NEWS AIDS epidemic grows but response slows AIDS is now a true pandemic and the worst is according to Dr Michael H Merson, the director of the World Health Organisation's global programme on AIDS, at the eighth international conference on AIDS in Amsterdam. "Geographically, AIDS is everywhere now," he said. "Women are infected as much as men. It is spreading from the high risk groups to the general population worldwide. From two million cases now the epidemic will grow to at least 12 million-maybe 15 or 18 million cases-by the year 2000. We will see an enormous increase in the numbers of people who are sick." One million people are estimated to have been infected with HIV in the first six months of this year; nearly half of these infections were in women. A new case of HIV infection occurs every 15 to 20 seconds. An expert on sexually transmitted disease, Dr Yamil Kouri of Harvard University, predicted that by the year 2000, 90% of HIV infections would be acquired through heterosexual sex. Said Dr Merson, "By the year 2000, 90% of the infections will be in the developing world. Africa didn't have a chance [because the virus was still unknown], but Asia, South America, and the Middle East don't have an excuse for not preventing the spread.... It's better to spend hundreds now on prevention than millions, billions, or trillions later on." Unless South East Asia takes preventive action now, in 10 years it will be in the same situation as Africa is today. Furthermore, the AIDS epidemic may be followed by another epidemic: of tuberculosis. "Thirty to 50% of people who have AIDS in the developing world also have tuberculosis," Dr Merson said. In Africa HIV infection is widespread. "What does high risk behaviour mean in a city where over a third of adults are infected? At an antenatal clinic in Kigali, Rwanda, no less than a quarter of women with only one lifetime partner had been infected with HIV, presumably by their steady partner. And the younger the age group the higher the prevalence of infection. It was 38% in the 19-23 year olds," said Dr Merson. Although the curve of the epidemic continues upward, "the curve of response has reached a plateau. The course of the epidemic is- not being influenced in any substantial way by current efforts. Existing approaches will not be sufficient to stem the pandemic," warned Dr Jonathan Mann of Harvard University, chairman of the conference. "AIDS exploits societal weaknesses. It proceeds along the major fault lines of

yet to come,

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society: inequity and discrimination. Belong-

Medical Association has emphasised doctors'

care and support."

surgeon had refused care to at least one of their patients infected with HIV. Yet most American adults believe that the risk of AIDS is irrelevant since they are currently monogamous or celibate, said Dr Curran: "They don't look at their lifetime risk." -JANICE HOPKINS TANNE, contributing editor, New York

ing to a marginalised or stigmatised group ethical obligations, 23% of residents said that creates an increased risk of HIV infection and they would not care for patients with AIDS increases the risk of receiving inadequate if they had a choice. And 39% said that a

The low social, political, and economic status of women often makes it impossible for them to negotiate use of a condom. To be effective against AIDS society must attack discrimination, stigmatisation of people with AIDS, the low status of women, and unequal access to care. In the United States there are at least enough new infections each year to keep the epidemic going at the present rate: 47 500 new cases were reported in the first six months of this year. AIDS is growing fastest in the south and among black and hispanic people and women, according to Dr James W Curran, acting deputy director for HIV at the Centers for Disease Control in Atlanta. Among homeless young people rates of HIV infection range up to 23%. "If Amsterdam has 8000 intravenous drug users New York City has 250 000, and 70% of them are infected," said Dr Marcus Conant, professor of dermatology at the University of Cali-

fornia San Francisco. Resident doctors in the United States are more reluctant to treat patients with AIDS than Canadian or French residents, said Dr Martin F Shapiro of the University of California Los Angeles. Although the American

Italian workers to be drug tested More than two million Italian workers could be subjected to six monthly drug tests if a proposed decree is made into state law. According to Guiseppe Cacopardi, the general director of the Ministry of Labour, parliamentary approval of the decree, which establishes mandatory testing for 12 categories of worker, is simply a matter of time. The decree is aimed at health workers and public transport workers, but other categories that will be affected include people who manufacture fireworks, those who operate nuclear plants, furnace workers in the steel 209

Headlines US legal battle over mifepristone: The US Supreme Court has upheld the Court of Appeal's decision that it was legal for Customs to seize a supply of mifepristone pills that a woman had imported from London to end an unwanted pregnancy. A federal judge had originally ruled that Customs had acted illegally.

