NEWS

Pesticide link with Gulf war syndrome

A possible link between Gulf war sickness and exposure to organophosphate insecti- cides has been admitted by Britain's min- istry of defence, which last week apologised for having overlooked the connection. Armed forces minister Nicholas Soames promised that this "new factor" will be examined thoroughly in a research pro- gramme to be supervised by the Medical Research Council. The records of750 veterans are being re-examined for specific symptoms. The disclosure, in a letter to the Com- mons defence committee, has added a polit- ical dimension to the controversy. Suspicions ofofficial incompetence will be pursued in a parliamentary debate next week. The ministry now concedes that organophosphate pesticides were used more widely in the Gulf than was previously realised. This arose because in the early stages supplies were augmented locally so as The Ministry ofDefence still does not accept that the Gulfwar syndrm exists to protect frontline troops against insect borne disease. In 1994 the ministry misinformed the select committee that American researchers into the Gulf war the New Statesman into the "adoptive organophosphates were not used by British syndrome have for some time suspected immunotherapy" clinic at the private Lon- troops. It now admits to the use ofdimethyl organophosphate poisoning interacting with don Bridge Hospital, run by Dr Sharp, a phosphorothionate, diazinon, and aza- other cholinesterase inhibitors among the haematologist, and Mr Sultan, a veterinary methiphos. Mr Soames stated: "The use of cocktail ofprotective drugs administered to surgeon. Mr Barker was managing director organophosphates may possibly be a clue to the troops (BMJ 1996;312:1058).-JOHN ofthe clinic. the conditions that some Gulf war veterans WARDEN, parliamentary correspondent, BMJ Adoptive immunotherapy consisted of have suffered from. It will be investigated injecting patients with killer T cells stimu- fully and with the utmost care." lated by lymphokines. The BBC secretly Dr Goran Jamal, consultant senior clini- taped a consultation between Dr Sharp and cal lecturer in neurology at Glasgow Univer- BMJ faces £107000 a decoy patient, who was prescribed a course sity, said that he had raised the possibility oftreatment costing £10 000 ($15000). The with the Ministry of Defence that bill over libel case General Medical Council's professional con- organophosphates were linked with the Gulf duct committee brought charges against Dr war syndrome in July 1995. His study had Sharp relating to four real patients and the found evidence of dysfunction of the ner- The promoters of an alleged cure for AIDS decoy, and he was struck offin 1989. vous system in 14 Gulf war veterans (7ournal have been forced to drop defamation actions The BMJ was sued for libel by Mr Sultan of Neurology, Neurosurgery, and Psychiatry against the BBC, the New Statesman, and the and for malicious falsehood by Dr Sharp 1996;60:449-5 1). "I believe there are a com- BMJ. Although the BBC won the action, over a news story covering Dr Sharp's strik- bination offactors responsible: organophos- brought by Dr James Sharp, Jabar Sultan, ing off. Legal aid is available for malicious phates, pyridostigmine bromide tablets, and Philip Barker, it still faces a bill of falsehood, but not for libel. Dr Sharp was which are given to protect against nerve between ;600 000 and £800 000 ($900 000 initially given legal aid to bring the case, but agents, and medical warfare agents, which and $120 000). it was withdrawn on the advice ofhis barris- are also mainly organophosphates." The BMJ and the New Statesman took a ter. All three plaintiffs had their claims The ministry, however, still does not back seat to the BBC in the litigation, but the struck out or abandoned them, but not until accept that a unique and previously unknown BMJ's costs totalled £107 000 and the New the BBC had spent seven years defending illness described as the Gulf war syndrome Statesman's was "a five figure sum." The them. Dr Sharp dropped his case after the does exist. But it wants to know whether any three plaintiffs represented themselves, a sce- judge told him the findings of the GMC Gulf veterans may be ill as a result of expo- nario that invariably drags out a case and dri- were binding on the court. sure to organophosphates so that they can ves up costs for the other side. Although the Richard Smith, editor of the BMJ, said: receive treatment. case was widely seen as unwinnable, the "This case illustrates for me the absurdity of Ministry sources suggest that only a small BBC and the two journals had no choice but Britain's libel laws. We have not lost this number of troops who operated spraying to defend it. Chris Hughes, head ofthe BMA's case, and yet we are faced with a bill that equipment were at risk, though this is disputed legal department, said: "There ought to be a would bankrupt many smaller medical by veterans' lawyers, who claim that there merits test for bringing defamation actions." journals. It is too easy for people to use libel was general exposure. The ministry is to invest- The action arose out of a joint investiga- laws to restrict free speech."-CLARE DYER, igate allegations oflax safety procedures. tion by the BBC's Watchdog programme and legal correspondent, BMJ

