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Notes and News

DRUG DEPENDENCY IMPROVEMENT GROUP

THE Drug Dependency Improvement Group (DIG) was formedearlier this year by opioid addicts who are patients of DrAnn Dally. They have been joined by others in need. The impetuscame from fear of what will happen should Dr Dally lose herforthcoming appeal to the Privy Council against the ruling that shebe banned from prescribing controlled drugs for 14 months. Thisruling was imposed in January by the General Medical Council,which found her guilty of serious professional misconduct becauseof the way in which she had treated one patient. She was found notguilty on the main charge concerning her general methods oftreatment for long-term addicts, involving 187 patients over someyears. The sentence has not yet come into force because Dr Dallydecided to appeal to the Privy Council. The Appeal was heard onJuly 27 and 28: judgment has been deferred until October. If DrDally loses, most of her remaining addict patients (about 70long-term opioid addicts, many of them intravenous injectors)could turn to the black market, with all its dangers.Members of DIG do not want to become street junkies. They are

stable citizens who stand to lose their jobs and perhaps theirmarriages, children, and homes as well. In addition, they run therisk of catching and spreading many infections, including AIDS.Most addicts report that if clean drugs and needles are not available,they are willing to take the chance of sharing, despite fear of AIDS.Relatives and other wellwishers have also joined the group, whichintends to establish its own non-profit-making clinic and is

presently negotiating for premises. DIG will hire its own doctorsand other staff. Members of the committee have had encouragingmeetings with officials at the Home Office and with the DHSS. Aretired consultant has offered to advise about clinic procedures andtraining doctors, and a barrister with experience of addicts in thecourts is acting as legal adviser and joint treasurer.For the past decade it has been the policy of most drug

dependency units to treat only those addicts who feel able to comeoff drugs in a short time, usually in a few weeks. There has been noprovision for long-term addicts except a few who have been patientsat the clinics for many years. New DDU patients who feel unable tobecome drug-free quickly, as well as those who cannot functionwithout injectable drugs, feel that they have no option but to use theblack market. Recently, some clinic consultants, encouraged by civilservants, expressed the intention of becoming more flexible becauseof the risk of AIDS. But in many cases this flexibility meant merelyan early appointment for a period of assessment, which resulted inmany more weeks on the black market, followed by a short periodon diminishing doses of oral methadone. Few long-term addicts cancomply with this regimen and others do not even get the chance totry because many areas, even in London, have no clinics, andexisting clinics operate within strict catchment areas.DIG seeks to inform the Government, the public, and the press

about drug addiction; it hopes to influence policies and improvetreatment. And it asks how the situation can be changed. Why is it,for instance, that humane treatment for long-term addicts isavailable in some places, such as Liverpool, but not elsewhere-hardly at all in London or the south of England? The group can becontacted at PO Box 150, 6 Albemarle Way, London EC1V 4JB.Donations will be gratefully received. Telephone contact may bedifficult until a regular office is opened, but the following numbersare available: 01-699 7832, Fred; and 0277 73061 (day), 0277-230129 (evening), Phil.

OZONE FEARS

Two things are certain about the earth’s ozone layer. The first isthat it is medically important (see p 443); the other is that thechemistry is complex. Fear about the destruction of the ozone layeremerged in the 1970s, and a popular theory was that man’s use ofinert propellant halogen-substituted hydrocarbons was to blame.For a few years the production of these chemicals declined. The

issue has been resurrected, at a time when propellant use is on theincrease once again, by the discovery of an "ozone hole" over theAntarctic in spring. Over the next few weeks the skies above theSouth Pole will see more aircraft than normal as a majorinternational programme of observation gets under way, from abase in southern Chile. For the moment at least the Antarctic hole isa curiosity; elsewhere, stratospheric ozone, though it may havefallen by 2-3% over the past decade, has not attracted the sameheadlines, and thekey question is whether the hole has implicationsfor ozone on a global scale. Medical readers will know that too littleozone means dangerously too much ultraviolet light and that anincrease in skin cancer would be a consequence. They will haveforgotten or never knew either the complex sequences ofinterrelated quenching and generating activities that come underthe specialty of atmospheric chemistry or the equally complexmeteorological factors that must be taken into account when

designing models for ozone distribution. All these interactions areclearly explained in a report from the United KingdomStratospheric Ozone Review Group.l This is in essence a digest andupdate of a massive review, published in 1986, by the US NationalAeronautics and Space Administration, World MeteorologicalOrganisation, and United Nations Environment Programme.

