 1987;74:12-7.
Pyoderma gangrenosum
Adenoma screening and colorectal cancer
about high infectivity of hepatitis B surgeons as a group have not appreciated the risks to which they are exposed and the protection that may be obtained by immunisation. There has been much discussion recently within the surgical royal colleges and the surgical specialty associations about transmission of HIV during surgical procedures. With the aim of determining attitudes about testing patients and doctors for HIV the Federation of Surgical Specialty Associations-representing the 10 major specialty associations-recently sent a questionnaire to all surgeons. The opportunity was taken to ask also whether the respondent has been immunised against hepatitis B and whether he or she thinks that such immunisation should be compulsory. The fact that the question has been asked may encourage those not immunised to seek this protection. In addition, the answers should give some indication of opinion about the whole question of the risk of infection from surgical practice.
SIR,-We were interested in the recent picture report of severe ulceration of the scalp.' Diabetes mellitus occasionally predisposes to severe skin infections, but the diagnosis of the ulceration in this case is unclear from the details given. The history of a rapidly expanding ulcer after minor trauma suggests pyoderma gangrenosum, for which paraproteinaemia is a known predisposing factor.2 The scalp is an unusual though well recognised site for pyoderma gangrenosum, and on the basis of the dramatic photograph we suggest that this was the diagnosis. Although the prognosis in such a severe case is likely to be poor, high dose systemic corticosteroids may be of dramatic
benefit.'4 A J G McDONAGH M J CORK C I HARRINGTON Rupert Hallam Department of Dermatology, Royal Hallamshire Hospital, Sheffield S10 2JF I Kumar S, Mohammed R. Minerva. BMJ3 1991;303:592. (7
September.) 2 Powell FC, Schroeter AL, Su WPD, Perry HO. Pyoderma gangrenosum: a review of 86 patients. Q 7 Med 1985;55: 173-86. 3 Mahood JM, Sneddon IB. Pyoderma gangrenosum complicating non-Hodgkin's lymphoma. BrJ7 Dermatol 1980;102:223-5. 4 Carr AJ, Percival RC, Rogers K, Harrington CI. Pyoderma gangrenosum after cholecystectomy. BMJ 1986;292:729-30.
Surgeons and hepatitis B SIR,-Dr David Snashall and colleagues,' commenting on Mr Stuart Kennedy's personal view,2 ask why the doctors had not been immunised. The regrettable answer must be that despite the considerable amount of information available
1 Snashall D, Peel M, Madan I. Surgeons and hepatitis B. BMJ 1991;303:413. (17 August.) 2 Kennedy S. An elementary mistake? BMJ7 1991;302:1614. (29 June.)
Taxation of alcoholic beverages SIR,-In the Observer colour magazine of 28 July 1991 Dr John Collee wrote about the excessive drinking of alcohol. His article included the following paragraph: A lead article by Luisa Dillner in the British Medical Journal points out that Britain will next year be committed to harmonising its import duty with the rest of the European Community. This will result in a fall in the price of most alcoholic drinks with, we anticipate, a dramatic rise in consumption. This would seem to be a quotation from the BMJ7 leader on alcohol abuse earlier this year': The most immediate threat to the level of alcohol consumption will come from the European Community. Britain is committed to the harmonisation of duty within the single market next year, which will mean a fall in the retail prices of most alcoholic beverages in this country. The Institute for Fiscal Studies estimates that this will result in a 46% increase in the volume of alcohol drunk in each household. This statement needs to be corrected. Although the original 1987 proposal of the commission might have posed a threat by setting a single rate of duty for each product group, the proposal was amended in December 1989 to provide for a minimum rate of duty to take effect on 1 January 1993 and a common target rate to be achieved over a longer period.2 This more flexible approach strikes a better balance between the member states' interest in determining tax revenues and health policy, and the European Community's interest in securing sufficient convergence of rates to abolish fiscal frontiers by 31 December 1992. In particular, the principle of a minimum rate leaves member states free to set the duty on alcoholic beverages at levels which reflect their health concerns. A significant step in this direction was taken on 24 June 1991 when the economics and finance ministers reached political agreement on minimum rates of excise duty for beer and wine. Those for fortified wines (sherry, port, vermouth, etc) and for spirits will be set later this year. 925
There is thus no threat that the European Community will compel the United Kingdom to reduce its excise taxation on alcoholic beverages. Nor was there when your leader appeared on 13 April 1991. I am grateful to be able to put the record straight-and reassure your readership. LEON GORDON
C(ustoms Ulnion and Indirect I'axation, Directorate-General, Commission ot the European Communities, 1049 Brussels, Belgium 1 I)illner L. Alcohol abuse. BAM 1991;302:859-60. (13 April.) 2 Amended proposal for a council directive on the approximation of the rates of excise duty on alcoholic beverages and on the alcohol contained in other products. Official Journal of the European Communities No C( 1990 Jan 18:12/12. (COM59)527
final.