BMJ VOLUME 313 12 OCTOBER 1996 897 Smoke does get in Headlines your eyes

Rebuff for haemophilic patients: Scientists in the United States have found a The British government has refused new addition to the long list of smoking compensation for some 3000 haemo- related diseases-age related macular philic patients who before 1985 were degeneration. infected with hepatitis C from conta- Smokers have a twofold to threefold minated blood during their NHS increased risk ofdeveloping age related mac- treatment. The Department ofHealth ular degeneration with vision loss compared does not accept that there was negli- with those who have never smoked, say two gence and argues that the patients studies reported inJAAIA. received the best treatment available But doctors may find it difficult to use this at the time. latest evidence to convince smokers to give up-as the increased risk persists even after Nobel prize for medicine won for stopping smoking for more than 15 years. cell research: Dr Rolf Zinkernagel In one study, researchers from the Massa- and Dr Peter Doherty jointly won the chusetts Eye and Ear Infirmary in Boston fol- $1.2m (X800 000) prize for their work lowed up 31 843 women from 1980 for 12 on cell mediated immunity carried out years. Results of the study showed that cur- at the John Curtin School of Medical rent and past smokers had a significantly Smoking may lead to blindness, research suggests Research in Canberra, Australia, dur- greater risk of age related macular degenera- ing the 1970s. Dr Zinkernagel now tion than women who had never smoked. heads the Institute of Experimental Women smoking 25 or more cigarettes a Widow backed in Immunology at the University of day had 2.4 times the risk of developing the Zurich, and Dr Doherty is professor of condition. Women with a history of smoking legal fight for immunology at the University ofTen- had a twofold increased risk of macular nessee in the United States. degeneration, with little drop in risk even in husband's sperm those who had stopped smoking more than Dutch AIDS deaths fall for first 15 years before (AMA 1996;276:1141-6). time: Last year 434 people died of In a separate study more than 21 000 doc- The 30 year old widow's legal fight to try to AIDS in the Netherlands, 2% less than tors aged between 40 and 84 who were conceive her dead husband's baby has been in 1994. AIDS remains the second enrolled in the physicians health study were backed by Lord Winston, professor of fertil- most common cause of death after followed up for an average of 12.2 years. ity studies at Hammersmith Hospital in suicide for men aged between 30 and Investigators found that smoking increased London. He told the court last week in a 40 years. the risk of age related macular degeneration written statement that there was "ample jus- in a dose dependent fashion. tification" for inseminating Mrs B. He had US Supreme Court to rule on Current smokers of 20 or more cigarettes himself been involved in a similar case, assisted suicide: The US Supreme a day had a twofold to threefold increased without the dead husband's written consent, Court has agreed to decide whether risk of developing the condition with vision and his experience was wholly positive. the constitution gives terminally ill loss compared with those who had never England's senior family judge, Sir patients a right to a doctor's help in smoked. Stephen Brown, president of the High hastening death. Last spring federal Those who smoked less than 20 a day Court's family division, is expected to decide appeal courts in New York and Wash- were at no increased risk, while those with a next week whether the woman will be ington states had ruled that people history of smoking more than 20 cigarettes a allowed to be inseminated with sperm taken who were mentally competent and day continued to have a 40% to 80% excess from her husband at her request while he was terminally ill had a constitutional right risk of age related macular degeneration for in a coma after contracting meningitis. to doctor assisted suicide. many years after stopping (7AMA The Midlands woman, known as DB, is 1996;276:1147-51). challenging the Human Fertilisation and Gene therapy may reduce side Mr Michael Lavin, consultant ophthal- Embryology Authority, which insists that the effects of chemotherapy: Scientists mologist at Manchester Royal Eye Hospital, law requires a man's written consent before at the Paterson Institute in Manches- welcomed the new data. "At present any- his gametes are used. Written consent is not ter report in the journal Gene Therapy thing that can reduce the frequency of age required if a couple are treated together. a new technique that could protect related macular degeneration is valuable Mrs B's QC, Lord Lester, said the author- healthy cells from damage caused by because it is one of the top three causes of ity had taken an "unduly narrow approach" chemotherapy. In laboratory condi- blindness or partial sight in the elderly. Age to the law. The couple had discussed the tions they have caused these cells to related macular degeneration with vision loss possibility of such a situation arising after produce the mutant form of a protein is a terribly difficult condition to adapt to-it reading a newspaper article and Mr B had called ATase. This protein can repair cuts away at the centre vision and makes it indicated that he would like his sperm to be damaged DNA but is usually inacti- very difficult to enjoy life as it can lead to loss used. "He lacked the capacity at the time to vated during chemotherapy. of independence," he said. give his consent, but his wishes were well Age related macular degeneration has known beforehand," said the QC. Malaria early in life may protect: been estimated to affect about 80% ofpeople Baroness Warnock, who chaired the com- Researchers report in Nature that chil- over 75, with the late stages of the disease mittee of inquiry whose report led to the dren who have the genetic disease tha- affecting about 7%. The condition is also dif- establishment of the Human Fertilisation lassaemia are less likely to die from ficult to treat. and Embryology Authority, told the judge in malaria because they have episodes of According to Mr Lavin, laser treatment a statement: "I feel certain, had the commit- non-severe illness while infants. They and surgery to remove the fluid under the tee of inquiry considered such a case, we say that the mild vivax malaria may retina are current options but are not widely would have seen no etical or public policy help provide immunity against the available. External beam irradiation, steroid objections to allowing the woman to become potentially fatal falciparum form. treatment, and anti-androgenic treatment pregnant by the use of her husband's frozen are currently being investigated.-zosIA KMI- sperm, either in this country or abroad." ETOWICZ, medicaljoumalist, London CLARE DYER, legal correspondent, BMy