Thatcher's smoking link: According to Baroness Thatcher's spokeswoman., the former prime minister is having talks with Philip Morris, the -world's biggest tobacco company, with a view tb a possible consultancy. Cash injection for London hospitals: North East Thames Regional Health Authority is to bail out five of its hospitals to -keep them from bankruptcy. The Middlesex and University College, St Bartholomew's, Royal London, and Whipps Cross hospitals are to share £9-2m. Delays in cash for mentally ill offenders: Despite a £4 million injection last year the Home Office has failed to fund a single project to help keep mentally ill offenders out of prison. A Home Office spokeswoman said that talks were still in progress with the Department of Health, but she could not explain the delay. More cases of listeriosis in France: Between mid-March and 6 July 105 patients with listeriosis were identified in France, according to Communicable Disease Report from the Public Health Laboratory Service. This is six times the usual incidence. Of the 105 cases, 29% were associated with pregnancy; there were 24 deaths and six abortions. A common food source is yet to be identified. Drink-drivers could face 10 years in prison: The home secretary has announced plans to double the present maximum prison sentence for motorists who kill while driving dangerously or under the influence of drink. Last month the maximum sentence was increased to five years (11 July, p 74).

Babies' higher risk: Babies registered jointly by unmarried parents are 39% more likely to die before their first birthday than children of married parents with fathers of the same social class, according to statistics released by the British government last week. Babies of unmarried parents are slightly lighter than those of married parents across all social classes.

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industry, and lift technicians. Under the terms of the decree a worker who tests positive will be moved to another job. Testing will be unannounced and unpredictable. "The reason is obvious," says Francesco De Lorenzo, the minister for health. "The test technique isolates drug metabolites from urine. If the analyses are at regular intervals subjects can avoid taking the drugs before the test." Test results will be confidential. Employers will know only that an employee has been moved to another job. Should the decree become law, testing will be done by the local health unit. To avoid discrimination against certain sectors of the workforce employers will not be allowed to request testing. When and where testing occurs will be decided entirely by the local health unit. Francesco De Lorenzo is opposed to indiscriminate testing of professional health care workers and has refused to sign the decree. The Italian trade unions are also against the decree. Airline pilots already undergo rigorous health checks twice a year. A spokesman from their union warned, "This is an American law which has been brought, unchanged, over the Atlantic. We are already tested twice a year; we don't need and won't tolerate any more than this." Italy's new government is in favour of compulsory drug testing, although, thanks to the minister of health, doctors may escape the tests. -ANDREA DIVO, freelance journalist, Saronno, Italy

Staffing dispute in Bristol trust hospital The clinical director of medicine of Southmead Health Services NHS Trust, Peter Harrison, has resigned over a dispute about medical staffing levels at Bristol's Southmead Hospital. Colin Williams, the trust's chairman, has also resigned. Junior staff blew the whistle on the dispute last week, exasperated

by the persistent lack of locum cover for annual and sick leave and the increase in work after three medical house officer posts were axed. Worried that low staffing levels put patients at risk, the juniors wrote a letter to the trust's chairman, but it went unanswered. They then contacted the media. David Reeves, the trust's medical director, denied allegations that two patients had died as a result of low staffing levels. One patient with a dense hemiplegia died between assessment in casualty and formal admission to the ward, and the other had a fatal gastrointestinal haemorrhage while being admitted. Dr Reeves said that both cases had been reviewed by the hospital board, which was satisfied with the care given. Philip Chubb, the chief executive of the trust, would not comment on the chairman's resignation. He reported that the hospital had been asked to cut three junior posts when Southmead Hospital and local geriatric hospitals merged last year. He admitted that it had been a mistake to lose them all from medicine. Other departments had been unaffected. Dr Reeves insisted that the problem was nothing to do with Southmead having recently become a trust. He emphasised that the trust's board had been aware of staffing problems for some time and said that £450 000 had already been allocated to improve the situation. According to Dr Reeves, the board acknowledged that doctors were working extremely hard, and it recognised the detriment to their medical education. The board has pledged to employ additional temporary staff immediately until things can be improved. Mr Chubb attributed recent events to a breakdown in communication and agreed that steps had not been taken early enough to ease staffing levels. -CHARLOTTE FLEMING, research fellow, Bristol

