238
amounted to a breach of their statutory duty. However, BT’s failure to warn of the risk that keyboard work might cause RSI to new recruits or to encourage workers to report any aches and pains at onset did not amount to a breach of
statutory duty. Diana Brahams
Conference AIDS in Africa 1 in 40 African adults is now infected with HIV. These 6 million women and men, and the three-quarters of a million infected children, are unevenly distributed over the continent. In East Africa the real burden of disease and death is only just beginning to be felt, but already AIDS cases make up to 80% of the case-load in some adult hospital wards. Practically everywhere the number of people with asymptomatic HIV infections is multiplying rapidly. 1 in 8 adults in Abidjan now carry HIV 1 or HIV 2. The burden of associated diseases is overwhelming: 40% of patients dying from AIDS have cerebral lesions, most commonly toxoplasmosis and tuberculosis. Already there are 50 000 AIDS orphans in just one region (Kagera) in Tanzania, and agricultural production in the same area has fallen by 3-20%. Yet only a small fraction of those infected with HIV in any part of Africa have died. From the point of view of cost to the community and health services the epidemic is
only just beginning. The Sixth International Conference
on
graciously opened by the President of Senegal, Monsieur Aboon Diouf, and even President Bush sent a message. Finally, such conferences disseminate information to the rest of the world. For example, studies in Nairobi suggest that the use of oral contraceptives and intrauterine devices is associated with any increased or reduced risk of seroconversion, and data from Cameroon give some preliminary evidence of a protective effect of spermicide use on the acquisition of HIV. More evidence is accumulating about the long incubation period of HIV-2. But despite much of interest, many of the outcomes of the meeting might have been achieved more cost-effectively. Perhaps the several, much smaller, satellite meetings by WHO/GPA, Family Health International, and Bristol Myers Squibb held in Dakar are a more appropriate model for the future. Certainly another world conference in Amsterdam in the middle of 1992 and a Seventh AIDS in Africa conference in Yaounde at the end of next year seems a bit like conference overload. One participant, who has known AIDS for longer and more closely than most, saw the Dakar meeting "as a rerun of the first AIDS in Africa conference in Brussels in 1985 but with the decimal point moved". In other words, HIV prevalences continue to rise and even experts do not always learn quickly enough.
not
International First Floor,
Family Health,
Margaret Pyke Centre, 15 Bateman’s Buildings, London W1V 5TW
Malcolm Potts
AIDS in Africa
(Dec 16-18, 1991) brought 1800 participants from 79 countries to Dakar, Senegal. Many conference presentations measured the spread of HIV or threw light on the
knowledge and attitudes of vulnerable groups such as prostitutes and their clients. Less than 10% of commercial sex workers in one Cameroon sample used condoms regularly and 60% of long-distance lorry drivers in Zimbabwe have sex with a prostitute at least once a month. Somewhat fewer papers dealt with preventive measures such as education, distribution of condoms, or treatment of other sexually transmitted diseases (STD). The poverty of the Sahel, political unrest in Zaire, debt burdens in Nigeria, and the legacy of previous bad government in Uganda are all factors mitigating against disease control. So is the low status of women. In many parts of Africa women handle much of the subsistence farming and petty commerce but receive the least reward. Even so, there have been successes in HIV prevention: prostitutes in Ghana have changed their behaviour, the social marketing of condoms in Zaire has been most successful, and the comprehensive control of STDs through government services has been initiated in Tanzania. The challenge is to develop the will and mobilise the resources (national and international) to turn pilot projects into epidemiologically significant programmes. At present, however, it is difficult to escape the conclusion that HIV is out of control. Among other things, it must also be asked whether large, expensive conferences are themselves an appropriate response? Conferences help forge needed partnerships between developing and developed countries and are certainly essential for recharging the skills and motivation for those fighting in the trenches in the battle against AIDS. Scientists from Belgium, France, and the USA played an important part in the Dakar meeting. Conferences also allow national leaders to express support: the sixth conference was
Noticeboard Safeguards for gene therapy Somatic gene
therapy
will be allowed in the UK if the
recommendations of the Committee on the Ethics of Gene Therapy are accepted by the Government. But the Department of Health will be seeking the views of many professional and lay organisations before the Government reaches its decision. The consultation period will end on May 18. Any proposed gene therapy must be ethically acceptable and shown to be safe, says the committee’s report, published last week.’ The committee, a non-statutory body set up by UK health ministers in 1989 under the chairmanship of Sir Cecil Clothier, QC, says that gene therapy raises no new ethical issues, but because the treatment is new it recommends that gene therapy should be subject to the ethical codes that apply to research involving patients. Familiar ethical considerations that are likely to assume greater prominence when gene therapy is being considered include safety (because of the possibility of unpredicted consequences of gene insertion), the need for long-term surveillance, consent (especially regarding uncertainties about outcome), the probability that children will be among the first candidates for gene therapy, and
confidentiality. Gene therapy, the committee recommends, should be restricted to the alleviation of disease in individual patients and should not be used to change normal human traits. The first candidates for gene therapy should be patients with a lifethreatening or seriously disabling genetic disease. Severe genetic disorders that show their effects in early childhood, or even before birth, should be treated correspondingly early. Germline gene therapy should not be attempted at present, says the report, because "there is insufficient knowledge to evaluate the risk to future generations". At a meeting of the Human Genome Organisation in London last August Dame Mary Warnock, chairman of the 1984 committee that approved in-vitro fertilisation and limited research on human embryos, said that unpredictable outcome was a more valid reason for rejecting germline therapy than was
fear of doctors’ powers.