898 BMJ voLuME 313 12 OCTOBER 1996 French doctors medical requirements. Gauteng province Push to allow contains Johannesburg, Soweto, and Preto- strie over night visits ria, as well as several vast sprawling industri- relatives to witness al towns and black townships. The dispute was precipitated by new conditions for earn- resuscitation Several medical unions in France have ing overtime payments that have been laid called for protest strikes against the reforms down by Gauteng's departmnent of health. It undertaken to reduce the deficit of the follows large increases in basic salaries for A report published by the Resuscitation health insurance branch of the social securi- doctors in the public service that have been Council last week recommends that relatives ty system. agreed by the central government's depart- should be allowed to witness resuscitation The first strike took place last week, when ment of health. Each province was given a attempts and that they should be supported about half ofall French general practitioners, finite lump sum to pay to its doctors to deal by appropriately trained medical staff. including members of the emergency service with the overtime issues. The council, which consists of a group of SOS Medecins, switched on their answering Adding to the problem was a delay in pay- general practitioners and hospital consul- machine or left their telephone off the hook ment ofovertime such that many doctors had tants, recognises that such a suggestion is from Thursday night to Friday morning to not been paid what they were owed from July controversial and says that additional sup- protest against the government's plan to this year. According to Dr Ralph Mgigima, port and training should be given to staff to reduce the night hours during which they are Gauteng's superintendent general, who runs cope with any resulting extra stress. entitled to receive supplementary fees. the health department, the doctor's claims The debate started in the BMJ when Doctors can charge Fr135 (about £17 or "were not reasonable." He said that the prob- Sarah Adams wrote movingly about her feel- $27) for a home visit, but the fee is increased lem had its origins in the previous adminis- ings when she witnessed her brother's death to Fr300 ifthe visit takes place between 8 pm tration when the basic salaries were (BMJ 1994;308:1687-9). She pointed out and 8 am. The social security department's extremely low, forcing doctors effectively to that watching resuscitation attempts will help health insurance branch proposes to shorten cheat the system by increasing their salaries some people to come to terms with the the time that the higher fee can be claimed by in overtime pay. Now, however, new increased anguish ofbereavement. two hours, from 9 pm to 7 am. The measure salaries and a different system of monitoring There are an estimated 25 000 to 30 000 would save about FrlOOm a year. doctors' overtime payment and practice resuscitation attempts in accident and emer- Three medical unions have called for mean that some doctors would not earn as gency departments in the United Kingdom another strike on October 17, urging doctors much as they had hoped. each year, but currently relatives are not to cease all activities, including in hospitals, In the old system overtime pay after tax allowed into the resuscitation room during as a protest against Prime MinisterAlainJuppe's could amount to as little as R12 000 (under most of them. The report states that many plan to reform the social security system, a £2; $3) for a shift. New rates are well in excess relatives would prefer to be present if given plan seen as a threat to turn doctors into civ- of this-but new conditions for monitoring the choice. Perceived advantages were that il servants. The Confederation des Syndicats the time worked will now apply. The provin- relatives could see that everything possible Medicaux Franqais (CSMF), which represents cial administration has placed a ceiling on the was done for the dying person and that their most ofthe general practitioner and specialist amount of overtime doctors can do every presence might have some positive benefit on unions, also plans a series of strikes that entail month, suggesting a maximum of 90 hours' the outcome. closing specialists' offices in rotation. overtime over a month. It is also requiring The report says that most emergency Medical unions complain that doctors that doctors on call for night shifts and emer- physicians and paediatricians are in favour of have become "the scapegoats of a society in gencies work across disciplines for their over- relatives being present during resuscitation, crisis." Penalties that would be imposed on time to try to spread the load more evenly. but physicians and anaesthetists are against. doctors who prescribe in excess of recently In certain hospitals the problem has been They fear that such a move would increase published medical guidelines have been exaggerated by an acute shortage of doctors. the stress put on staff. Another concern was criticised, and the government's decision to Two Gauteng regional hospitals with short- that the reality of resuscitation may prove limit health expenditure in 1997 to only 1.3% ages have had to close their after hours ser- distressing for the relatives themselves. Other above that of 1996 is said to be unrealistic. vice, and may not reopen. A temporary worries were that the presence of relatives Negotiations have started this week to agreement has been reached and most doc- may influence the decision to stop resuscita- renew the agreements between doctors and tors are back at work, but further discussions tion or that the relatives may interfere or the social security department that have are scheduled for later this month.-PAT physically or emotionallyhinderthe staffinvolved made nationwide health insurance possible SIDLEY, medicaljournalist, ohannesburg in the resuscitation attempt.-JACQUI WSE, BW since 1971. If no agreement is reached then government has the right to take authoritari- an measures to reform a system that has lead to an increasing debt for the department- a deficit of Fr5Obn has been forecast for this year alone.-ALEXANDER DOROZYNSKI, medicaljournalist, Paris