Top US doctors press Democrats for reform Change was in the air last week at an all star symposium run by. the New York Academy of Medicine and the Greater New York Hospital Association to inform delegates at the Democratic convention about health care reforms in the US. "The current system is a shambles," said Joseph A Califano Jr, who was secretary of health, education, and welfare during Lyndon Johnson's administration and moderator of the symposium. Although health care will take 18% of the gross national product by the year 2000, "infant mortality is higher than in 22 other developed countries and tuberculosis is back as a major threat." "The American Medical Association is committed to changing the way health is financed and delivered," said Dr James S Todd, its executive vice president. "Its aims are universal access to a defined level of care,

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to restrain the increase in costs, to improve the quality and appropriateness of the care that is given, and to reduce the hassle factor that has put the government and the insurance companies between physicians and their patients." Karen Ignagni, an expert on benefits working for a labour organisation, said, "Health care is a dollars and cents issue for working families. They would have better housing and could provide better education for their children if they had the money available that they now spend on health care." Health costs are a problem for manufacturers, too, according to Walter B Maher of the Chrysler Corporation, the car manufacturer. He estimated that the cost of providing health care to workers added $1100 (about £500) to the cost of every car. Hawaii may have some of the answers, according to governor John D Waihee III. "Here we take universal access to health care for granted," he said. Employers must provide health insurance for employees; most cover dependants as well. Those who are not covered by Medicare or Medicaid get insurance under a state plan. "Universal access is a cost cutting device," Governor Waihee said, because people get preventive care. "We have the lowest insurance rates in the country. The total cost is comparable to France, Germany, and Japan, which have similar

After a pro-military, coalition government came to power in March this year the original £30m budget for the planned nationwide education drive to alert the 58 million population to the risks of HIV infection was slashed by nearly half. Health ministry officials said that the campaign had overstated the country's problem and had "seriously affected tourism" (16 May, p 1264). But after bloody pro-democracy clashes in Bangkok in May, in which scores of protesters were gunned down by troops, the politicians who had initiated the antiAIDS drive returned to run the country until new elections in September. Two weeks ago Minister Mechai Viravaidya, the man credited with Thailand's new, open policy on its AIDS crisis and known throughout the country as "Mr Condom," threatened to resign unless the original £30m for the education and awareness budget was restored in full. The budget was then increased to just below this figure. "There is no cure. There is no vaccine for AIDS. The only projection we have is education," he said, speaking on the final day of Thailand's second national seminar on AIDS. Mr Mechai said that Thailand faced the prospect of two to four million Thais becoming infected with HIV by 2000. "If we work on it now we can stop the spread by 75%," he explained. The minister said that if HIV spread at the current rate it would devastate the country. Government figures estimate that 400 000 Thais are now HIV positive. The planned campaign will use the mass media to spread the anti-AIDS message through schools and universities and among high risk occupational groups, such as Bangkok's growing army of construction workers. Mr Mechai concluded by castigating tourists who travel to Thailand to experience its £Lbn a year sex industry. "We do not want that tourist money. We do not need to be called 'Thailand: the sex capital."' -ALISON CLEMENTS, freelance journalist,

systems." Dr Arnold S Reiman, emeritus editor of the New England Journal of Medicine, proposed a system of salaried doctors to replace the fee for service system in a community network of large group practices. "We should have two systems; one subsidised through an income tax that provides a defined level of basic services, and an optional system that allows a patient to go to any physician, to go to the Mayo Clinic for a headache, if he's willing to pay for it. If 90% of us were in the subsidised system it wouldn't get shabby. We're the voters." There's no time to wait, said Richard J Davidson, president of the American Bangkok Hospital Association. "We have to redesign from the community level up, with community care networks that provide a point of entry. We should begin today, using what we have-employment based insurance-and expand on it." -JANICE HOPKINS TANNE, contributing editor, New York

