The safe sex messenger, views & REVIEWS p 1002

If it was breast (Not) warts and all cancer, there would doubtless be an PERSONAL VIEW Phil Hammond industry supported march on Downing ou’d be mad not to pro- Immunisation is most illuminating. “If the vac- Street, but the tect your daughter against cines were offered at similar prices, then the genital warts lobby genital warts if you can committee recommended choosing the quad- is largely under afford to.” So advised rivalent vaccine, which would protect against BARRY BATCHELOR/PA ARCHIVE/PA PHOTOS ARCHIVE/PA BATCHELOR/PA BARRY cover Peter Greenhouse, a sex- cervical cancer and genital warts,” said a com- “Yual health consultant in Bristol, when I asked mittee statement (www.advisorybodies.doh.gov. in the programme getting Cervarix and most him which human papillomavirus vaccine uk/jcvi/HPV_JCVI_report_18_07_2008.pdf). outside it getting Gardasil. This clearly has the I should choose for my daughter. The NHS The British National Formulary gives exactly potential to undermine the programme (or at vaccination programme may have opted for the same price (£80.50 for each of three injec- least it would if anyone was brave enough to the bivalent vaccine (Cervarix) to concentrate tions) for the two vaccines, so ­GlaxoSmithKline shout about genital warts). resources on preventing cervical cancer, but (GSK), which makes Cervarix, offered a dis- For any licensed treatment, the public (and every doctor I’ve spoken to has chosen the count to undercut Gardasil’s manufacturer, NHS staff) need quick and easy access to unbi- quadrivalent vaccine (Gardasil) for their own Sanofi Pasteur. ased data on efficacy and safety, updated as daughters (and the odd son, though of course I have no issue with this. New drugs are ludi- it emerges. The NHS website would seem to this is off licence). crously expensive, and the NHS deserves credit be a logical gateway for this, but it currently Genital warts are common (100 000 new for beating GSK down. Or perhaps GSK was restricts information about treatments it doesn’t cases in England each year), and the condi- desperate to break into a market dominated in wish to fund. Vaccination programmes have a tion is on the rise, particularly among young most other developed countries by Sanofi Pas- coercive flavour, but some parents, quite legiti- people: in women 60% of cases occur in the teur. The size of the discount is “commercially mately, may want to delay vaccination until 16-24 years age group. They don’t kill you, but confidential,” said my MP, Dan Norris. I asked more comprehensive safety and efficacy data they can kill your sex life, and in some people him about this because I wanted to “top up” emerge (http://content.nejm.org/cgi/content/ they can be recurrent and extensive. The health the difference so that my daughter can have full/359/8/861). Others simply don’t trust data minister Dawn Primarolo claims that warts are Gardasil with her classmates, within the NHS presented and controlled by drug companies. “preventable,” but meticulous condom use cuts programme. But this choice, apparently, is not They should not be made to feel guilty if they transmission of the human papillomavirus by allowed. decide against vaccination. only 50%. A far safer option is to vaccinate. Parents who choose Gardasil will almost cer- I have worked in sexual health and seen The NHS Choices website (www.nhs.uk) tainly have to pay privately for it. The going plenty of people whose warts have been suc- promotes Cervarix but doesn’t return a single rate in local general practices seems to be £350 cessfully treated. I’ve seen others with exten- hit for Gardasil. Having chosen one vaccine for to £400. We can (reluctantly) afford this, but sive, recurrent warts that need prolonged and us, the government has decided we don’t need many parents can’t. My primary care trust fiddly treatment and florid anogenital warts that information about another that could prevent allows those in the vaccine programme to have resisted just about every treatment. We’ve opted 90% of warts (as well as 70% of cervical cancer). Gardasil if there is “a specific clinical need,” to pay for Gardasil. Unlike the Blairs I’m happy Those administering Cervarix at my daughter’s without defining what this means. For girls to go public about vaccination of my children. school offer no information about Gardasil. who are particularly at risk of genital warts (for I tell parents what vaccine we’ve chosen if they Whatever happened to informed choice? example, those with type I diabetes or exten- ask me, and I’ve written about it in Private Eye. The NHS vaccination site (www.immu- sive verrucas or hand warts) or skin conditions If it was breast cancer, there would doubtless nisation.nhs.uk) is also a Gardasil free zone. that make genital warts particularly unpleasant be an industry supported march on Downing An editorial in Sexually Transmitted Infections (such as extensive psoriasis or eczema), it seems Street, but the genital warts lobby is largely (2008;84:251, doi:10.1136/sti.2008.032755) unethical not to offer them Gardasil. And how under cover. There are no letters to the Times, describes the government’s decision as “a long will it take for a woman with warts to sue and warts have never made it to the cover of sad day for sexual health.” The decision also the NHS for not offering her the choice? Doc- the Mail. But go to www.chestersexualhealth. doesn’t seem to make long term economic tors are supposed to use clinical judgment in co.uk/genitalwarts.htm to see what we could sense. Within three or four years, the editorial individual cases, but the pressure to reduce be preventing. says, the use of Gardasil “would begin to have prescribing costs is relentless. Phil Hammond is a general practitioner, writer, and a big financial payback, as the current estimate The cheap GSK deal for Cervarix applies broadcaster [email protected] of treating genital warts in England every year only to vaccines in the programme. Outside Competing interests: PH has been paid to speak at dinners is £23 million [€30m; $40m].” the programme many doctors will recom- by many drug companies (including GSK and Sanofi So why did the government opt for ­Cervarix? mend Gardasil, because of the extra protection Pasteur) and NICE. The Joint Committee on Vaccination and it offers, so we may end up with all women Cite this as: BMJ 2008;337:a2186

