NEWS & Political Review
Vaccines for HIV infected pregnant women? Pregnant women infected with HIV could benefit from an AIDS vaccine-but a trial of such a vaccine, devised by US health officials, has met with problems. The protocol for such a trial, which would involve immunising 10 to 20 HIV positive pregnant women beginning at the 14th week of pregnancy, was written last spring, according to Barney Graham, a virologist and immunologist at Vanderbilt University, Nashville. The trial would be sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) but it cannot proceed until a manufacturer willing to supply a viral product for the vaccine is found. The problem is that manufacturers fear they will be held liable if an infant born to a vaccinated woman has a birth defect or has any other complication that could conceivably be linked to the vaccine. This fear persists despite the fact that, according to Dr Graham, no lawsuit has ever been filed in the United States because of harm resulting from a trial of a maternal vaccine. But with so few women receiving the vaccine researchers will be able to assess only the vaccine's effect on maternal health and not its effect on the fetus. They will be looking at what types of antibodies to HIV are produced and whether CD4+ cells and viral loads increase or decrease. Dr Graham said; determining whether transmission of HIV to infants is affected would have to wait for a longer trial. How many pregnant women are at risk of the effects Qf HIV? According to one NIAID source, currently about 6000 HIV positive pregnant women give birth each year in the United States, and up to a third of their infants are infected. There is advance knowledge of only about 2000 of these births. One drawback of an active vaccine is that it might not protect against new variants of HIV that seem continually to arise. Some believe that these "escape mutants" are the viruses that infect the fetus. A passive vaccine would also have problems. More safety precautions would be necessary in preparing the vaccine and-as it would have to be given intravenously-more medical staff would be required. Such a preparation will also spoil, making it suitable for use only in developed countries. If the time of transfer of virus from mother to child and the type of antibody that is truly protective were known it might be possible to improve passive maternal vaccines, scientists say, perhaps by "spiking" them' with the appropriate monoclonal antibodies at the
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right time. The infant alone might be immunised after birth, or perhaps all women could be immunised in childhood, receiving booster shots later. Discussions with manufacturers about supplying a product for a maternal trial are now under way, according to Daniel Hoth, director of the Division of AIDS at National Institute of Allergy and Infectious Disease. "It would help the companies for the government to be involved [in a trial of their products] because it demonstrates a long term commitment and would give an independent perspective [the government's] on the ethics of the vaccine administration as well as on the safety and efficacy of the product. These would be blue ribbon trials." -GAIL WcBRIDE, medical writer, Chicago
AIDS conference moves to Amsterdam The 1992 international AIDS conference will be held in Amsterdam, "a city of tolerance," said its chair, Dr Jonathan Mann, professor of epidemiology and international health at Harvard and former head of the World Health Organisation's Global Programme on AIDS. The meeting was shifted from the United States because the US government did not end restrictions on entry by HIV positive people (24 August, p 432). "An international AIDS conference is essential in 1992. Moving the conference to
Amsterdam ensures continued progress in understanding and stemming the HIV pandemic," Dr Mann said. The meeting will be cosponsored by the Harvard AIDS Institute, directed by Dr Max Essex, and a new Dutch foundation headed by immunologist Professor Joost Ruitenberg, chairman of the executive board of the central laboratory of the Netherlands Red Cross Blood Transfusion Service. Professor Ruitenberg is active in AIDS research, prevention, and care. Vice chair of the conference will oe Professor Ernst Roceam Abbing, head of the Dutch national AIDS committee. The agreement to hold the meeting in the Netherlands "is not a marriage of convenience, but a marriage of the heart and mind," said Dr Mann. "The Dutch have no restrictions on the entry of HIV infected people and a longstanding devotion to human rights. Their domestic AIDS policy is creative and enlightened, with good working relationships between community organisations and the government. They were among the first supporters of the global programme against AIDS and have a strong commitment to assist developing countries." However friendly the Dutch, the Amsterdam meeting will not be sedate. Peter Staley of Act Up promised demonstrations similar to that against the US Consulate at this year's meeting in Florence: "Amsterdam is not the target, but as long as there's a huge international media gathering, we are going to use the avenue to get our message out."-JANICE HOPKINS TANNE, contributing editor, New York magazine 665
Headlines Condoms for New York teenagers: The board of education in New York City has voted to make condoms available to high school students whether their parents agree or not. The board hopes that the programme will prevent AIDS and other sexually transmitted diseases and reduce the number of pregnancies among teenagers. Terodiline withdrawn: Reports of torsades de pointes in patients taking terodiline for urinary incontinence (BMJ ,991;302:1469) have led the manufacturers, Kabi Pharmacia, to withdraw the drug while awaiting further tests. The Committee on Safety of Medicines is advising doctors to take patients off terodiline as soon as possible and warns that the drug may take up to six weeks to be cleared from the body. AIDS failure: A new report from the Office of Health Economics on worldwide policies for AIDS shows how countries have been slow to take the necessary precautions. In Denmark, despite almost universal knowledge about condoms only one third of adolescents use them, while in France 9% of the population use condoms. New women's hospital: A new £16m women's hospital in Liverpool should start to take its first patients within two years. The hospital will bring together obstetric, gynaecological, and neonatal services.
Drug seizures: Home Office figures show that the number of drug offenders in sritgin rose in 1990 by 15% to 44 900. Their avei-Lsc aee continued to fall to under 25 years and 90% of LlLc crimes were for possession, usually of
cannabis.
Liberal Democrats condemn trusts If the Liberal Democrats came to power (or shared it) they would immediately cancel the second wave of NHS trusts and review the position of the existing 57 trusts. Delegates attending the party's annual conference in Bournemouth last week condemned the concept of "opting out" but voted against abolishing all trusts to avoid throwing the NHS into yet more disarray. Health spokesman, Charles Kennedy MP, claimed that the health service could not afford the further massive upheaval that immediate abolition would bring. "We cannot lurch from the limbo of current changes into further reorganisation-that would dismay and depress the staff still further." Instead, each existing trust would be carefully scrutinised, and it would be up to local people to decide its future. In his preconference briefing party leader Paddy Ashdown admitted that some of the trusts would probably retain their status. Several of those who spoke in the debate on trusts worked in the health service, including Andy Myles, a hospital administrator in Edinburgh and prospective parliamentary candidate. He argued against "tampering" with trusts, claiming that they were "too deeply embedded in Tory legislation and too steeped in the ideology of Thatcherism." Another prospective candidate, junior doctor and chairman of the Hospital Doctors Association, David Wrede, raised the problem of training. If trusts limited the type of medical procedures they performed they would become unsuitable for training. While they still existed, however, the conference wanted more accountability. Trusts would be compelled to publish their business plans, take directly elected local representatives to their boards, measure efficiency in terms of quality as well as cash, and publish service development plans. Trusts would also have to conform to Whitley Council terms and conditions. Despite the dislike of trusts, the conference generally supported the purchaser-provider split, though delegates wanted to reassess general practi-ioner fundholding and ban qtreue jumping by fundholders' patients.
