1533
of those who are not sympathetic to the fundamentalist cause are nevertheless concerned both about interference with the association, and about the increasingly harsh treatment of Islamic groups throughout the country. The EMA has described the treatment of these groups by the security forces as harsh and bitter, and accused the Government of abuses of human rights and personal liberty. Even so, aggressive anti-fundamentalist activity continues. Armed raids on poor districts in many parts of the country are common, and on Dec 8 an estimated 15 000 armed troops were used to raid the district of Imbaba, north of Cairo. Concern is growing about the treatment of detainees and the use of the death penalty. Days after the Imbaba raid, President Hosni Mubarek confirmed the death sentence on eight men arrested during another raid, for alleged terrorist activities. As the country’s internal politics increase in violence, the country’s doctors, through the EMA, look set to become inextricably involved.
amicably. Many
Peter Kandelal
London
France: Nosocomial For
multidrug-resistant TB
years now, doctors in infectious diseases have been expecting nosocomial outbreaks of departments tuberculosis among AIDS patients. Yet much anxiety has been provoked by news of the first-known case of a health-care worker to have acquired multidrug-resistant TB (MDR-TB) from a patient. The doctor had been exposed to the infection during the last quarter of 1989, while looking after AIDS patients at the Claude Bernard Hospital. She was diagnosed as having TB a year ago, and is still fighting the disease after two courses of 4 antibiotics and lung some
surgery.
The US Centers for Disease Control and Prevention
(CDC) has reported twelve nosocomial outbreaks of severe MDR-TB over the past year, with many strains resisting 9-11 antituberculosis drugs and with up to 200 patients and 40 health-care personnel being infected. Only one such outbreak has been reported in France. In November 1991, Dr Elisabeth Bouvet, Bichat Hospital, Paris, described in Bulletin Epidemiologique Hebdomadaire (BEH) a nosocomial outbreak of Mycobacterium bovis infection among 6 AIDS patients in one ward at the Claude Bernard Hospital between 1989 and 1991. The index patient had been diagnosed as having TB in August, 1989, on his return from 4 months in Brazil but, despite the presence of many acid-fast bacilli in the sputum, it took 3 months for the strain be identified and 5 months to obtain a profile of drug sensitivity. By this time the patient, who had been treated to
with isoniazid, rifampicin, ethambutol, and pyrazinamide, had died. No isolation measures had been taken. According to the report in BEH, investigations had not revealed secondary cases among health-care members. However, since then there has been a seventh case, the doctor, whose case will be reported in Revue de /’f6M6 (published by the Assistance Publique de Paris for its
employees). None of the 35 000 wards of the hospitals of APP has a negative-pressure ventilation system, which is specifically recommended in CDC guidelines. It would cost almost $450 000 to build one such room. With money short, and nurses overworked, Prof Gilles Brucker, director of the APP hygiene department, hopes that this case will encourage the administration to build more isolation cubicles in infectious
diseases
departments and that hospital staff will take precautions to prevent cross-infection when looking after AIDS-TB patients. But at the Direction Generale de la Sante there is fear that other imported MDR-TB cases may cause further outbreaks. Dr Lee Reichman, president of the American Lung Association, said recently that with "the next outbreak, it will be impossible to find doctors or nurses who will accept work in those AIDS wards". Although France has paid much attention to TB control, public health specialists here may soon have to address this difficulty. Jean-Michel Bader
India: Disquiet about AIDS control The Ministry of Health and Family Welfare has allocated Rs2800 million (approximately US$100 million) for the National AIDS Control project in the Eighth Five-Year (1992-97) plan for health. The sum constitutes more than 15% of the country’s health budget, placing AIDS second only to malaria, for which a little more than 19% has been ear-marked. Leprosy and tuberculosis get about half and less than a third, respectively, of the AIDS budget. The bulk (US$84-5 million) of the sum for AIDS control is a loan from the World Bank. WHO is providing US$1.5 million by way of technical expertise. The World Bank loan was sought at a time when India’s foreign exchange crisis was at its worst, so there is concern about the strain that it is putting on the economy. There are also questions about how the money is being spent. According to Dr 1. S. Gilada, founder and secretary of the Indian Health Organisation, "... 