HEALTH EFFECTS OF AROMATIC AMINES

THE monitoring and assessment centre at King’s College,University of London, have reviewed the health hazards of aromaticamines on behalf of the international programme on chemical

Safety.2 The report discusses the degree of toxicity, the extent ofexposure, and the relation between exposure and toxic response,based on data in man and animals. The dermal route is particularlyimportant, and exposure to phenylenediamines is significantlyassociated with allergic contact dermatitis. Mixed exposures and thepossibility of cross-sensitisation make it difficult to assess the extentof this problem. Several aromatic amines are known carcinogens inman, especially after occupational exposure, including benzidine,2-naphthylamine, chlornaphazine, and 4-aminophenyl, and themanufacturing process for auramine has also been linked withcarcinogenicity. Also included in this category are analgesicmixtures that contain phenacetin. Abuse of these mixtures has beenlinked with transitional-cell carcinoma of the renal pelvis, althoughthe carcinogenic compounds cannot be specified; phenacetin itself isa probable carcinogen. There is less evidence linking 2-chloroaniline with bladder and liver cancer, and 2-methylanilinewith bladder cancer. The production volumes of aromatic aminesare reported in a few countries only. Most aromatic amines do notoccur naturally and are rapidly oxidised in air and water. However,some aromatic amines or their decomposition products do have longhalf-lives in soil. Aminoazobenzenes may accumulate in theenvironment but would be expected to be extensively metabolisedbecause of their lipophilicity. Aromatic amines have been detectedin surface water, soil, and foods, and exposure of the generalpopulation can occur via products in which aromatic amines havebeen used, such as textile dyes, rubber products, pesticides, foodadditives, and cosmetics. More than 15 million people in the USAmay be exposed to phenylenediamines in hair and fabric dyes or inphotographic development fluids. Smokers of more than ’40

cigarettes per day may inhale up to 1 jig 2-naphthylamine daily.

AIDS IN PRISON

A VIDEO intended to defuse fear of AIDS among prison staff,commissioned by the Home Office, mirrors what is happening inthe community, where fear of the disease leads inexorably towardsdiscrimination against people known to be HIV-positive. The20-minute video, which is to be shown to all 19 000 prison officers,emphasises that HIV infection can be transmitted only by sexual

1. Stratosphenc Ozone. By the United Kingdom Stratospheric Ozone Review Group(chairman, A. F. Tuck). London: HM Stationery Office. 1987. Pp 83. £9.95. ISBN0117520187.

2. The Health Effects of Aromatic Amines: a Review. By L. K. Shuker, S Batt, I.Rystedt and M. Berlin. Monitoring and Assessment Centre, King’s CollegeLondon, Octagon Building, 459A Fulham Road, London SW10 0QX. 1987 Pp127. ISBN-0905918320.

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acts, by injection of blood, and from mother to fetus. An

accompanying leaflet, AIDS Inside, spells out this message: "It isnot possible to be infected by casual contact. Sharing a cup or glasswith someone who is infected is not dangerous, nor is there any riskfrom towels, clothing, bed linen, swimming pools, or from thelavatory". In the video a scene of violence involving blood, vomit,urine, and faeces is presented as a circumstance in which risk oftransmission is very small. Nevertheless, prisoners who are found tobe HIV-positive will be placed under "viral infectivity restrictions,"which entail segregated cells, separate washing of clothes andutensils, and the barring of prisoners from industrial work, foodpreparation, and contact sports.Dr John Kilgour, director of the Prison Medical Services,