South African doctors work to rule

Dissatisfied public service doctors in South Africa's most populated province, Gauteng, went on an effective work to rule, forcing the closure of casualty departments and emergency services after hours in many hos- pitals throughout the province. It is the first time doctors in South Africa have carried out industrial action. Many of the areas affected serve the province's poorest residents, who rely on state hospitals for their In Britain, relatives are not usually allowed into the resuscitation room

BMJ VOLUME 313 12 OCTOBER 1996 899 Halfof German doctors were Nazis

The 24 doctors and public health officials who faced trial as war criminals at Nuremberg 50 years ago this summer were neither demented nor unwillingly coopted by the Nazi regime, Dr Michael Grodin told a conference organised by the University of Pennsylvania's centre for bioethics last week. Dr Grodin, professor of medical ethics at Boston University and author of The Nazi Doctors and the Nuremberg Code, said that, unlike other war crimes in which it was diffi- cult to determine precisely who had been responsible for which crimes, there was clear evidence to link doctors with specific instances of murder, torture, and grotesque experiments. For example, they had carried out high altitude experiments that resulted in patients' lungs exploding, and patients had frozen to death after induced hypother- "German doctorsfailed to challenge Nazism," said Professor Robert Proctor mia. Half of the German medical profession was active in the Nazi party, Dr Grodin said, pages oftranscripts seven ofthe accused doc- pass a special examination to allow them to and the hundreds of thousands of victims tors were hanged, five received life sentences, practise as general practitioners or specialists. owed their fate to a meshing of medical sci- four were sentenced to between 10 and 20 But the quota was lifted after the Human ence and Nazi ideology, an ideology that ven- years in prison, and eight were acquitted. Rights Commission found that it was dis- erated Aryan purity and viewed as subhuman Most of those imprisoned were free after 10 criminatory. The government later won an and "dispensable" mentally retarded or years. Few of the victims or their families appeal against the ruling in the Federal physically handicapped people, homosexu- were compensated.-DAvID WOODS, medical Court, but the quota was not reintroduced. als, gypsies, and Jews. journalist, Philadelphia The Australian Doctors Trained Overseas The conference, mounted to mark the Association has already condemned plans to anniversary of the Nuremberg hearings, was bring the quota back. But the head of the titled "The Nazi medical trials: a legacy of Australian Medical Students Association, horrors." Among the atrocities were inducing Australia to Ms Sarah Whitelaw, said that she supported diseases such as spotted fever and malaria, the review of the quota system if it was biopsying liver without anaesthesia, force reintroduce quotas an alternative to restricting access to the feeding sea water, sterilisation, and testing provider numbers. "Given that Dr phosphorus and mustard gas. The 10 point on foreign doctors Wooldridge's agenda is to decrease the num- code that came about as a result of the trials ber of doctors, we've said to him if that's called for voluntary consent as the paramount what you want to achieve then your first criterion for research on human subjects. Australia's medical students have backed option has to be to reduce the number of Part of the defending doctors' defence plans to reintroduce quotas for the number overseas trained doctors coming and obtain- was that those on whom the experiments of foreign doctors who can practise in the ing Australian medical registration," she said. were conducted were prisoners and doomed country. But they remain unhappy about Dr Michael Wooldridge said that the to die anyway; that exceptional circum- the government's planned restrictions on the reforms, to restrict those doctors able to bill stances led to exceptional acts; and that number of doctors who can claim under the under the Medicare system, would start in experimentation on the few might lead to Medicare system. November. The government wants to cut to new knowledge and cures for the many. Prime MinisterJohn Howard has said that 400 a year the key general practice "provider In fact, said Robert Proctor, professor of there will be a review of the quota system as numbers" that new doctors need to work the history ofscience at Penn State Universi- part of the government's plans to reduce within the Medicare system. The numbers ty and author of Racial Hygiene: Medicine costs in the federal Medicare health service. were previously given automatically on com- under the Nazis, the atrocities were conduct- Health minister Dr Michael Wooldridge was pletion of a year in the hospital system. ed against a backdrop of respectable public more forthright. "If you are a doctor living Medical students say the plan, which will health initiatives, such as screening for tuber- overseas and iing ofcoming to Australia, save $A570m (C285m) could mean that culosis, free gynaecological examinations, by all means come but don't ever expect to about 500 graduates a year will end up "on powerful attacks on the evils of tobacco and practise on Medicare," he said. the scrapheap." Dr Todd Eggleton a 26 year alcohol (Hitler neither smoked nor drank), Last year almost 1200 overseas trained old Sydney intern said that he felt cheated by and the first studies linking smoking and lung doctors were allowed to practise in Australia, the federal government's ruling which would cancer. But the atrocities, he said, were part which is about the same as the total of med- deny him a job after seven years of training. of a "homeopathic paranoia"-a desire to ical students graduating. The government's "The government is targeting the innocent cleanse the German Volk of all impurities move on quotas came after medical gradu- people in the medical system who have not and health threats, including contamination ates demonstrated around the country created the cost problem," he said. by "undesirable" elements in society. against plans to restrict the number of new But the spokeswoman for health minister Professor Proctor said that German physi- doctors who could claim under the govern- Dr Wooldridge said that overseas doctors cians failed to challenge "the rotten core of ment's Medicare system. They want doctors would also be hit by the restrictions on