40% of the budget from a bilateral donor agency goes to an intermediary agency and 19% of the funds are reserved for spending on foreign consultants. The monthly costs of two such consultants is equivalent to the cost of condom purchase for 100% coverage of Bombay’s entire red light district per month". The current disquiet is not confined to economic concerns. The National AIDS Control Organisation, formed in August to implement the control programme, favours unlinked anonymous testing over mandatory testing (as does WHO), but the medical community, fearful of nosocomial spread of infection, is divided on this issue. A recent television programme suggests that three-quarters of health professionals favour mandatory testing of patients. The question of blood safety has yet to be resolved fully. Efforts to prevent contamination of blood have been made since 1989, when antibodies to HIV were discovered in some indigenously produced blood products (see Lancet 1989; 338: 151). Yet, when presented at a meeting convened by India’s Prime Minister P. V. Narasimha Rao earlier this year to review the AIDS control programmes, the plans contained no mention of the safety of blood and blood products. The plans were sent back for review. NACO has now allocated US$30 million for blood safety. With the cost of testing by ELISA being a little less than US$1 per sample, the sum should be sufficient to screen all the 2 million units collected each year, but NACO says that it cannot be responsible for the practice in commercial blood banks, which supply 29% of the blood collected in the country. Last month’s news that 16 renal failure patients in Madras had acquired HIV infection probably from contaminated dialysis machines has increased public pressure for more attention to be paid to health-care settings and health-care products. According to Dr Michael Merson, director of the WHO
1534
AIDS programme, the prevalence of HIV infection in India could reach that in Africa if spread of the infection is not limited within the next three years. The theme for World AIDS Day here this year (Dec 1) was Community Commitment. Sudha Tewari, managing director of Parivar Seva Sanstha, a non-governmental organisation, believes that, unless there is a change in strategies for extending channels of communication, it will be eight years before the message on how to prevent the spread of HIV infection will reach the grassroots community. Many people think that better use can be made of existing systems of promoting health messages, instead of duplicating efforts by developing a separate system for AIDS control. If the opportunity to control the spread of AIDS is lost, it will not be the first time that this has happened. Much time and effort were wasted in the past few years, when AIDS was perceived to be a foreign problem. This perception led to the introduction in Aug, 1989, of a bill that sought to legislate the disease out of the country. The controversial bill-to legalise prostitution, to test all people practising high-risk behaviour, and to rehabilitate HIV/AIDS patients-was eventually withdrawn.
Bhupesh Mangla
Germany: Bleak mid-winter for students? Doctors, dentists, and the pharmaceutical industry all claim that they will be the main victims of the new health-structure law that aims to reduce costs by DM 11 billion. (The law was swiftly passed by parliament in early December.) But the true victims may be the medical students, since their prospects are decidedly bleak. The law states that from February, 1993, no practices may be set up in areas where there are already enough doctors to provide health care. Since many areas are now crowded with doctors, a sharp rise in unemployment among newly qualified doctors is forecast. In the past, medicine meant a secure job and a good income. Only in the past 5 years have an increasing number of doctors been struggling to find jobs or earn a living. Many people are 30 years old or more when they qualify and still have a few years of hospital training ahead before they can set up their own practice. In the future, a considerable proportion of today’s 105 000 medical students will be unable to do this. Of the total of 202 000 doctors, about 75 000 have their own practices. Each year only about 2000 retire and are replaced by 4300 newcomers. The new law says that from Feb 1,1993, the number of doctors in an area agreed by doctors and health insurers must not be exceeded by more than 10%. In many areas this limit has been surpassed. Tenured jobs in hospitals are available for only a minority of consultants and senior registrars. Specialist trainees are expected to set up their practices after a few years. The predicted unemployment rate might fall slightly when doctors have to retire by the age of 68 after 1999. Only in the past few weeks have medical students realised the potential impact of the law and started to protest. They cannot expect support from their future colleagues who are now established, since the latter are afraid for their own jobs. One hope for the students remains: the constitutional court in Karlsruhe will have to decide whether it is legal to hinder qualified doctors from working in their intended profession. Annette Tuffs