The report comes as the government completes consultation on a strategy for the nation's health. Sir Donald's report suggests just how necessary such a strategy is. The problem of extending life expectancy without extending the period free from disability is no doubt one reason why the chief medical officer devotes a substantial section of his report to the health of the elderly- a group conspicuously missing from The Health of the Nation (17 August, p 408). He emphasises how important it is to include the elderly in health promotion and in prevention programmes. Like younger people, the elderly can "reap immediate benefits" from stopping smoking, eating a balanced diet, and taking regular exercise. The other new subject that gets a chapter to itself is health needs assessment, including an account of research commissioned by the Department of Health using diabetes as a model. Assessing health needs is part of what Sir Donald calls the rejuvenation of public health, exemplifying it in his own report by his reminder that inequalities in health are still as persistent as in John Simon's day. Indeed, he says, the inequalities are probably increasing, not only in the United Kingdom but also in countries like Sweden, which suggests a complex interaction between ill health and factors such as low income, unhealthy behaviour, a poor environment, and a lack of choice. AIDS has dominated Sir Donald's term, and he has been important in shaping the health departments' response to it. His final report shows a total of almost 4000 cases by the end of 1990 but also a lengthening median survival time. Despite the fact that 81% of cases of AIDS have been in men who have had intercourse with men, Sir Donald emphasises the rapid increase in the numbers of cases of heterosexual transmission of the virus. He also suggests that some of the excess deaths among adults attributed to suicide or an open verdict are in fact associated with undisclosed HIV related disease. Women do not come out well from the report. They share in the rising death rates
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Dentists' survey: A British Dental Association study has shown a dramatic fall in the number of dental practices accepting NHS patients. The results show a wide variation throughout the country from 100% acceptance in Newcastle to 30% in parts of Central London. Medical demography: Portugal has the highest proportion of women doctors (39%), according to the medical insurance branch of the French securite sociale. Greece has 31%, Spain and Austria 30%, the United Kingdom 28%, and France and Denmark 27%.
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The public health: could be better Over Sir Donald Acheson's seven year term chief medical officer, life expectancy in England and Wales has risen by about three years-but there has been no corresponding increase in the length of life without disability. Despite substantial improvements in some aspects of the public's health (such as infant mortality), Sir Donald's final annual report, published as he leaves office, shows disappointing setbacks in other aspects, such as an increased mortality among young adults. as
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among adults aged 15-39. Particular contributors to this increase are cancers of the breast and cervix and chronic liver diseasethe last attributed to increased alcohol consumption. In 1990, breast cancer killed 13 000 women. Sir Donald states that throughout the 1980s there has been no convincing fall in mortality from this cause among young women, and he wants more research into this "common, distressing, and fatal disease" that continues to have a higher incidence in England than elsewhere. On a more positive note, Sir. Donald mentions that the NHS will have to, and is starting to, adapt its practices to the needs of women doctors. He also claims some success in obtaining extra, earmarked cash for postgraduate and continuing medical education. -DAVID GILLEN and JANE SMITH, BMJ
On the State of the Public Health. London: HMSO, 1991. Will it take 20 years to come up to standard?
Poor housing, vulnerable people
Responding to the report, Peter Archer. terms and conditions of service, which gives of the Institution of Environmental Health sacked consultants an automatic right of Officers said it was "misdirected," as "unfit" appeal to the health secretary. In his stateOver half of all bedsits and hostels in England privately rented housing constituted only a ment of case, Mr Raymond cites internal and Wales fail to meet health and safety small proportion of the total problem when documents disclosed by the health authority standards, and repairs could take 20 years to compared with owner occupied acommoda- which he alleges show that managers took a complete, says a survey published last week. tion. He went on to criticise the commission secret decision that Dr Zeitlin had to be The Audit Commission's latest report for measuring the quantity rather than the "removed from the scene." Dismissal for looks at housing in general, but it concen- quality of services provided and for failing redundancy would be legally justified only "to examine real work done by environ- if the authority's need for the services of trates on houses of multiple occupation. This category, which includes bed and breakfast, mental health officers in relieving urban consultant haematologists had diminished or bedsit, and hostel accommodation, houses deprivation." was expected to diminish. Mr Raymond, While endorsing many of the commis- who represented the obstetrician Wendy some of the most vulnerable members of society-single mothers, the poor, the sion's proposals, particularly those relating Savage and the paediatrician Marietta Higgs to the development of proactive strategies in their legal battles with their employers, mentally ill, and the homeless. The report, which took 18 months to based on regular surveys of the condition of contends that no need for redundancy compile and studied over 300 local authori- the housing stock, Archer concluded that the existed. ties, criticises authorities for not appreciating report's calls for increased processing of imDr Zeitlin was appointed to a new post in the true scale of the problem. One authority, provement grants and more rapid responses 1986 as a second consultant haematologist to for example, undercalculated the number of to residents' complaints would be a "total Bromsgrove and Worcester District Health houses in multiple occupation by over 4000, waste of resources." -DAVID GILLEN, BMJ Authority. In January 1990, at a public meetwhile half failed to estimate how many were ing called to discuss the hospital's possible substandard. According to the commission, Healthy Housing: The Role of Environmental Health opting out, she claimed there was a critical Services. ISBN 0-11-886065-8. Available from shortage of nurses at the Alexandra Hospital, more than 180000 multioccupied houses need attention, but last year environmental HMSO, price £7.50. adding that this was a national problem. In health officers issued only 10000 enforceSeptember 1990, she learnt that an analysis ment notices requiring owners to bring them of nurse staffing levels under the American up to standard. The commission concludes GRASP system showed a widening gap that local authority environmental health between nursing hours required and those officers often lack adequate policies and -provided between 1987 and 1990. This instrategies to deal with such poor quality cluded anonymous comments by nurses, housing and are therefore inactive in tackling who spoke of patients lying in faeces and the problems. patients at risk through the shortage of Seven years ago the Institution of Environ- West Midlands Regional Health Authority nurses. Dr Zeitlin obtained a copy, sent it mental Health Officers recognised that this invoked a redundancy situation as a pretext to district chairman Dawn Price, and told type of housing was more at risk of domestic for dismissing a consultant, her solicitors colleagues about it. fires than was owner occupied accommoda- allege in an appeal to the health secretary, In November, at a meeting Dr Zeitlin tion. It blamed a shortage of staff for inade- William Waldegrave. requested with Dr Harrison, the regional quate monitoring by environmental health Helen Zeitlin, a former consultant haema- medical officer, to discuss working diffidepartments. The Audit Commission, tologist at the Alexandra Hospital, Redditch, culties, she was told that a complaint of however, insists that services could be is appealing against her dismissal last Feb- personal misconduct was going to be made improved without staff changes provided all ruary, when she was told to clcar her desk against her. This alleged that she had told the authorities perform as effectively as the best and leave the hospital on paid leave at less public meeting in January that "patients 25% in terms of enforcement notices issued than 12 hours' notice. It was only after her were dying for lack of care." Dr Zeitlin, the and improvement grants processed. The solicitor, Brian Raymond, intervened that meeting's chairman, and a fellow consultant commission does concede that current levels she was allowed a further week to hand over deny that these words were used, and a local of funding would prevent local authorities her patients. newspaper report of the meeting makes no from implementing all its recommendaDr Zeitlin is appealing under paragraph mention of any comments by Dr Zeitlin. tions. 190 of hospital medical and dental staffs Other charges relate to an incident when
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Dr Zeitlin is said to have lost her temper because a patient's notes were missing, and to minor disagreements between herself and the other consultant haematologist, Dr Daisy Obeid, with whom she had a longstanding personality conflict. In January 1991 the possibility of redundancy was mentioned for the first time. On 28 February Dr Zeitlin received a letter putting her on paid leave from that day and making her redundant from 27 May. An internal memorandum dated 14 December 1990 accuses Dr Zeitlin of"disruptive and malicious" conduct and an "unpredictable, unpleasant and. abrasive manner" and adds, "There is a common recognition that the problems can only be resolved by the removal of Dr Zeitlin from the scene." The memorandumrl discusses possible ways of achieving this: allowing her to resign with an ex gratia payment ("£135,000?"), formal disciplinary procedure ("outcome uncertain"), referring her to a consultant psychiatrist ("the opinions expressed about her health have not come from qualified psychiatrists"), or transferring her to another hospital. This document, Mr Raymond concludes in his statement of claim, "wholly undermines to the point of nullity the RHA's contention that Dr Zeitlin was dismissed by reason of redundancy." Mr Colin Smith, for the health authority, declined to comment on the allegations. "We have got to respond first to the secretary of state," he said.-CLARE DYER, legal correspondent, BMJ
country are gradually changing for the better." -LUISA DILLNER, BMJ The UN Convention and Children's Rights in the UK by Peter Newell was written for the National Children's Bureau in collaboration with the Calouste Gulbenkian Foundation and is published by the National Children's Bureau.