How to pay for expensive drugs SIR,-Professor M Orme's editorial presents a balanced view of the merits of various economic strategies for hospitals' and general practitioners' drug prescribing budgets. He failed, however, to highlight one important aspect. Although there is a trend for hospitals to defer prescribing for outpatients, and for some patients on discharge, to general practitioners in order to reduce hospital pharmacy budgets, the overall cost to the NHS will increase if this policy is pursued. The cost of drugs dispensed by hospital pharmacies is, almost without exception, substantially lower than that levied by the "high street" pharmacist, who, understandably, adds a sizeable mark up to the costs to produce a profit. Professor Orme is right when he says that a national solution should be sought; it should embrace both hospitals and general practitioners and might also include high street pharmacies. STEPHEN ASH
Ealing Hospital, Middlesex UB I 3HW 1 Orme M. How to pay for expensive drugs. BMJ 1991;303:593-4. (14 September.)
Health of the nation SIR,-Professor I B Pless's comments on accident prevention in his response to The Health of the Nation should be noted by politicians, officials in the Department of Health, and all health workers.' What he is asking is for the Department of Health to take a firm lead in accident prevention (injury control in North American terminology). The justification for this is sound. Accidents are the leading cause of death in the early years of life. In the United States they account for a greater proportion of years of potential life lost than cancer and heart disease combined. They cause much suffering and hardship. They lose the NHS millions of pounds a year. In supporting Professor Pless's proposals for a division of injury control in the Department of Health I would go even further. I believe that until the discipline is given a similar status to heart disease, cancer, and communicable disease control it will not make any real progress. For advances to be made an institute (or centre) for accident prevention and injury control attached to an academic institution in the United Kingdom is urgently needed. Such an institute would have a similar role to that of the Communicable Diseases Surveillance Centre. It would act as a clearing house for information on accidents but also collate and stimulate research. It would act as a national focus for action on accidents. Some will argue that such an institute already exists in the form of the Medical Commission on
926
Accident Prevention, the Child Accident Prevention Trust, and the Parliamentary Advisory Council on Transport Safety (PACTS). These important organisations are either too specialised or too restricted within their terms of reference. The Royal Society for the Prevention of Accidents operates on a broader front, especially in education. It has already taken a considerable initiative towards working more closely with health authorities with the production of its report Action on Accidents in conjunction with the National Association of Health Authorities and Trusts.' Despite all this activity the need for a national institute still exists. Several regional and district health authorities have now developed strategies and plans for accident prevention. They cannot go it alone. The government must play its part. As no other agency is likely to take the lead the Department of Health should seize the initiative, recognise its key role, and put substantial resources into making appreciable inroads into this major modern epidemic. JAMES GORDON AVERY Flecknoe, Near Rugby, Warwickshire CV23 8AT I Pless IB. Accident prevention. BAJ 1991;303:462-4. 2 National Association of Health Authorities and Royal Society for the Prevention of Accidents Strategy Group. Report. Action on
accidents: the unique role of the health serzvice. Birmingham: NAHA, 1990.