Medicine and the Law Persistent vegetative state On Dec 9, 1992, the Court of Appeal held unanimously that the withdrawal or withholding of medical treatment of any kind from a patient in a persistent vegetative state (PVS) was not unlawful even though the patient would then die. So far, all the judges have required, "for the time being at least" and "to allay public concern", that the court be invited to sanction every PVS case where treatment is to be discontinued. Public concern might be better directed at the length of time that was allowed to elapse in the so-called "Hillsborough case" before steps were taken to withdraw medical treatment that was clearly not in the patient’s best interests. Given that doctors daily must make life-and-death decisions on when to discontinue or withhold treatment from the dying, the imposition of an artificial constraint on PVS patients looks unjustified. The Court of Appeal’s judgments are welcome and wise but do not yet bring the matter to an end because the Official Solicitor has appealed to the House of Lords, continuing to argue, formally, that withdrawal of treatment would be tantamount to murder. That hearing began on Dec 14, and one of the five law lords has said (Independent, Dec 15) that the court now "has to redefine murder in the light of new technology". Another (Times, Dec 16) stated, not wholly reassuringly: "what is being said in this case is that [the patient] should be starved to death based on an assessment of his quality of life". We may have to wait until mid-January for the House of Lords’ decision. Anthony Bland was trapped in the Hillsborough (Sheffield) football stadium disaster on April 15, 1989, and by the time he was resuscitated he had suffered devastating brain damage. He now lies in a hospital bed with his eyes open, breathing unaided, but without any cognitive function (he cannot see, hear, think, or feel pain). He is fed liquid food by a pump via a nasogastric tube; his bladder is emptied via a catheter, and his bowels by enema. His limbs are stiff and contracted. Reflex movements in his throat cause him to vomit and dribble. The parts of his brain that provided him with consciousness have turned to liquid but the "advances of modern medicine permit him to be kept in this state for years, even perhaps for decades". He has had many infections, which have been treated with antibiotics; drugs have been administered to reduce salivation and encourage gastric emptying, for example; and urogenital problems have required surgical intervention. Before the accident he had never expressed a view on whether or not he would wish to be maintained long term in PVS; it is not a topic that 17-year-olds usually address. He could not be deemed to have consented to or refused treatment and all treatments have had to be provided on the basis that his doctors considered them to be in his best interests, taking into account the family’s views and other factors. On that basis he should have been allowed to die quietly long ago. As Lord Justice Butler-Sloss said, a patient has "a right to avoid unnecesary humiliation and degrading invasion of his body for no good purpose". She was dismayed by the Official Solicitor’s contention that if the patient had a cardiac arrest or renal failure it would be the duty of doctors to perform a coronary heart bypass or a kidney transplant. Why, then, has treatment been continued for 31 years against the interests of the patient? The answer seems to be the doctors’ not unreasonable fear of criminal prosecution were they to cease active treatment to keep him
of those who are not sympathetic to the fundamentalist cause are nevertheless concerned both about interference with the association, and about the increasingly harsh treatment of Islamic groups throughout the country. The EMA has described the treatment of these groups by the security forces as harsh and bitter, and accused the Government of abuses of human rights and personal liberty. Even so, aggressive anti-fundamentalist activity continues. Armed raids on poor districts in many parts of the country are common, and on Dec 8 an estimated 15 000 armed troops were used to raid the district of Imbaba, north of Cairo. Concern is growing about the treatment of detainees and the use of the death penalty. Days after the Imbaba raid, President Hosni Mubarek confirmed the death sentence on eight men arrested during another raid, for alleged terrorist activities. As the country’s internal politics increase in violence, the country’s doctors, through the EMA, look set to become inextricably involved.
amicably. Many
Peter Kandelal
London
France: Nosocomial For
multidrug-resistant TB
years now, doctors in infectious diseases have been expecting nosocomial outbreaks of departments tuberculosis among AIDS patients. Yet much anxiety has been provoked by news of the first-known case of a health-care worker to have acquired multidrug-resistant TB (MDR-TB) from a patient. The doctor had been exposed to the infection during the last quarter of 1989, while looking after AIDS patients at the Claude Bernard Hospital. She was diagnosed as having TB a year ago, and is still fighting the disease after two courses of 4 antibiotics and lung some
surgery.