Nazism ... there was no speaking out, no from abroad to be tightly controlled to provider numbers and trainingplaces. "To say resistance, no sabotage," although there were reduce the oversupply ofdoctors in Australia, we are favouring the position ofoverseas doc- written codes of ethics proscribing experi- which is estimated to be 5000. tors over Australian doctors in not true," she ments on dying people and on children. Until last year there was a quota of200 on said.-CHmSTOPHER ZINN, Australian corre- After 139 days of hearings and 11 500 the number of foreign doctors who could spondent, Guardian

900 BMJ voLUME 313 12 OCTOBER 1996 Flu jab cuts hospital New Zealand's voters admissions by two focus on health thirds Health has been the issue of most concern to New Zealanders in the run up to today's Influenza vaccination can reduce hospital (12 October) general election. Media polls admissions for pneumonia, influenza, bron- consistently found that health -was cited as chitis, and emphysema by around 60%, the electorate's single biggest anxiety even according to new research. among government supporters. The data were presented earlier this week After five years of health restructuring, at the Department of Health's launch of its New Zealanders' perception of the health Flu Awareness Campaign, where Sir Ken- system is one oflonger waiting lists and fewer neth Calman, the chief medical officer, reit- services and hospitals than that which the erated the importance of vaccination for presentNational govemment inherited in 1990. patients at high risk. He said that the vaccine In 1991 the National party set in place a should be given to people regardless of age massive overhaul of the health system, intro- who have a chronic heart or chest complaint, i ducing accountability and creating a pur- chronic kidney disease, or diabetes or who i chaser-provider split and a contractual basis have lowered immunity. In addition, people for all providers of care, both primary and in residential or nursing homes, where z secondary. influenza can spread quickly, should also be Flu vaccination protects within days These changes have been immensely vaccinated. unpopular with the public and health profes- DrJon Van-Tam, lecturer in public health sionals alike. The cost of introducing medicine and epidemiology at the University state sector and partly in private practice. accountability is an administrative system Hospital in Nottingham, presented the Most of the doctor's fee in private practice is 40% larger than before. Waiting lists for pro- results of his case-control study, which is to paid directly by the patient, with around one cedures in public hospitals are up by 50% be published shortly in the journal Epideniology sixth claimed back through direct reimburse- on 1992 figures, and spending on health and Infection. He compared adults admitted ment from the national health service. It is per head has decreased from $NZ1459 to hospitals in Leicestershire between 1 this contribution which the department of (£651;$868) in 1989 to $NZ1395 in 1995. December 1989 and 31 January 1990 who health proposes to abolish. There are still 94 000 people waiting for had a diagnosis on discharge of pneumonia, The measure aims to save the Norwegian treatments in a country with a population of emphysema, influenza, and bronchitis with state Krl50m (J15m; $20m), which is to be just 3.5 million. As a result halfthe population matched controls. redirected into the public health system. It is now holds private health insurance. The likelihood ofbeing admitted to hospi- also intended to keep state employed doctors But the electorate faced a difficult deci- tal was twice as high as baseline in patients in within the public sector. sion on how to vote at this country's first the high risk groups. But the study found that "This amounts to a declaration of war," election held under a proportional represen- hospital admission was reduced by 63% in said Dr Leif Ness, a surgeon from Ulleval tation system. The high degree of concern the patients who had