SIR,-Drs Martin Dennis and Charles Warlow's proposed strategy for stroke' in response to The Health of the Nation ignores the potentially large contribution of oestrogen replacement treatment in preventing stroke in postmenopausal women: it is estimated to reduce the relative risk by about half in this group.2 Reductions in the relative risks of killing or disabling diseases that have been reported in controlled studies of oestrogen replacement treatment with or without balancing progestogens include for strokes 0.53,2 myocardial infarction 0 30,' and hip fracture 033.4 Additionally, there are significant reductions in other fractures related to osteoporosis.5 6 These observations are supported by a decreased mortality in women using oestrogen replacement treatment., In the absence of circulating oestrogens there is a threefold to fourfold increase in atherosclerosis in postmenopausal women.' With one exception,9 these figures for the reduction of relative risks have been confirmed to various degrees by other studies. Oestrogen replacement treatment should be considered in calculations of strategies for decreasing the risk of stroke and improving the health of the nation. ALLAN ST J DIXON
Chairman, National Osteoporosis Society, PO Box 10,
Radstock, Bath BA3 3YB
1 Dennis M, Warlow C. Strategy for stroke. BMJ 1991;303:636-8. (14 September.) 2 Paganini-Hill A, Ross RK, Henderson BE. Postmenopausal oestrogen treatment and stroke: a prospective study. BMJ 1988;297:5 19-22. 3 Stampfer MJ, Willet WIC, Colditz GA, Rosner B, Speizer FE, Hennekens CA. A prospective study of estrogen therapy and coronary heart disease. N EnglJ7 Med 1985;313:1044-9. 4 Kiel DP, Felson DT, Anderson JJ, Wilson PW, Moskewitz MA. Hip fractures and the use of estrogens in postmenopausal women, the Framingham study. N Engl Jf Med 1987;317: 1169-74. 5 Lindsay R, Hart DM, Forrest C, Baird C. Prevention of spinal osteoporosis in oophorectomised women. Lancet 1980;ii: 1152-4. 6 Hutchinson TA, Polansky SM, Feinstein AR. Postmenopausal oestrogens protect against fractures of hip and distal radius, a case control study. Lancet 1979;ii:705-9. 7 Henderson BE, Paganini-Hill A, Ross RK. Decreased mortality in users of estrogen replacement therapy. Arch Intern Med
1991;151:75-8. 8 Witteman JCM, Grobbee DE, Kok FJ, Hofman A, Valkenburg HA. Increased risk of atherosclerosis in women after the menopause. BMlJ 1989;289:642-4.
9 Wilson PWF, Garrisoni RJ, Castelli W'P. Ilostmenopausal estrogen use, cigarette smoking and cardiovascular morbidity in women over 50. N EnglJ Med 1985;313:1038-43.
Consultants in communicable disease control SIR,-Dr G J Duckworth's editorial highlighted the lack of resources, power, and training attached to the newly established posts of consultant in communicable disease control.' This will strike a chord with all junior doctors considering or currently training for this specialty. Junior doctors head for specialties for many reasons, including interest, the availability of consultant posts, convenience (including the availability of part time work), and possibilities for career progression. A clear career pathway is needed from the various entry routes of public health medicine, microbiology, and infectious disease. Also needed is a description of what promotional possibilities exist-for example, to director of public health or regional epidemiologist. Projections of the future availability of consultant posts could do much to attract high calibre junior doctors to the specialty. A commitment to continuing education for those appointed is required. In addition, as new consultants in communicable disease continue to choose a part time commitment the Joint Committee on Higher Medical Training should make it easier to obtain accreditation in
joint specialties. A steering group on training for consultants in communicable disease control is currently examining these and other issues. This group includes representatives from the major connected medical specialties and junior doctors. Dr Duckworth's assertion that aspects of environmental health are not within the remit of consultants in communicable disease control is not universally shared. Many doctors consider that these important issues are, or should be, within the remit of public health. The public certainly considers that someone should be in charge. The debate is by no means settled. People are made uncomfortable by change. The Chinese ideogram for change has two parts: "danger" and "opportunity." We should not lose sight of the opportunities for marching boldly forward while we are temporarily stuck in the dangerous and uncertain mire of limited resources. Otherwise consultants in communicable disease control will find themselves in a career cul de sac. MARY E BLACK
Department of Public Health Medicine, Eastern Health and Social Services Board, Belfast BT2 8BS I Duckworth GJ. Consultants in communicable disease control.