The US Centers for Disease Control and Prevention
(CDC) has reported twelve nosocomial outbreaks of severe MDR-TB over the past year, with many strains resisting 9-11 antituberculosis drugs and with up to 200 patients and 40 health-care personnel being infected. Only one such outbreak has been reported in France. In November 1991, Dr Elisabeth Bouvet, Bichat Hospital, Paris, described in Bulletin Epidemiologique Hebdomadaire (BEH) a nosocomial outbreak of Mycobacterium bovis infection among 6 AIDS patients in one ward at the Claude Bernard Hospital between 1989 and 1991. The index patient had been diagnosed as having TB in August, 1989, on his return from 4 months in Brazil but, despite the presence of many acid-fast bacilli in the sputum, it took 3 months for the strain be identified and 5 months to obtain a profile of drug sensitivity. By this time the patient, who had been treated to
with isoniazid, rifampicin, ethambutol, and pyrazinamide, had died. No isolation measures had been taken. According to the report in BEH, investigations had not revealed secondary cases among health-care members. However, since then there has been a seventh case, the doctor, whose case will be reported in Revue de /’f6M6 (published by the Assistance Publique de Paris for its
employees). None of the 35 000 wards of the hospitals of APP has a negative-pressure ventilation system, which is specifically recommended in CDC guidelines. It would cost almost $450 000 to build one such room. With money short, and nurses overworked, Prof Gilles Brucker, director of the APP hygiene department, hopes that this case will encourage the administration to build more isolation cubicles in infectious
diseases
departments and that hospital staff will take precautions to prevent cross-infection when looking after AIDS-TB patients. But at the Direction Generale de la Sante there is fear that other imported MDR-TB cases may cause further outbreaks. Dr Lee Reichman, president of the American Lung Association, said recently that with "the next outbreak, it will be impossible to find doctors or nurses who will accept work in those AIDS wards". Although France has paid much attention to TB control, public health specialists here may soon have to address this difficulty. Jean-Michel Bader
India: Disquiet about AIDS control The Ministry of Health and Family Welfare has allocated Rs2800 million (approximately US$100 million) for the National AIDS Control project in the Eighth Five-Year (1992-97) plan for health. The sum constitutes more than 15% of the country’s health budget, placing AIDS second only to malaria, for which a little more than 19% has been ear-marked. Leprosy and tuberculosis get about half and less than a third, respectively, of the AIDS budget. The bulk (US$84-5 million) of the sum for AIDS control is a loan from the World Bank. WHO is providing US$1.5 million by way of technical expertise. The World Bank loan was sought at a time when India’s foreign exchange crisis was at its worst, so there is concern about the strain that it is putting on the economy. There are also questions about how the money is being spent. According to Dr 1. S. Gilada, founder and secretary of the Indian Health Organisation, "... 40% of the budget from a bilateral donor agency goes to an intermediary agency and 19% of the funds are reserved for spending on foreign consultants. The monthly costs of two such consultants is equivalent to the cost of condom purchase for 100% coverage of Bombay’s entire red light district per month". The current disquiet is not confined to economic concerns. The National AIDS Control Organisation, formed in August to implement the control programme, favours unlinked anonymous testing over mandatory testing (as does WHO), but the medical community, fearful of nosocomial spread of infection, is divided on this issue. A recent television programme suggests that three-quarters of health professionals favour mandatory testing of patients. The question of blood safety has yet to be resolved fully. Efforts to prevent contamination of blood have been made since 1989, when antibodies to HIV were discovered in some indigenously produced blood products (see Lancet 1989; 338: 151). Yet, when presented at a meeting convened by India’s Prime Minister P. V. Narasimha Rao earlier this year to review the AIDS control programmes, the plans contained no mention of the safety of blood and blood products. The plans were sent back for review. NACO has now allocated US$30 million for blood safety. With the cost of testing by ELISA being a little less than US$1 per sample, the sum should be sufficient to screen all the 2 million units collected each year, but NACO says that it cannot be responsible for the practice in commercial blood banks, which supply 29% of the blood collected in the country. Last month’s news that 16 renal failure patients in Madras had acquired HIV infection probably from contaminated dialysis machines has increased public pressure for more attention to be paid to health-care settings and health-care products. According to Dr Michael Merson, director of the WHO
1534
AIDS programme, the prevalence of HIV infection in India could reach that in Africa if spread of the infection is not limited within the next three years. The theme for World AIDS Day here this year (Dec 1) was Community Commitment. Sudha Tewari, managing director of Parivar Seva Sanstha, a non-governmental organisation, believes that, unless there is a change in strategies for extending channels of communication, it will be eight years before the message on how to prevent the spread of HIV infection will reach the grassroots community. Many people think that better use can be made of existing systems of promoting health messages, instead of duplicating efforts by developing a separate system for AIDS control. If the opportunity to control the spread of AIDS is lost, it will not be the first time that this has happened. Much time and effort were wasted in the past few years, when AIDS was perceived to be a foreign problem. This perception led to the introduction in Aug, 1989, of a bill that sought to legislate the disease out of the country. The controversial bill-to legalise prostitution, to test all people practising high-risk behaviour, and to rehabilitate HIV/AIDS patients-was eventually withdrawn.
