Benson contends that surgery demands certain characteristics in doctor, including a high level of confidence and a lack of diffidence. These demands may, of course, be tragically mismatched with the expertise of doctors still in training.5 His implicit paradigm of doctor-as-hero may help to explain why the NCEPOD report" for 1990 still reports deficiencies highlighted 5 years ago: poor supervision of junior staff and surgeons operating outside their field of expertise have been recurrent difficulties. This poor supervision and inadequate training can also have disastrous consequences for the career of the doctor, as well as for the patient. These and other aspects of the junior doctors’ life have prompted calls for changes in the postgraduate registration year, with an emphasis on the reduction of junior doctors’ hours and improved training and education.’ Perhaps a more cautious approach to medicine and life, especially other peoples’, is to be encouraged in junior doctors rather than mocked. a
Department of Epidemiology and Public Health, University College and Middlesex Schools of Medicine, London WC1E 6EA, UK
NISH CHATURVEDI ALLYSON POLLOCK
1. Elliot DL, Girard DE. Gender and the emotional impact of internship. J Am Med Wom Assoc 1986; 4: 54-56. 2. Firth-Cozens J Emotional distress in junior house officers. BMJ 1987; 295; 533-36. 3. Firth-Cozens J. Sources of stress in women junior house officers. BMJ 1990; 301: 89-91. 4. Payne RL, Firth-Cozens J, eds. Stress in the health profession. Chichester: Wiley, 1987. 5. Dyer C. Manslaughter convictions for making mistakes. BMJ 1991; 303: 1218. 6. Nixon SJ. NCEPOD: revisiting perioperative mortality. BMJ 1992; 304: 1128-29. 7. Richards P. Educational improvement of the preregistration period of general clinical training. BMJ 1992; 304: 625-27.
European Bureau for Action 117, rue des Atrébates, B-1040 Bruxelles,
claims that the commercial industry can guarantee a controllable quality that the European blood-bank community cannot. I strongly object to this statement. The fractionation laboratories belonging to the non-profit-making blood transfusion services comply with the same quality requirements and good manufacturing practice as does the industry, and the exclusive use of voluntary, unpaid donors adds to the safety of the products.1 The quality assurance of plasma separated from whole-blood donations is more difficult than that from plasmapheresis, but there is no foundation to indicate that plasma from commercial centres is of higher quality than that of unpaid plasmapheresis donors. The EC is not yet self-sufficient for plasma products. The increased yields of factor VIII and the emergence of recombinant products help the Community to achieve its goal in that respect. Albumin remains a difficulty. Japan has taken measures to reduce the excessive use of albumin in that country. Europe should take similar action, in addition to active promotion of non-remunerated donations of blood and plasma. I am convinced that self-sufficiency based on voluntary and unpaid blood donors as expressed in the Directive 89/381/EEC is a realistic goal. Establishment of new commercial plasmapheresis centres and increasing the frequency of paid plasma donation is not necessary.
1. Beal RW, van Aken WG. Gift or good? A contemporary examination of the voluntary and commercial aspects of blood donation. Vox Sang (in press).
EC oral snuff ban and Sweden SIR,-At the European Community (EC)
SIR,-Dr Smit Sibinga comments on the European Community (EC) policy of self-sufficiency in blood and blood products, based on voluntary and non-remunerated donations (June 13, p 1485). He
Finnish Red Cross Blood Transfusion Service, 00310 Helsinki, Finland
resembling a food product.l In a report that the European Bureau for Action on Smoking Prevention (BASAP) undertook at the request of the EC in December, 1990,2 we concluded that the use of moist snuff causes cancer in man, addiction to nicotine, and is increasingly being targeted at young people (as can be seen in Sweden and the USA). Dr Fagerstrom and colleagues (April 11, p 935) criticise this Directive, citing the World Health Organisation’s report on smokeless tobacco3 which made clear distinctions between countries with different tobacco use traditions and did not recommend a ban of smokeless tobacco in those where the products are well established. However, as snuff consumption is not yet established in the twelve EC countries, the Commission was acting in line with the results of WHO’s working group which said that countries with no established smokeless tobacco habit should, as a matter of urgency, ban the manufacture, importation, sale, and promotion of smokeless tobacco products before they were introduced in the marketplace or became an established product. Moist snuff (especially that packaged in small tea-bags) is especially popular in Sweden, and its consumption is high among young people. However, the EC Directive was aimed at the twelve present members of the EC where oral snuff use is not yet established. Dispositions for Sweden may be negotiated separately within the framework of the European Economic Area negotiations. Finally, it should be pointed out that snuff in Europe is mainly produced by the Swedish company Svenska Tobak, which has been restructured and given a new name-Procordia United Brands Group. Fagerstrom works for Kabi Pharmacia, which is owned by Procordia, which in turn is mainly owned by the Swedish State.