BMJ7 1991;303:483-4. (31 August.)
SIR,-All health authorities are now busy with purchasing and contracting just as in 1974 they were busy with information and planning. In such a situation control of communicable disease may be considered to be unimportant. I find, however, that Dr G J Duckworth failed to mention in his editorial' the role of the consultant in communicable disease control regarding the childhood vaccination and immunisation programme and the control programme for HIV infection and AIDS. In many districts the immunisation coordinator is the consultant in communicable disease control, who also has executive responsibility for HIV infection and AIDS. In some districts this is not the case. This situation therefore requires rectification for obvious reasons and was referred to in the report Public Health in England.2 Dr Duckworth also speaks of "financial autonomy" to match but does not indicate how this should be brought about. My proposal is for a communicable disease control unit headed by the
BMJ VOLUME 303
12 OCTOBER 1991
Section of Radiotherapy, Institute of Cancer Research, Sutton, Surrey SM2 5NG 1 Allen-Mersh TG. Improving survival after large bowel cancer. BMJ 1991;303:595-6. (14 September.) 2 Palmer M, Petrelli NJ, Herrera L. No treatment option for liver metastases from colorectal adenocarcinoma. Dis Colon Rectum 1989;32:698-701. 3 Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, ct al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engly Med 1981;305:6-1 1. 4 Metzger U. Adjuvant therapy for colon and rectal cancer-NIH consensus development conference. Eur J Cancer 1990;26: 755-62. 5 Taylor I, Machin D, Mullee M, Trotter G, Cooke T, West C. A randomised controlled trial of adjuvant portal vein cytotoxic perfusion in colorectal cancer. BrJ Surg 1985;72:359-63. 6 Slesin ML, Gray R. Adjuvant therapy for cancer of the colon. BMVJ 1991;302:1100-1. (11 May.) 7 James RD. 'Axis': a new type of cancer trial. Clin Oncol 1990;2: 125-9.
