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inappropriate activity, and to heed warning symptoms such as chestpain, an awareness of cardiac irregularity, fainmess, or exercisedyspnoea. The working party concludes its report by stating that"When exercise is of a suitable intensity for the individual, is takenregularly and with sensible precautions, the benefits greatlyoutweigh the risks".

1. Medical aspects of exercise. Benefits and risks. London: Royal College of Physicians.1991. Pp 33. £7.50 (plus 50p postage and packing). ISBN 1-87324021X.

Exaggerated claims?

Those with a financial interest in pointing to the potential burdenof medical negligence claims have outlined their proposals for bothrisk management (see Lancet Feb 2, p 290) and claims handling (seeLancet March 23, p 725). Some pessimistic predictions have put theproportion of the health service budget that will need to be set asidefor settling claims at around 12% by 1996.

This view has been rebutted by the National Health Service(NHS) management executive,l who suggest that the mediaattention given to high settlements is unrepresentative of the truepicture. Up to 1988, the total annual cost to the hospital service ofpaying part of defence organisation subscriptions was about c30million. With transfer of indemnity in 1990, this 30m was added toa combined fund of [,5Om from defence organisations for paymentof claims. The 1990/91 cost to the NHS of medical negligence was40-45m in England. These figures are lower than those forecast.During 1990/91 only 30 applications were made to the Departmentof Health for help with claims above z300 000; expenditure onclaims remains below 0-5% of total NHS revenue, and the NHS

management executive emphasise that no money is drawn fromfunds allocated to patient services. From April 1, 1991, opted-outhospital trusts became directly responsible for all negligence costsincurred after that date. If settlements exceed 05% of their income,then trusts can borrow from either the Government or commerciallenders to meet the excess. The period of repayment would be setaccording to the size of the loan-eg, 1 year for advances of belowjClOO 000, but 10 years for loans of over ,900 000-and costsarising from such borrowing should be borne by the relevant clinicaldepartment. The suggestion by some that the NHS will becomeoverwhelmed by medical negligence claims seems to be

exaggerated.

1. Anonymous. Clinical negligence: mountains and molehills. NHS ManagementExecutive News 1991; May: 15.

Proposed ban on genetic testing in Denmark

On April 25, 1991, by a majority of 1 (61:60), Folketinget, theDanish Parliament, resolved to ban the use of genetic testing for thepurposes of employment, pensions, and insurance. The Minister ofEmployment is to draft a bill before the end of this year. Denmark isthe first country definitely to propose legislation of this type, thoughthere is concern in the West as to the impact of genetic informationin this area. It seems likely that some other countries, particularlythose in Scandinavia, may follow Denmark’s example.’ In the USA,genetic testing is not yet a major issue but there is concern that aperson’s genetic information and profile could present him as anunattractive proposition to employers, health insurers, and pensionschemes (and even to those offering mortgage and loan facilitiesgenerally). Whereas a person may be able to improve his health andprospects of longevity by a change in lifestyle-for example, bylosing weight, taking regular exercise, and moderating alcoholintake and work levels-some genetically marked disorders allowfor little or no scope for remission. People rejected by insurers ongrounds of genetic testing will be doubly disadvantaged if thegenetic predictions prove accurate and wrongly so if the test resultswere falsely positive. It could be argued, though, that people whohave conditions readily identifiable without genetic testing will beunfairly discriminated against if others with less readilydiscoverable problems are protected.On one view, Denmark’s proposed legislation seems a little

premature, but apparently the narrow majority in Parliament was

not evidence of opposition in principle to the ban, but to timing ofthe bill, which is to be passed before there is any experience of howtesting would work.’ The view of the promoters is that legislationshould be introduced before it is too late.

1. Hodgson J. Danish initiative in gene testing. Biotechnology 1991; 9: 508.

Disappearing services?

When, three months ago, news leaked out that North EastThames Region was going to withdraw five services (see LancetFeb 9, p 351)—varicose vein operations, removal of non-malignantlumps and bumps, extraction of symptomless wisdom teeth,in-vitro fertilisation, and removal of tattoos-many people mighthave thought that the Region’s decision to stop offering a

comprehensive health service was something new. The news raisedconcern about patients’ treatment being decided by administratorsrather than by clinicians or nationally. A BBC survey1 has, however,found that one in five health authorities have withdrawn or severelyrestricted sterilisation services. Some, such as North Bedfordshire,do not provide social sterilisation. Medway restricts socialsterilisation to special groups such as problem families, families witha history of child abuse, or families with disabled children. Threeapply a means test for vasectomies; in Oxford, for instance, thosejudged able to pay are sent to a private clinic run by a non-profittrust that charges around ;[100, whereas the other men may applyfor aid from the family planning fund. And other authorities put aquota on the number of sterilisations for which it will payconsultants the fee to which they have been entitled since 1976. Thisfee was intended to encourage the use of sterilisation for

