486
Beaujon Hospital abortion centre in Paris refuses to accept
women more than 8 weeks pregnant, even though the law
authorises abortion up to 10 weeks. In Paris and its region,
only a third of abortions are done in public hospitals. The
law stipulates that abortion cannot make up more than 25 %
of obstetric and surgical activity in private clinics. Many
institutions do not declare the excess number of abortions
done; some do them for free whereas others are alleged to
record abortions as some other activity. Thousands of
women go abroad for (late) abortions.
The ANCIC and the doctors at Louis Mourier Hospital
are seeking not only better employment terms but also
permission to do preventive work on sexually transmitted
diseases and research on sterility. The Ministry of Health
has set up a working party to find solutions for the abortion
centres, but political observers wonder if the inquiry will be
halted after the elections in March.
Jean-Michel Bader
Europe: Unrealistic target for bioethics
convention
Only the most optimistic sources in the Council of Europe
are giving much credence to the official line that the
organisation’s European Convention on Bioethics will be
ready for signature by spring 1994. 1995 is a more realistic
prospect. At "the first bioethics summit" in March, 1992,
there had been hopes for completion by the end of that
year. A report summarising progress to date reveals
that barely half the 24 articles in the main Convention
have been discussed by the steering committee (and it
has been the least controversial clauses that have been
tackled).
A stipulation that practitioners should not be required to
carry out a direct intervention that is contrary to their
conscience has been dropped. The present (provisional)
wording on embryo research does not seem to seek
international alignment since it specifies that the 14-day rule
that applies in the UK and Denmark should be the norm
"where research on embryos is allowed by national law".
Similarly, "when states authorise artificial procreation, they
shall take measures to ensure that the child may realise
his/her right to family life". A suggested ban on "the
creation of embryos solely for research" seems to have been
widely supported, but there has been no substantive
discussion on a prohibition on "ectogenesis", asexual
reproduction, and the creation of hydrids.
The draft protocols on medical research, like that on
organ transplants, builds on earlier work by the Council of
Europe in securing agreement on non-binding European
recommendations. In article 3 of the protocol on research-
which cover ethical evaluation-matters are clearly getting
bogged down over issues of whether ethics committee
members "shall be known for their moral values and their
knowledge of ethical problems" (leading scientists who are
notorious adulters, presumably, need not apply ... ).
Articles 4 to 17 have yet to be agreed.
With the organ transplantation protocol difficulties are
being encountered in terms of defining tissues to be covered
by the document’s provisions. By article 4, the draft runs
headlong into the issue of organ removal from deceased
donors, with a multiple choice of drafting options. Articles 5
to 16 have still to be cleared.
Arthur Rogers
Noticeboard
Cancer prevention tomorrow
When first faced with the notion that smoking might explain the
large increase in lung cancer recorded in the UK between the wars
Richard Doll was more inclined to blame the tar on our roads or the
cars on them rather than tobacco. He soon changed his mind when,
with the late Austin Bradford Hill and others, he set up and then
followed up the now famous study of almost 40 000 male British
doctors. That study, like Sir Richard himself, might be thought to
have yielded its best by now but Doll’s 80th birthday tribute
organised by the Imperial Cancer Research Fund proved otherwise.
At a mere stripling of 40 the British doctors’ study is pretty lively
too, and Doll gave those at the Royal Society in London last
Monday an early look at the position by the end of 1991. Doll’s focus
was the cancers caused in part by smoking but the figures for six
very common causes of death in this cohort so far are:
Deaths per 100000
per annum*
*Non-S=non-smokers, Ex-S=ex-smokers, C-S = continuing smokers
( > 25 daily).
In life-table terms the gap between non-smokers and cigarette
smokers was wider for the second half of the study than for the first
20 years. For the 40 years 1951-91 the survival rate to age 70 was
roughly 80% for non-smokers and 68%, 60%, and 50%,
respectively, for those smoking 1-14, 15-24, or 25 + cigarettes a
day.
