1289
spread of AIDS, mainly from Thailand. The threat is made all the more serious by the population’s almost complete lack of knowledge about the disease and by the fact that the sex industry, rather than intravenous drug use, has become the major medium for the spread of the disease. That Burma is a source of recruitment for Thai prostitution rings makes the country the weakest point in the anti-AIDS efforts throughout the region. Burma has what is believed to be the highest infection rate in the area. Of an estimated 160 000 drug addicts, at least half are said to be infected with HIV. Troubles in rural areas have created international difficulties. There, government troops, officially known as "Tatmadaw", arbitrarily seize and extrajudicially execute members of religious and ethnic minorities. The brutal persecution drove over 250 000 Rohingya Muslims into neighbouring countries, mainly Bangladesh, and strained relations not only with that country but also with Indonesia and Malaysia. Bangladesh can no longer cope with the influx. On April 28 the Governments of Bangladesh and Burma agreed on the repatriation of Burmese refugees. The plan was to repatriate 5000 people a day from May 15. The US Committee for Refugees (USCR) has, however, urged the international community not to support the repatriation if Burma does not allow international monitoring of the refugees’ safety once they return home. The USCR is also concerned that the words "safe and voluntary" have dropped out of the original wording of the agreement. There are indications that repatriation is not fully voluntary; the starting date of the exercise was postponed after the police opened fire on refugees protesting against repatriation, killing one and wounding six. Medical societies around the world should raise their voices against all abuses directed at the Burmese people. New York
Cesar A. Chelala
Germany: New health strategy in the making? Officially the main reasons for the health minister’s resignation were poor health and the disclosure that one of her most trusted advisers was a spy for the Polish security service. Gerda Hasselfeldt, a member of the Bavarian Christian Social Union with a shooting-star career in Bonn, held out for 16 months in one of the most difficult jobs the German Government has to offer. But nobody was taken by surprise when she announced her going at the end of last month-which many believe is because she had no prescription for countering the malaise of ever-increasing health-service costs (Lancet May 2, p 1104). By resigning she almost certainly forestalled dismissal in the next cabinet reshuffle, due at the end of the year. Her successor Horst Seehofer, also from Bavaria, is judged to be a highly competent politician and administrator. He has been a secretary of state in the Social Ministry and is said to be a fervent supporter of the recent health reform. One of his first suggestions, to increase taxation on tobacco, did not meet with much approval from the Chancellor. But Seehofer is determined to pursue a strategy of minimising health costs. Furthermore, he plans to introduce obligatory insurance for old-age care. This might be financed partly by relieving employers of having to pay wages for the first three days of illness. Whether he will stick to the old policies for the health reforms or come up with new ideas, possibly touching on hospital costs, is not yet clear. At the moment he has imposed a strict news blackout on policy statements about further health reforms until the end of May. In the meantime the Government is holding
secret meetings to discuss their new strategy. Health politicians did not turn up to make their customary speeches at the annual doctors’ meeting in Cologne last week.