reported in London on August 13 that only one prisoner had so fardied of AIDS-a Milan-based drug user and dealer, who wastransferred from Wormwood Scrubs to an NHS hospital, where hedied. To date, there are 62 prisoners who are known to beHIV-positive out of a total prison population in England and Walesof 51000. Dr Kilgour believes this figure to be a considerableunderestimate, bearing in mind that there might be expected to bemore people at high risk of infection in prison. Dr Kilgourunderlined that the HIV test was to be offered to a prisoner only onrequest or if a doctor suspected that HIV-positivity might underlyan illness. In the video, however, a prisoner known to have injecteddrugs is told by the prison medical officer: "What we’re going to dois give you a blood test." Dr Kilgour agreed that this scene shouldhave been changed to match the voice-over. Mandatory HIVtesting of prisoners already takes place in the United States and theHim is to be marketed abroad at the cost of 60. When askedwhether condoms should be provided in prisons, Dr Kilgourexplained that a homosexual act (between two consenting adults inprivacy) could not be conducted in privacy in prison, and mighttherefore constitute an act of gross indecency. Theoretically, sex didnot occur in prison, although the video showed two men in bedtogether. Dr Len Curran, chairman of the AIDS advisorycommittee, added that condoms could also be used to smuggledrugs around prisons. A special care and support 12-bedded unitfor prisoners with AIDS is under construction in Brixton and afurther video is being planned for prisoners.

AIDS AND INSURANCE

Prof David Wilkie, partner in the actuaries R. Watson & Sons,has forecast the size of the AIDS epidemic in the UK and its impacton the insurance industry.’ The main assumptions underlyingWilkie’s "basic" model are that 5% of the male population arehomosexual and that AIDS does not spread significantly to

heterosexuals. The basic model predicts that the number of maleswho could become sick or die from AIDS will reach a peak in 1998before levelling out. The forecast is 63 000 sick from AIDS in thatyear with another 48 000 dying. Thereafter the number of deathswill be 7600 annually. Six other projections are variations on thebasic model. The worst case (10% of males are homosexual)predicts nearly 90 000 deaths in 1999 followed by a level of about15 000 per year. Another variation assumes that the propagandaeffect of health education is nil. In this model, nearly 62 000 will diein 1999 with an annual level of 7900 thereafter. Mortality ratios orexcess mortality rates are of most interest to actuaries. With thebasic model, in 1997, males aged 35 will have 4-3 times the normalmortality. The pattern of ratios will then subside as the current"AIDS generation" dies out, to reach a stable level of 3-08 at age 32.Actuaries are also interested in the impact of AIDS prediction onemployers, who may face increased sick-pay costs and claims onpension funds because of ill-health retirement, and on life insuranceand long-term disability insurance. Wilkie plans furthercalculations to assess this impact.

NEW PERFORMANCE INDICATORS

THE Performance Indicator Group, set up last September toproduce revised performance indicators from K6mer data, has

1. Preliminary Memorandum on AIDS. July, 1987 R. Watson & Sons, Watson House,London Road, Reigate, Surrey RH2 9PQ (0737 241144).

recently circulated proposals for consultation. Help is sought fromhealth authorities and professional and other interested bodies. Thegroup sees this as an opportunity for people with direct experienceof the health service to influence the kind of information that will beavailable to them. The group’s task is to bring together the currentinter-authority comparisons and consultancy indicators developedby John Yates (Health Services Management Centre, BirminghamUniversity) and DHSS indicators into a single package. Theindicators must be revised in line with the Komer data collectedsince April 1 this year and improved. K6mer data will make itK6mer data will make it possible to include community services forthe first time and there will also be indicators based on specialtycosting. 9 papers have been issued on manpower, acute hospitalservices, PIs with a financial component, support services, servicesfor mentally handicapped people, community services, services forthe mentally ill, services for the elderly, and maternity andchildren’s services. Comments on the papers, which may beobtained from Paul Mason, Secretary of the Group, Department ofHealth and Social Security, Room 625A, Hannibal House,Elephant and Castle, London SE1 6TE (01-703 6380 ext 3195),should reach the DHSS by Sept 25.

CALCIUM-SUPPLEMENTED MILK

LAST February the British dairy industry, worried about fallingmilk sales, tried to win back some customers--especially health-conscious women-with a new product, calcium-supplementedskimmed milk.l The Advertising Standards Authority has nowrejected a claim made by one milk producer, Unigate. In a leafletadvertising its calcium-enriched milk, ’Calcia’, the company claimsthat "ensuring your diet contains the correct amount of calcium"helps to prevent postmenopausal osteoporosis. The ASA found thatthe consensus view among the medical profession was that hormonereplacement therapy was the only effective means of preventing thedisorder. The authority is therefore concerned that Unigate’s leafletcontains "categoric and unqualified claims". Express Dairy madesimilar claims when it launched its own brand of calcium-

supplemented skimmed milk, ’Vital’, but it modified its advertisingsome months ago in response to a warning from the ASA Code ofAdvertising Practice Committee. The ASA has no control over foodlabelling (which is the responsibility of local-authority tradingstandards offices), and cartons of both Calcia and Vital still carry thesame misleading claims as the offending advertisements. Vital, forinstance, is presented as an "ideal milk for ... people concernedabout their bones becoming weak in old age".