Controlling drug companies
He. has a right to "the highest attainable standard of health"
origin was 15-2 per 1000 live births compared with 8 9 for those born to mothers of British
origin.
Children are also guaranteed, by article 6, "the inherent right to life." Peter Newell cites a 1988 report from the Royal College of Physicians which criticised the shortage of intensive care facilities for neonates. "Without the necessary resources," says the report, "many babies who could have been rescued will die." It is over article 27 of the convention, which sets out "the right of every child to a standard of living adequate for the child's physical, mental ... and social development" that the report is particularly critical of Britain's record. It quotes a comparative Britain's children are being denied basic study of child poverty in industrialised rights set out in the 1989 United Nations countries published by Unicef in 1990 which convention on the rights of the child. A concluded that British children had become report published this week by the National poorer over the past decade. Peter Newell Children's Bureau dispels the myth that the states that "large numbers of children are articles of the convention are relevant only to living in bed and breakfast accommodation, raising concerns about health, development, developing countries. According to Peter Newell, author of the safety, education, and diet." The report states that the government is report, British children suffer from poverty, inadequate housing, and physical, mental, too restrictive in providing income support. and sexual abuse. All of these contravene the An unemployed and pregnant woman under convention, which Britain is committed to 18 cannot claim income support until she is ratifying. The convention has already been six months pregnant. This, suggests the ratified by 90 states. report, contravenes article 26 of the convenThe report argues that implementing the tion, which states that the circumstances of convention will be difficult because of lack of the child should be considered when granting information. "There is only patchy monitor- benefit. ing of the state of the UK's children," says Although the United Nations convention the report. "The lack of ... information will not make it illegal for children to be makes it hard to judge precisely how changes denied adequate health and housing, it has in social and economic policies are affecting made children's rights a political issue. This week the Labour party announced its intenchildren." Under the convention children have a right tion to appoint a minister for children. to "the highest attainable standard of health. " "The convention provides a new yardstick The report argues that Britain contravenes to embarrass governments with," says Peter this. The standard of health care, it alleges, Newell. "The next election will be the first varies with the social class, ethnic back- time that political parties will compete in ground, and region. In 1987 the death rate offering commitments to children. I believe for infants born to mothers of Pakistani social attitudes towards children in this
Please can I have some more rights?
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Following allegations made in a report in the First Tuesday television documentary series last November, Pizer, Lederle, ScheringPlough, and Lipha were this spring reprimanded by the code of practice committee of the Association of the British Pharmaceutical Industry (ABPI). Complaints against two other firms were rejected. The main negative consequences for those found "guilty"-of giving inappropriate benefits to doctors in the form of meetings abroad and attendance at golfing and similar events-has been negative publicity. A notable example of this was an expose in the Guardian (9 September 1991, p 5) which highlighted the previously little reported findings of the disciplinary committee with the headline "Drugs firms rebuked for sales perks." First Tuesday's producer, James Cutler, believes that the ABPI's sanctions are inadequate. He argues that the industry's self policing is bound to be lax and that as well as the legal sanctions which already exist (independently of the ABPI scheme) a more independent public body should be responsible for handling complaints made against pharmaceutical companies' promotional practices. In a recent radio interview he also suggested that all company sponsorship of medical meetings should be channelled through third parties such as "the British Medical Association or the Royal College of Physicians." Ideas like this are likely to gain some
When hospitality goes over the top
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popular support. Many patients may be disturbed by stories of lavish treatment of doctors by pharmaceutical companies. Their concerns are not merely about cost: such behaviour may also undermine their trust in the therapeutic judgment of their medical advisers. This is probably reflected in survey findings from organisations such as the ABPI showing that over 70% of people in Britain now say they want much more information about medicines they are prescribed. The practicality of Cutler's proposals for involving third parties in industry support of medical meetings, however, is open to question. So too is the fairness of his dismissal of self policing exercises like those conducted by ABPI. (The medical profession itself is largely self policed.) The fact, for instance, that Pfizer, Lederle, ScheringPlough, and Lipha are facing continued discussion of their misjudgments over promotion should not be overlooked. No company can afford to ignore its good name being called into question any more than it could devote promotional resources to ends that offered no chance of increasing its sales. Responsibly conducted promotion clearly has a role in any competitive market place. Hence many doctors (despite the obvious discomfort of some of those caught in the light of First Tuesday's investigation) will be reluctant to eschew all- offers of pharmaceutical company sponsorship and allied support. But they arguably share an ethical responsibility with companies to ensure that money spent to purchase their attention or goodwill is being reasonably and acceptably spent. One test of whether this is so or not is to check with the ABPI's code of practice. Another, of course, is to ponder on how legitimate or otherwise the activity being funded might appear on television. -DAVID TAYLOR, King's Fund Institute, London The ABPI's code of practice is available from Dr John Griffin or Dr Frank Wells, ABPI, 12 Whitehall, London SWIA 2DY.
The young in science Young researchers do as well as older ones in winning grants, shows a report from the Science and Engineering Council (SERC) published last week. The study was conducted because of widespread anxiety-the Advisory Board for the Research Councils was among those concerned-that young researchers were having more difficulties than older ones in getting their grant applications funded. In particular, a study that compared top rated grant applications that were funded and not funded found that a higher proportion of those not funded came from researchers under 40. The new study sent questionnaires to a sample of 231 permanent academic staff under 35 and 227 aged 35-45 and 142 scientists who were Royal Society university research fellows (non-permanent academic staff); response rates were 80%, 77%, and
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81% respectively. Researchers came from the disciplines of biology, chemistry, electrical engineering, physics, and physiology. The young researchers made slightly more grant applications than the older ones (a mean of 1 6 a year compared with 1-2) and had a slightly lower success rate (52% versus 59%), but there was no significant difference in the value of the grant awarded. Nor was there any significant difference between new and more established young researchers. There were, however, significant differences between disciplines, with biology having the lowest success rate (47%) and physics the highest (76%). Researchers who were more active (in terms that included the number of papers published) submitted the largest grant requests and were the most successful, but there were no significant variations in success rates by gender or seniority (lecturers versus more senior staff). Younger researchers had several strategies to increase their success rates: getting help from senior staff or staff from the funding agency; collaborating with others; and orienting research towards a special initiative or a subject funded by industry. The commonest criticism of funding bodies was their failure to give feedback, and applicants liked to be able to see referees' comments. Sir Mark Richmond, the chairman of SERC, welcomed the results of the study but said that there was no room for complacency: "In the present financial climate, all research workers find obtaining research funding extremely difficult, and it must be cold comfort to the newly appointed lecturer to learn that he or she is not being singled out for particularly harsh treatment by the funding bodies." SERC thus remains concerned and plans to try to do more to make sure that young researchers can establish their careers. One step that it might take would be to set up a young investigators award. At the moment the Agricultural and Food Research Council is the only council with such a scheme.RICHARD SMITH, BMJ
Indoor pollution: restricting smoking Government advice to restrict smoking in public places will be contained in guidelines to be issued by the Department of the Environment before the end of the year. A code of good practice will recommend that all public places should be non-smoking, with separate provision for smokers if necessary. All government and local authority buildings will be expected to comply with the code and the government hopes that public pressure will ensure a smoke free environment in other public buildings such as shopping centres, banks, and leisure facilities. A white paper last week confirmed the government's policy that non-smoking should be the norm inside buildings, with segregation of smokers. Replying to a Commons environment committee report on indoor pollution (20 July, p 150), the Department of the Environment sees environmental tobacco smoke as one of the most important of indoor air pollution problems. It regrets that the clear scientific evidence of the adverse effects of tobacco smoke is often clouded by intense campaigning from the pro-tobacco lobby, though there is a groundswell of public opinion in favour of action. On other sources of indoor air pollution, such as radon, dampness, or the so called sick building syndrome, the 23 page white paper is more tentative. While sharing many of the select committee's concerns, the government supports further research but baulks at expenditure on such proposals as a new inspectorate or increasing remedial grants. Ins'tead it is attracted by non-statutory guidelines for indoor air quality to provide a common basis for actions by architects, builders, product manufacturers, and owners. -JOHN WARDEN, parliamentary correspondent, BMJ Indoor Pollution, the Government's response to the Commons select committee on the environ-
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ment, Cm 1633, is available from HMSO, price
£4.15.
