EDITORIALS * EDITORIAUX
AIDS research funding in Canada: future directions and government policy Mark A. Wainberg, PhD; Martin T. Schechter, MD, MSc, PhD A 11 parties concerned with funding for acquired immunodeficiency syndrome (AIDS) research in Canada have acted out of a genuine desire to develop research in this area expeditiously and fairly, recognizing that this was necessary both for Canada to respond to the global issues raised by the epidemic and for the provision of critical information required by Canadian society. However, opinions differ as to the proper formulation of tactics to encourage AIDS research in this country. To discuss effective strategies for the future we must first briefly review the history of Canadian AIDS research over the past 7 years. In the first 2 years of the epidemic, although some progress in epidemiology had been made, most aspects of AIDS were poorly understood. Subsequently, in 1983 and 1984, human immunodeficiency virus type 1 (HIV) was discovered in France' and in the United States.2 Over the next 3 years grant requests were submitted to the Medical Research Council of Canada (MRC) for basic retroviral studies as well as for clinical and epidemiologic projects. Most of these requests were found to be either unsuitable for support or failed to meet the competitive cut-off point for funding. At that time a number of scientists and politicians expressed the concern that MRC was not responsive to the need to rapidly develop AIDS research programs in Canada. In order to develop proactive policies to encourage AIDS research by Canadian investigators the federal government turned to the National Health Research and Development Program (NHRDP) of the Department of National Health and Welfare. In
1986 $20.5 million was dedicated to a 5-year initiative to promote HIV and AIDS research; $12 million was later added to continue the program through the fiscal year 1992-93. NHRDP was asked to foster quality AIDS research in all relevant areas, including clinical science, epidemiology, public health, health service delivery, ethics and law, and behavioural and social science, as well as in basic science, the traditional mandate of MRC. The AIDS research initiatives that NHRDP promoted have been successful by a number of criteria. Specialized committees of AIDS investigators have been established to consider relevant proposals. Applications in priority areas have been solicited from the research community, and competitions for funding have been held as often as three times per year. NHRDP has funded several clinical trials on AIDS and sponsored workshops that contributed to the development of the HIV Clinical Trials Network, a clinical scientific infrastructure on which multicentre clinical trials can now be based. In addition, NHRDP has funded important studies on HIV epidemiology in Canada and on the social and psychologic dimensions of the AIDS crisis. Support mechanisms for graduate students and postdoctoral fellows wishing to obtain training have been established. NHRDP has created scholarship programs for the career development of scientists hoping to work in the field of AIDS investigation. As of 1990 over 100 Canadian researchers have either successfully competed for funding or have contributed to the AIDS literature. Controversy has continued about the relative
Dr. Wainberg is director of the McGill AIDS Centre and professor, departments ofMedicine and ofMicrobiology and Immunology, McGill University and Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Que.; Dr. Schechter is associate professor, Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, BC.
The opinions expressed in this article are those of the authors and do not necessarily reflect the opinions of any committees on which they sit.
Reprint requests to: Dr. Mark A. Wainberg, Sir Mortimer B. Davis-Jewish General Hospital, 3755 C6te Ste-Catherine Rd., Montreal, PQ H3T IE2 -
For prescribing information
see
page 815
CAN MED ASSOC J 1991; 144 (6)
651
role of NHRDP and MRC in HIV and AIDS research. NHRDP has funded epidemiologic and health services research for many years but has also financed many basic and clinical projects on AIDS that fell within the MRC mandate. Some of these projects might not have succeeded in MRC competition, and this has given rise to the opinion in some quarters that NHRDP's funding policies are less rigorous. Evidence supporting this is meagre, and NHRDP continues to reject over half the AIDS research applications it receives as being scientifically unworthy of support. This controversy aside, research on AIDS in Canada has far from reached its full potential. During 1988 Canadians had contributed only 130 of the 17 000 English articles