19

in the

proportion of papers from France and West Germany. Although both sets of researchers draw firm conclusions from their analyses, it has to be borne in mind that the baseline proportion of Japanese papers was low (5-4% compared with 9-5% of papers originating from the UK and 37-3% from the USA in 1975). In isolation, therefore, these figures could be regarded as a result of a "catching up" exercise. Such a view is simplistic. For one thing, as the AHA Task Force point out, publications are closely correlated with government funding.5 They serve as an indication of the priority and value placed by governments on research. International comparison suggests a much greater Japanese investment in research and development.More sinister, perhaps, is the correlation noted by the AHA between publications in the biomedical field and patent awards. Thus, there has been a decline in the US share of patents registered compared with a major rise in the Japanese share and a lesser rise in patent awards from Western Europe, the British showing a slight decline. The overall picture is uncomfortably consistent. It

EDITORIALS

Clinical research: disturbing present, uncertain future If the New Year brings little comfort for medical researchers on either side of the Atlantic, they can at least argue that their misery is shared. In the UK, the hand-wringing was led by Dr Dai Rees, Secretary of the Medical Research Council, who announced a projected deficit of £ 35 million and consequential threats to "extremely promising" research into Alzheimer’s disease, diabetes, and bovine spongiform encephalopathy.! The increase in Government funding had failed to keep pace with salary increases and inflation of research costs. In the USA, the American Heart Association stated its fears of an accelerating decline in research and development in cardiovascular disease2 resulting from the failure of Federal funding of research to keep pace with inflation. There are strong reasons for unease in both countries. Thus, the proportion of papers from the USA published in four leading clinical research journals has declined over recent - years-a phenomenon that Stossel and Stossel in Boston attribute to decreased government funding of clinical research.3 A more extensive British-based analysis of the Science Citation Index from 1976 to 1984 showed a relative decline in the proportion of papers from the UK published and cited in the areas of biomedical and clinical research.4The only consolation in this analysis was that medical research seemed to fare less badly than engineering and earth sciences. However, the contribution of case-reports rather than substantive research emanating from the UK may have helped considerably to put clinical productivity in a favourable light. The reports are at one in indicating strong progressive growth in Japanese productivity and

a

lesser,

but

still

impressive,

growth

is not necessary to look far to find the common cause of these troubles. Reaganomics in the USA and Thatcherism in the UK have essentially pruned public expenditure in favour of a reduction in direct taxation-the reasoning being that increased personal incentives will ultimately lead to economic success and growth of private investment. So far this has not happened. The UK has an unenviably low proportion of its gross domestic product invested in non-military research and development compared with other technically advanced European countries.6°’ The result for the UK is a declining international position imperilled by recurrent crises in government-funded research. The analogy with funding of the National Health Service (also deficient by international standards) will not have escaped clinical scientists. Clinical research has an additional problem-that of recruitment. In the face of so much uncertainty, medically qualified staff are opting for a more secure clinical career and, in some cases, the increasingly rich pickings from private practice in the UK (another predictable byproduct of Thatcherism).8 Lobbying for clinical research has not begun to challenge that for basic science,although diseases that figure large in the public eye are understandably emphasised. Even the AHA finds it necessary to emphasise the benefits of basic scientific discoveries.z2 In the UK, Dr Rees is genuinely aware of the problems faced by clinical researchers, but has at times proved accident prone in the face of growing difficulties with his political paymasters. The first widely publicised triumph-the new National Centre for Clinical Research--did not survive into the planning stage and Dr Rees was left not so much waving as drowning.9 Later, when it became necessary to close rather than open units, clinical scientists were reprimanded for expressing their views