* The Health Education Authority has just published a guide recommending that all local authorities have a policy on tobacco for the communities they serve. Towards a Smokefree Environment includes a survey of all 405 local authorities in England showing that only half of the district councils have a formal policy on smoking, that few prosecute shopkeepers for selling tobacco to children under 16, and that few take seriously their duty to protect non-smoking employees from tobacco smoke. When authorities do enforce restrictions on smoking these most often apply to communal areas and public waiting areas, with staff restaurants and open plan offices included to a lesser extent. Most authorities still allow tobacco to be sold on council premises, and a few permit tobacco sponsored events to take place. The guide recommends that all local authorities should have a written policy providing for a smoke free environment but also recognising the needs of staff who do smoke. They should also prohibit the sale of tobacco and tobacco advertising and sponsorship on their property and prosecute retailers who sell tobacco to children.
"Rationing": Maryland style Maryland's governor, William Donald Schaefer, has the same problem with his state's Medicaid programme as have governors of America's other 49 states. Maryland cannot afford the rising cost of health care for its poor. This is partly due to the fact that revenues are down in the recent recession, and partly because the US government continues to add new benefits to the federalstate programme without assuming a larger share of the economic burden. One state-Oregon-has tried to resolve its fiscal dilemma by restricting the medical services it will purchase, with the aim of getting the most out for its limited Medicaid dollars. Oregon will pay for well baby care, for example, but not for heart transplants. Maryland's Schaefer, too, wants to emphasise preventive health care over acute care, but he does not want Maryland to suffer the onus for "rationing" health care that Oregon has had to bear. Schaefer's idea is to require Maryland welfare applicants to submit to a range of preventive health measures to both obtain and keep their eligibility for welfare payments and Medicaid certification. All applicants would have to undergo periodic physical examination, women would have to get cervical smears and mammograms taken; pregnant women would have to receive prenatal care; children would have to visit paediatricians and receive inoculations for childhood diseases; drug addicts and alcoholics would have to enter treatment programmes. The savings could be considerable, accord670
ing to Maryland's secretary of health, Nelson Sabatini. He noted that breast cancer can be treated for under $6000 if caught early but would cost $30 000 or more if it progresses to later stages. The same differences apply for extensive prenatal care compared with treatment in a neonatal intensive care unit. The concept (described by Schaefer as "an ounce of prevention") has drawn both praise and criticism. An editorial in one Maryland newspaper calls it "an excellent plan to reduce Medicaid costs and offer better health care." But the influential Washington Postwarns that "not everyone who fails to obtain medical care is a deadbeat. Some are discouraged by the need to visit several offices
for sign-ups and actual treatment. Then there is the matter of delays in obtaining appointments for various kinds of care, waiting lists and long lines. Moreover, in some areas, few doctors are willing to accept Medicaid patients." Schaefer's plan must receive a waiver from the federal government before it can proceed. Federal Medicaid administrators are still studying the plan and may well decide that imposing restrictions for Medicaid eligibility that are not applicable in other statesincluding Oregon -really is a form of rationing that cannot be allowed under the law. REX RHEIN, medical journalist, Washington, DC
The Week The friends of (non-human) animals are scenting victory, at least in Britain. The fur trade is on its knees, thanks to one of the cleverest advertising campaigns in years (slogan: "It takes up to 40 dumb animals to make a fur coat. But only one to wear it.") Animal testing of cosmetics fell by nearly two thirds between 1989 and 1990. Fox hunting has become almost as unpleasant for the hunters as for their quarry. Vegetarianism stands at 3% and is rising. One big push and animal activists believe that they can take out vivisection (even if it means taking out a few humans in the process). They are not alone in this belief. Aware that the battle for public opinion was being lost, the British Association for the Advancement of Science launched a declaration on the use of animals in medical research at its conference last year (8 September 1990, p 460). Since then 1000 leading scientists (including 31 Nobel prize winners) have signed it. Recently eight medical charities have "gone on the offensive against animal rights activists to try to restore public support for controlled animal experiments" (Times, 21 August 1991, p 8). Doctors will want to join the fray: more than that, they have an obligation to do so. As Sir Walter Bodmer, head of the Imperial Cancer Research Fund, told the press conference announcing the medical charities' initiative: "Hardly a person in this room has not benefited from animal experiments and some of you would not be alive today if they had been banned." Defending the past is easy; defending the present is much harder. The problem is that the obvious source to go to, the government's Statistics of Scientific Procedures on Living Animals Great Britain 1990, is so opaque despite its 50 pages, 27 tables, and five figures. The report divides up the total of 3 2 million procedures performed on animals last year in eight different ways. "Species" is no problem (nearly 80% of procedures were performed on rats and mice). But how about "primary purpose," which is
subdivided into three categories: body system studies, applied studies or purposes, and breeding (a new category for animals bred with harmful genetic defects). On its own it makes sense, until you read that body system studies are divided into fundamental studies and applied studies. The procedures are also divided up by "legislation or other reason for procedure" and "type," which is either efficacy evaluation, metabolic profiles, nutritional evaluation, and other non-toxicity procedures or toxicity tests. It makes the plotting of Twin Peaks look positively linear. Doctors wanting to defend Britain's 3 2 million scientific procedures on living animals will want to know much more about what they are defending than this book tells them. It's impossible to answer such simple questions as how many procedures are accounted for by the search for new drugs and to which pharmacological groups they belong. (Doctors may find it difficult to muster much enthusiasm for the nth 1 blocker or the n+1th non-steroidal anti-inflammatory drug.) We're not told how many purely psychological studies were performed, although there is the tantalising detail that for 11 100 procedures the induction of psychological stress was integral to the procedure. (Why? What was learnt, or hoped to be learnt, from frightening rodents, reptiles, amphibians, and fish?) Arguing the virtues of knowledge for the sake of knowledge will no longer work with the general public, which is where this debate must be won. The general public no longer believes that the planet's resources -whether animal, vegetable, or mineral-are there for man to exploit at will in his quest for knowledge or power. Most doctors don't think so either. Certainly they will want to enter the debate over animal experimentation, but they will want to know what they're defending in greater detail than Statistics of Scientific Procedures on Living Animals provides. HART