contraception; it costs about ;[26 a year to provide the pill, whereascosts, based on private sector charges, are ;[35û--óOO for femalesterilisation and ;[60-100 for vasectomy. Doctors may dosterilisations beyond the quota but without receiving the fee;Basildon and Thurrock (part of NE Thames Region) had a quota of15 vasectomies a year, but 303 were done. According to IsobelEwart, an NHS general management trainee spending her electiveworking with a BBC health correspondent, the current pressure onhealth service spending provides no justification for such a fee todayand several public health directors have reservations aboutconsultants being paid twice for a standard operation. One publichealth director is hoping to reduce costs by paying doctors persession rather than per operation, which, as Ewart points out, is nota popular scheme among medical staff.

Abortion for social reasons is another service for which muchreliance is placed on the private sector. Last week Pro-choiceAbortion announced that in over a hundred health districts less than60% of abortions were done within the NHS-the target set in 1979

by the Royal Commission on the NHS was 75%. Although manywomen prefer to be treated privately, the worry is that difficulty ingetting an abortion on the NHS is a major contributor to a sizeableproportion of late abortions-37% in a survey of 140 womenpresenting after 16 weeks’ pregnancy to the British PregnancyAdvisory Service during one month in 1990.

1. Ewart I. A family matter? Health Service 1991; May 9: 18-20.

How Cuba controls HIV infection

Cuba’s success at limiting the spread of HIV infection mustsurely be the envy of the rest of the world (of 5117 250 persons aged15 and above tested in 1986-89 434 were positive}-but the meansemployed would raise an outcry in many countries. Governmentpolicy in Cuba is to quarantine, for life, all individuals seropositivethree times on ELISA testing and unequivocally positive onwestern blot. Quarantined persons receive their full salary, or anallowance if previously unemployed, and they live in residentialparks with adequate housing and facilities for sports and exerciseand medical care. Weekend passes are allowed-under supervision.The main risk factor for HIV infection has been contact with

foreigners at home or abroad (eg, through Cuba’s military and

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political involvement in Africa). Citizens who go abroad are nowscreened, but the exemption of visitors to the country from

screening represents potential for introduction of infection.Development of their own serological tests (validated with

collaboration from Brazil and Sweden) and the provision of facilitiesfor the tests cost approximately US$3 million, while the programmeof screening all individuals aged 15 and above has cost [2m per yearsince 1986. The educational programme takes second place in HIVcontrol.The quarantine policy is said to be under constant revision. Since

there is no immediate prospect of an effective vaccine or othermeans of eradicating the infection, there are tentative plans toreintroduce selected infected individuals to the community. In themean time, even when their views are specifically sought, membersof the public do not express their disagreement with the policy.

1. Perez-Stable EJ. Cuba’s response to the HIV epidemic. Am J Publ Health 1991; 81:563-87.

Trials progress report

Do patients with symptomless prostate cancer require immediatetherapy? 700 patients have been recruited to a study of immediate vsdeferred prostatectomy or hormone therapy, the only randomisedtrial in the 40 years of hormone treatment for prostate cancer toexamine this question-but 2000 are needed for an unequivocalanswer to be obtained. Similarly, 400 patients are required for thetrial to confirm whether the superior survival rates obtained byJapanese surgeons for advanced gastric cancer is the result oftheir practice of radical resections involving extended

lymphadenectomy. The trial required the recruitment of surgeonsable and willing to do the operations in a standardised manner. Thestudy was begun in October, 1985, but cases are not beingaccumulated as fast as the expected rate of 4 per surgeon per year.311 patients were recruited in the first 3 years, but only 153 weresuitable for randomisation to standard resection or to radical

procedures. More participants are needed. Dutch surgeons areabout to start a similar trial, and there are plans to pool the UK andthe Dutch data.

Attracting participants for their trials was one of the aims of theMedical Research Council’s Cancer Therapy Committee in

producing the report of the activities of their working parties.Another was to show participants the achievements of the trialsorganisation to which they have contributed. Publications of thiskind are bound to be of interest to many, whether or not past,present, or potential trial participants. The descriptions of the workof the various working groups are a good summary of the issues thatneed to be settled. Data from completed trials are presented in clearand simple tabular or diagrammatic form (these tables andillustrations are available as teaching slides). And there must havebeen many a time when one has wondered what stage a trial has

reached; such information is usually hard to obtain elsewhere.

