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opposed by several Spanish groups, especially the RomanCatholic Church and the Catholic Confederation of

Schoolparents (CONCAPA). The latter is known for itsopposition to many government initiatives on education andyouth subjects. CONCAPA argued that the slogan clearlyencouraged free sexual relations among young people andcharged in court that the campaign breached the law onadvertisements. CONCAPA’s main argument was that thestatement that condoms are a safeguard against unplannedpregnancies and AIDS was not true. A key reason why thejudges accepted the argument was that the campaign did notimpart the message that only "the complete abstinence fromsexual relations and the mutual fidelity between sexualpartners who are not infected eliminates completely the riskof infection". The judges also criticised the statement thatthe use of condoms is the safest method for preventingpregnancies.The decision has surprised the Government and many

Spaniards. The Ministries of Health and Social Affairsintend to appeal to the Tribunal Supremo, the highest court.Several organisations, such as the Spanish Confederation ofAssociations of Spanish Schoolparents (CEAPA), whichbrings together 8000 groups, have expressed their supportfor the campaign. Trade unions, the Spanish Consumer’sUnion, and anti-AIDS committees have said that theverdict is bad news for the fight to prevent AIDS.The campaign had been completed long before the

judgment but the verdict could have short and mid termconsequences. It may hinder subsequent campaigns on theuse of condoms in health promotion. More importantly, itprovides encouragement to those opposed to any

government measure that conflicts with traditional RomanCatholic morals. The Catholic church has already expressedits strong opposition to some of the suggested changes onabortion and euthanasia regulation in the new CriminalCode that will be presented in the next few months. There islittle doubt that these modifications will generate legalbattles.

Josep E. Baños

Germany: Tackling iodine deficiencyThe use of iodinated salt has never become customary

here as it has in neighbouring countries such as Switzerlandand Austria, whose soil is similarly iodine deficient, but anew regulation is being prepared by the health ministry. In1989 food manufacturers, canteens, and restaurants werepermitted to use iodinated salt in their products as long asthey declared it specially (eg, on the packaging or on themenu). The new regulation removes the need for thisdeclaration; on packaging iodinated salt need only be listedroutinely with other contents.The proposed measure should help to reduce the cost,

now standing at DM 2 billion annually, of treating thyroiddisease due to iodine deficiency. Every year about 100 000thyroid operations are done here. Every 20th newborn babyhas a goitre, and half these have impaired thyroid function.A north to south gradient exists; a study has shown that inthe south, where iodine is very deficient, a third of youngsoldiers in this area had a goitre, compared with 4-10% inthe north.

Experts agree that all measures so far to raise daily iodineintake to 200 mg/day for an adult have failed. Iodinated salthas been on the market for years, but accounts for a little lessthan half the total salt used. But even if everybody used it, itsaddition in domestic food preparation would not have

corrected the deficit. Hence experts such as Prof RolfGrossklaus from the Bundesgesundheitsamt in Berlinrecommended its use in packaged foods and in canteens orrestaurants. However, the declarations required by the 1989regulation are thought to put purchasers off the product.The new regulation is therefore welcomed as an importantstep.

Ironically, iodine deficiency had already been tackledwith some success in East Germany, where the introductionof iodinated salt in food products and in animal fodder, forinstance, had reduced the number of goitres in newbornbabies from 6-24% to less than 1 %. Since reunification thesituation has worsened.

Annette Tuffs

Canada: Increased spending on AIDS

Faced with conflicting opinion about the level of federalmonies devoted to AIDS research, Health Minister BenoitBouchard has announced that Ottawa will spend Can$211million on AIDS research and education over the next five

years, an increase of 13%. "This investment is indicative ofthe federal government’s commitment to find a cure to thisfully preventable communicable disease which has reachedepidemic proportions", Bouchard told reporters. "It’s neverenough... but we have to keep in mind the pressures on thesystem for many other diseases." The$42-2 million per yearAIDS outlay falls well short of the "minimum"$55’35million per year demanded by a highly vocal coalition ofAIDS groups and by an all-party Parliamentary Ad-hocCommittee on AIDS. But at a time when other medicalresearch budgets have been frozen, the$42,2 million alsorepresents a considerable increase over current federalAIDS outlays of about$37-3 million per year. Nevertheless,Opposition critics were harsh in their judgment of the newfive-year national AIDS strategy.However, in recent months, there has been increasing

discontent within the biomedical community over thedisproportionate share of federal assistance given to AIDSresearch and education. Bouchard himself highlighted thatdiscrepancy earlier this year when he noted, "in breastcancer there are about 1 million women who face the

problem and we spend about$25 million. There are about30 000 people with HIV in Canada and we are spendingbetween$35 and$37 million a year. We need to keepperspective".The most recent Health and Welfare statistics on AIDS

indicate that the cumulative number of confirmed cases inCanada from 1979 to the end of 1992 was 7282, includingabout 4700 deaths. Under the new$211 million/5 yearprogramme, Ottawa will spend about$17.8 million annuallyon AIDS research,$9-8 million in support of communityorganisations,$6-2 million on prevention education,$54million for care and treatment, and$3 million forcoordination and other activities.

Wayne Kondro

India: Betel nut warningThe Ministry of Health and Family Welfare has decided

to include betel-nut or supari as a food item "injurious tohealth" under the Prevention of Food Adulteration (PFA)rules because of its causal association with oral cancer.