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in public. to Directors read of the closure of their units in the weekend press, and one was even invited to discipline his wife, who worked in the same unit, for a letter of protest in NatureY Is there naught to comfort the clinical research community in the 1990s? At first sight alternative sources of help would seem unpromising. In Britain the NHS, a near monopoly supplier of facilities for such research, has had a baneful influence because services to patients and the career structures of doctors have taken priority. This is especially unfortunate because the service has much to gain from research on questions involving large numbers of individuals. The abysmal record of the UK in clinical research was castigated by a House of Lords Select Committee,12 and last year saw the appointment of Prof Michael Peckham as Director of Research and Development. Although this creation may bring a wry smile to those who remember the former post of Chief Scientist, it raises the hope that clinical research will be viewed more favourably in the future. Theoretically, the NHS still provides an excellent environment for such research; and there are many questions requiring answers. The Director might do well to settle for half a dozen subjects and lead from the front rather than to encourage a flood of projects. In the USA, as in the UK, there is a widespread feeling that clinical issues are being neglected. Some zealots have suggested that the National Institutes of Health should concentrate on basic research and leave clinical studies to charities and the pharmaceutical industry. The downside of commercial support for such research is that it may hazard academic independence and hamper communication between researchers. Special anxieties arise when clinicians depend for their academic survival on the goodwill of the pharmaceutical industry. On both sides of the Atlantic, medical charities are the main hope for clinical research. In the UK, funding from charities by far exceeds that from the MRC, and there is a tendency for such money to be spent on clinical rather than basic investigations. Charities are not subject to political whim and so far have had no publicised wrangles about academic freedom. They may suffer the disadvantage of all funding bodies that are dependent on peer reviewtheir activities tend to reflect prevailing scientific fashion-but at least there are many charities and first-class investigative work has a good chance of being funded. Moreover, they often receive enthusiastic public support. According to the latest MRC newsletter, 13 the Council is progressively handing over financial responsibility to charities. Yet, elsewhere in the newsletter the MRC seems reluctant to give much credit to charitable support of medical research. The presence of charities as a major source of funds for medical (and especially clinical) research will grow as the difficulties of state-funded research proliferate.

It is equally likely (and justifiable to many) that the charities will demand a greater say in presenting medical research interests both nationally and to governments. In the light of experience over the past few years this may prove no bad outcome for the clinical researchers-if the Department of Health does not stifle them completely. 1. Hunt L. Cash crisis forces MRC to cut back research work. Independent, Dec 13 1990: 2. 2. Rosen R, Strauss HC, Atkinson HG, et al. The report of the Amencan Heart Association Task Force on Strategies to Increase Federal Research Funding. Circulation 1990; 82: 1549-59. 3. Stossel TP, Stossel SC. Declining American representation in leading clinical research journals. N Engl J Med 1990; 322: 739-42. 4. Martin BR, Irvine J, Narin F, Sterritt C. The continuing decline of British science. Nature 1987; 330: 123-26. 5. McAllister PR, Narin F. Characterisation of the research papers of US medical schools. J Am Soc Inform Sci 1983; 34: 123-31. 6. Save British Science Society. British science: benchmarks for the year 2000. Save British Science Society, Box 241, Oxford OX1 3QQ. 7. House of Lords Select Committee on Science and Technology. Civil Research and Development. London, HM Stationery Office 1986. 8. The Academic Medicine Group. Academic medicine: problems and solutions. Br Med J 1989; 289: 573-79. 9. Editorial. What price MRC initiatives now? Lancet 1989; ii: 900. 10. Editorial. The MRC’s muffler. Lancet 1988; ii: 200. 11. Concor D, Aldhous P. Storm over funding policy. Nature 1990; 348: 6. 12. Editorial. Medical research in the UK: their Lordship’s view. Lancet 1988; i: 862-63. 13. Medical Research Council. MRC News. December 1990, no 49.

Mycoplasma and AIDS—what connection? AIDS can take 2-20 years to develop after onset of human immunodeficiency virus (HIV) infection. Is mycoplasma infection a factor that hastens development of the syndrome? This question has lately aroused much interest and was the main topic of discussion at a meeting on infectious co-factors in HIV infection held by the Medical Research Council AIDS Secretariat in London on December 11. The story of a possible link between mycoplasma infection and AIDS stems from claims by Lo and colleagues of the isolation of a novel virus from Kaposi sarcoma cells’ and other tissues2 from AIDS patients. The discovery that the organism contained ribosomal genes led to the appellation "virus-like infectious agent".3.4 When culture was achieved in cell-free medium, the organism was identified as a species of mycoplasma and termed Mycoplasma incognitus.S,6 However, this term is invalid because the agent has now been identified as a strain of M fermentans,7 a mycoplasma hitherto isolated rather infrequently from the human urogenital tract. Lo’s team have reported that inoculation of their isolate produced fatal infection in laboratory monkeys;3 and that it has been detected in 6 previously healthy HIV-negative patients from geographically distinct areas who died a few weeks after an acute fulminant illness and who showed no evidence of infection by other infectious

agents.4 The scientific community initially dismissed Lo’s work, but subsequently took a certain sceptical

Clinical research: disturbing present, uncertain future.

19 in the proportion of papers from France and West Germany. Although both sets of researchers draw firm conclusions from their analyses, it has to...
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