received influenza vac- Hospital near Oslo. Dr Sverre Strand, head about health suggests that people would vote cine. "This clearly shows the importance and ofthe Norwegian medical association's nego- for opposition parties with different health efficacy of flu vaccines for those at higher tiating department, described the move as policies, but health workers in particular are risk," said Dr Van-Tam. "If we extrapolated "just another tightening of the screw." worried about having to go through yet this finding influenza vaccination would have According to Dr Ness, doctors have suffered another overhaul of the health service. prevented between 40 and 45% ofthe admis- a significant drop in relative salary over the The government has not been helped by sions we encountered, which has obvious past 10 years. A typical hospital consultant the former director general of health, Dr cost implications for the NHS," he said. serving a population of 870 000 currently George Salmond, who has been criticising A second study also reported at the earns a basic salary of £35000 ($52 000) a the reforms, saying the New Zealand health launch showed that the protection given by year in the national health service, and many system can no longer be compared with that influenza vaccination is achieved quickly, rely on working overtime in private practice of Sweden or Denmark: "It's the level of with an effective titre of antibodies against to supplement this income. health care provided in Turkey and Greece. the virus present within a few days of vacci- Overtime in private practice typically That's what we can actually afford." nation.-JACQUI WISE, BMJ accounts for around 40% of a the income of The three main opposition parties that a health service doctor at present. Local gov- look likely to form a coalition government ernments, or kommuner, which own many of each promises to scrap the commercial mod- the hospitals, would prefer that doctors work el on which the National party's reforms are Furore in Norway overtime in the public sector, but many based, although quite what it would be decline on the grounds that overtime pay- replaced with is less than certain. over private practice ments are inadequate. An hour's overtime Most opposition parties want health for a health service consultant currently spending increased and the gradual moves clampdown attracts just £40, compared with the £60 to towards increasing privatisation of the sec- £70 he or she was used to receiving in the past. ondary sector halted. Opponents of the The new legislation, if ratified, may lead reforms claim that the long term goal is to Norwegian doctors are bitterly opposed to a doctors to resign their contracts in the completely privatise the hospitals. Already government proposal to stop public sector national health service, according to Dr many health services previously conducted reimbursement for consultations and treat- Nass. Alternatively, they may demand that by public hospitals have been tendered out to ment carried out in private practice. the whole of the private fee be met by the private sector. As a result public hospitals In a discussion document published last the patient, which is not in patients' interests, lose staff and morale through a fall in the Friday the secretary of state for health Gud- he says. number of services they are left providing. mund Hernes proposed that doctors primar- The proposal has been announced as part The government has done little to allay ily employed in the national health service of the autumn budget proposal to be put fears of privatisation, merely stating that the should lose their right to reimbursement for before parliament. This makes it likely that it public health system will always be available such treatment. will be ratified since the Krl50m it saves for emergencies and for those who need The group that will be hardest hit are hos- would otherwise have to be found from other it.-CARmEL wnILiAms, freelance journalist, pital specialists who work partly within the sources.-SANDRA GOIDBECK-WOOD, BMg Auckland