BMJ | 25 OCTOBER 2008 | Volume 337 999 VIEWS & REVIEWS

A capital idea

FROM THE I handed over my Visa card. The assistant disap- sive, new “quality assured” NHS call centres, with FRONTLINE peared, and the queue grew long and noisy. I twitched. the same sweet apologies about the volume of calls, “Sir, your card has been refused,” he said, confiscating illogical menus, and, eventually, a tick list medical Des Spence the card. I flushed. I was a young and stupid student, algorithm that always seems to end in “call a 999 so why had the bank given me the credit card? ambulance.” Traditional local general practices are From a red call box in the dark driving rain I under threat of closure from shiny new polyclinics phoned my bank manager in Orkney. He knew whose smart managers have implausibly impressive me—his son had been in my class at school. Over the titles and who are driven by short term targets. Cot- crackling line he gave me a thunderous rebuke on tage hospitals and district general hospitals continue conservative fiscal management. He assessed the risk, to disappear. lent me the money, and saved me from being placed We see the rise of superspecialists and the end of on the credit blacklist. I still use the same bank: loyalty the consultant generalist. Doctors are left no longer has no price. knowing their patients or the community and are But these days I can no longer phone my branch in therefore unable to assess risk. Uncertainty is sold on Orkney. Instead I spend hours listening to a panpipe through the medical derivatives market of more refer- version of Copacabana only to be passed to a call centre rals, feeding yet more medical demand and the hugely in Delhi to be asked for a long forgotten password. Or indebted public finance initiative projects. This is a I am sent endless letters for loans “for any purpose” or medical expansionist bubble. seductive glossy pamphlets offering a limitless plati- When the bubble bursts we will be left with junk num credit card because of “my high status.” But I NHS bonds. The time has come for a return to old have long learnt my lesson with credit cards. Gone, fashioned medicine and conservative and restrained it seems, is personal judgment; and knowledge of the medical practice. Above all, we need to regain the customer has been replaced by tick list credit rating. ability to evaluate whether an individual can afford Now, however, banking has come unstuck as a result the personal costs and risk of medical interventions. of feckless lending and greed. These days the talk is Des Spence is a general practitioner, Glasgow of a return to “old fashioned banking.” [email protected] Medicine has seen similar changes. We have expen- Cite this as: BMJ 2008;337:a2203