published on AIDS, less than the 2% to 5% of the world's English language scientific literature usually produced in this country.3 Fewer than 60 of these publications received any citations during 1990 other than by the authors themselves in subsequent articles. Although the number of AIDS-committed investigators in Canada would likely be even fewer without the NHRDP initiatives there is still a paucity of people training as AIDS researchers. Fewer than 15 involved in HIV and AIDS are supported by career awards. In 1987 the Royal Society of Canada was funded by both NHRDP and MRC to review Canada's response to the AIDS epidemic. Included in its 1988 report4 were recommendations that MRC, NHRDP and the Social Sciences and Humanities Research Council use proactive dedicated AIDS committees to promote and support HIV-related research in their respective fields (although NHRDP had already done this) and that a national research committee be formed to coordinate the AIDS-related research efforts of these agencies. We believe that AIDS research in Canada could be strengthened by a proactive commitment by the MRC. Although the number of AIDS-related grants funded by MRC has risen over the last 5 years projects that impact on the AIDS field account for only approximately $3 million (1.6%) of MRC's total annual spending of $191 million. In contrast NHRDP has outspent MRC annually on AIDS research by several million dollars, despite an annual overall budget of only $29 million. Given these data it is not surprising that the Parliamentary Ad Hoc Committee on AIDS recommended that "MRC consider the dedication of funds for basic research on AIDS and HIV infection."5 At present, grant submissions to MRC which deal with AIDS are considered by any of several MRC committees. We would propose, as did the Royal Society,4 that MRC establish a committee to deal with the broad issue of AIDS and human retroviruses analogous to the committee that already 652
CAN MED ASSOC J 1991; 144 (6)
exists for cancer. This should be relatively easy, since many distinguished Canadian retrovirologists and immunologists already receive MRC support. It would provide a mechanism to ensure that AIDSrelated projects were considered relative to each other rather than to projects submitted on other topics. It would also underline MRC's commitment to AIDS as an important disease and should lead to the submission of significant numbers of new proposals on AIDS and related subjects. Moreover, it would not compromise the principle that only the best investigator-initiated projects be funded. The implementation of such a policy might allow NHRDP to concentrate on its more traditional role of funding epidemiologic and health service research related to HIV and AIDS. At the same time NHRDP, in collaboration with the Federal Centre for AIDS (Health Protection Branch, Department of National Health and Welfare), should continue to support clinical AIDS research and clinical trials in Canada. Coordination between all organizations that fund AIDS research is essential, and we concur with the Royal Society recommendation4 that a national research committee be struck to ensure such coordination and to facilitate interdisciplinary research that "may transcend traditional mandates." The recent decision by MRC and NHRDP to cooperatively sponsor a research competition on AIDS and to jointly fund a number of HIV and AIDS research projects is a step forward. Canada lags far behind other developed countries in the amount of money that it has committed to its domestic AIDS problem so far. It has been estimated, for example, that Canada's federal expenditure on AIDS education, prevention and research is only 40% of that of the United States and Australia after adjustment for the estimated number of HIV-infected people in each country (Normand Lapointe, Catherine A. Hankins, Martin T. Schechter: unpublished data, 1989). To make matters worse, funds for the federal AIDS initiative, including the NHRDP AIDS research program, will expire in March 1993. Unfortunately, the national AIDS strategy6'7 recently announced by the Minister of National Health and Welfare has done little to address this problem: no new funds were introduced in the strategy, which merely reshuffled an existing 3-year commitment of $112 million for the fiscal years from 1990-91 to 1992-93 to deal with all aspects of AIDS in Canada, including education, information, prevention, counselling, HIV seroprevalence monitoring and research. The dwindling amount of uncommitted research funds and the short time before expiration are such that important long-term projects or trials cannot be considered for NHRDP funding at present. The urgency of the situation was not lost on the nonpartisan Parliamentary Ad Hoc