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Vaccines for HIV infected pregnant women? Pregnant women infected with HIV could benefit from an AIDS vaccine-but a trial of such a vaccine, devised by US health officials, has met with problems. The protocol for such a trial, which would involve immunising 10 to 20 HIV positive pregnant women beginning at the 14th week of pregnancy, was written last spring, according to Barney Graham, a virologist and immunologist at Vanderbilt University, Nashville. The trial would be sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) but it cannot proceed until a manufacturer willing to supply a viral product for the vaccine is found. The problem is that manufacturers fear they will be held liable if an infant born to a vaccinated woman has a birth defect or has any other complication that could conceivably be linked to the vaccine. This fear persists despite the fact that, according to Dr Graham, no lawsuit has ever been filed in the United States because of harm resulting from a trial of a maternal vaccine. But with so few women receiving the vaccine researchers will be able to assess only the vaccine's effect on maternal health and not its effect on the fetus. They will be looking at what types of antibodies to HIV are produced and whether CD4+ cells and viral loads increase or decrease. Dr Graham said; determining whether transmission of HIV to infants is affected would have to wait for a longer trial. How many pregnant women are at risk of the effects Qf HIV? According to one NIAID source, currently about 6000 HIV positive pregnant women give birth each year in the United States, and up to a third of their infants are infected. There is advance knowledge of only about 2000 of these births. One drawback of an active vaccine is that it might not protect against new variants of HIV that seem continually to arise. Some believe that these "escape mutants" are the viruses that infect the fetus. A passive vaccine would also have problems. More safety precautions would be necessary in preparing the vaccine and-as it would have to be given intravenously-more medical staff would be required. Such a preparation will also spoil, making it suitable for use only in developed countries. If the time of transfer of virus from mother to child and the type of antibody that is truly protective were known it might be possible to improve passive maternal vaccines, scientists say, perhaps by "spiking" them' with the appropriate monoclonal antibodies at the
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right time. The infant alone might be immunised after birth, or perhaps all women could be immunised in childhood, receiving booster shots later. Discussions with manufacturers about supplying a product for a maternal trial are now under way, according to Daniel Hoth, director of the Division of AIDS at National Institute of Allergy and Infectious Disease. "It would help the companies for the government to be involved [in a trial of their products] because it demonstrates a long term commitment and would give an independent perspective [the government's] on the ethics of the vaccine administration as well as on the safety and efficacy of the product. These would be blue ribbon trials." -GAIL WcBRIDE, medical writer, Chicago
AIDS conference moves to Amsterdam The 1992 international AIDS conference will be held in Amsterdam, "a city of tolerance," said its chair, Dr Jonathan Mann, professor of epidemiology and international health at Harvard and former head of the World Health Organisation's Global Programme on AIDS. The meeting was shifted from the United States because the US government did not end restrictions on entry by HIV positive people (24 August, p 432). "An international AIDS conference is essential in 1992. Moving the conference to
Amsterdam ensures continued progress in understanding and stemming the HIV pandemic," Dr Mann said. The meeting will be cosponsored by the Harvard AIDS Institute, directed by Dr Max Essex, and a new Dutch foundation headed by immunologist Professor Joost Ruitenberg, chairman of the executive board of the central laboratory of the Netherlands Red Cross Blood Transfusion Service. Professor Ruitenberg is active in AIDS research, prevention, and care. Vice chair of the conference will oe Professor Ernst Roceam Abbing, head of the Dutch national AIDS committee. The agreement to hold the meeting in the Netherlands "is not a marriage of convenience, but a marriage of the heart and mind," said Dr Mann. "The Dutch have no restrictions on the entry of HIV infected people and a longstanding devotion to human rights. Their domestic AIDS policy is creative and enlightened, with good working relationships between community organisations and the government. They were among the first supporters of the global programme against AIDS and have a strong commitment to assist developing countries." However friendly the Dutch, the Amsterdam meeting will not be sedate. Peter Staley of Act Up promised demonstrations similar to that against the US Consulate at this year's meeting in Florence: "Amsterdam is not the target, but as long as there's a huge international media gathering, we are going to use the avenue to get our message out."-JANICE HOPKINS TANNE, contributing editor, New York magazine 665
Headlines Condoms for New York teenagers: The board of education in New York City has voted to make condoms available to high school students whether their parents agree or not. The board hopes that the programme will prevent AIDS and other sexually transmitted diseases and reduce the number of pregnancies among teenagers. Terodiline withdrawn: Reports of torsades de pointes in patients taking terodiline for urinary incontinence (BMJ ,991;302:1469) have led the manufacturers, Kabi Pharmacia, to withdraw the drug while awaiting further tests. The Committee on Safety of Medicines is advising doctors to take patients off terodiline as soon as possible and warns that the drug may take up to six weeks to be cleared from the body. AIDS failure: A new report from the Office of Health Economics on worldwide policies for AIDS shows how countries have been slow to take the necessary precautions. In Denmark, despite almost universal knowledge about condoms only one third of adolescents use them, while in France 9% of the population use condoms. New women's hospital: A new £16m women's hospital in Liverpool should start to take its first patients within two years. The hospital will bring together obstetric, gynaecological, and neonatal services.
Drug seizures: Home Office figures show that the number of drug offenders in sritgin rose in 1990 by 15% to 44 900. Their avei-Lsc aee continued to fall to under 25 years and 90% of LlLc crimes were for possession, usually of
cannabis.
Liberal Democrats condemn trusts If the Liberal Democrats came to power (or shared it) they would immediately cancel the second wave of NHS trusts and review the position of the existing 57 trusts. Delegates attending the party's annual conference in Bournemouth last week condemned the concept of "opting out" but voted against abolishing all trusts to avoid throwing the NHS into yet more disarray. Health spokesman, Charles Kennedy MP, claimed that the health service could not afford the further massive upheaval that immediate abolition would bring. "We cannot lurch from the limbo of current changes into further reorganisation-that would dismay and depress the staff still further." Instead, each existing trust would be carefully scrutinised, and it would be up to local people to decide its future. In his preconference briefing party leader Paddy Ashdown admitted that some of the trusts would probably retain their status. Several of those who spoke in the debate on trusts worked in the health service, including Andy Myles, a hospital administrator in Edinburgh and prospective parliamentary candidate. He argued against "tampering" with trusts, claiming that they were "too deeply embedded in Tory legislation and too steeped in the ideology of Thatcherism." Another prospective candidate, junior doctor and chairman of the Hospital Doctors Association, David Wrede, raised the problem of training. If trusts limited the type of medical procedures they performed they would become unsuitable for training. While they still existed, however, the conference wanted more accountability. Trusts would be compelled to publish their business plans, take directly elected local representatives to their boards, measure efficiency in terms of quality as well as cash, and publish service development plans. Trusts would also have to conform to Whitley Council terms and conditions. Despite the dislike of trusts, the conference generally supported the purchaser-provider split, though delegates wanted to reassess general practi-ioner fundholding and ban qtreue jumping by fundholders' patients.