makes it unlikely that their natural course can be observed ethically as the polyp-cancer relation is widely accepted. It is, unfortunately, simplistic to call for an "urgent ... randomised controlled trial of polypectomy" as Reasbeck has calculated that, even in high risk subjects, matched groups of 7000 patients would be needed to show a reduction in mortality from cancer.5 Studying patients with an average risk would avoid the ethical problems of not subjecting the control group to colonoscopy, but the numbers in each group would need to be increased at least threefold (to allow for decreased compliance as well as a lower yield). A society like ours must surely wish to identify those at risk of such a common and potentially preventable cancer, and (except for surgery in certain cases) polypectomy is currently our only weapon for reducing that risk. Epidemiologists may wish to debate available data, but surely the commonly held view that polyps present a golden opportunity to prevent cancer should remain the basis for surveillance. To denigrate colonic polypectomy in blanket fashion in a general medical journal is unreasonably nihilistic and clinically misleading. C B WILLIAMS I C TALBOT W S ATKIN St Mark's Hospital for Diseases of the Rectum and Colon, London ECIV 2PS
SIR,-The central theme of the editorial by Drs Allyson M Pollock and Philip Quirke is that the value of polypectomy as a means of preventing colorectal cancer is unproved and by implication perhaps not worth while.' From their armchair viewpoint, however, the authors contribute little other than "knocking copy." They challenge the "inevitability of the adenomacarcinoma sequence," but no one has ever claimed this. Morson emphasised that only a small proportion ofcolorectal adenomas progress to carcinoma.2 About 30% of the population have an adenoma by the age of 60, but the lifetime risk of colorectal cancer is only about 3%, which suggests that only 10% with adenomas develop cancer in their lifetime. A minimum of five genetic changes are required for the formation of a colorectal cancer; fewer changes are required for the development of an adenoma.3 Larger adenomas seem to have more genetic abnormalities, which fits with the clinical observation of their greater likelihood of containing cancer. Most adenomas are small, and it is indeed problematic to predict which could become malignant. From the observation by Muto et al that 40% of villous adenomas already had a focus of malignancy by the time of excision,4 however, Drs Pollock and Quirke incorrectly conclude that the remaining 60% would never progress to cancer. They also state that "only 46% of polyps more than 2 cm will contain an invasive focus"; this figure, based on Muto et al's surgical series,4 is probably an exaggeration, but the incidence is still exceedingly high. We do not know how to identify those adenomas that will grow, but the ease of endoscopic removal
BMJ VOLUME 303
12 OCTOBER 1991
MALCOLM H GOUGH
Chairman, Federation of Surgical Specialty Associations, Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU BERNARD F RIBEIRO
Honorary Secretary, Association of Surgeons of Great Britain and Ireland, London WC2A 3PN
1 Pollock AM, Quirke P. Adenoma screening and colorectal cancer. BMJ 1991;303:3-4. (6 July.) 2 Morson B. The polyp-cancer sequence in the large bowel. Proc R Soc Med 1974;67:451-7. 3 Fearon ER, Vogelstein B. A genetic model for colorectal tumorigenesis. Cell 1990;61:759-67. 4 Muto T, Bussey HJR, Morson BC. The evolution of cancer of the colon and rectum. Cancer 1975;36:2251-70. 5 Reasbeck PG. Colorectal cancer: the case for endoscopic screening. BrJSurg 1987;74:12-7.
Pyoderma gangrenosum
Adenoma screening and colorectal cancer
about high infectivity of hepatitis B surgeons as a group have not appreciated the risks to which they are exposed and the protection that may be obtained by immunisation. There has been much discussion recently within the surgical royal colleges and the surgical specialty associations about transmission of HIV during surgical procedures. With the aim of determining attitudes about testing patients and doctors for HIV the Federation of Surgical Specialty Associations-representing the 10 major specialty associations-recently sent a questionnaire to all surgeons. The opportunity was taken to ask also whether the respondent has been immunised against hepatitis B and whether he or she thinks that such immunisation should be compulsory. The fact that the question has been asked may encourage those not immunised to seek this protection. In addition, the answers should give some indication of opinion about the whole question of the risk of infection from surgical practice.
SIR,-We were interested in the recent picture report of severe ulceration of the scalp.' Diabetes mellitus occasionally predisposes to severe skin infections, but the diagnosis of the ulceration in this case is unclear from the details given. The history of a rapidly expanding ulcer after minor trauma suggests pyoderma gangrenosum, for which paraproteinaemia is a known predisposing factor.2 The scalp is an unusual though well recognised site for pyoderma gangrenosum, and on the basis of the dramatic photograph we suggest that this was the diagnosis. Although the prognosis in such a severe case is likely to be poor, high dose systemic corticosteroids may be of dramatic
benefit.'4 A J G McDONAGH M J CORK C I HARRINGTON Rupert Hallam Department of Dermatology, Royal Hallamshire Hospital, Sheffield S10 2JF I Kumar S, Mohammed R. Minerva. BMJ3 1991;303:592. (7
September.) 2 Powell FC, Schroeter AL, Su WPD, Perry HO. Pyoderma gangrenosum: a review of 86 patients. Q 7 Med 1985;55: 173-86. 3 Mahood JM, Sneddon IB. Pyoderma gangrenosum complicating non-Hodgkin's lymphoma. BrJ7 Dermatol 1980;102:223-5. 4 Carr AJ, Percival RC, Rogers K, Harrington CI. Pyoderma gangrenosum after cholecystectomy. BMJ 1986;292:729-30.