Committee on AIDS, which recently recommended "in the strongest terms possible, that the Minister of National Health and Welfare undertake a review of the overall funding commitment of the federal government to the struggle against AIDS and HIV infection with a view to increasing it to a level which is adequate to meet the increasing challenge which must be faced."8 Testimony before that committee indicated that if the federal allocation for the current year were to be quadrupled to $120 million and this level maintained, the additional spending would actually result in future savings in direct personal costs (not including the much higher indirect costs) if more than 900 cases of HIV infection per year were prevented across the country.9 In conclusion, Canadians can take pride in some of the innovative programs in AIDS research, community-based intervention and education that have been developed nationally over the past 5 years. However, we have not achieved our potential in the area of research, and an ongoing commitment from government to support AIDS investigations and to attract investigators into the field is necessary. This must occur in the near future if we wish to
Conferences continuedfrom page 649 Apr. 22-23, 1991: Symposium on Bioequivalence and Interchangeability of Pharmaceutical Products Queen Elizabeth Hotel, Montreal Dr Jacques Gagne, Faculte de pharmacie, Universite de Montreal, CP 6128, succ. A, Montreal, QC H3C 3J7; (514) 343-2102 Apr. 24, 1991: 4th Annual Conference on Education in Aging and Health - Educational Implications of the Provincial Long Term Care Reform Sheraton Hotel, Hamilton, Ont. Educational Centre for Aging and Health, Faculty of Health Sciences, McMaster University, PO Box 2000, Stn. A, Hamilton, ON L8S 3N5; (416) 525-9140, ext. 84-4011, fax (416) 574-2838
Apr. 24-26, 1991: Western Phlebology Conference (18th Annual Meeting of the Canadian Phlebology Society) Chateau Whistler Resort, Whistler, BC Dr. Louis Grondin, scientific director, Western Phlebology Conference, c/o Ste. 10, 1420-40 Ave. NE, Calgary, AB T2E 6L1; (403) 250-3526, fax (403) 291-9755
Apr. 24-27, 1991: Canadian Association of SpeechLanguage Pathologists and Audiologists 16th Annual Convention H6tel Le Meridien, Montreal JPdL Multi Management Inc., 609-1410 Stanley St., Montreal, PQ H3A 1P8; (514) 287-1070, fax (514) 287-1248
build on the potential for Canadian research excellence that exists.
References 1. Barre-Sinoussi F, Chermann JC, Rey F et al: Isolation of a T-lymphocyte retrovirus from a patient at risk for acquired immune deficiency syndrome (AIDS). Science 1983; 220: 868870 2. Gallo RC, Salahuddin SZ, Popovic M et al: Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS. Science 1984; 224: 500-503 3. Ronald AR: The Canadian AIDS Research Contribution: a Critique [abstr ThHP8]. Presented at the Vth International Conference on AIDS, Montreal, June 4-9, 1989 4. AIDS: a Perspective for Canadians, Royal Society of Canada, Ottawa, 1988 5. Confronting a Crisis. The Report of the Parliamentary Ad Hoc Committee on AIDS, Ottawa, 1990: 20 6. HIV and AIDS: Canada's Blueprint, Dept of National Health and Welfare, Ottawa, 1990 7. Building an Effective Partnership: the Federal Government's Commitment to Fighting AIDS, Dept of National Health and Welfare, Ottawa, 1990 8. Confronting a Crisis. The Report of the Parliamentary Ad Hoc Committee on AIDS, Ottawa, 1990: 63 9. Ibid: 59-60
Du 24 au 27 avril 1991: XVIe Congres de l'Association canadienne des orthophonistes et des audiologistes H6tel Le Meridien, Montreal JPdL Multi Management Inc., 609-1410, rue Stanley, Montreal, QC H3A IP8; (514) 287-1070, fax (514) 287-1248 Apr. 25-26, 1991: Canadian Association for Quality Assurance in Health Care Annual Conference Dawning of Quality Management Harbour Castle Hilton, Toronto Amanda Curtis, Canadian Association for Quality Assurance in Health Care, 409-1 Eva Rd., Etobicoke, ON M9C 4Z5; (416) 626-0102, fax (416) 620-5392
Apr. 25-26, 1991: Ontario Gerontology Association 10th Annual Conference - Choices for the 1990s: Economics, Practice and Ethics Sheraton Hotel, Hamilton, Ont. Ontario Gerontology Association, 7777 Keele St., 2nd Fl., Concord, ON L4K 1Y7; (416) 660-1056 or 660-1076, fax (416) 660-7450
May 2-3, 1991: Introduction of Recombinant Factor VIII to Clinical Practice: an International Symposium Symposium postponed until Fall. For further information contact: Canadian Hemophilia Society, 840-1450 City Councillors St., Montreal, PQ H3A 2E6, (514) 848-0503, fax (514) 848-9661; or Dr. Man-Chiu Poon, Foothills Provincial General Hospital, 1403-29 St. NW, Calgary, AB T2N 2T9
continued on page 680 CAN MED ASSOC J 1991; 144 (6)