Complaints about Treatment

A guide to the procedure for making complaints about medicaltreatment has been produced by MIND, the National Associationfor Mental Health. Written by Lydia Sinclair, a solicitor for

MIND, the publication sets out how to complain about hospitalcare, clinical judgment, community care, maladministration in thehealth service, local authority and central government departments,and professional misconduct. Proper Channels is available (2.90)from MIND Mail Order, Fourth Floor, 24-32 Stephenson Way,London NW1 2HD (01-637 0741).

Community Health Projects

Detailed information about the development of over 30

community health projects, their aims and activities, has beencompiled to help community health professionals. The Guide toCommunity Health Projects is available (3) from the CommunityHealth Initiatives Resource Unit, 26 Bedford Square, LondonWC1B 3HU, and includes a section on funding.

Additions to Medicines Available under NHS Prescription

’Pregnavite Forte F’ is to be available under NHS prescription toreduce the risk of spina bifida or anencephaly in infants born towomen who have previously given birth to one or more infants (oraborted a fetus) with a neural tube defect.

1. Editorial. Calcium supplements: Does the milkman know best? Lancet 1987; ii: 370.

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Six further drugs are to be generally available on NHSprescription: ’Dynese Plus’ aqueous suspension, ’Haymine’ tablets,’Kolanticon’ gel, ’Polycrol Forte’ gel, ’Polycrol’ gel, and ’Polycrol’tablets.Two drugs will no longer be available under the NHS:

’Fiberform’ and ’Octovit’ tablets.

Fact Sheets from MIND

The National Association for mental Health (MIND) hasproduced 4 new fact sheets on schizophrenia, manic depression,mental handicap, and understanding mental illness. The last factsheet (number I) is available in Bengali and Cantonese. Othersheets, on depression, anxiety, and talking treatments, are alsoavailable at the same price (25 pence each) from MIND Mail Order,4th Floor, 24-32 Stephenson Way, London NWl 2HD.

Common Eye Conditions

The Royal National Institute for the Blind has published 4leaflets on comrrion disorders of the eye: cataracts, glaucoma,diabetic retinopathy, and macular degeneration. The leaflets may beobtained from the RNIB Health Department, 224 Great PortlandStreet, London WIN 6AA (01-388 1266).

Management of Parkinson’s Disease

General practitioners are invited to send for an information folderon the management of Parkinson’s disease, which affects about100 000 people in Britain. The folder is available z7 to members,k8 to non-members) from the Royal College of GeneralPractitioners, 14 Prince’s Gate, Hyde Park, London SW7 1PU(01-5813232).

Asthma Aid

The Government is to make a grant of c3O 000 over three years tothe Asthma Society and Friends of the Asthma Research Council.

Fulbright Travel and Maintenance Awards

Information about the awards for postgraduate study in theUnited States and for visiting lecturers and researchers to the Statesmay be obtained from the British Programme Administrator, TheFulbright Commission, 6 Porter Street, London W1M 2HR (4867697).

The London Hospital Insulins Chart

The sixth edition of the London Hospital Insulins Chart is nowavailable ([,1.50, cheque to be made payable to Tower HamletsHealth Authority) from the Regional Drugs Information Centre,The London Hospital, London El IBB. The new version includesall products on the UK market and changes due to alterations in theBritish Pharmacopoeia monographs.

Medical Association for Prevention of War

The proceedings of a conference on the medical needs of Africaheld in London on Sept 27, 1986 (see Lancet Oct 4, p 819) andsponsored by the Medical Association for Prevention of War andthe United Nations Association of Great Britain and NorthernIreland have now been published as a supplement to the Youmal ofTropical Pediatrics, vol 33, June, 1987. Copies are available fromMAPW, Sudbury, 16b Prince Arthur Road, London NW3 6AY(01-794 1430). Prices ,2 (UK), ,E3 (overseas), including postage.