Surgeons and hepatitis B SIR,-Dr David Snashall and colleagues,' commenting on Mr Stuart Kennedy's personal view,2 ask why the doctors had not been immunised. The regrettable answer must be that despite the considerable amount of information available
1 Snashall D, Peel M, Madan I. Surgeons and hepatitis B. BMJ 1991;303:413. (17 August.) 2 Kennedy S. An elementary mistake? BMJ7 1991;302:1614. (29 June.)
Taxation of alcoholic beverages SIR,-In the Observer colour magazine of 28 July 1991 Dr John Collee wrote about the excessive drinking of alcohol. His article included the following paragraph: A lead article by Luisa Dillner in the British Medical Journal points out that Britain will next year be committed to harmonising its import duty with the rest of the European Community. This will result in a fall in the price of most alcoholic drinks with, we anticipate, a dramatic rise in consumption. This would seem to be a quotation from the BMJ7 leader on alcohol abuse earlier this year': The most immediate threat to the level of alcohol consumption will come from the European Community. Britain is committed to the harmonisation of duty within the single market next year, which will mean a fall in the retail prices of most alcoholic beverages in this country. The Institute for Fiscal Studies estimates that this will result in a 46% increase in the volume of alcohol drunk in each household. This statement needs to be corrected. Although the original 1987 proposal of the commission might have posed a threat by setting a single rate of duty for each product group, the proposal was amended in December 1989 to provide for a minimum rate of duty to take effect on 1 January 1993 and a common target rate to be achieved over a longer period.2 This more flexible approach strikes a better balance between the member states' interest in determining tax revenues and health policy, and the European Community's interest in securing sufficient convergence of rates to abolish fiscal frontiers by 31 December 1992. In particular, the principle of a minimum rate leaves member states free to set the duty on alcoholic beverages at levels which reflect their health concerns. A significant step in this direction was taken on 24 June 1991 when the economics and finance ministers reached political agreement on minimum rates of excise duty for beer and wine. Those for fortified wines (sherry, port, vermouth, etc) and for spirits will be set later this year. 925
There is thus no threat that the European Community will compel the United Kingdom to reduce its excise taxation on alcoholic beverages. Nor was there when your leader appeared on 13 April 1991. I am grateful to be able to put the record straight-and reassure your readership. LEON GORDON
C(ustoms Ulnion and Indirect I'axation, Directorate-General, Commission ot the European Communities, 1049 Brussels, Belgium 1 I)illner L. Alcohol abuse. BAM 1991;302:859-60. (13 April.) 2 Amended proposal for a council directive on the approximation of the rates of excise duty on alcoholic beverages and on the alcohol contained in other products. Official Journal of the European Communities No C( 1990 Jan 18:12/12. (COM59)527
final.
How to pay for expensive drugs SIR,-Professor M Orme's editorial presents a balanced view of the merits of various economic strategies for hospitals' and general practitioners' drug prescribing budgets. He failed, however, to highlight one important aspect. Although there is a trend for hospitals to defer prescribing for outpatients, and for some patients on discharge, to general practitioners in order to reduce hospital pharmacy budgets, the overall cost to the NHS will increase if this policy is pursued. The cost of drugs dispensed by hospital pharmacies is, almost without exception, substantially lower than that levied by the "high street" pharmacist, who, understandably, adds a sizeable mark up to the costs to produce a profit. Professor Orme is right when he says that a national solution should be sought; it should embrace both hospitals and general practitioners and might also include high street pharmacies. STEPHEN ASH
Ealing Hospital, Middlesex UB I 3HW 1 Orme M. How to pay for expensive drugs. BMJ 1991;303:593-4. (14 September.)