653
AIDS research funding in Canada: future directions and government policy Mark A. Wainberg, PhD; Martin T. Schechter, MD, MSc, PhD A 11 parties concerned with funding for acquired immunodeficiency syndrome (AIDS) research in Canada have acted out of a genuine desire to develop research in this area expeditiously and fairly, recognizing that this was necessary both for Canada to respond to the global issues raised by the epidemic and for the provision of critical information required by Canadian society. However, opinions differ as to the proper formulation of tactics to encourage AIDS research in this country. To discuss effective strategies for the future we must first briefly review the history of Canadian AIDS research over the past 7 years. In the first 2 years of the epidemic, although some progress in epidemiology had been made, most aspects of AIDS were poorly understood. Subsequently, in 1983 and 1984, human immunodeficiency virus type 1 (HIV) was discovered in France' and in the United States.2 Over the next 3 years grant requests were submitted to the Medical Research Council of Canada (MRC) for basic retroviral studies as well as for clinical and epidemiologic projects. Most of these requests were found to be either unsuitable for support or failed to meet the competitive cut-off point for funding. At that time a number of scientists and politicians expressed the concern that MRC was not responsive to the need to rapidly develop AIDS research programs in Canada. In order to develop proactive policies to encourage AIDS research by Canadian investigators the federal government turned to the National Health Research and Development Program (NHRDP) of the Department of National Health and Welfare. In
1986 $20.5 million was dedicated to a 5-year initiative to promote HIV and AIDS research; $12 million was later added to continue the program through the fiscal year 1992-93. NHRDP was asked to foster quality AIDS research in all relevant areas, including clinical science, epidemiology, public health, health service delivery, ethics and law, and behavioural and social science, as well as in basic science, the traditional mandate of MRC. The AIDS research initiatives that NHRDP promoted have been successful by a number of criteria. Specialized committees of AIDS investigators have been established to consider relevant proposals. Applications in priority areas have been solicited from the research community, and competitions for funding have been held as often as three times per year. NHRDP has funded several clinical trials on AIDS and sponsored workshops that contributed to the development of the HIV Clinical Trials Network, a clinical scientific infrastructure on which multicentre clinical trials can now be based. In addition, NHRDP has funded important studies on HIV epidemiology in Canada and on the social and psychologic dimensions of the AIDS crisis. Support mechanisms for graduate students and postdoctoral fellows wishing to obtain training have been established. NHRDP has created scholarship programs for the career development of scientists hoping to work in the field of AIDS investigation. As of 1990 over 100 Canadian researchers have either successfully competed for funding or have contributed to the AIDS literature. Controversy has continued about the relative
Dr. Wainberg is director of the McGill AIDS Centre and professor, departments ofMedicine and ofMicrobiology and Immunology, McGill University and Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Que.; Dr. Schechter is associate professor, Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, BC.
The opinions expressed in this article are those of the authors and do not necessarily reflect the opinions of any committees on which they sit.
Reprint requests to: Dr. Mark A. Wainberg, Sir Mortimer B. Davis-Jewish General Hospital, 3755 C6te Ste-Catherine Rd., Montreal, PQ H3T IE2 -
For prescribing information
see
page 815
CAN MED ASSOC J 1991; 144 (6)
651
role of NHRDP and MRC in HIV and AIDS research. NHRDP has funded epidemiologic and health services research for many years but has also financed many basic and clinical projects on AIDS that fell within the MRC mandate. Some of these projects might not have succeeded in MRC competition, and this has given rise to the opinion in some quarters that NHRDP's funding policies are less rigorous. Evidence supporting this is meagre, and NHRDP continues to reject over half the AIDS research applications it receives as being scientifically unworthy of support. This controversy aside, research on AIDS in Canada has far from reached its full potential. During 1988 Canadians had contributed only 130 of the 17 000 English articles published