Domestic violence out of the closet? According to a report of a national interagency working party published last week, the issue has been largely ignored, treated as a low priority, and regarded as the domain of specialist agencies and women's groups. Victim Support, the national charity that counsels victims of crime, convened the working party after seeing a substantial increase in its caseload of victims of domestic violence. The report goes on to say that when provisions are made for victims of domestic violence they tend to be haphazard, focused primarily on the needs of any children involved, and hampered by ignorance and underfunding. In 1990 the London Women's Aid Advice Centre, which coordinates the referral of abused women to refuges in London, received over 5000 requests for placement; it was able to place only 40% of these women. Many woman who leave abusive partners face extremely long waits for housing or have to live in bed and breakfast accommodation. Ineffective legislation and red tape doesn't help. Jean Barton, a volunteer for Victim Support in north London, cites a case of a pregnant woman who was beaten up by her partner. He was charged but given bail. After he made further threats he was remanded in custody for two weeks and then given bail again. Injunctions issued against abusive partners are not much of a deterrent, according to recent research by the Women's Aid Federation. It suggests that fewer than half of the injunctions that are taken out are complied with. "The fear of the violence is often the worst part," said Jean Barton, "and the longer it goes on the more the woman loses her self respect and is unable to get out. It is often just as hard for a woman who is working to leave: sometimes it's harder, because she has more

Reprieve for Thailand's AIDS campaign An AIDS awareness campaign in Thailand, drastically toned down by the country's previous pro-military government, has been resurrected with the unexpected return to power of its original architects. Thailand's recent political traumas have had a stop-go effect on the AIDS awareness effort launched in 1991 to stem the spread of HIV infection in a country facing one of the most serious

projected epidemics.

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to lose and she still earns less than him." Dr Iona Heath, a general practitioner in London and member of the working party, said, "The fact is, women often love the men who beat them up. It's still their core relationship. That's why they can't be hurried." Dr Heath believes that general practitioners often fail to recognise symptoms of abuse and are poorly informed about the resources available. She believes that a national helpline would help doctors as well as the abused women. The working party also recommends that fact packs on domestic violence should be widely available. The packs have been piloted by the Home Office in Camden, London, and detail services available in the local area for victims of domestic violence. A questionnaire survey of 100 patients in Dr Heath's waiting room showed that a third of them had been subjected to some form of domestic violence. "People are very covert about it," she said, "but there are certain indicators." Women who are being abused are often the "heartsink" patients who repeatedly present with minor ailments or with the psychiatric consequences of abuse, such as depression and alcoholism. The Royal College of General Practitioners will shortly be issuing guidelines for its members on good practice in managing domestic violence. The report recommends that a single government department should be responsible for ensuring that agencies work effectively together. The director of Victim Support, Helen Reeves, commented, "This report marks the first time that all the organisations which women turn to for help have worked together to seek solutions. This needs to continue if we are to tackle the tragedy of domestic violence."-CAROLINE WHITE,Joumnal of Clinical Pathology Domestic Violence is published by Victim Support, 39 Brixton Road, London SW9 6DZ, price £3.

Fifteen years of deprivation: Britain's inner cities Fifteen years of government initiatives have failed to lift Britain's inner cities out of poverty and deprivation, according to a report published last week by the Policy Studies Institute. Figures show that families living in areas like Hackney and Tower Hamlets in London, Rotherham, and Rochdale suffer higher rates of premature death, poverty, unemployment, and homelessness than their more affluent counterparts. "Decay at the heart of Britain's cities is one of the biggest challenges faced by its government," says the report, which is the first of its kind-an independent assessment of the impact of government policy since 1977 on deprived urban areas. It examines trends in employment, housing, education, and welfare in 36 of the most poverty stricken areas of Britain, including parts of Greater London, the north west, the west midlands, Yorkshire, Scotland, and Wales. 212