The report comes as the government completes consultation on a strategy for the nation's health. Sir Donald's report suggests just how necessary such a strategy is. The problem of extending life expectancy without extending the period free from disability is no doubt one reason why the chief medical officer devotes a substantial section of his report to the health of the elderly- a group conspicuously missing from The Health of the Nation (17 August, p 408). He emphasises how important it is to include the elderly in health promotion and in prevention programmes. Like younger people, the elderly can "reap immediate benefits" from stopping smoking, eating a balanced diet, and taking regular exercise. The other new subject that gets a chapter to itself is health needs assessment, including an account of research commissioned by the Department of Health using diabetes as a model. Assessing health needs is part of what Sir Donald calls the rejuvenation of public health, exemplifying it in his own report by his reminder that inequalities in health are still as persistent as in John Simon's day. Indeed, he says, the inequalities are probably increasing, not only in the United Kingdom but also in countries like Sweden, which suggests a complex interaction between ill health and factors such as low income, unhealthy behaviour, a poor environment, and a lack of choice. AIDS has dominated Sir Donald's term, and he has been important in shaping the health departments' response to it. His final report shows a total of almost 4000 cases by the end of 1990 but also a lengthening median survival time. Despite the fact that 81% of cases of AIDS have been in men who have had intercourse with men, Sir Donald emphasises the rapid increase in the numbers of cases of heterosexual transmission of the virus. He also suggests that some of the excess deaths among adults attributed to suicide or an open verdict are in fact associated with undisclosed HIV related disease. Women do not come out well from the report. They share in the rising death rates
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Dentists' survey: A British Dental Association study has shown a dramatic fall in the number of dental practices accepting NHS patients. The results show a wide variation throughout the country from 100% acceptance in Newcastle to 30% in parts of Central London. Medical demography: Portugal has the highest proportion of women doctors (39%), according to the medical insurance branch of the French securite sociale. Greece has 31%, Spain and Austria 30%, the United Kingdom 28%, and France and Denmark 27%.
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The public health: could be better Over Sir Donald Acheson's seven year term chief medical officer, life expectancy in England and Wales has risen by about three years-but there has been no corresponding increase in the length of life without disability. Despite substantial improvements in some aspects of the public's health (such as infant mortality), Sir Donald's final annual report, published as he leaves office, shows disappointing setbacks in other aspects, such as an increased mortality among young adults. as
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among adults aged 15-39. Particular contributors to this increase are cancers of the breast and cervix and chronic liver diseasethe last attributed to increased alcohol consumption. In 1990, breast cancer killed 13 000 women. Sir Donald states that throughout the 1980s there has been no convincing fall in mortality from this cause among young women, and he wants more research into this "common, distressing, and fatal disease" that continues to have a higher incidence in England than elsewhere. On a more positive note, Sir. Donald mentions that the NHS will have to, and is starting to, adapt its practices to the needs of women doctors. He also claims some success in obtaining extra, earmarked cash for postgraduate and continuing medical education. -DAVID GILLEN and JANE SMITH, BMJ
On the State of the Public Health. London: HMSO, 1991. Will it take 20 years to come up to standard?
Poor housing, vulnerable people
Responding to the report, Peter Archer. terms and conditions of service, which gives of the Institution of Environmental Health sacked consultants an automatic right of Officers said it was "misdirected," as "unfit" appeal to the health secretary. In his stateOver half of all bedsits and hostels in England privately rented housing constituted only a ment of case, Mr Raymond cites internal and Wales fail to meet health and safety small proportion of the total problem when documents disclosed by the health authority standards, and repairs could take 20 years to compared with owner occupied acommoda- which he alleges show that managers took a complete, says a survey published last week. tion. He went on to criticise the commission secret decision that Dr Zeitlin had to be The Audit Commission's latest report for measuring the quantity rather than the "removed from the scene." Dismissal for looks at housing in general, but it concen- quality of services provided and for failing redundancy would be legally justified only "to examine real work done by environ- if the authority's need for the services of trates on houses of multiple occupation. This category, which includes bed and breakfast, mental health officers in relieving urban consultant haematologists had diminished or bedsit, and hostel accommodation, houses deprivation." was expected to diminish. Mr Raymond, While endorsing many of the commis- who represented the obstetrician Wendy some of the most vulnerable members of society-single mothers, the poor, the sion's proposals, particularly those relating Savage and the paediatrician Marietta Higgs to the development of proactive strategies in their legal battles with their employers, mentally ill, and the homeless. The report, which took 18 months to based on regular surveys of the condition of contends that no need for redundancy compile and studied over 300 local authori- the housing stock, Archer concluded that the existed. ties, criticises authorities for not appreciating report's calls for increased processing of imDr Zeitlin was appointed to a new post in the true scale of the problem. One authority, provement grants and more rapid responses 1986 as a second consultant haematologist to for example, undercalculated the number of to residents' complaints would be a "total Bromsgrove and Worcester District Health houses in multiple occupation by over 4000, waste of resources." -DAVID GILLEN, BMJ Authority. In January 1990, at a public meetwhile half failed to estimate how many were ing called to discuss the hospital's possible substandard. According to the commission, Healthy Housing: The Role of Environmental Health opting out, she claimed there was a critical Services. ISBN 0-11-886065-8. Available from shortage of nurses at the Alexandra Hospital, more than 180000 multioccupied houses need attention, but last year environmental HMSO, price £7.50. adding that this was a national problem. In health officers issued only 10000 enforceSeptember 1990, she learnt that an analysis ment notices requiring owners to bring them of nurse staffing levels under the American up to standard. The commission concludes GRASP system showed a widening gap that local authority environmental health between nursing hours required and those officers often lack adequate policies and -provided between 1987 and 1990. This instrategies to deal with such poor quality cluded anonymous comments by nurses, housing and are therefore inactive in tackling who spoke of patients lying in faeces and the problems. patients at risk through the shortage of Seven years ago the Institution of Environ- West Midlands Regional Health Authority nurses. Dr Zeitlin obtained a copy, sent it mental Health Officers recognised that this invoked a redundancy situation as a pretext to district chairman Dawn Price, and told type of housing was more at risk of domestic for dismissing a consultant, her solicitors colleagues about it. fires than was owner occupied accommoda- allege in an appeal to the health secretary, In November, at a meeting Dr Zeitlin tion. It blamed a shortage of staff for inade- William Waldegrave. requested with Dr Harrison, the regional quate monitoring by environmental health Helen Zeitlin, a former consultant haema- medical officer, to discuss working diffidepartments. The Audit Commission, tologist at the Alexandra Hospital, Redditch, culties, she was told that a complaint of however, insists that services could be is appealing against her dismissal last Feb- personal misconduct was going to be made improved without staff changes provided all ruary, when she was told to clcar her desk against her. This alleged that she had told the authorities perform as effectively as the best and leave the hospital on paid leave at less public meeting in January that "patients 25% in terms of enforcement notices issued than 12 hours' notice. It was only after her were dying for lack of care." Dr Zeitlin, the and improvement grants processed. The solicitor, Brian Raymond, intervened that meeting's chairman, and a fellow consultant commission does concede that current levels she was allowed a further week to hand over deny that these words were used, and a local of funding would prevent local authorities her patients. newspaper report of the meeting makes no from implementing all its recommendaDr Zeitlin is appealing under paragraph mention of any comments by Dr Zeitlin. tions. 190 of hospital medical and dental staffs Other charges relate to an incident when
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Dr Zeitlin is said to have lost her temper because a patient's notes were missing, and to minor disagreements between herself and the other consultant haematologist, Dr Daisy Obeid, with whom she had a longstanding personality conflict. In January 1991 the possibility of redundancy was mentioned for the first time. On 28 February Dr Zeitlin received a letter putting her on paid leave from that day and making her redundant from 27 May. An internal memorandum dated 14 December 1990 accuses Dr Zeitlin of"disruptive and malicious" conduct and an "unpredictable, unpleasant and. abrasive manner" and adds, "There is a common recognition that the problems can only be resolved by the removal of Dr Zeitlin from the scene." The memorandumrl discusses possible ways of achieving this: allowing her to resign with an ex gratia payment ("£135,000?"), formal disciplinary procedure ("outcome uncertain"), referring her to a consultant psychiatrist ("the opinions expressed about her health have not come from qualified psychiatrists"), or transferring her to another hospital. This document, Mr Raymond concludes in his statement of claim, "wholly undermines to the point of nullity the RHA's contention that Dr Zeitlin was dismissed by reason of redundancy." Mr Colin Smith, for the health authority, declined to comment on the allegations. "We have got to respond first to the secretary of state," he said.-CLARE DYER, legal correspondent, BMJ
country are gradually changing for the better." -LUISA DILLNER, BMJ The UN Convention and Children's Rights in the UK by Peter Newell was written for the National Children's Bureau in collaboration with the Calouste Gulbenkian Foundation and is published by the National Children's Bureau.