Saving lives OUTSIDE THE BOX The other day I gave a careers would you save in a week?” throats or sore knees to whom Trisha Greenhalgh talk at a local school. A boy I explained that those stories I’ve said, “Let’s just check your came up to me afterwards and were from a previous life as a blood pressure while you’re said, “Miss, have you ever saved hospital doctor and that I didn’t here”? Or the countless smokers anyone’s life?” save many lives now as a who have left my consulting “Of course,” I replied. “I’m a general practitioner. He was room with a dose of what is doctor. Saving lives is my core disappointed, so I recounted how known in the literature as “brief business.” I had once spotted the rapidly advice”? Or those interminable “Tell me about some,” he spreading rash of meningococcal diabetes clinics where I’ve pleaded. septicaemia and given the urgent worked with patient after patient I picked some stories to shot of penicillin and another time in an effort to align the medical entertain and inspire the lad. I called a “no delay ambulance” ideal of “tight control” with the told him of shocking someone for a pregnant woman with lived reality of work and family out of ventricular fibrillation advanced pre-eclampsia: two life? when carrying the cardiac arrest lives saved. And I told him about It’s 25 years since I qualified as bleep; the hypovolaemic teenage administering adrenaline and a doctor. Depending on how you victim of a road crash I managed hydrocortisone to a patient with define “saving a life,” my personal to get a drip into; and the anaphylactic shock. tally amounts to fewer than a woman gasping with pulmonary Afterwards I wondered why dozen in my entire career—or oedema who responded within I had chosen all these heroic several thousand. seconds to my syringe of examples. What is it, to “save a Trisha Greenhalgh is professor of primary frusemide. life”? Why did I not tell him of the health care, University College London “I’d like to do that,” he said, hundreds of middle aged people [email protected] with shining eyes. “How many attending with sore Cite this as: BMJ 2008;337:a2202