on AIDS, less than the 2% to 5% of the world's English language scientific literature usually produced in this country.3 Fewer than 60 of these publications received any citations during 1990 other than by the authors themselves in subsequent articles. Although the number of AIDS-committed investigators in Canada would likely be even fewer without the NHRDP initiatives there is still a paucity of people training as AIDS researchers. Fewer than 15 involved in HIV and AIDS are supported by career awards. In 1987 the Royal Society of Canada was funded by both NHRDP and MRC to review Canada's response to the AIDS epidemic. Included in its 1988 report4 were recommendations that MRC, NHRDP and the Social Sciences and Humanities Research Council use proactive dedicated AIDS committees to promote and support HIV-related research in their respective fields (although NHRDP had already done this) and that a national research committee be formed to coordinate the AIDS-related research efforts of these agencies. We believe that AIDS research in Canada could be strengthened by a proactive commitment by the MRC. Although the number of AIDS-related grants funded by MRC has risen over the last 5 years projects that impact on the AIDS field account for only approximately $3 million (1.6%) of MRC's total annual spending of $191 million. In contrast NHRDP has outspent MRC annually on AIDS research by several million dollars, despite an annual overall budget of only $29 million. Given these data it is not surprising that the Parliamentary Ad Hoc Committee on AIDS recommended that "MRC consider the dedication of funds for basic research on AIDS and HIV infection."5 At present, grant submissions to MRC which deal with AIDS are considered by any of several MRC committees. We would propose, as did the Royal Society,4 that MRC establish a committee to deal with the broad issue of AIDS and human retroviruses analogous to the committee that already 652
CAN MED ASSOC J 1991; 144 (6)
exists for cancer. This should be relatively easy, since many distinguished Canadian retrovirologists and immunologists already receive MRC support. It would provide a mechanism to ensure that AIDSrelated projects were considered relative to each other rather than to projects submitted on other topics. It would also underline MRC's commitment to AIDS as an important disease and should lead to the submission of significant numbers of new proposals on AIDS and related subjects. Moreover, it would not compromise the principle that only the best investigator-initiated projects be funded. The implementation of such a policy might allow NHRDP to concentrate on its more traditional role of funding epidemiologic and health service research related to HIV and AIDS. At the same time NHRDP, in collaboration with the Federal Centre for AIDS (Health Protection Branch, Department of National Health and Welfare), should continue to support clinical AIDS research and clinical trials in Canada. Coordination between all organizations that fund AIDS research is essential, and we concur with the Royal Society recommendation4 that a national research committee be struck to ensure such coordination and to facilitate interdisciplinary research that "may transcend traditional mandates." The recent decision by MRC and NHRDP to cooperatively sponsor a research competition on AIDS and to jointly fund a number of HIV and AIDS research projects is a step forward. Canada lags far behind other developed countries in the amount of money that it has committed to its domestic AIDS problem so far. It has been estimated, for example, that Canada's federal expenditure on AIDS education, prevention and research is only 40% of that of the United States and Australia after adjustment for the estimated number of HIV-infected people in each country (Normand Lapointe, Catherine A. Hankins, Martin T. Schechter: unpublished data, 1989). To make matters worse, funds for the federal AIDS initiative, including the NHRDP AIDS research program, will expire in March 1993. Unfortunately, the national AIDS strategy6'7 recently announced by the Minister of National Health and Welfare has done little to address this problem: no new funds were introduced in the strategy, which merely reshuffled an existing 3-year commitment of $112 million for the fiscal years from 1990-91 to 1992-93 to deal with all aspects of AIDS in Canada, including education, information, prevention, counselling, HIV seroprevalence monitoring and research. The dwindling amount of uncommitted research funds and the short time before expiration are such that important long-term projects or trials cannot be considered for NHRDP funding at present. The urgency of the situation was not lost on the nonpartisan Parliamentary Ad Hoc