The International Agency for Research on Cancer has just
launched a 10-year follow-up of diet as a cause of cancer. The
European Prospective Investigation of Cancer (EPIC) will cost
millions of pounds. If 250 000 volunteers are recruited the expected
cancers will number 9000 or so. A decade ago a "best guess" was
that 35% of cancers could be avoided by dietary means. As Dr
David Forman noted, however, the dietary factors established
beyond reasonable doubt formed "a pitifully small list". In the
developed world gastric cancer is already in decline. Overviews of
45 published studies tell us that the relative risk falls to 0-4-0-8 with
the intake of fruit and vegetables and rises to 1 4-2-0 with salted
foods. The LJK National Food Survey for 1991 contains figures for
fresh fruit consumption since 1942; it trebled, but fruit may not be
the whole explanation for the fall in deaths from carcinoma of the
stomach. For two other candidates for the dietary prevention
approach-namely, bowel cancer (more fibre) and breast cancer
(less fat}-the evidence is far from clear. The seven-countries EPIC
study, with diets ranging from north European haggis to southern
hummus, looks far more difficult than the British doctors’ one.
David Sharp
Vasectomy and prostate cancer
Two cohort studies1,2 reported this week indicate that the risk of
prostate cancer increases after vasectomy and with interval since the
operation. Together they looked at over 73 000 men. In the Health
Professionals Follow-up Studyl vasectomised men had an age-
adjusted relative risk of prostate cancer of 1-66 (95% CI 1 15-2 21).
The risk was 1 -85 (1-26-2-72) among those who had undergone the
operation at least 22 years previously. In the Nurses’ Health Study2
the age-adjusted relative risk of prostate cancer for vasectomised
men was 1-56 (1-03 to 2-37) overall and 1-89 (1-14-3 14) for those
who had had their vasectomy at least 20 years previously. In neither

study was the risk influenced by factors such as detection bias or by
diet or a range of potential risk factors.
Questions about the long-term safety of vasectomy raised by
these reports could reduce the acceptability of this form of family
planning, relied upon by about 42 million couples worldwide. An
accompanying editorial3 points out that, although the studies were
well designed and analysed and that the association is unlikely to be
due to chance, it is not clear whether the relation is causal. Prostate
cancer develops in about 1 of 11 men in the US, and most of those
affected would not have undergone vasectomy. In neither study was
the primary purpose the evaluation of vasectomy as a risk factor for
prostate cancer. The editorial also says that the most likely
non-causal explanation for the findings is unmeasured
confounding. Since the causes of prostate cancer are unknown, it is
impossible to be sure that true risk factors were equally distributed
between vasectomised and control groups, a point supported by the
finding that in the Nurses’ Health Study the vasectomised group
had a lower total mortality rate than did the controls. The editorial
further points to the weakness of the association, the arguable
degree of consistency among epidemiological studies of the relation
between vasectomy and prostate cancer (the three other known
cohort studies have not shown an association), and the doubtful
plausibility of the biological explanations that the authors of the two
papers offer for the association. The editorialists believe that the
conclusions of experts convened by the World Health Organisation
in 1991 still hold-ie, that, on the basis of existing biological and
epidemiological evidence, a causal relation between vasectomy and
prostate cancer was unlikely and that no changes in family planning
policies concerning vasectomy were justified.’ However, they say
that existing information on the risk ought to be included in
presterilisation counselling and that men aged 50-70 who have had a
vasectomy should consider annual checks for prostate cancer.
Officials from the WHO Human Reproduction Programme have
issued a statement reiterating many of these points and drawing
attention to the up to a fifty-fold lower annual incidence of prostate
cancer in developing countries compared with that in some parts of
the USA. They also say that the association observed in the USA
has yet to be established in developing countries. WHO-supported
studies are underway, the pilot studies are being conducted this year
and the main study, case-control in design, is expected to start next
year. Family Health International likewise emphasises the
differences between the USA and developing countries.
Vivien Choo
1. Giovannucci E, Ashcheno A, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. A
prospective cohort study of vasectomy and prostate cancer in US men. JAMA
1993; 260: 873-77.
2. Giovannucci E, Tosteson TD, Speizer FE, Ascherio A, Vessey MP, Colditz GA. A
retrospective cohort study of vasectomy and prostate cancer in US men. JAMA
1993; 269: 878-82.
3. Howards SS, Peterson HB. Vasectomy and prostate cancer. Chance, bias or a causal
relationship? JAMA 1993; 269: 914-14.