BMJ voLuME 313 12 OCTOBER 1996 Prozac linked with turely and more than twice as likely to be (Reproductive Toxicology 1996;1O:285-94). admitted to special care nurseries. "They Dr McElhatton pointed out that the new minor birth defects also showed nearly nine times the incidence Californian study has several methodological ofpoor neonatal adaptation, including respi- problems. "It is a non-randomised study and ratory difficulty, cyanosis on feeding, and jit- does not exclude depressive illness as a con- Babies born to women taking the antide- teriness," reported the authors. They founding factor in the observed association," pressant fluoxetine (Prozac) in the third concluded: "These data suggest that ifpreg- she warned. trimester of pregnancy may be at increased nant women are unable to discontinue flu- The timing of telephoning the informa- risk of minor abnormalities but show no oxetine therapy before the third trimester, tion service was the only criterion used to increase in major problems, suggests new the risk of perinatal complications is match subjects with controls. Women with research. increased." queries about taking fluoxetine were Researchers from the University of Cali- The findings were unexpected as previous matched with those who called at a similar fornia found that the incidence of three or studies have failed to show teratogenic time with queries about other types of drug more minor anomalies occurred in more effects with antidepressants. The European during pregnancy. "Maternal age was also than twice as many babies born to women network of the Teratology Information Ser- higher in the fluoxetine group, which may taking fluoxetine (15.5%) than in controls vice published research earlier this year eval- partly explain the excess of poor perinatal (6.5%). However, the rate of spontaneous uating data on 689 pregnancies in which outcomes," she suggested. pregnancy loss and of major structural exposure to tricyclic and other antidepres- Channi Kumar, professor of perinatal anomalies was the same in both groups, sants, including fluoxetine, had occurred. psychiatry at the Institute of Psychiatry in according to the research published in Analysis showed that 97% of babies born London, said: "The ideal strategy for man- the New England Journal of Medicine live to the women included in the study were aging women suffering depression during (1996;335: 10 10-5). morphologically normal. pregnancy is obviously to avoid medi- The results came from analysing preg- Long term antidepressant treatment, usu- cation if possible, giving psychotherapy and nancy outcomes in 228 women taking ally in association with multidrug treatment, support." fluoxetine who contacted the California Ter- was associated with neonatal withdrawal However, if these fail, drug treatment is atogen Information Service and in controls symptoms in a small number ofinfants. "But generally required. "There have been few who had telephoned the service with queries overall, no causal relationship could be signs of teratogenic problems with tricyclic about other drugs. established between in utero exposure to antidepressants. However, if a patient is Problems were found to be most com- antidepressants and adverse pregnancy out- already on a drug such as fluoxetine it is mon in infants exposed to fluoxetine during come," concluded author Dr Patricia McEl- probably best to carry on but monitor the third trimester. They were nearly five hatton, from the National Teratology very carefully," he added.-susAN MAYOR, times more likely to be delivered prema- Information Service, Newcastle upon Tyne medicaljournalist, London