Council of May 15, 1992, a Directive was adopted that will ban the
marketing, in the Community, of certain types of oral tobacco-ie, all products for oral use, apart from those intended to be smoked or chewed, made wholly or partly of tobacco, in powder or particulate form or in any combination of these forms, especially those presented in sachet portions, porous sachets, or in a form
1. Council Directive 92/41/EEC of 15 May 1992 amending directive 89/622/EEC on the approximation of laws, regulations and administrative provisions of the Member States concerning the labelling of tobacco products. Offic J Eur Commun L158 of 11Tune 1992, p 30-33. 2. A new form of smokeless tobacco: moist snuff. European Bureau for Action on Smoking Prevention (BASP), December 1990. 3. World Health Organisation. Smokeless tobacco control. Report of a WHO study group. Tech Rep Ser 773, Geneva: WHO 1988.
Safer sex and
SIR,-In your note on safer sex and women (April 25, p 1048) you consider why women in London are not responding to safer sex messages. There may be parallels with the situation in Africa. Despite the fact that there are as many women as men with AIDS in Africa, research has focused on the role of women as transmitters rather than as recipients of infection. The emphasis has been on the study of female prostitutes, who may be important in maintaining transmission but are only a proportion of all infected women.1 It has been suggested that this partly results from women being regarded as either bad (sexually promiscuous) and at risk or good and therefore not at risk.2 This view may underline health education campaigns that are restricted to advocating faithfulness, and which do not address the protection of individual women who are at risk of infection even if faithful because many of their husbands are or will become infectious.3 In a recent study in Rwanda, the prevalence of HIV infection among women who reported a single lifetime sexual partner was 21 %.4 Even an appropriate health education message is not guaranteed to change behaviour: women might not have adequate access to information, might not be able to perceive the risk in their own situation, and might not be in a position to alter their lifestyle or to negotiate successfully change of behaviour with their partners. Research has shown that some women have little access to information; some perceive condoms as having negative health effectsor as necessary only for prostitutes and promiscuous women.s Social and cultural norms may prevent women from perceiving risk in their personal situation: in the same study in Rwanda, 24% of the women who did not regard themselves as at risk (most of whom were in monogamous relationships) had already
been infected.4 Reduction of number of partners may not be an easy option for women for whom this is a part of their strategy for social and economic survival.6 Women’s subordinate position may not allow them to negotiate successfully the use of safe sex even when they perceive the risk correctly. 7,8 This process is also influenced by men’s attitudes and by notions of masculinity.7 Women’s knowledge, perceptions, choices, and ability to negotiate change with their partners should be understood in the context of the power balance in gender relationships and against its wider historical and cultural basis (Brooke GS, et al, unpublished). An effective contribution to facilitate change towards safer practices for women will need a better understanding of the conditions of transmission to all women, not just those in at-risk categories, of the social and cultural norms that shape women’s perception of risk, and of the constraints that women face to change their risk behaviour and to negotiate safer sex practices with their partners. This in turn will help to develop strategies to redress the lack of power of women to protect themselves against HIV infection and to negotiate safer sex with their partners.8 This lack of power is most often real, not merely perceived, as you suggest in your note. Oxfam, 274 Banbury Road, Oxford OX2 7DZ, UK, and London School of Hygiene and Tropical Medicine, London WC1
CLAUDIA GARCÍA MORENO LAURA C. RODRIGUES
1. Garda Moreno C. AIDS: women and not just transmitters. In: Wallace T, March C, eds. Changing perceptions: gender in development. Oxford: Oxfam, 1990. 2. Carovano K. More than mothers and whores: redefining the AIDS prevention needs of women. Int J Health Ser 1991; 21: 131-42. 3. Rodrigues LC, Garcia Moreno C HIV transmission to women in stable relationships. N Engl J Med 1991; 325: 966. 4. Lindam C, Allen S, Carael M, et al. Knowledge, attitudes, and perceived risk of AIDS among urban Rwandan women: relationship to HIV infection and behaviour change. AIDS 1991; 5: 993-1002. 5. Worth D. Sexual decision-making and AIDS: why condom promotion among vulnerable women is likely to fail. Stud Fam Plann 1989; 20: 297-307. 6. Bassett MT, Mhloyi M. Women and AIDS in Zimbabwe: the making of an epidemic. Int J Health Ser 1991; 21: 143-56. 7. Ankrah EM. AIDS and the social side of health. Soc Sci Med 1991; 32: 967-80. 8. Ulin PR. African women and AIDS: negotiating behavioural change. Soc Sci Med
1992; 34: 63-73.