4. Anon. Vasectomy and cancer. Lancet 1991; 338: 1586.
in
Postgraduate training developing countries
All developing countries find it difficult to attract their doctors to
serve at district-level (cottage) hospitals, where they are most
needed. Awarding an "acceptable" postgraduate degree after
training in hospital-based general practice is one solution that would
also improve quality of care. Nepal began tentatively back in 1982,
with help from the University of Calgary and the Canadian
Government, and with candidates being trained partly overseas and
partly at home. From 1991 all training has been in Nepal. The
three-year programme for 8 trainees a year takes place mostly in
Kathmandu, but also at a non-governmental organisation (NGO)
district hospital in a distant town and in a more rural government
outpost. The final qualification-the MD, GP-will be given the
same status as other postgraduate degrees.
Dr S. K. Gupta and his colleagues in charge of this project
(Tribhuvan University, Kathmandu) hosted an international
conference on Feb 1-4 on The Role of General Practitioners in
Developing Countries-Training and Utilisation for District
487
Health Services. It was a bold venture for a small country, and the
theme broke new ground. One Nepali doctor, who had been 2 years
in one of these remote centres (which can be 8 hours by foot from the
nearest motor road) said, "Being a doctor in such a place is not a
comfortable job; but the advantage of the poor patient receiving care
is always a great reward". Such is the spirit that the MD, GP
programme wants to encourage.
Similar developments in other countries were presented at the
conference. In Nigeria, where general practice embracing both
family doctor and district hospital work has been recognised as a
specialty since 1970, postgraduate training for a Fellowship of the
National Postgraduate Medical College, in General Practice, began
in 1981, and 37 have qualified. Many now serve in small rural
townships. In Malaysia, the good training programme run for
several years by the private general practitioners of the Malaysian
College of General Practice, in association with their Australian
counterparts, has not received government approval. However, the
importance of the discipline has been recognised and the
Government and university plan to train general practice specialists
for the public service, through a 4-year programme leading to a
Masters degree. In India, where general practice is not recognised as
a specialty by the Government, the Christian Academy of Medical
Science, encompassing three medical colleges, has started
postgraduate training for what they call the "multispecialty"
specialty, since the name "general practice" is not acceptable. The
aim, too, is to prepare competent doctors for positions of leadership
in rural hospitals. And in Zambia there are plans for the MMed
(District Hospital Specialist) programme (see Lancet Jan 16, p 168).
Some kind of networking between programmes of the types
described above might be an outcome of the conference. The
participants hoped that WONCA, the world organisation of GPs,
would take note of the needs of that branch of the discipline.
C. Andrew Pearson
Source of listeriosis outbreak in France
The listeriosis outbreak that affected 279 people in France
between March and December, 1992, and caused 63 deaths and 23
abortions, was caused by pork prepared in "jelly". A case-control
study done by the Direction Générale de la Sante showed that
45-6% of people affected had taken pork tongue in jelly. 12 000
pathogenic listeria strains were isolated in dairy milk cooperatives,
delicatessen plants, patients’ refrigerators, and supermarkets, but
only the epidemic strain was isolated from pork tongue. The
epidemic strain was also found in 203 other foods (mainly ham,
pates, delicatessen foods in jelly, and some cheese).
Jean-Michel Bader
British Medical Bulletin at 50
It is strange which present-day publications owe their origins to
the 1939-45 war. The Lancet’s In England Now started off as
accounts, wittily told, of how doctors, nurses, and patients were
coping with the adversities of the time,1 The first appearance of the
British Medical Bulletin, which turns 50 in March, was also brought
on by the war. In 1940, the British Medical Journal and the Ministry
of Information, after discussion with the Medical Research
Council, were stimulated by the perceived need to "counter
misrepresentations made by the enemy" to launch a project that
should have been embarked upon many years earlier.2 The British
Medical Information Service that was then formed at first
distributed, through British Council representatives abroad,
mimeographed lists of abstracts of British papers of medical
interests. The abstracts first appeared under the title British Medical
Bulletin in March, 1943, with a declaration that the objective was
"to provide a guide to medical science and thought in Britain". Now
the Bulletin (published since 1980 by Churchill Livingstone for the
British Council) consists of highly regarded review articles (no
longer restricted to British work), with each of the quarterly issues
being confined to one topic. The value of specially commissioned
review articles had been recognised early, and the first, on medical