Controlling drug companies
He. has a right to "the highest attainable standard of health"
origin was 15-2 per 1000 live births compared with 8 9 for those born to mothers of British
origin.
Children are also guaranteed, by article 6, "the inherent right to life." Peter Newell cites a 1988 report from the Royal College of Physicians which criticised the shortage of intensive care facilities for neonates. "Without the necessary resources," says the report, "many babies who could have been rescued will die." It is over article 27 of the convention, which sets out "the right of every child to a standard of living adequate for the child's physical, mental ... and social development" that the report is particularly critical of Britain's record. It quotes a comparative Britain's children are being denied basic study of child poverty in industrialised rights set out in the 1989 United Nations countries published by Unicef in 1990 which convention on the rights of the child. A concluded that British children had become report published this week by the National poorer over the past decade. Peter Newell Children's Bureau dispels the myth that the states that "large numbers of children are articles of the convention are relevant only to living in bed and breakfast accommodation, raising concerns about health, development, developing countries. According to Peter Newell, author of the safety, education, and diet." The report states that the government is report, British children suffer from poverty, inadequate housing, and physical, mental, too restrictive in providing income support. and sexual abuse. All of these contravene the An unemployed and pregnant woman under convention, which Britain is committed to 18 cannot claim income support until she is ratifying. The convention has already been six months pregnant. This, suggests the ratified by 90 states. report, contravenes article 26 of the convenThe report argues that implementing the tion, which states that the circumstances of convention will be difficult because of lack of the child should be considered when granting information. "There is only patchy monitor- benefit. ing of the state of the UK's children," says Although the United Nations convention the report. "The lack of ... information will not make it illegal for children to be makes it hard to judge precisely how changes denied adequate health and housing, it has in social and economic policies are affecting made children's rights a political issue. This week the Labour party announced its intenchildren." Under the convention children have a right tion to appoint a minister for children. to "the highest attainable standard of health. " "The convention provides a new yardstick The report argues that Britain contravenes to embarrass governments with," says Peter this. The standard of health care, it alleges, Newell. "The next election will be the first varies with the social class, ethnic back- time that political parties will compete in ground, and region. In 1987 the death rate offering commitments to children. I believe for infants born to mothers of Pakistani social attitudes towards children in this
Please can I have some more rights?
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Following allegations made in a report in the First Tuesday television documentary series last November, Pizer, Lederle, ScheringPlough, and Lipha were this spring reprimanded by the code of practice committee of the Association of the British Pharmaceutical Industry (ABPI). Complaints against two other firms were rejected. The main negative consequences for those found "guilty"-of giving inappropriate benefits to doctors in the form of meetings abroad and attendance at golfing and similar events-has been negative publicity. A notable example of this was an expose in the Guardian (9 September 1991, p 5) which highlighted the previously little reported findings of the disciplinary committee with the headline "Drugs firms rebuked for sales perks." First Tuesday's producer, James Cutler, believes that the ABPI's sanctions are inadequate. He argues that the industry's self policing is bound to be lax and that as well as the legal sanctions which already exist (independently of the ABPI scheme) a more independent public body should be responsible for handling complaints made against pharmaceutical companies' promotional practices. In a recent radio interview he also suggested that all company sponsorship of medical meetings should be channelled through third parties such as "the British Medical Association or the Royal College of Physicians." Ideas like this are likely to gain some
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popular support. Many patients may be disturbed by stories of lavish treatment of doctors by pharmaceutical companies. Their concerns are not merely about cost: such behaviour may also undermine their trust in the therapeutic judgment of their medical advisers. This is probably reflected in survey findings from organisations such as the ABPI showing that over 70% of people in Britain now say they want much more information about medicines they are prescribed. The practicality of Cutler's proposals for involving third parties in industry support of medical meetings, however, is open to question. So too is the fairness of his dismissal of self policing exercises like those conducted by ABPI. (The medical profession itself is largely self policed.) The fact, for instance, that Pfizer, Lederle, ScheringPlough, and Lipha are facing continued discussion of their misjudgments over promotion should not be overlooked. No company can afford to ignore its good name being called into question any more than it could devote promotional resources to ends that offered no chance of increasing its sales. Responsibly conducted promotion clearly has a role in any competitive market place. Hence many doctors (despite the obvious discomfort of some of those caught in the light of First Tuesday's investigation) will be reluctant to eschew all- offers of pharmaceutical company sponsorship and allied support. But they arguably share an ethical responsibility with companies to ensure that money spent to purchase their attention or goodwill is being reasonably and acceptably spent. One test of whether this is so or not is to check with the ABPI's code of practice. Another, of course, is to ponder on how legitimate or otherwise the activity being funded might appear on television. -DAVID TAYLOR, King's Fund Institute, London The ABPI's code of practice is available from Dr John Griffin or Dr Frank Wells, ABPI, 12 Whitehall, London SWIA 2DY.
The young in science Young researchers do as well as older ones in winning grants, shows a report from the Science and Engineering Council (SERC) published last week. The study was conducted because of widespread anxiety-the Advisory Board for the Research Councils was among those concerned-that young researchers were having more difficulties than older ones in getting their grant applications funded. In particular, a study that compared top rated grant applications that were funded and not funded found that a higher proportion of those not funded came from researchers under 40. The new study sent questionnaires to a sample of 231 permanent academic staff under 35 and 227 aged 35-45 and 142 scientists who were Royal Society university research fellows (non-permanent academic staff); response rates were 80%, 77%, and
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81% respectively. Researchers came from the disciplines of biology, chemistry, electrical engineering, physics, and physiology. The young researchers made slightly more grant applications than the older ones (a mean of 1 6 a year compared with 1-2) and had a slightly lower success rate (52% versus 59%), but there was no significant difference in the value of the grant awarded. Nor was there any significant difference between new and more established young researchers. There were, however, significant differences between disciplines, with biology having the lowest success rate (47%) and physics the highest (76%). Researchers who were more active (in terms that included the number of papers published) submitted the largest grant requests and were the most successful, but there were no significant variations in success rates by gender or seniority (lecturers versus more senior staff). Younger researchers had several strategies to increase their success rates: getting help from senior staff or staff from the funding agency; collaborating with others; and orienting research towards a special initiative or a subject funded by industry. The commonest criticism of funding bodies was their failure to give feedback, and applicants liked to be able to see referees' comments. Sir Mark Richmond, the chairman of SERC, welcomed the results of the study but said that there was no room for complacency: "In the present financial climate, all research workers find obtaining research funding extremely difficult, and it must be cold comfort to the newly appointed lecturer to learn that he or she is not being singled out for particularly harsh treatment by the funding bodies." SERC thus remains concerned and plans to try to do more to make sure that young researchers can establish their careers. One step that it might take would be to set up a young investigators award. At the moment the Agricultural and Food Research Council is the only council with such a scheme.RICHARD SMITH, BMJ
Indoor pollution: restricting smoking Government advice to restrict smoking in public places will be contained in guidelines to be issued by the Department of the Environment before the end of the year. A code of good practice will recommend that all public places should be non-smoking, with separate provision for smokers if necessary. All government and local authority buildings will be expected to comply with the code and the government hopes that public pressure will ensure a smoke free environment in other public buildings such as shopping centres, banks, and leisure facilities. A white paper last week confirmed the government's policy that non-smoking should be the norm inside buildings, with segregation of smokers. Replying to a Commons environment committee report on indoor pollution (20 July, p 150), the Department of the Environment sees environmental tobacco smoke as one of the most important of indoor air pollution problems. It regrets that the clear scientific evidence of the adverse effects of tobacco smoke is often clouded by intense campaigning from the pro-tobacco lobby, though there is a groundswell of public opinion in favour of action. On other sources of indoor air pollution, such as radon, dampness, or the so called sick building syndrome, the 23 page white paper is more tentative. While sharing many of the select committee's concerns, the government supports further research but baulks at expenditure on such proposals as a new inspectorate or increasing remedial grants. Ins'tead it is attracted by non-statutory guidelines for indoor air quality to provide a common basis for actions by architects, builders, product manufacturers, and owners. -JOHN WARDEN, parliamentary correspondent, BMJ Indoor Pollution, the Government's response to the Commons select committee on the environ-
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ment, Cm 1633, is available from HMSO, price
£4.15.