SIR,-Professor Lecatsas and Professor Alexander’s (June 6, 1427) suggestion that the simultaneous appearance of HIV-1and
HIV-2 is evidence for the contamination of poliovirus vaccine being the origin of AIDS is flawed. They need to explain several points. How did two distantly related viruses contaminate the poliovaccine ? Why did this affect African countries more than others with much higher poliovaccine coverage? And why has long-term follow-up of people who received retrovirus-contaminated batches of poliovaccine failed to demonstrate ill health?l A simpler explanation for the simultaneous appearance of two dissimilar viruses lies in the main route of transmission. Since the end of colonialism there have been major social and economic changes in African countries.2 Those relevant to the HIV epidemic include rapid urbanisation across the continent, new road building improving communications, and the mass movement of people as a result of civil war and starvation. Urbanisation is likely to have brought HIV-1and HIV-2 into the cities and towns. Accompanying this urbanisation is greater sexual freedom from loss of tribal traditions, the migrant worker system which encourages multiple sexual partners and stimulates demand for prostitution, along with the growing poverty of many urban women increasing the numbers engaging in prostitution.2 These social factors lead to an increase in the number of new sexual partners, which allows any sexually transmitted disease, especially one with a long duration of infectivity to produce an epidemic. The developing road system allowed the virus to be moved across the continent. The high prevalence in truck drivers testifies to this potential. When people live in small social groups with little movement, as in rural villages, the spread of sexually transmitted diseases is much less than in large heterogeneous populations. HIV-1 has a low probability of infectivity, 0.1 to 0-2 for each relationship,3 and is dependent on the long duration of infectivity to maintain the infection. Major spread could only occur when the behaviour of the population changed, which happened with urbanisation. This theory explains how 2 dissimilar viruses, both sexually transmitted, have suddenly appeared and rapidly produced
major epidemics. Westbrook House, Sharrow Vale Road, Sheffield S11 8EU, UK
AIDS in India SIR,-It is gratifying to note, as your Round-the-World correspondent says (May 9, p 1162), that the Indian Government will be initiating a national control plan for AIDS with the monies given by the World Bank and the World Health Organisation. The plan is necessary because very few preventive measures are being undertaken, despite evidence that the infection is spreading. Although the initiative overcomes governmental reluctance to accept AIDS as a serious public health issue in India, there are several other difficulties that pose a greater challenge. Successful health education campaigns in developed countries may not work very well in India in view of low literacy levels, limited access to radio and television, and large rural populations. Added to these is the growing nationwide problem of alcohol consumption, which encourages casual sex. What is needed, therefore, is an active attempt to educate and modify behaviour through personal intervention. This has been successfully achieved in other communicable diseases and in maternal and child health. There has to be a national programme with community health workers whose primary aim is to inform people of the risks of AIDS and how these risks can be avoided. This may mean also a free distribution of condoms for safer sex which can also be an effective birth control method. Some use of existing communication channels needs to be undertaken simultaneously, aimed especially at urban populations. India needs a comprehensive and complex plan to prevent the spread of AIDS infection, and this may mean personal contact with 900 million people over some time. The current initiative can only be a starting point. Poole
Hospital, Nunthorpe, Middlesbrough, Cleveland TS7 ONJ, UK
Origins of HIV
R. S. RAMAIAH
1. Beale AJ. Polio vaccines: time for a change in immunisation policy? Lancet 1990; 335: 839-42. 2. Larson A. Social context of human immunodeficiency virus transmission in Africa: historical and cultural bases of east and central African sexual relations. Rev Infect
Dis 1989; 2: 716-31. 3.
European Study Group on Heterosexual transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992; 304: 809-13.
Peripartum HIV seroconversion: a cautionary tale SIR,-A bottle-fed child aged 4 months was admitted to hospital with a provisional diagnosis of bronchiolitis. The child deteriorated and he required ventilation. On day 5 a tracheal aspirate was found to be positive for Pneumocystis carinii by a fluorescence antibody test and on day 6 a serum sample was reported positive for HIV-1/2 antibody. The child died on hospital day 27. The blood was sent to a reference laboratory for confirmatory tests for anti-HIV-1/2 and both gave low positive results. Immunoblot testing was indeterminate but there was reactivity to proteins p24, gp 120, and gp 160; the bands on the blot were definite but not strong, and could be consistent with low antibody level. The polymerase chain reaction (PCR) for HIV RNA was positive and p24 antigen was detected by enzyme immunoassay. During 1991, when this child was born, no HIV antibody positive newborn babies were found in Aberdeen by anonymous Guthrie card testing. The batch of Guthrie cards pertaining to this birth was retested by the department of child health, Yorkhill, Glasgow, and found to be HIV antibody negative. This was confirmed by a reference laboratory. The mother denied that she might be HIV positive. Later her general practitioner was able to discuss with her the death of her