Annette Tuffs
Conference Alternative view
on
AIDS
Journalists formed the bulk of the 100-150 people attending the International Symposium "AIDS, a different view", organised by the Foundation for Alternative AIDS Research and held on May 14-16 in Amsterdam. The topic that attracted the greatest interest was whether HIV is the cause of AIDS or, more accurately, whether HIV infection is both necessary and sufficient to cause AIDS. Peter Duesberg took the stand, as always, that HIV infection was neither necessary nor sufficient to cause AIDS. Luc Montagnier and the representatives of the Amsterdam Cohort Studies, Roel Coutinho and Frank Miedema, presented evidence for the opposite view. As the discussions revealed, not all Duesberg’s observations were controversial, though some of his interpretations were. There were fierce exchanges. Duesberg’s first thesis was that AIDS does not have the characteristics of an ordinary infectious disease. This view is incontrovertible. AIDS is caused by an extraordinary virus. The unprecedented affinity that its envelope has for the CD4 molecule enables it to enter CD4 cells and monocytes. Moreover, as Miedema and Montagnier pointed out, they and others have found that in HIV-infected individuals, but not in HIV-uninfected people, a large percentage of the uninfected CD4 cells are anergic or programmed for cell death by apoptosis. Montagnier suggested that the complexes formed between CD4 molecules and the HIV envelope or HIV-envelope antibodies may be the cause of this HIV-related apoptosis. This process indicates that HIV is able to have systemic effects on the immune system, which counters Duesberg’s point that in AIDS patients too few CD4 cells are infected by HIV for the virus to be the cause of AIDS. The only viruses known to use the CD4 molecule as a receptor are the primate lentiviruses, HIV and SIV. Duesberg’s point that there is no reason why a person with tuberculosis (TB) and HIV antibodies has AIDS, whereas a person with TB but without HIV antibodies has plain TB, had more to do with the clinical definition rather than the cause of AIDS. Miedema argued for that definition by describing how the progressive and irreversible functional immunodeficiency produced in the first six months of HIV infection results in opportunistic infections dependent on the ubiquity of a particular microbe.2 Duesberg’s third point, that HIV cannot be isolated from every HIV-antibody-positive individual and that disease progression is not always accompanied by active viral replication, probably held true in the days when it was difficult to isolate HIV from peripheral blood cells or plasma. But Miedema reported that there has now been 100% virus recovery rates and that virus isolates with enhanced replicative and cytopathic properties are associated with disease progression;2 others too have shown that virus replication speeds up during disease progression. Duesberg’s next thesis was that, if AIDS were an ordinary infectious disease (which it is not), it would spread randomly between the sexes, yet in Europe and the US AID S affects mainly men. A key question is the definition of randomness (or representativeness). A random (or
1290
representative) sample of the general population in Europe or the US will contain an equal number of males and females, but neither HIV infection nor AIDS is prevalent among the general population in the developed world. Like syphilis, gonorrhoea, and hepatitis B, HIV is prevalent among subsets of the population that happen to be made up mainly of men. A random sample of males would thus contain only males. Duesberg said that HIV infection does follow Farr’s law because the incidence of HIV is in the general population (Farr’s law predicts an increase in the epidemic curve followed by an even more rapid descent). However, AIDS does not seem to affect the general population in the developed world. Whether Farr’s law is applicable to chronic diseases such as TB or AIDS may be questioned. In any case, Coutinho presented convincing evidence that both AIDS and HIV have followed Farr’s law within the risk group (homosexual men).5 Duesberg’s last argument was that HIV did not fulfil Koch’s postulates. That HIV can be isolated in every AIDS case fulfils the first postulate. The second postulate requires that HIV is not isolated in any other disease and that, as Evans4added in 1973, virus-specific antibody appears after onset of illness. As Duesberg pointed out, many individuals positive for HIV and antibody to the virus have no clinical signs of immunodeficiency or AIDS-defining illnesses. Miedema argued that this postulate could be fulfilled when AIDS was defined as a functional immunodeficiency but accepted that it could not with the clinical definition of AIDS. There is no convincing evidence that AIDS occurs in the absence of HIV, except in the case of Kaposi’s sarcoma, where there is the possibility that the tumour may be caused by a different faeces-derived agent. Coutinho presented the best data to support HIV as a cause of AIDS: the Amsterdam cohort studies have shown that within 90 months of follow-up no AID S-defming illness has occurred among 655 HIV seronegatives, 30 cases of AIDS defining illnesses have occurred among 110 seroconverters after virus transmission, and 97 cases of AIDS have occurred among 370 individuals HIV seropositive at entry to the study. But is an HIV infection sufficient to cause AIDS? This question concerns Koch’s third postulate, which has not been fulfilled by HIV but has for another primate lentivirus (SIV) that uses the same CD4 receptor as HIV. Montagnier, referred to the experiments of Desrosiers at the New England Primate Center that virus derived from a single molecule of the complete genome of SIV causes AIDS in rhesus macaques. Although AIDS has developed in man after a single inoculation with a minuscule amount of blood containing HIV, it has not done so in any of the laboratory workers accidentally infected with purified HIV. Duesberg’s final point was that AIDS was not caused by HIV but by recreational drugs used by a subset of homosexual men. However, Coutinho presented evidence that there were no significant differences in AIDS progression rates among HIV-infected individuals belonging to different AIDS risk groups (homosexual men, intravenous drug users and haemophiliacs) after correction for age. On the basis of careful analysis of risk factors for disease progression among HIV seroconverters and seropositives,6 CoutiÍlho concluded that HIV was necessary and sufficient to cause AIDS, but Montagnier did not exclude the possibility that other co-factors, such as not
1. Duesberg PH. Human immunodeficiency virus and acquired immunodeficiency syndrome: correlation but not causation. Proc Natl Acad Sci USA 1989; 86: 755-64. F, Tersmette M, Lier van L. AIDS pathogenesis: a dynamic interaction between HIV and the immune system. Immunol Today
2. Miedema
1990; 11,8: 293-97.