Health of the nation SIR,-Professor I B Pless's comments on accident prevention in his response to The Health of the Nation should be noted by politicians, officials in the Department of Health, and all health workers.' What he is asking is for the Department of Health to take a firm lead in accident prevention (injury control in North American terminology). The justification for this is sound. Accidents are the leading cause of death in the early years of life. In the United States they account for a greater proportion of years of potential life lost than cancer and heart disease combined. They cause much suffering and hardship. They lose the NHS millions of pounds a year. In supporting Professor Pless's proposals for a division of injury control in the Department of Health I would go even further. I believe that until the discipline is given a similar status to heart disease, cancer, and communicable disease control it will not make any real progress. For advances to be made an institute (or centre) for accident prevention and injury control attached to an academic institution in the United Kingdom is urgently needed. Such an institute would have a similar role to that of the Communicable Diseases Surveillance Centre. It would act as a clearing house for information on accidents but also collate and stimulate research. It would act as a national focus for action on accidents. Some will argue that such an institute already exists in the form of the Medical Commission on
926
Accident Prevention, the Child Accident Prevention Trust, and the Parliamentary Advisory Council on Transport Safety (PACTS). These important organisations are either too specialised or too restricted within their terms of reference. The Royal Society for the Prevention of Accidents operates on a broader front, especially in education. It has already taken a considerable initiative towards working more closely with health authorities with the production of its report Action on Accidents in conjunction with the National Association of Health Authorities and Trusts.' Despite all this activity the need for a national institute still exists. Several regional and district health authorities have now developed strategies and plans for accident prevention. They cannot go it alone. The government must play its part. As no other agency is likely to take the lead the Department of Health should seize the initiative, recognise its key role, and put substantial resources into making appreciable inroads into this major modern epidemic. JAMES GORDON AVERY Flecknoe, Near Rugby, Warwickshire CV23 8AT I Pless IB. Accident prevention. BAJ 1991;303:462-4. 2 National Association of Health Authorities and Royal Society for the Prevention of Accidents Strategy Group. Report. Action on
accidents: the unique role of the health serzvice. Birmingham: NAHA, 1990.
SIR,-Drs Martin Dennis and Charles Warlow's proposed strategy for stroke' in response to The Health of the Nation ignores the potentially large contribution of oestrogen replacement treatment in preventing stroke in postmenopausal women: it is estimated to reduce the relative risk by about half in this group.2 Reductions in the relative risks of killing or disabling diseases that have been reported in controlled studies of oestrogen replacement treatment with or without balancing progestogens include for strokes 0.53,2 myocardial infarction 0 30,' and hip fracture 033.4 Additionally, there are significant reductions in other fractures related to osteoporosis.5 6 These observations are supported by a decreased mortality in women using oestrogen replacement treatment., In the absence of circulating oestrogens there is a threefold to fourfold increase in atherosclerosis in postmenopausal women.' With one exception,9 these figures for the reduction of relative risks have been confirmed to various degrees by other studies. Oestrogen replacement treatment should be considered in calculations of strategies for decreasing the risk of stroke and improving the health of the nation. ALLAN ST J DIXON
Chairman, National Osteoporosis Society, PO Box 10,
Radstock, Bath BA3 3YB
1 Dennis M, Warlow C. Strategy for stroke. BMJ 1991;303:636-8. (14 September.) 2 Paganini-Hill A, Ross RK, Henderson BE. Postmenopausal oestrogen treatment and stroke: a prospective study. BMJ 1988;297:5 19-22. 3 Stampfer MJ, Willet WIC, Colditz GA, Rosner B, Speizer FE, Hennekens CA. A prospective study of estrogen therapy and coronary heart disease. N EnglJ7 Med 1985;313:1044-9. 4 Kiel DP, Felson DT, Anderson JJ, Wilson PW, Moskewitz MA. Hip fractures and the use of estrogens in postmenopausal women, the Framingham study. N Engl Jf Med 1987;317: 1169-74. 5 Lindsay R, Hart DM, Forrest C, Baird C. Prevention of spinal osteoporosis in oophorectomised women. Lancet 1980;ii: 1152-4. 6 Hutchinson TA, Polansky SM, Feinstein AR. Postmenopausal oestrogens protect against fractures of hip and distal radius, a case control study. Lancet 1979;ii:705-9. 7 Henderson BE, Paganini-Hill A, Ross RK. Decreased mortality in users of estrogen replacement therapy. Arch Intern Med
1991;151:75-8. 8 Witteman JCM, Grobbee DE, Kok FJ, Hofman A, Valkenburg HA. Increased risk of atherosclerosis in women after the menopause. BMlJ 1989;289:642-4.