Supari is chewed alone or as pan, a mixture of supari, lime,and other ingredients with or without tobacco wrapped in abetel leaf. Every packet of supari will now have to carry the

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warning "chewing of supari is injurious to health". People inthe supari business lobbied against the statutory warningwhen in July last year, a draft of the regulation was issued forcomment. They claimed that chewing of supari is an age-oldpractice and, according to ancient literature, helps in

digestion. The Government’s resistance to pressures frombusiness interests in the case of supari assumes significancebecause of the time it took to issue similar notification forpanmasala, a concentrated powdered form of the preparationused in pan (see Lancet, 1989, i: 663). When the healthministry finally thought of bringing pan masala under thePFA rules, its draft called for the labelling of pan masalapackaging with the warning "Consumption of pan masalamore than four grams per day may prove harmful". Theministry’s inability to explain the rationale for the "fourgrams per day" limit suggested that it might have beenunder pressure from a strong pan masala lobby to preventthe inclusion of pan masala under PFA rules. (Annual salesof the pan masala industry in 1989 amounted to R 300crores, or 11.32 million.) The dose limit would have giventhe impression that consumption of less than 4 g/day of panmasala was safe. However, in Sept, 1990, the health ministrybrought pan masala under the PFA rules and dropped thedose limit. All packagings of pan masala now carry thestatutory warning "chewing of pan masala may be injuriousto health".The health ministry had also approached the Ministry of

Information and Broadcasting to ban all advertisements ofpan masala on Doordarshan, the government-controlledtelevision network. It took the I & B Ministry over a year toagree to implement the ban. The same approach is beingmade for supari. In addition, the health ministry intends toseek the help of Ministry of Welfare in launching a massiveadvertisement campaign to warn the public about harmfuleffects of both pan masala and supari. It will also ask stategovernments to discourage sale of these items in

government-run stores, supermarkets, and educationalinstitutions.

Bhupesh Mangla

USA: Declassification of WWII chemical-warfare research

The US Department of Defense has announced that itwould declassify documents relating to chemical-warfareexperiments that the Government conducted on 60 000servicemen during and immediately after World War II(WWII). In addition, the defence department said that themen were released from their oaths; they may now speakfreely about their experiences.The announcement was a response to a National

Academy of Sciences Institute of Medicine study (Veteransat risk: the health effects of mustard gas and Lewisite) releasedearlier this year on a US chemical-warfare research

programme that involved human experimentation withsulphur-mustard gas and Lewisite, an arsenic-containingchemical weapon. The NAS panel said that the soldierswere subjected to a wide range of exposures, from "patchtests" to severe exposures, including "repeated gas chambertrials without protective clothing". The panel estimated thatmore than 4000 men were exposed to high concentrations ofthe blistering agents during the programme. "The end pointof all the WWII mustard agent and Lewisite experimentswas tissue injury-from mild skin bums to severe, andwidespread, skin bums that took more than a month to heal.The chamber and field tests were actually called ’Man-

Break’ tests", the committee reported. Despite the seriousnature of the injuries and the well-known long-term risks ofexposure, there was no medical follow-up on the subjects,said the panel, which concluded that there is a causal relationbetween exposure to these chemicals and conditions such as

respiratory system cancers, skin cancer, chronic diseases ofthe eye, bone-marrow suppression, sexual dysfunction fromscarring of the genitalia, and some psychological disorders.The panel urged the Department of Defense to end its

policy of secrecy and to identify and provide benefits to allsurviving subjects of the programme and to any chemicalworkers or other personnel, military or civilian, who havesuffered because of exposure to these agents.

Michael McCarthy

Finland: Increasing competitiveness

As is happening in many other countries, Finland hasembarked on increasing the competitiveness and marketorientation of its health-care system. The change representsanother well-defined trend that has shaped the evolution ofthe system. During the 1940s the policy was aimed atservices providing maternal and child health care, butduring the next 25 years the emphasis shifted to building anational hospital network, with a stock of 19 000 beds ingeneral hospitals and 11 000 beds in mental hospitals beingadded. The resulting shortage of doctors led to the openingof three new medical faculties, which helped to change thedoctor to population ratio from 1/1100 at the end of the1960s to 1/356 in 1992. Except for maternal and child care,primary care services were provided mainly by privatepractitioners, and patients had no income security duringillness. In 1963 the Government created the NationalSickness Insurance, funded by employers, employees, andthe state. Subsidising the doctor’s fees (up to 60%) wasexpected to give equal access to health care for the wholepopulation. But a decade later there were still social andgeographical inequalities, the health of the population wasnot improving, too little (10%) of public resources was beingspent on primary care (against 90% on hospital care), andhealth costs were growing about twice as fast as the grossdomestic product. New reforms were launched in 1972-resources for primary care were increased, and services, freeof charge, were brought under the control of health centres,which were run by the municipalities. The reforms were asuccess-between 1973 and 1983 health costs grew onlyfrom 5-6% to 6,6%. But since the start of the 1990s, therecession has restrained tax revenue, and resources could notmatch health-costs growth. In 1992, 9% of GDP was spenton health (with public resources paying 80 % of the bill); thisyear the ratio is expected to rise even more.

Although the 1972 Primary Health Care Act promotedstrong descentralisation of health management by lettingmunicipalities run their health centres, personnel andresources were allocated centrally. State subsidies were

passed directly to hospitals and health centres with

municipalities paying only the sums not covered bysubsidies. Now state subsidies are paid directly to

municipalities, which can use their budget allocations asthey see fit--eg, choose which medical services they want tobuy, and from which hospital; or level of subsidy forconsultations. One other change that has been introduced isthat patients will be free to choose their doctors, but onlyfrom among those at their health centre.

Cláudio Csillag