1. Medical Research Council Cancer Therapy Committee Report 1990. London. MRC.1991. Pp 109.

In England Now

I met Kieran again at a meeting recently, and we spent half anhour catching up on each other’s news. Kieran is the occupationalphysician for Lincaster Health Authority and is outspoken on mosttopics. "Playing the devil’s advocate", he calls it, but he invariablyends up in court or on the television, which, of course, as a goodIrishman, he relishes.

"Solvents", he said after a while. "Oh yes?" I replied, sensing aKieran specialty. "Yes, solvents. A solicitor rang yesterday for myexpert opinion." Kieran recognises himself as an expert in

everything from blue-green algae to electromagnetic fields, so a newexpertise came as no surprise. I plugged him further.

"The solicitor represents two octogenarian sisters who have run asmall dry-cleaning business for sixty years. They claim the

dry-cleaning fluid has caused mental deterioration and they want tosue the company that makes the solvent. The solicitor sought myservices but that is the only sensible thing he has done so far.

"First I asked him whether he had the datasheet on the solvent; hehadn’t. Had exposure levels been measured? No. Which neurologistexamined the old girls? They hadn’t seen one. What were the resultsof the psychometric assessments, CT scans, EEGs, and relevantblood tests? Were they necessary, he asked? And no, he hadn’tapproached the manufacturer. He did have a letter from the generalpractitioner, who was sure that the dementia was due to solvent,however."When I told him that probably wasn’t much use and there was

no good evidence that exposure to solvent caused dementia, he gotquite annoyed and asked if I could recommend any other experts.""And did you?" "Of course. There are three other experts I know,but didn’t tell him that two work for the manufacturers and the thirdis an academic in Japan."

"

This all seemed a bit disappointing for Kieran. I’m still waitingfor another incident on the scale of the body mass index at

pre-employment screening episode. That ended with a

confrontation between Kieran and fifty overweight and very angrydomestics on live television. He obviously detected mydespondency and so kindly reassured me that he felt there wasbound to be more mileage in this one.

Funnily enough, I bumped into Kieran shopping with his wife afew weeks later. "Any more on the solvents?", I asked eagerly. No.came the somewhat muted reply. Then I noticed that Kieran wasbeardless. His beard has always been his pride and joy, which hestrokes while passing some expert comment on television. "What onearth happened to your beard?", I exclaimed, incredulous that Ihadn’t noticed its absence sooner. Kieran took a sudden interest inan adjacent tobacconists’, which is also strange for a man who has anasthma attack when exposed to cigarette smoke. I turned myquestions to his wife.

"Kieran managed to stick a carpet tile to his face at the weekend",she obliged. "The staff at Lincaster General had quite a jobdetaching him from it." I was still not much wiser but persisted."He was laying carpet tiles in the hall", she explained. "All went

quiet for a long time, so I went to investigate and found himunconscious with his face stuck to the floor. The hospital thought hemust have been overcome by the solvent in the glue as he hadn’topened the windows."

I looked around to see Kieran through the shop window about tobuy a pipe.

I’ve decided not to mention solvents for a while at least untilKieran’s beard grows back, but I am just wondering if that pipe isthe first sign of dementia.

* * *

It is true, or so it seems to me, that the older you get the quickertime passes. My psychologist colleagues have an explanation:something to do with the proportion of time one has been alive-ie,at age 10, one year is a tenth of one’s life, whereas at 60 it is but asixtieth and thus appears to pass more quickly. Well, maybe. But Ithink that, as with so many things these days, market forces have alot to do with it.Once the nation drags itself back to work in January, the shops

shriek "Valentine’s Day" at us; on Feb 15, out come the Easter cardsand chocolate eggs. On Easter Tuesday this year, our local

newsagent brought out the 1992 calendars, and that has really upsetmy internal clock. Normally, at this time of year, one has a briefrespite until, in August, the first Christmas cards appear, a preludeto the Season of III Will, with crowded shops, inflated prices, andinflamed tempers. So we have reached the end of another year,whilst somewhere are warehouses packed with Valentine cards,Easter bunnies, and witches’ masks-to say nothing of 1993calendars-ready to begin the giddy cycle once again. Thus, thanksto market forces, we are constantly looking weeks or months ahead,never able to enjoy the fleeting seconds as they pass, merelyregarding them as padding between one pseudo-festival and thenext.

Or is it just that I am getting older?