1000 BMJ | 25 october 2008 | Volume 337 VIEWS & REVIEWS

Medical Classics Victorian values Diseases of the Heart and Circulation We all dislike emo- so strong an effect on By Paul Wood First published 1950 tional shocks, of course, BETWEEN Sir John that he falls As a senior house officer at the Royal Brompton Hospital but it seems that only THE LINES immediately into a in 2005 I came across several exceptionally detailed in Victorian novels Theodore Dalrymple swoon; Dr Empson is records of examination findings dating back to the 1950s. are they regularly fol- called, and the inevi- These entries were by the late Paul Wood. My subsequent lowed by “brain fever” table happens: “His inquiries helped me discover Diseases of the Heart and Circulation, the legacy of one of the greatest names of lasting several weeks. [Dr Empson’s] verdict British cardiology. Born in India in 1907, Wood attended Pip in Great Expecta- was sufficiently grave: medical school in Australia. He was house physician at tions and Catherine in John was suffering the Royal Brompton before becoming a consultant in the Wuthering Heights both from a sharp access late 1940s. Wood was a master of clinical cardiology, get it, and for a time it of brain-fever; his renowned for his extraordinary bedside examination is touch and go with condition afforded skills and diagnostic powers. them whether they will cause for alarm; he He first published Diseases of the Heart and survive. It sometimes [Doctor Empson] Circulation in 1950. He was not fond of anatomy but was fascinated by cardiovascular physiology and was seems as if no Victorian could not answer for thus greatly motivated by the recently discovered novel is quite complete any turn his sickness cardiac catheterisation. This allowed him to investigate without a bout of brain might take.” and corroborate his clinical suspicions with precision. fever. Although Sir John Much of Wood’s own experiences in day to day practice Sir John Maltravers, But were all cases of recovers, he is never inform the book, and many passages are written in in J Meade Falkner’s brain fever in Victorian quite the same again. the first person. The clinical deductions he was able to The Lost Stradivarius, novels encephalitis? His personality has make in the days before tests such as echocardiography were available are astounding. Much of the text is still published in 1895, has The current incidence in changed: he is not relevant today. He realised that the decisive factor in a fairly typical bout of Britain is four cases per so much in love as surviving cardiac arrest is the speed with which chest this fell disease. Falkner 100 000 people a year, he was, becoming compressions are started. He avidly describes the (1858-1932) was a man whereas the incidence in inattentive and even difficulties of treating bradycardia-tachycardia syndrome, of parts, perhaps the Victorian novels must be cruel towards his fian- so easily dealt with today by pacemakers. He explains only chairman of a many, many times higher cée and later wife; at great length the foods that are “permitted, doubtful, major arms manufac- he is distracted and or forbidden” in heart failure and in fact dedicates four turing company (Arm- distant even from whole pages to this exhaustive list. He advocates the use of olive oil in cooking rather than butter and the strong Whitworth) also to have achieved his friends; and he is preoccupied by the importance of a low sodium diet. some literary prominence as a novelist. life of Adrian Temple to the exclusion of For me the book’s highlight is the first chapter on history He was an antiquarian, too, and really ­everything else. taking—one of the most astutely written passages of rather preferred mediaeval manuscripts Was his brain fever viral encephalitis, medical text I have come across. Wood highlights the to machine guns, receiving a medal from with subtle after effects? Falkner wants us fact that answers often reflect the way questions are the Pope for his researches in the Vati- to believe that his change of personality framed and insists on thorough cross examination of all can library. He collected a very valuable was of supernatural cause, effected by the answers. An example of his level of attention to detail library himself. evil spirit of Temple, but we doctors know was his classification of The clinical haemoptysis in mitral The Lost Stradivarius is a Gothic ghost that it was really organic in origin. deductions Wood was stenosis into five distinct story. As a student at Oxford the protago- But were all cases of brain fever in able to make in the categories: the sudden nist, Sir John, is a keen musician; in his Victorian novels encephalitis? The cur- days before tests such profuse haemorrhage rooms, hidden behind a bookcase, he finds rent incidence in Britain is four cases per of pulmonary apoplexy; a lost Stradivarius that once belonged to 100 000 people a year, whereas the inci- as echocardiography blood streaked mucoid Adrian Temple, an ancestor of his fiancée dence in Victorian novels must be many, were available are sputum as a result (who is destined to die of puerperal fever many times higher. Perhaps encephalitis astounding of winter bronchitis; later in the novel). was much more common in those days, blood stained sputum of paroxysmal cardiac dyspnoea; pink frothy sputum Now this Adrian was an evil man, tal- however. And the question remains to be complicating pulmonary oedema; and frank haemoptysis ented but dissolute and completely amoral, answered as to whether a severe emotional from pulmonary infarction. whose shade is called up every time Sir shock, or state of stress, renders someone The book was an instant hit, and a second edition John plays a certain piece of 18th century susceptible to viral encephalitis. It is easy followed in 1956. Tragically Wood died prematurely after Italian music. One night, at the Temple enough to find research on postencepha- a heart attack in 1962 while working on the third edition. ancestral home, Sir John catches a glimpse litic effects on the state of mind but more He analysed his own electrocardiogram and knew his of a portrait of Adrian Temple (by Pompeo difficult to find research on pre-encepha- fate. What might Wood have made of today’s practice of percutaneous revascularisation, which could have dealt Battoni, the Italian painter who specialised litic states of mind. with his single coronary thrombosis? in portraits of Englishmen on the Grand Could so many Victorian novelists have Benoy N Shah, specialist registrar in cardiology, Poole Tour and who was recently the subject of been wrong? General Hospital, Poole, Dorset [email protected] an exhibition at the National Gallery) by Theodore Dalrymple is a writer and retired doctor Cite this as: BMJ 2008;337:a2125 the light of a flash of lightning. This has Cite this as: BMJ 2008;337:a2230

