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Encouragement forprivate health insurance

Australia’s new federal minister for Health,Graham Richardson, has exhibited his

predicted strength and pragmatism in hisportfolio (see Lancet April 3, p 885). He hasasserted his strength in Cabinet by gettingit to relent on its hitherto unassailable rulethat people cannot insure privately for the"gap" between hospital and medical costsand Medicare rebates.He was responding to questions follow-

ing his criticism of exorbitant medical andsurgical specialists’ fees (higher than thoseallowed by the Medicare schedule), whichhe described as evidence of some doctors’

avarice. He urged private hospitals and theprivate health insurance industry to recom-mend fixed fees that are more equitable topatients and the system.Mr Russell Schneider, chief executive

officer of the Voluntary Health InsuranceAssociation of Australia (VHIAA), saysthat if something is not done soon to getmore people into private insurance, thenthe industry could collapse. The total

burden would then fall on Medicare, whichis already not coping. Schneider is disap-pointed that Richardson has not been ableto convince Cabinet to agree to give taxrelief for private insurance premiums, anincentive removed and continuouslydenied by Labor governments. This lack ofrelief and rising costs have caused the

proportion of Australian taxpayers withprivate health insurance to fall from morethan 70% in the early 1970s to less than40% at present. The private funding poolhas recently been further eroded byemployer-sponsored health funds, againstwhich Richardson now says he will legislateunder the National Health Act, anotherRichardson initiative. In the meantime,increasing numbers of people are optingout of private insurance, faced with athree-tiered cost-the Medicare levy of1 -25 % of taxable income; private insurancepremiums; and the gap between medical,surgical, and hospital charges and amountsrecoverable from private insurance andMedicare. It is not uncommon for a "pri-vate" patient to be billed for several thou-sand dollars for a two-week stay, even in a

public hospital. Richardson says that he iskeen to "encourage people to take outprivate health insurance", a completereversal of Labor policy to date. Someexperts say that this is a forlorn hopewithout any tax relief. Richardson has setthe scene for unprecedented cooperationfrom a Labor government by telling the .medical profession and the private health :insurance industry that, although he is not a"captive friend", he is "certainly not anenemy". He has promised more an-

nouncements and details of those alreadymade, later this year.

Peter Harrigan

Circadian clocks

Even without the stimulus provided by therising and setting of the sun, human

beings-and most other organisms-have anatural cycle with a period very close to24 h. This cycle does not happen by chance;it is governed by the so-called circadianclock, which in mammals is located in thesuprachiasmatic nuclei of the hypotha-: lamus. Circadian clocks and their

adjustment were the subject of a CibaFoundation Symposium held in London onSeptember 7-9. Little is known about how

the circadian clock works, although neu-rons within the suprachiasmatic nucleihave been shown to undergo near 24 h: oscillations in firing rate with peak activityaround midday. Many diseases appear to beaffected by the circadian rhythm-for ex-ample, hypertensive subjects have higherblood pressure during the day than at night,asthmatic attacks are more common in theevening than at any other time, and the peaktime for cardiac infarction is in the earlymorning. Such knowledge enables

treatment for these conditions to be given atthe most appropriate times. Because thecircadian clock does not work in isolationand is influenced by light and activity, itcan be upset by rapid travel across timezones (jet lag) and by shift work. Anotherdisorder of the circadian clock is winterdepression, which is caused by the late

Tacrine approved

The US Food and Drug Administrationhas formally approved Warner Lambert’stacrine hydrochloride (Cognex) for the

treatment of symptoms of Alzheimer’s

disease, as recommended by its advisorycommittee (see Lancet 1992; 341: 820).Because of tacrine’s propensity to causeliver toxicity, the drug label will carry arecommendation for an escalating dosingregimen with repeated blood tests to

identify patients sensitive to the drug. Inpatients who experience mild liver toxicity,the suggestion is that the dose be reduced orthe drug be withdrawn altogether and thenrestarted at a lower dose. Since February,1992, more than 7000 patients in the UShave received tacrine as part of controlledclinical trials. Other side-effects that werenoted include nausea, vomiting, diarrhoea,and rash. :

Analysts predict that the approval oftacrine will generate US$500 million by1996 in revenue for Warner Lambert,which since last December has voluntarilyrecalled over one dozen products because of :product quality problems and manufac-turing breaches costing the company about$150 million in lost revenues. :

Syed Rizwanuddin Ahmad

dawn on short winter days. These disorderscan be treated by bright light and by

melatonin. Bright light given in the mom-ing shifts the clock into an earlier phase,whereas the same treatment given in theevening shifts the clock into a later phase. Ithas been used with some success to treatwinter depression. Melatonin, which is anatural product of the pineal gland, worksthe opposite way to bright light-ie, it

shifts the circadian clock later when givenin the morning and earlier when given inthe evening. Although melatonin has beenused experimentally to treat jet-lag withoutapparent side-effects, it is not licensed forgeneral use in the USA or UK (one delegatereported buying melatonin over thecounter in a bottle without instructions in ahealth food shop in the USA). Drug com-panies show little interest in licensingmelatonin because of the difficulties of

obtaining a patent for a natural substance;instead, the companies are developing re-lated compounds. However, Prof Al

Lewry, Oregon Health Sciences Univer-sity, has obtained a use patent for melato-nin, and on this basis hopes to interest areceptive drug company in financing thelicensing procedure.

John McConnell

News in brief

Czech Courses The UK chief medicalofficer has expressed concern over adver-tisements in national newspapers offeringplaces in university medical schools in theCzech and Slovak republics that state thatthe degrees are recognised by the GeneralMedical Council for limited registration.Limited registration, granted at thediscretion of the GMC to doctors holdingan acceptable overseas qualification to

work under the supervision of a fullyregistered person, cannot be held for aperiod or aggregate periods of more than 5years. Moreover, the GMC has not yetdecided whether the Czech or Slovak

degrees concerned will remain acceptable;the council will consider the matter furtherwhen it has received information aboutwhat changes the universities will make tothe courses to accommodate the needs of

English-speaking students.

Halofantrine As a result of recent reportsin The Lancet (1993; 341: 1054-56, 1541,1541-42), the World Health Organizationhas been notified by the pharmaceuticalcompany manufacturing halofantrine thatthe drug should not be given to people whomight have a long Q-T interval (either as afamilial condition, or associated with othertreatments) (Weekly Epidemiol Rec 1993;68: 269-76). Halofantrine should not betaken with food nor by people deficient inthiamine.