Suffer little children

The report shows that although perinatal include city action teams, task forces, action and infant mortality is much lower now than for cities, urban development corporations, in 1977, most inner cities still lag far behind and, most recently, the Urban Regeneration the rest of the country. In England and Wales Agency. the risk of a baby dying before its first According to the report, most of the birthday has fallen by 43% over the past 15 government money earmarked for urban years. In the inner cities of the west midlands regeneration has in recent years gone to (Birmingham, Coventry, Sandwell, and urban development corporations, in partiWolverhampton) infant mortality has fallen cular to London's docklands. The report by only 32%. The only area where the gap warns that, particularly with regard to between rich and poor has narrowed is Scot- housing, special programmes have simply land. failed to spend the money where it has been Adults living in urban poor areas have most needed. fared no better. Standardised death rates The report demands more money and have been higher than the national average better management for Britain's poor areas throughout the 15 years, in certain London but concludes, "After 15 years and many boroughs. Furthermore, "in England the new initiatives surprisingly little has been probability of your dying early increases achieved. Given the record so far, it is the further north you live": Blackburn and difficult to have confidence in more of the Burnley have the highest death rates, closely same or to feel at all hopeful about the future followed by Manchester and Middlesbrough. prospects for deprived urban areas."Children growing up in inner cities suffer ALISON TONKS, BMJ more from the distress of poverty and are more likely to end up in the care of local Urban Trends I can be obtained from BEBC Distribuauthorities than children growing up in more tion, PO Box 1496, Poole, Dorset BH12 3YD, price £19.95. affluent suburbs. "It is inevitable that when things get really bad children suffer first," said a spokeswoman from the Child Poverty Action Group. "Poverty casts a long shadow, which means that growing up in poverty affects them for the rest of their lives. This evidence shows that the postwar trend towards redistribution of wealth has been put into reverse." The report blames a drastic cut in house The Department of Health wants to take a building and the sale of council houses for a deep breath before it reappraises 20 years of steep rise in the number of people without government policy in favour of hospital homes. The greatest increases in home- births in Britain. The breathing space will lessness have been in London's inner city be afforded by setting up. a new "expert boroughs and in Manchester and Middles- committee" to review policy on pregnancy brough. In Manchester in 1989, 1 6 house- and childbirth. This is the government's main response to holds per 1000 were classified as homeless; by 1990 the number had-increased more than the Commons health committee, whose report, just before the general election, eightfold to 13-8. Since 1977 there have been 12 government completed a year long inquiry into the initiatives to improve the lot of inner city maternity services (14 March, p 657). The populations. The catalogue begins with the select committee said that hospitals are not Labour government's white paper Policy for the right place to care for healthy women. the Inner Cities, published in 1977. Others Membership of the new expert committee

Stalling on reform of maternity care

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will include women who use the service as well as professionals. It will re-evaluate arrangements for both hospital births and home deliveries. In the meantime, a departmental task force will examine and disseminate good practice in the management of maternity services, including the provision of maternity care in units run by general practitioners or midwives. The government's response acknowledges the need to take account of the shift in attitude of many women who favour a more homely and less technological setting for childbirth. It concedes that women should be able to choose between hospital and home birth provided the safety of mothers and babies is not compromised. All of the select committee's most radicalrecommendations are being referred to the new expert committee. For example, the select committee's view that shared care between hospitals and community services should be abandoned. Though the government does not agree it will consider how best to avoid duplication of professional effort. Also passed to the experts are the select committee's proposals for a greater role for midwives, changes in general practitioners' remuneration for maternity care, and the relegation of senior house officers to the status of trainees supervised by midwives. The department is not enthusiastic about the creation of an obstetric only specialty. The select committee also states that there are no hard and fast rules about how maternity services should be organised. The key factor is the outcome: a well baby and a healthy, happy mother. But the department does not support the select committee's view that there should be a presumption against closing small rural maternity units uniess the case is overwhelming. Mr Nicholas Winterton, former chairman of the select committee, called the department's response bland and added: "I would have expected a more positive response from Mrs Bottomley as a woman secretary of state who was herself a young mother."-JOHN WARDEN, parliamentary correspondent, BMJ Maternity Services: Government Response to the Health Select Committee, Cm 2018, is published by HMSO, price £6.25.