National Conference on Diabetes

A multidisciplinary conference, organised by the Royal Collegeof General Practitioners and Rybar Laboratories Ltd, is to takeplace at the College on Wednesday, Nov 11. GPs, practice andcommunity nurses, general physicians, diabetic liaison nurses,dieticians, and chiropodists are all invited to participate: JanetHawkins, Course Administrator, Royal College of General

Practitioners, 14 Prince’s Gate, Hyde Park, London SW7 1PU(01-581 3232).

Paediatric Training in the UK

The 4th edition of the British Paediatric Association’s guide toopportunities for training for postgraduates from overseas is nowavailable: Mrs Jean Gaffin, BPA, 5 St Andrew’s Place, Regent’sPark, London NWl 4LB (01-486 6151).

Royal College of General Practitioners

Dr Morris Gallagher, Dr Stephen Iliffe, and Dr Aly Rashid,general practitioners in Tyne and Wear, North London, andLeicester, respectively, have been appointed to the College’s new2-year research fellowships. Their research projects will investigatethe impact of AIDS on general practice, the mental health of carersof elderly patients, and patterns of disease among Asian patients.

A study tour of Public Health and Epidemiology in the Soviet Unionwill visit Leningrad, Kharkov, and Moscow on Oct 17-31: UK-USSRMedical Exchange Programme, 9d Stanhope Road, London N6 5NE.

Three Microsurgical workshops will be held at Northwick Park ClinicalResearch Centre, Harrow, on Oct 26-30, Nov 2-6, and Nov 9-13: Dr C. J.Green, Surgical Research Group, MRC Clinical Research Centre,Northwick Park Hospital, Harrow, Middlesex HA1 3UJ (01-864 5311 ext2511).

A conference on Domestic Violence will be held at Bristol Polytechnic onThursday, Oct 29: Roy Light, Conference Organiser, Law DepartmentOffice, Bristol Polytechnic, Coldharbour Lane, Frenchay, Bristol BS161QY(0272-656261).

A management course in Geriatric Medicine is to take place at

Manchester Business School on Nov 2-6: Prof M. Lye, Department ofGeriatric Medicine, Royal Liverpool Hospital, Prescot Street, Liverpool L693BX (051-709 0141 ext 2630).

A course entitled Integrated Management of Head and Neck Cancerwill be held at Stoke Rochford Hall, near Grantham, Lincs, on Nov 5-9: MrP. J. Bradley, Department of Otolaryngology, University Hospital, Queen’sMedical Centre, Nottingham NG7 2UH (0602-700111).

A seminar on The Management ofDifficult Facial Pain (H), CentralDisturbances or Endorgan Changes is to take place at the EastmanDental Hospital, London, on Friday, Nov 6: Dr C. Feinmann, EastmanDental Hospital, 256 Gray’s Inn Road, London WC1X 8LD (01-837 3646ext 2171).

International Diary1987

International conference on Hospice Care-the Way Forward:London, United Kingdom, September 18 (Annabel Miller, The Universe,33-39 Bowling Green Lane, London EC1R OAB).

A course on The Skin from A to Z: San Francisco, USA, October 10-11(Extended Programs in Medical Education, School of Medicine, Room569-U, San Francisco, Calfornia 94143).

A meeting on Viral Infections-a Problem in Liver

Transplantation: Chicago, Illinois, October 25 (Louise Rappaport,Charles B. Slack Inc, 6900 Grove Road, Thorofare, New Jersey 08086,USA).

An update on Current Concepts of Common Carcinomas-Breast,Colon, and Prostate: San Francisco, USA, October 29-30 (ExtendedPrograms in Medical Education, School of Medicine, Room 569-U, SanFrancisco, California 94143).

1988

Joint meeting of the International Epidemiological Association andthe International Clinical Epidemiology Network: Bangkok, Thailand,January 24-29 (Secretariat, National Epidemiology Board, Ministry ofPublic Health, Devavesm Palace, Bangkok 10200).

6th biennial scientific meeting of Asian Pacific Association for theStudy of the Liver: New Delhi, India, February 13-15 (Chairman,Organising Committee, Asian Pacific Association for the Study of Liver,Department of Gastroenterology and Human Nutrition, All India Instituteof Medical Sciences, New Delhi 110 029).