9 Wilson PWF, Garrisoni RJ, Castelli W'P. Ilostmenopausal estrogen use, cigarette smoking and cardiovascular morbidity in women over 50. N EnglJ Med 1985;313:1038-43.
Consultants in communicable disease control SIR,-Dr G J Duckworth's editorial highlighted the lack of resources, power, and training attached to the newly established posts of consultant in communicable disease control.' This will strike a chord with all junior doctors considering or currently training for this specialty. Junior doctors head for specialties for many reasons, including interest, the availability of consultant posts, convenience (including the availability of part time work), and possibilities for career progression. A clear career pathway is needed from the various entry routes of public health medicine, microbiology, and infectious disease. Also needed is a description of what promotional possibilities exist-for example, to director of public health or regional epidemiologist. Projections of the future availability of consultant posts could do much to attract high calibre junior doctors to the specialty. A commitment to continuing education for those appointed is required. In addition, as new consultants in communicable disease continue to choose a part time commitment the Joint Committee on Higher Medical Training should make it easier to obtain accreditation in
joint specialties. A steering group on training for consultants in communicable disease control is currently examining these and other issues. This group includes representatives from the major connected medical specialties and junior doctors. Dr Duckworth's assertion that aspects of environmental health are not within the remit of consultants in communicable disease control is not universally shared. Many doctors consider that these important issues are, or should be, within the remit of public health. The public certainly considers that someone should be in charge. The debate is by no means settled. People are made uncomfortable by change. The Chinese ideogram for change has two parts: "danger" and "opportunity." We should not lose sight of the opportunities for marching boldly forward while we are temporarily stuck in the dangerous and uncertain mire of limited resources. Otherwise consultants in communicable disease control will find themselves in a career cul de sac. MARY E BLACK
Department of Public Health Medicine, Eastern Health and Social Services Board, Belfast BT2 8BS I Duckworth GJ. Consultants in communicable disease control.
BMJ7 1991;303:483-4. (31 August.)
SIR,-All health authorities are now busy with purchasing and contracting just as in 1974 they were busy with information and planning. In such a situation control of communicable disease may be considered to be unimportant. I find, however, that Dr G J Duckworth failed to mention in his editorial' the role of the consultant in communicable disease control regarding the childhood vaccination and immunisation programme and the control programme for HIV infection and AIDS. In many districts the immunisation coordinator is the consultant in communicable disease control, who also has executive responsibility for HIV infection and AIDS. In some districts this is not the case. This situation therefore requires rectification for obvious reasons and was referred to in the report Public Health in England.2 Dr Duckworth also speaks of "financial autonomy" to match but does not indicate how this should be brought about. My proposal is for a communicable disease control unit headed by the
BMJ VOLUME 303
12 OCTOBER 1991