Smog bound in Santiago Earlier this month the government declared a state of emergency in Santiago, the Chilean capital, when pollution from particulate matter climbed to dangerous levels. Nursery schools were shut, physical education classes were suspended, and 40% of Santiago's 450 000 vehicles were not allowed to be

driven. All factory emissions were prohibited. The very old and the very young were advised to stay indoors. "The situation in Santiago is getting progressively worse," said Dr Alfredo Tagle, head of emergency services at the Felix Bulnes Hospital in an industrial suburb of BMJ VOLUME 305

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"pollution stock exchange" for factories in Santiago, with the government setting the total amount of pollution permitted each year. From September all imported cars will have to be fitted with catalytic converters. The decontamination commission is being criticised for proposing little more than stopgap measures to deal with Santiago's environmental problems. "What we really need," said Dr Aranda, "is a long term urban development plan for Santiago. The government should be thinking of policies that encourage the relocation of industry: the creation of satellite towns and the development of a clean public transport network."LESLIE CRAWFORD, freelance journalist, Santiago

GPs want to hear of cases of overwork Dr John Cormack, the general practitioner who tried to take the government to court Antipollution masks pn the streets ofSantiago over the general practitioners' contract, has taken up the cudgels over a new issue: general practitioners' hours. Dr Cormack Santiago. "The respiratory ailments we are and his co-campaigner, Dr Peter Gray, a treating are more severe; some require student barrister, hope to mount a legal hospitalisation; and we are seeing the same challenge to the requirement on general children more often-a sign that they are practitioners to provide 24 hour cover for patients. developing chronic chest complaints." They want doctors who believe that their Dr Carlos Aranda, a paediatrician who conducted a comparative health study health has been damaged by long working between schoolchildren in Santiago and Los hours to contact them, with a view to launchAndes, a smaller town with no pollution ing claims for damages against the doctors' problems, said that children are three times family health services authorities. "Almost more likely to develop bronchitis in Santiago. all the doctors who have written to us so far The incidence of pneumonia is also 2 - 5 times have asked us to keep the details private and higher in Santiago than in Los Andes. confidential," said Dr Cormack, of Woodham Pneumonia, in fact, has become the biggest Ferrars, Essex. "We need to hear from cause of infant deaths in Santiago after doctors who have strong cases and who are prepared to stand up and say so." accidents. Injuries could include those caused by The reasons for Santiago's smog lie in the city's unchecked growth, its dry Mediter- falling asleep at the wheel of a car while on ranean climate, and its geographical location call, illness related to stress, and injury to a -a windless, semiarid valley surrounded by patient the general practitioner was too tired mountains. The city's 4 5 million inhabitants to* treat properly. Dr Cormack said that have over 450 000 vehicles, and a consumer general practitioners' responsibilities had boom is adding over 60 000 cars a year to the become more onerous since the introduction capital's congested streets. The amount of of the new contract. "Not only do we have particulate matter-dust, soot, and a blend more to do during the day, but we're more of other toxins-never falls below twice the regimented; we're told what to do and accepted international health standards. In when." The campaigners believe that a Court of winter, when hot air traps the smog at ground level, the concentration of airborne particles Appeal ruling that Dr Chris Johnstone could sometimes increases fivefold. More than 70% sue Bloomsbury Health Authority over his 88 of the particulate pollutants are produced hour working week as a junior hospital by Santiago's privately owned fleet of 11 000 doctor is a helpful precedent. Dr Johnstone's case is expected to go to trial later this year. diesel buses. President Patricio Aylwin's civilian They also cite the case of Dr Premanenda government took over from the military in Roy, who was given the go ahead by the March 1990. Its efforts to clean up the city, House of Lords last February to sue his however, have been bitterly opposed by family health services authority for withSantiago's bus owners. An attempt to ration- holding 20% of his basic practice allowance. Dr Johnstone's case, however, was based on alise bus services by putting routes out to tender is currently caught by legal red tape. a contract of employment whereas general Santiago's decontamination commission practitioners are self employed. And Dr Roy wants to charge a toll on all cars entering the was attempting to enforce-not challenge-a city centre and impose higher road taxes on statutory term governing doctors' and family older vehicles, but this needs the approval of health services authorities' obligations. parliament. Another law would create a CLARE DYER, legal correspondent, BMJ 213