* The Health Education Authority has just published a guide recommending that all local authorities have a policy on tobacco for the communities they serve. Towards a Smokefree Environment includes a survey of all 405 local authorities in England showing that only half of the district councils have a formal policy on smoking, that few prosecute shopkeepers for selling tobacco to children under 16, and that few take seriously their duty to protect non-smoking employees from tobacco smoke. When authorities do enforce restrictions on smoking these most often apply to communal areas and public waiting areas, with staff restaurants and open plan offices included to a lesser extent. Most authorities still allow tobacco to be sold on council premises, and a few permit tobacco sponsored events to take place. The guide recommends that all local authorities should have a written policy providing for a smoke free environment but also recognising the needs of staff who do smoke. They should also prohibit the sale of tobacco and tobacco advertising and sponsorship on their property and prosecute retailers who sell tobacco to children.
"Rationing": Maryland style Maryland's governor, William Donald Schaefer, has the same problem with his state's Medicaid programme as have governors of America's other 49 states. Maryland cannot afford the rising cost of health care for its poor. This is partly due to the fact that revenues are down in the recent recession, and partly because the US government continues to add new benefits to the federalstate programme without assuming a larger share of the economic burden. One state-Oregon-has tried to resolve its fiscal dilemma by restricting the medical services it will purchase, with the aim of getting the most out for its limited Medicaid dollars. Oregon will pay for well baby care, for example, but not for heart transplants. Maryland's Schaefer, too, wants to emphasise preventive health care over acute care, but he does not want Maryland to suffer the onus for "rationing" health care that Oregon has had to bear. Schaefer's idea is to require Maryland welfare applicants to submit to a range of preventive health measures to both obtain and keep their eligibility for welfare payments and Medicaid certification. All applicants would have to undergo periodic physical examination, women would have to get cervical smears and mammograms taken; pregnant women would have to receive prenatal care; children would have to visit paediatricians and receive inoculations for childhood diseases; drug addicts and alcoholics would have to enter treatment programmes. The savings could be considerable, accord670
ing to Maryland's secretary of health, Nelson Sabatini. He noted that breast cancer can be treated for under $6000 if caught early but would cost $30 000 or more if it progresses to later stages. The same differences apply for extensive prenatal care compared with treatment in a neonatal intensive care unit. The concept (described by Schaefer as "an ounce of prevention") has drawn both praise and criticism. An editorial in one Maryland newspaper calls it "an excellent plan to reduce Medicaid costs and offer better health care." But the influential Washington Postwarns that "not everyone who fails to obtain medical care is a deadbeat. Some are discouraged by the need to visit several offices
for sign-ups and actual treatment. Then there is the matter of delays in obtaining appointments for various kinds of care, waiting lists and long lines. Moreover, in some areas, few doctors are willing to accept Medicaid patients." Schaefer's plan must receive a waiver from the federal government before it can proceed. Federal Medicaid administrators are still studying the plan and may well decide that imposing restrictions for Medicaid eligibility that are not applicable in other statesincluding Oregon -really is a form of rationing that cannot be allowed under the law. REX RHEIN, medical journalist, Washington, DC
The Week The friends of (non-human) animals are scenting victory, at least in Britain. The fur trade is on its knees, thanks to one of the cleverest advertising campaigns in years (slogan: "It takes up to 40 dumb animals to make a fur coat. But only one to wear it.") Animal testing of cosmetics fell by nearly two thirds between 1989 and 1990. Fox hunting has become almost as unpleasant for the hunters as for their quarry. Vegetarianism stands at 3% and is rising. One big push and animal activists believe that they can take out vivisection (even if it means taking out a few humans in the process). They are not alone in this belief. Aware that the battle for public opinion was being lost, the British Association for the Advancement of Science launched a declaration on the use of animals in medical research at its conference last year (8 September 1990, p 460). Since then 1000 leading scientists (including 31 Nobel prize winners) have signed it. Recently eight medical charities have "gone on the offensive against animal rights activists to try to restore public support for controlled animal experiments" (Times, 21 August 1991, p 8). Doctors will want to join the fray: more than that, they have an obligation to do so. As Sir Walter Bodmer, head of the Imperial Cancer Research Fund, told the press conference announcing the medical charities' initiative: "Hardly a person in this room has not benefited from animal experiments and some of you would not be alive today if they had been banned." Defending the past is easy; defending the present is much harder. The problem is that the obvious source to go to, the government's Statistics of Scientific Procedures on Living Animals Great Britain 1990, is so opaque despite its 50 pages, 27 tables, and five figures. The report divides up the total of 3 2 million procedures performed on animals last year in eight different ways. "Species" is no problem (nearly 80% of procedures were performed on rats and mice). But how about "primary purpose," which is
subdivided into three categories: body system studies, applied studies or purposes, and breeding (a new category for animals bred with harmful genetic defects). On its own it makes sense, until you read that body system studies are divided into fundamental studies and applied studies. The procedures are also divided up by "legislation or other reason for procedure" and "type," which is either efficacy evaluation, metabolic profiles, nutritional evaluation, and other non-toxicity procedures or toxicity tests. It makes the plotting of Twin Peaks look positively linear. Doctors wanting to defend Britain's 3 2 million scientific procedures on living animals will want to know much more about what they are defending than this book tells them. It's impossible to answer such simple questions as how many procedures are accounted for by the search for new drugs and to which pharmacological groups they belong. (Doctors may find it difficult to muster much enthusiasm for the nth 1 blocker or the n+1th non-steroidal anti-inflammatory drug.) We're not told how many purely psychological studies were performed, although there is the tantalising detail that for 11 100 procedures the induction of psychological stress was integral to the procedure. (Why? What was learnt, or hoped to be learnt, from frightening rodents, reptiles, amphibians, and fish?) Arguing the virtues of knowledge for the sake of knowledge will no longer work with the general public, which is where this debate must be won. The general public no longer believes that the planet's resources -whether animal, vegetable, or mineral-are there for man to exploit at will in his quest for knowledge or power. Most doctors don't think so either. Certainly they will want to enter the debate over animal experimentation, but they will want to know what they're defending in greater detail than Statistics of Scientific Procedures on Living Animals provides. HART
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