L, et al. Introduction of human T lymphotropic virus homosexual community in Amsterdam. Genitourin Med 1986; 62: 38-43. 4. Evans AS. Causation and disease: the Henk-Koch postulates revisited. 3. Coutinho RA,
Human Retrovirus Laboratory, University of Amsterdam
Jaap Goudsmit
Smit
Yale J Biol Med 1976; 49: 175-95.
constant
mycoplasma proteins might act as superantigens.
Krone WJA,
lymphadenopathy associated virus or (LAV/HTLV-III) into the male
5. Evans AS. Causation and disease: a chronical journey. Am J Epidemiol 1978; 108: 249-58. 6. Griensven van GJP, Vroome de EMM, Wolf de F, Goudsmit J, Roos M, Coutinho RA. Risk factors for progression of human immunodeficiency virus (HIV) infection among seroconverted
seropositive homosexual men. Am J Epidemiol 1990; 132,2: 203-10.
Noticeboard GMC remedy for poor performance The General Medical Council has approved a draft consultation on proposals for dealing with doctors whose professional performance is seriously deficient, a group against which they can at present take no action. The GMC has powers to deal with doctors whose fitness to practise is seriously impaired by ill-health, those convicted of a criminal offence, or those guilty of serious professional misconduct. The serious professional misconduct charge has to be specific and clearly defmed. The hearing has to be conducted very much in the way a case would be heard in a court of law. And a verdict cannot be interpreted to mean that the doctor is generally incompetent. The new proposals are intended to be remedial and to cover not only standards of professional knowledge and skill but also attitudes towards patients and colleagues. All four broad stages in the proposed performance procedures will include lay participation. At the first stage, the GMC preliminary screener will, with expert help if necessary, decide whether the case should proceed to the assessment of performance stage; a decision not to proceed would require the agreement of a lay screener. Assessment of performance-by review of records, third-party inquiries, and extended interview with the doctor-will be done by at least two medically qualified specialists and a lay person. The third stage will consist of counselling, retraining, and reassessment, to be followed by further counselling and retraining if required. A doctor who refuses to undergo assessment would be referred to an assessment referral panel, which could impose a condition on the doctor’s registration (ie, a requirement to undergo assessment within a set time) if they deemed the refusal unjustified. Doctors appearing before the panel would be entitled to legal representation. The fourth stage, referral to a GMC professional committee, may take place when a doctor refuses to accept or does not comply with the assessor’s recommendations, does not comply with the referral panel’s condition, or does not improve despite counselling and retraining. The proposal is that, to maintain the position of the medical profession as a self-regulated profession, the GMC should bear the costs of screening, assessment, and referral panel or performance committee hearings. At current prices the annual retention fee of 80 would have to increase by [,8to 10. The GMC is discussing with the departments of health the possibility of government funds for retraining and counselling for doctors in NHS practice. It is inviting comments on the suggestions that NHS doctors contribute to these costs and that doctors in the private sector bear the full costs of retraining. Parliamentary time for a change in the Medical Act will be sought probably in early 1993. According to the GMC implementation of the proposals would be the biggest change in the way that the medical profession is regulated since the inception of the Council in 1858. paper