amounted to a breach of their statutory duty. However, BT’s failure to warn of the risk that keyboard work might cause RSI to new recruits or to encourage workers to report any aches and pains at onset did not amount to a breach of
statutory duty. Diana Brahams
Conference AIDS in Africa 1 in 40 African adults is now infected with HIV. These 6 million women and men, and the three-quarters of a million infected children, are unevenly distributed over the continent. In East Africa the real burden of disease and death is only just beginning to be felt, but already AIDS cases make up to 80% of the case-load in some adult hospital wards. Practically everywhere the number of people with asymptomatic HIV infections is multiplying rapidly. 1 in 8 adults in Abidjan now carry HIV 1 or HIV 2. The burden of associated diseases is overwhelming: 40% of patients dying from AIDS have cerebral lesions, most commonly toxoplasmosis and tuberculosis. Already there are 50 000 AIDS orphans in just one region (Kagera) in Tanzania, and agricultural production in the same area has fallen by 3-20%. Yet only a small fraction of those infected with HIV in any part of Africa have died. From the point of view of cost to the community and health services the epidemic is
only just beginning. The Sixth International Conference
on
graciously opened by the President of Senegal, Monsieur Aboon Diouf, and even President Bush sent a message. Finally, such conferences disseminate information to the rest of the world. For example, studies in Nairobi suggest that the use of oral contraceptives and intrauterine devices is associated with any increased or reduced risk of seroconversion, and data from Cameroon give some preliminary evidence of a protective effect of spermicide use on the acquisition of HIV. More evidence is accumulating about the long incubation period of HIV-2. But despite much of interest, many of the outcomes of the meeting might have been achieved more cost-effectively. Perhaps the several, much smaller, satellite meetings by WHO/GPA, Family Health International, and Bristol Myers Squibb held in Dakar are a more appropriate model for the future. Certainly another world conference in Amsterdam in the middle of 1992 and a Seventh AIDS in Africa conference in Yaounde at the end of next year seems a bit like conference overload. One participant, who has known AIDS for longer and more closely than most, saw the Dakar meeting "as a rerun of the first AIDS in Africa conference in Brussels in 1985 but with the decimal point moved". In other words, HIV prevalences continue to rise and even experts do not always learn quickly enough.
not
International First Floor,
Family Health,
Margaret Pyke Centre, 15 Bateman’s Buildings, London W1V 5TW
Malcolm Potts
AIDS in Africa
(Dec 16-18, 1991) brought 1800 participants from 79 countries to Dakar, Senegal. Many conference presentations measured the spread of HIV or threw light on the
knowledge and attitudes of vulnerable groups such as prostitutes and their clients. Less than 10% of commercial sex workers in one Cameroon sample used condoms regularly and 60% of long-distance lorry drivers in Zimbabwe have sex with a prostitute at least once a month. Somewhat fewer papers dealt with preventive measures such as education, distribution of condoms, or treatment of other sexually transmitted diseases (STD). The poverty of the Sahel, political unrest in Zaire, debt burdens in Nigeria, and the legacy of previous bad government in Uganda are all factors mitigating against disease control. So is the low status of women. In many parts of Africa women handle much of the subsistence farming and petty commerce but receive the least reward. Even so, there have been successes in HIV prevention: prostitutes in Ghana have changed their behaviour, the social marketing of condoms in Zaire has been most successful, and the comprehensive control of STDs through government services has been initiated in Tanzania. The challenge is to develop the will and mobilise the resources (national and international) to turn pilot projects into epidemiologically significant programmes. At present, however, it is difficult to escape the conclusion that HIV is out of control. Among other things, it must also be asked whether large, expensive conferences are themselves an appropriate response? Conferences help forge needed partnerships between developing and developed countries and are certainly essential for recharging the skills and motivation for those fighting in the trenches in the battle against AIDS. Scientists from Belgium, France, and the USA played an important part in the Dakar meeting. Conferences also allow national leaders to express support: the sixth conference was
Noticeboard Safeguards for gene therapy Somatic gene
therapy
will be allowed in the UK if the
recommendations of the Committee on the Ethics of Gene Therapy are accepted by the Government. But the Department of Health will be seeking the views of many professional and lay organisations before the Government reaches its decision. The consultation period will end on May 18. Any proposed gene therapy must be ethically acceptable and shown to be safe, says the committee’s report, published last week.’ The committee, a non-statutory body set up by UK health ministers in 1989 under the chairmanship of Sir Cecil Clothier, QC, says that gene therapy raises no new ethical issues, but because the treatment is new it recommends that gene therapy should be subject to the ethical codes that apply to research involving patients. Familiar ethical considerations that are likely to assume greater prominence when gene therapy is being considered include safety (because of the possibility of unpredicted consequences of gene insertion), the need for long-term surveillance, consent (especially regarding uncertainties about outcome), the probability that children will be among the first candidates for gene therapy, and
confidentiality. Gene therapy, the committee recommends, should be restricted to the alleviation of disease in individual patients and should not be used to change normal human traits. The first candidates for gene therapy should be patients with a lifethreatening or seriously disabling genetic disease. Severe genetic disorders that show their effects in early childhood, or even before birth, should be treated correspondingly early. Germline gene therapy should not be attempted at present, says the report, because "there is insufficient knowledge to evaluate the risk to future generations". At a meeting of the Human Genome Organisation in London last August Dame Mary Warnock, chairman of the 1984 committee that approved in-vitro fertilisation and limited research on human embryos, said that unpredictable outcome was a more valid reason for rejecting germline therapy than was
fear of doctors’ powers.