Focus: Sydney

Shooting the messenger

New South Wales's two teaching hospitals compared with seven sake ofa less privileged hospital is unthinkable. health minister, serving the middle and inner city areas. But this is the biggest medical drama in town. Andrew Refshauge, is Health expenditure per head in two of the Since June, Refshauge has suffered two not likely to forget the outer health districts is about halfthat in the humiliating rebuffs. A decision to all but past few months. He wealthier central city zones, and each year close the inner city St Vincent's Hospital, has endured everything some 80 000 have to travel into central hos- amalgamating it with St George Hospital, but a public flogging pitals for treatment. Traffic the other way is was reversed by the premier after protests; from the opposition, negligible. and a massive redistribution exercise was sections of his own party, truculent hospital The Labor party's charter for social jus- cancelled, with the premier throwing Ref- doctors and their community supporters, tice charter faces its most fundamental chal- shauge a consolation prize of an extra and a media circling round like vultures lenge in these enduring facts. Every second $A34m (JJ17;$25). Moreover, the despair- over carrion. Refshauge is only the second political speech and health department doc- ing medical staff at Nepean Hospital in medically qualified health minister in the ument is double dipped in the rhetoric of Sydney's far west last week passed a motion state's history and a member of the only equity of access and outcomes. But in of no confidence in Refshauge, his premier, Labor government in a country now other- attempting to redistribute resources more and the state health department. When the wise run by Liberals (conservatives), heilbent equitably Refshauge has come up against the intended beneficiaries of your plans join the on steering the country's health system aggressive refusal of the older hospitals to choru baying for your blood, you start to feel toward privatisation. What has he done countenance such redistribution. Nothing very isolated. wrong? Refshauge's troubles stem from his less than more money for all is their bottom In May the federal government raised the unrelenting efforts to resdistribute hospital line and shroud waving their strategy. Medicare levy from 1.5% to 1.7% as a one resources in Sydney more equitably. Night after night Australian television off, temporary, rise to pay for buying back Most of Sydney's population already lives offers high rating medical soaps which rein- semiautomatic guns after the Port Arthur in the grossly under-resourced outer residen- force public expectations of boundless care massacre. Public support for the rise was tial belt, to the west and south west of the and intervention-the "spare no cost or overwhelming, estimated to raise $A500m. city. Projections for the year 2021 show 2.5 effort" subtext beneath every protest about Refshauge is currently being shot as a mes- million living there, 1.25 million in the mid- funding cuts to inner city hospitals. One pro- senger trying to deliver a thoroughly decent dle belt, and only 750 000 in the harbourside gramume is the documentary RPA, about the agenda with wholly inadequate finding. He and inner region. The residents ofthe popu- inner city Royal Prince Alfred Hospital. RPA would do well to spend the next year cham- lous west and south west are of lower socio- follows frantically busy hospital staff and pioning the retention ofthe Medicare rise to economic status and have worse health eternally grateful patients. An episode set deliver a lifeline to an impossible situation.- profiles on almost every indicator than their around a resource rich hospital board mag- SIMON CHAPMAN, associateprofessor ofcommu- inner city counterparts yet are served by only nanimously agreeing to shed funds for the nitzy medicine, Sydney 902 BMJ VOLUME 313 12 OCTOBER 1996