spread of AIDS, mainly from Thailand. The threat is made all the more serious by the population’s almost complete lack of knowledge about the disease and by the fact that the sex industry, rather than intravenous drug use, has become the major medium for the spread of the disease. That Burma is a source of recruitment for Thai prostitution rings makes the country the weakest point in the anti-AIDS efforts throughout the region. Burma has what is believed to be the highest infection rate in the area. Of an estimated 160 000 drug addicts, at least half are said to be infected with HIV. Troubles in rural areas have created international difficulties. There, government troops, officially known as "Tatmadaw", arbitrarily seize and extrajudicially execute members of religious and ethnic minorities. The brutal persecution drove over 250 000 Rohingya Muslims into neighbouring countries, mainly Bangladesh, and strained relations not only with that country but also with Indonesia and Malaysia. Bangladesh can no longer cope with the influx. On April 28 the Governments of Bangladesh and Burma agreed on the repatriation of Burmese refugees. The plan was to repatriate 5000 people a day from May 15. The US Committee for Refugees (USCR) has, however, urged the international community not to support the repatriation if Burma does not allow international monitoring of the refugees’ safety once they return home. The USCR is also concerned that the words "safe and voluntary" have dropped out of the original wording of the agreement. There are indications that repatriation is not fully voluntary; the starting date of the exercise was postponed after the police opened fire on refugees protesting against repatriation, killing one and wounding six. Medical societies around the world should raise their voices against all abuses directed at the Burmese people. New York
Cesar A. Chelala
Germany: New health strategy in the making? Officially the main reasons for the health minister’s resignation were poor health and the disclosure that one of her most trusted advisers was a spy for the Polish security service. Gerda Hasselfeldt, a member of the Bavarian Christian Social Union with a shooting-star career in Bonn, held out for 16 months in one of the most difficult jobs the German Government has to offer. But nobody was taken by surprise when she announced her going at the end of last month-which many believe is because she had no prescription for countering the malaise of ever-increasing health-service costs (Lancet May 2, p 1104). By resigning she almost certainly forestalled dismissal in the next cabinet reshuffle, due at the end of the year. Her successor Horst Seehofer, also from Bavaria, is judged to be a highly competent politician and administrator. He has been a secretary of state in the Social Ministry and is said to be a fervent supporter of the recent health reform. One of his first suggestions, to increase taxation on tobacco, did not meet with much approval from the Chancellor. But Seehofer is determined to pursue a strategy of minimising health costs. Furthermore, he plans to introduce obligatory insurance for old-age care. This might be financed partly by relieving employers of having to pay wages for the first three days of illness. Whether he will stick to the old policies for the health reforms or come up with new ideas, possibly touching on hospital costs, is not yet clear. At the moment he has imposed a strict news blackout on policy statements about further health reforms until the end of May. In the meantime the Government is holding
secret meetings to discuss their new strategy. Health politicians did not turn up to make their customary speeches at the annual doctors’ meeting in Cologne last week.