Committee on AIDS, which recently recommended "in the strongest terms possible, that the Minister of National Health and Welfare undertake a review of the overall funding commitment of the federal government to the struggle against AIDS and HIV infection with a view to increasing it to a level which is adequate to meet the increasing challenge which must be faced."8 Testimony before that committee indicated that if the federal allocation for the current year were to be quadrupled to $120 million and this level maintained, the additional spending would actually result in future savings in direct personal costs (not including the much higher indirect costs) if more than 900 cases of HIV infection per year were prevented across the country.9 In conclusion, Canadians can take pride in some of the innovative programs in AIDS research, community-based intervention and education that have been developed nationally over the past 5 years. However, we have not achieved our potential in the area of research, and an ongoing commitment from government to support AIDS investigations and to attract investigators into the field is necessary. This must occur in the near future if we wish to
Conferences continuedfrom page 649 Apr. 22-23, 1991: Symposium on Bioequivalence and Interchangeability of Pharmaceutical Products Queen Elizabeth Hotel, Montreal Dr Jacques Gagne, Faculte de pharmacie, Universite de Montreal, CP 6128, succ. A, Montreal, QC H3C 3J7; (514) 343-2102 Apr. 24, 1991: 4th Annual Conference on Education in Aging and Health - Educational Implications of the Provincial Long Term Care Reform Sheraton Hotel, Hamilton, Ont. Educational Centre for Aging and Health, Faculty of Health Sciences, McMaster University, PO Box 2000, Stn. A, Hamilton, ON L8S 3N5; (416) 525-9140, ext. 84-4011, fax (416) 574-2838
Apr. 24-26, 1991: Western Phlebology Conference (18th Annual Meeting of the Canadian Phlebology Society) Chateau Whistler Resort, Whistler, BC Dr. Louis Grondin, scientific director, Western Phlebology Conference, c/o Ste. 10, 1420-40 Ave. NE, Calgary, AB T2E 6L1; (403) 250-3526, fax (403) 291-9755
Apr. 24-27, 1991: Canadian Association of SpeechLanguage Pathologists and Audiologists 16th Annual Convention H6tel Le Meridien, Montreal JPdL Multi Management Inc., 609-1410 Stanley St., Montreal, PQ H3A 1P8; (514) 287-1070, fax (514) 287-1248
build on the potential for Canadian research excellence that exists.
References 1. Barre-Sinoussi F, Chermann JC, Rey F et al: Isolation of a T-lymphocyte retrovirus from a patient at risk for acquired immune deficiency syndrome (AIDS). Science 1983; 220: 868870 2. Gallo RC, Salahuddin SZ, Popovic M et al: Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS. Science 1984; 224: 500-503 3. Ronald AR: The Canadian AIDS Research Contribution: a Critique [abstr ThHP8]. Presented at the Vth International Conference on AIDS, Montreal, June 4-9, 1989 4. AIDS: a Perspective for Canadians, Royal Society of Canada, Ottawa, 1988 5. Confronting a Crisis. The Report of the Parliamentary Ad Hoc Committee on AIDS, Ottawa, 1990: 20 6. HIV and AIDS: Canada's Blueprint, Dept of National Health and Welfare, Ottawa, 1990 7. Building an Effective Partnership: the Federal Government's Commitment to Fighting AIDS, Dept of National Health and Welfare, Ottawa, 1990 8. Confronting a Crisis. The Report of the Parliamentary Ad Hoc Committee on AIDS, Ottawa, 1990: 63 9. Ibid: 59-60
Du 24 au 27 avril 1991: XVIe Congres de l'Association canadienne des orthophonistes et des audiologistes H6tel Le Meridien, Montreal JPdL Multi Management Inc., 609-1410, rue Stanley, Montreal, QC H3A IP8; (514) 287-1070, fax (514) 287-1248 Apr. 25-26, 1991: Canadian Association for Quality Assurance in Health Care Annual Conference Dawning of Quality Management Harbour Castle Hilton, Toronto Amanda Curtis, Canadian Association for Quality Assurance in Health Care, 409-1 Eva Rd., Etobicoke, ON M9C 4Z5; (416) 626-0102, fax (416) 620-5392
Apr. 25-26, 1991: Ontario Gerontology Association 10th Annual Conference - Choices for the 1990s: Economics, Practice and Ethics Sheraton Hotel, Hamilton, Ont. Ontario Gerontology Association, 7777 Keele St., 2nd Fl., Concord, ON L4K 1Y7; (416) 660-1056 or 660-1076, fax (416) 660-7450
May 2-3, 1991: Introduction of Recombinant Factor VIII to Clinical Practice: an International Symposium Symposium postponed until Fall. For further information contact: Canadian Hemophilia Society, 840-1450 City Councillors St., Montreal, PQ H3A 2E6, (514) 848-0503, fax (514) 848-9661; or Dr. Man-Chiu Poon, Foothills Provincial General Hospital, 1403-29 St. NW, Calgary, AB T2N 2T9
continued on page 680 CAN MED ASSOC J 1991; 144 (6)
653