BMJ | 25 OCTOBER 2008 | Volume 337 1001 VIEWS & REVIEWS

review of the week The safe sex messenger A documentary profiling the work in the 1980s of safe sex warrior Richard Berkowitz is still highly relevant, finds Khalid Ali

Sex Positive London Film Festival, 27 October, National Film Theatre, London www.bfi.org.uk Rating: ****

With the resurgence of HIV and other sexu- ally transmitted diseases in the United King- dom, Sex Positive is a timely documentary about Richard Berkowitz, one of those who pioneered the safe sex message to the gay community in the United States in the mid- 1980s. Studies in the past two years show that HIV transmission is on the rise again and that, among men who have sex with men, those who know they are HIV positive are more likely to indulge in risky sexual behav- Richard Berkowitz: his safe sex message was misinterpreted iour than those who are not infected or those who don’t know their HIV status (Sexually A chance encounter in a sexually trans- In the midst of this hostility he wrote Transmitted Infections 2007;83:392-6; AIDS mitted disease clinic with the virologist and How to Have Sex in an Epidemic, a 2008;22:1063-70). microbiologist Joseph Sonnabend was a revolutionary pamphlet thought Berkowitz, a former hustler who special- turning point. Sonnabend persuaded him to be the first community driven ised in sadomasochism, is interviewed along- that sexual promiscuity promoted HIV side fellow gay activists from the 1980s, HIV transmission. Berkowitz, Sonnabend, and publication advocating safe sex researchers, patients, and porn stars. They the singer and gay activist Michael Callen talk about the turbulent times at the begin- then started to campaign among the New Berkowitz continued to be marginalised and ning of the HIV epidemic in the US, when York gay community to raise awareness of ridiculed by the gay community. His former misinformation was rife about the causes and HIV. Sonnabend publicised the “multifac- job was used to discredit him: his antagonists routes of transmission. Berkowitz speaks can- torial theory” that AIDS was caused by a cried out that “a former S&M hustler cannot didly about being a liberal Jew from a work- combination of infection with more than dictate the ethical agenda for the future of ing class family coming out as a gay man in one virus and an underlying susceptibility gay men.” a conservative environment. From his col- to the disease modified by lifestyle factors The film also tackles the issue of the dura- lege days in New Jersey he was involved in such as diet, drug use, and multiple sexual tion and effects of antiretroviral treatment. organising marches against homophobia. In partners. Berkowitz appeared on national People with HIV describe the pressure put a dramatic turn of events he became a com- US television condemning the lifestyles of on them by health professionals and gov- mercial sex worker. many gay people, thus antagonising the gay ernments to start treatment as soon as pos- community, which labelled him a self hating sible. It is now known that the lifespan of gay man with a “sex negative” attitude. He HIV positive patients is approaching that of was quoted as saying that “people deserve the general population (JAMA 2008;300:51- to have the disease as they brought it upon 9), but at what cost? The film argues that themselves” and calling for “a quarantine for antiretrovirals generate a false sense of secu- gay men.” rity, encouraging more risky sexual behav- His stance was interpreted by some as a iour, despite the fact that unprotected anal call for the federal government to stop fund- intercourse with multiple partners and drug ing research into HIV. Amid this hostility he use is associated with a higher risk of HIV wrote How to Have Sex in an Epidemic, a revo- seroconversion (Sexually Transmitted Infections lutionary pamphlet thought to be the first 2008;84:8-13). “Be safe and alive” was (and community driven publication advocating still is) Richard’s motto, and it rings as true safe sex. But his safe sex message was mis- today as it did back in the 1980s. interpreted by some as advocating celibacy Khalid Ali is a senior lecturer in geriatrics, Brighton and or monogamy. Even after his book Staying Sussex Medical School [email protected] Alive: The Invention of Safe Sex was published, Cite this as: BMJ 2008;337:a2235

1002 BMJ | 25 october 2008 | Volume 337