Annette Tuffs
Conference Alternative view
on
AIDS
Journalists formed the bulk of the 100-150 people attending the International Symposium "AIDS, a different view", organised by the Foundation for Alternative AIDS Research and held on May 14-16 in Amsterdam. The topic that attracted the greatest interest was whether HIV is the cause of AIDS or, more accurately, whether HIV infection is both necessary and sufficient to cause AIDS. Peter Duesberg took the stand, as always, that HIV infection was neither necessary nor sufficient to cause AIDS. Luc Montagnier and the representatives of the Amsterdam Cohort Studies, Roel Coutinho and Frank Miedema, presented evidence for the opposite view. As the discussions revealed, not all Duesberg’s observations were controversial, though some of his interpretations were. There were fierce exchanges. Duesberg’s first thesis was that AIDS does not have the characteristics of an ordinary infectious disease. This view is incontrovertible. AIDS is caused by an extraordinary virus. The unprecedented affinity that its envelope has for the CD4 molecule enables it to enter CD4 cells and monocytes. Moreover, as Miedema and Montagnier pointed out, they and others have found that in HIV-infected individuals, but not in HIV-uninfected people, a large percentage of the uninfected CD4 cells are anergic or programmed for cell death by apoptosis. Montagnier suggested that the complexes formed between CD4 molecules and the HIV envelope or HIV-envelope antibodies may be the cause of this HIV-related apoptosis. This process indicates that HIV is able to have systemic effects on the immune system, which counters Duesberg’s point that in AIDS patients too few CD4 cells are infected by HIV for the virus to be the cause of AIDS. The only viruses known to use the CD4 molecule as a receptor are the primate lentiviruses, HIV and SIV. Duesberg’s point that there is no reason why a person with tuberculosis (TB) and HIV antibodies has AIDS, whereas a person with TB but without HIV antibodies has plain TB, had more to do with the clinical definition rather than the cause of AIDS. Miedema argued for that definition by describing how the progressive and irreversible functional immunodeficiency produced in the first six months of HIV infection results in opportunistic infections dependent on the ubiquity of a particular microbe.2 Duesberg’s third point, that HIV cannot be isolated from every HIV-antibody-positive individual and that disease progression is not always accompanied by active viral replication, probably held true in the days when it was difficult to isolate HIV from peripheral blood cells or plasma. But Miedema reported that there has now been 100% virus recovery rates and that virus isolates with enhanced replicative and cytopathic properties are associated with disease progression;2 others too have shown that virus replication speeds up during disease progression. Duesberg’s next thesis was that, if AIDS were an ordinary infectious disease (which it is not), it would spread randomly between the sexes, yet in Europe and the US AID S affects mainly men. A key question is the definition of randomness (or representativeness). A random (or
1290
representative) sample of the general population in Europe or the US will contain an equal number of males and females, but neither HIV infection nor AIDS is prevalent among the general population in the developed world. Like syphilis, gonorrhoea, and hepatitis B, HIV is prevalent among subsets of the population that happen to be made up mainly of men. A random sample of males would thus contain only males. Duesberg said that HIV infection does follow Farr’s law because the incidence of HIV is in the general population (Farr’s law predicts an increase in the epidemic curve followed by an even more rapid descent). However, AIDS does not seem to affect the general population in the developed world. Whether Farr’s law is applicable to chronic diseases such as TB or AIDS may be questioned. In any case, Coutinho presented convincing evidence that both AIDS and HIV have followed Farr’s law within the risk group (homosexual men).5 Duesberg’s last argument was that HIV did not fulfil Koch’s postulates. That HIV can be isolated in every AIDS case fulfils the first postulate. The second postulate requires that HIV is not isolated in any other disease and that, as Evans4added in 1973, virus-specific antibody appears after onset of illness. As Duesberg pointed out, many individuals positive for HIV and antibody to the virus have no clinical signs of immunodeficiency or AIDS-defining illnesses. Miedema argued that this postulate could be fulfilled when AIDS was defined as a functional immunodeficiency but accepted that it could not with the clinical definition of AIDS. There is no convincing evidence that AIDS occurs in the absence of HIV, except in the case of Kaposi’s sarcoma, where there is the possibility that the tumour may be caused by a different faeces-derived agent. Coutinho presented the best data to support HIV as a cause of AIDS: the Amsterdam cohort studies have shown that within 90 months of follow-up no AID S-defming illness has occurred among 655 HIV seronegatives, 30 cases of AIDS defining illnesses have occurred among 110 seroconverters after virus transmission, and 97 cases of AIDS have occurred among 370 individuals HIV seropositive at entry to the study. But is an HIV infection sufficient to cause AIDS? This question concerns Koch’s third postulate, which has not been fulfilled by HIV but has for another primate lentivirus (SIV) that uses the same CD4 receptor as HIV. Montagnier, referred to the experiments of Desrosiers at the New England Primate Center that virus derived from a single molecule of the complete genome of SIV causes AIDS in rhesus macaques. Although AIDS has developed in man after a single inoculation with a minuscule amount of blood containing HIV, it has not done so in any of the laboratory workers accidentally infected with purified HIV. Duesberg’s final point was that AIDS was not caused by HIV but by recreational drugs used by a subset of homosexual men. However, Coutinho presented evidence that there were no significant differences in AIDS progression rates among HIV-infected individuals belonging to different AIDS risk groups (homosexual men, intravenous drug users and haemophiliacs) after correction for age. On the basis of careful analysis of risk factors for disease progression among HIV seroconverters and seropositives,6 CoutiÍlho concluded that HIV was necessary and sufficient to cause AIDS, but Montagnier did not exclude the possibility that other co-factors, such as not
1. Duesberg PH. Human immunodeficiency virus and acquired immunodeficiency syndrome: correlation but not causation. Proc Natl Acad Sci USA 1989; 86: 755-64. F, Tersmette M, Lier van L. AIDS pathogenesis: a dynamic interaction between HIV and the immune system. Immunol Today
2. Miedema
1990; 11,8: 293-97.