Letter from Westminster

Committee of conflict

of the party whips, however, fell on another committee, then chaired by Frank Field. nominee, Mrs Marion Roe, who has had a Last week Mr Field sought to have Mrs Roe long career as a committee woman and, removed from the health committee. The health committee has plainly been Winterton, was unceremoniously dumped perhaps more to the point, was once deputy overboard. Now with a new captain and crew chief whip on the Greater London Council. weakened by the events of the past two This is the second time that Mrs Roe has weeks. The rebuilding of its reputation rests it is still no happier. The background is a sorry tale of divided been drafted on to a select committee on the on the political astuteness of its experienced loyalties, ineptitude, and corruption of the government's behalf. Three years ago her's members and the fresh approach of its newparliamentary process-merely to remove a was a dissenting voice in the social services comers, who, in Jacqui Lait, include a troublesome committee chairman. A simple committee when it urged the government to recent chairwoman of a family health services piece of surgery totally mishandled has pull back from the NHS reforms. At that authority. Meanwhile, a three month recess discredited those in authority, not least the time Mrs Roe made no secret of her mission can allow wounds to heal. -JOHN WARDEN, Tory establishment. to counter an antigovernment bias in the parliamentary correspondent, BMJ For Mr Winterton, an incorrigibly nonconformist Tory, the writing has been on the wall from the start, ever since he was propelled into the health committee's chair by the votes of opposition MPs (BMJ 1991; 302:312). Then followed the spectacular episode of his draft report on NHS trusts being leaked to the Department of Health so that the department was tipped off in advance of his criticisms. Mr Winterton suspected interference by his party's whips and sought redress by resorting to the committee of privileges. Its inquiry was cut short by the election and is unlikely to be resumed unless pressure is applied. An alert opposition would ensure that it is, for the episode raises exactly the same issue as Mr Winterton's deselection-namely, the alleged manipulation of a select committee by the executive. Though the leak might. have been passed off as a misdemeanour, it is now compounded by the victimisation of Mr Winterton. At this time a year ago I was reporting that Tory elders were already preparing a black hole for him (1991;303:268). Although their trap of a three parliament rule was overelaborate, Mr Winterton was finally engulfed by the votes of his fellow Tory MPs, who thought that they owed him no more loyalty than he had accorded to them down the years. Only four other Tory MPs, one of them his wife, supported his reinstatement to the chair of the health committee. His departure does not command wide sympathy on his own benches. But to others than Tories Nicholas Winterton was an effective chairman of the health committee because of his deep knowledge of how the NHS works as well as the independent streak that was his downfall. It is ironic that at the very moment he was deposed the government was erecting its own monument to him by announcing a departvi.~~~~ ~~.s.....4 ~ ~~~~.... 6 .:4S" mental review of maternity care in response to the Winterton report (p 212). Few select committees are so honoured. If the strategy of the government whips in m i~o Tereor n ishothi ws"('r te's e&*thiat~~~~~~~~~~~~~~~~~~~~~~~~~~0 : N71; was to blunt the health committee's scrutiny Kene,,II ,,,.iak, .,s;ge, t~ ................. an4 .w.l be ,t, .~ini ; . of the NHS it did not stop with the clumsy removal of Mr Winterton but extended also referm~~~ we~t~~i ~ ~V~~n4~ ~ $~~o$r (~~C is bold ea~~~ough to ez~~eed his to the choice of his successor. Good sense and 4.n .t . . ......, ;. . S .... continuity pointed to Mr Roger Sims, the senior Conservative member. The preference

The Commons health committee has not been a happy ship since its inception 18 months ago. Last week its skipper, Nicholas

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Reprieve for Thailand's AIDS campaign.

A promilitary coalition began to govern Thailand in March 1992. It reduced the budget for the original proposed national AIDS awareness campaign from ...
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