Bhupesh Mangla
Germany: Bleak mid-winter for students? Doctors, dentists, and the pharmaceutical industry all claim that they will be the main victims of the new health-structure law that aims to reduce costs by DM 11 billion. (The law was swiftly passed by parliament in early December.) But the true victims may be the medical students, since their prospects are decidedly bleak. The law states that from February, 1993, no practices may be set up in areas where there are already enough doctors to provide health care. Since many areas are now crowded with doctors, a sharp rise in unemployment among newly qualified doctors is forecast. In the past, medicine meant a secure job and a good income. Only in the past 5 years have an increasing number of doctors been struggling to find jobs or earn a living. Many people are 30 years old or more when they qualify and still have a few years of hospital training ahead before they can set up their own practice. In the future, a considerable proportion of today’s 105 000 medical students will be unable to do this. Of the total of 202 000 doctors, about 75 000 have their own practices. Each year only about 2000 retire and are replaced by 4300 newcomers. The new law says that from Feb 1,1993, the number of doctors in an area agreed by doctors and health insurers must not be exceeded by more than 10%. In many areas this limit has been surpassed. Tenured jobs in hospitals are available for only a minority of consultants and senior registrars. Specialist trainees are expected to set up their practices after a few years. The predicted unemployment rate might fall slightly when doctors have to retire by the age of 68 after 1999. Only in the past few weeks have medical students realised the potential impact of the law and started to protest. They cannot expect support from their future colleagues who are now established, since the latter are afraid for their own jobs. One hope for the students remains: the constitutional court in Karlsruhe will have to decide whether it is legal to hinder qualified doctors from working in their intended profession. Annette Tuffs
Medicine and the Law Persistent vegetative state On Dec 9, 1992, the Court of Appeal held unanimously that the withdrawal or withholding of medical treatment of any kind from a patient in a persistent vegetative state (PVS) was not unlawful even though the patient would then die. So far, all the judges have required, "for the time being at least" and "to allay public concern", that the court be invited to sanction every PVS case where treatment is to be discontinued. Public concern might be better directed at the length of time that was allowed to elapse in the so-called "Hillsborough case" before steps were taken to withdraw medical treatment that was clearly not in the patient’s best interests. Given that doctors daily must make life-and-death decisions on when to discontinue or withhold treatment from the dying, the imposition of an artificial constraint on PVS patients looks unjustified. The Court of Appeal’s judgments are welcome and wise but do not yet bring the matter to an end because the Official Solicitor has appealed to the House of Lords, continuing to argue, formally, that withdrawal of treatment would be tantamount to murder. That hearing began on Dec 14, and one of the five law lords has said (Independent, Dec 15) that the court now "has to redefine murder in the light of new technology". Another (Times, Dec 16) stated, not wholly reassuringly: "what is being said in this case is that [the patient] should be starved to death based on an assessment of his quality of life". We may have to wait until mid-January for the House of Lords’ decision. Anthony Bland was trapped in the Hillsborough (Sheffield) football stadium disaster on April 15, 1989, and by the time he was resuscitated he had suffered devastating brain damage. He now lies in a hospital bed with his eyes open, breathing unaided, but without any cognitive function (he cannot see, hear, think, or feel pain). He is fed liquid food by a pump via a nasogastric tube; his bladder is emptied via a catheter, and his bowels by enema. His limbs are stiff and contracted. Reflex movements in his throat cause him to vomit and dribble. The parts of his brain that provided him with consciousness have turned to liquid but the "advances of modern medicine permit him to be kept in this state for years, even perhaps for decades". He has had many infections, which have been treated with antibiotics; drugs have been administered to reduce salivation and encourage gastric emptying, for example; and urogenital problems have required surgical intervention. Before the accident he had never expressed a view on whether or not he would wish to be maintained long term in PVS; it is not a topic that 17-year-olds usually address. He could not be deemed to have consented to or refused treatment and all treatments have had to be provided on the basis that his doctors considered them to be in his best interests, taking into account the family’s views and other factors. On that basis he should have been allowed to die quietly long ago. As Lord Justice Butler-Sloss said, a patient has "a right to avoid unnecesary humiliation and degrading invasion of his body for no good purpose". She was dismayed by the Official Solicitor’s contention that if the patient had a cardiac arrest or renal failure it would be the duty of doctors to perform a coronary heart bypass or a kidney transplant. Why, then, has treatment been continued for 31 years against the interests of the patient? The answer seems to be the doctors’ not unreasonable fear of criminal prosecution were they to cease active treatment to keep him