L, et al. Introduction of human T lymphotropic virus homosexual community in Amsterdam. Genitourin Med 1986; 62: 38-43. 4. Evans AS. Causation and disease: the Henk-Koch postulates revisited. 3. Coutinho RA,
Human Retrovirus Laboratory, University of Amsterdam
Jaap Goudsmit
Smit
Yale J Biol Med 1976; 49: 175-95.
constant
mycoplasma proteins might act as superantigens.
Krone WJA,
lymphadenopathy associated virus or (LAV/HTLV-III) into the male
5. Evans AS. Causation and disease: a chronical journey. Am J Epidemiol 1978; 108: 249-58. 6. Griensven van GJP, Vroome de EMM, Wolf de F, Goudsmit J, Roos M, Coutinho RA. Risk factors for progression of human immunodeficiency virus (HIV) infection among seroconverted
seropositive homosexual men. Am J Epidemiol 1990; 132,2: 203-10.
Noticeboard GMC remedy for poor performance The General Medical Council has approved a draft consultation on proposals for dealing with doctors whose professional performance is seriously deficient, a group against which they can at present take no action. The GMC has powers to deal with doctors whose fitness to practise is seriously impaired by ill-health, those convicted of a criminal offence, or those guilty of serious professional misconduct. The serious professional misconduct charge has to be specific and clearly defmed. The hearing has to be conducted very much in the way a case would be heard in a court of law. And a verdict cannot be interpreted to mean that the doctor is generally incompetent. The new proposals are intended to be remedial and to cover not only standards of professional knowledge and skill but also attitudes towards patients and colleagues. All four broad stages in the proposed performance procedures will include lay participation. At the first stage, the GMC preliminary screener will, with expert help if necessary, decide whether the case should proceed to the assessment of performance stage; a decision not to proceed would require the agreement of a lay screener. Assessment of performance-by review of records, third-party inquiries, and extended interview with the doctor-will be done by at least two medically qualified specialists and a lay person. The third stage will consist of counselling, retraining, and reassessment, to be followed by further counselling and retraining if required. A doctor who refuses to undergo assessment would be referred to an assessment referral panel, which could impose a condition on the doctor’s registration (ie, a requirement to undergo assessment within a set time) if they deemed the refusal unjustified. Doctors appearing before the panel would be entitled to legal representation. The fourth stage, referral to a GMC professional committee, may take place when a doctor refuses to accept or does not comply with the assessor’s recommendations, does not comply with the referral panel’s condition, or does not improve despite counselling and retraining. The proposal is that, to maintain the position of the medical profession as a self-regulated profession, the GMC should bear the costs of screening, assessment, and referral panel or performance committee hearings. At current prices the annual retention fee of 80 would have to increase by [,8to 10. The GMC is discussing with the departments of health the possibility of government funds for retraining and counselling for doctors in NHS practice. It is inviting comments on the suggestions that NHS doctors contribute to these costs and that doctors in the private sector bear the full costs of retraining. Parliamentary time for a change in the Medical Act will be sought probably in early 1993. According to the GMC implementation of the proposals would be the biggest change in the way that the medical profession is regulated since the inception of the Council in 1858. paper
