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for application and sufficient numbers to bring it to

fulfilment. Mitchell concentrated on the deprivation of hisown and similar medical schools in contrast to the relative

luxury enjoyed in London, but the principle that research canonly be done if continuous time is available for it is clear,whether it be in Nottingham or Paddington. My opinion thatbridgemen (with a basic scientific training as well as clinicalability) are vital to the success of clinical research in medicalschools has only strengthened with time. The best com-bination for training undergraduates to appreciate and

-

participate in the changes I have described is to link the basicscientist firmly to the clinicians by way of the bridgemen.The rebirth of the professor of medicine, despite the diffi-

culties of his role, could help achieve this task. Excellentexamples exist of contributions to clinical research outside ofwhat is usually regarded as the academic sphere, but I havecome to believe that in most university medical schools, thebest clinical research requires adequate academic under-pinning. If there are insufficient numbers in departments ofmedicine to allow full-time application in research, then thatresearch may well be ineffective and superficial, incapable ofoffering a proper liaison with basic scientific departmentswithin the very institution that should be a source of strength.When lecturers in medicine are equated within the NationalHealth Service head-counting process with registrars, andhave to specialise to protect their careers, take a considerableload of the teaching, and, at the same time, develop researchin depth, it must be asked whether this is possible or evendesirable? Equally, the possibility of employing postgraduatescientists with any prospect of long-term careers in clinicaldepartments is negligible, yet they are just as essential to thefuture of clinical research. I think that the bridge principlecould be applied in this area so that postgraduate scientistswould have joint appointments with the basic scientificdepartments. With all the university and health-serviceeconomies of the present and future, it might even seem futileto enter upon a discussion, but we are at a time when activediscussion is ever more essential if solutions are to be reached.On the one hand, the new medical schools have suffered insome respects from their complete integration with theN.H.S., and they are in the same position as many medicalschools were in London when I was appointed, when onlyhalf the schools had a professor of medicine and it was

thought possible to make the academic medical unit functionon a "man and a boy" basis. Then, however, it was easier toacquire staff, the dual support system worked, and the futurewas not so problematical as it now appears to many youngpeople.

I believe that the union of the N.H.S. and the medicalschools must be made complete, and joint appointments at alllevels in the major disciplines could be the best solution. Allacademic departments would have staff with an A + B typecontract between the N.H.S. and the university, and thus thereal cost of research, teaching, and clinical care would beapportioned in a realistic fashion. In university terms, the fullacademic staff would consist of tenured and variably tenuredposts from professor downwards. One way in which a schoolcan retain freedom of manoeuvre while simultaneouslyfulfilling clinical commitments is to be able to move ineffec-tive research workers into more useful clinical and teachingroles, and free more research-time and its associated financialsupport to new projects and areas where requirements havegrown. We are dealing with a system that has become rigidand stultifying owing to the breakdown of the marriagebetween the N.H.S. and university, and any answer must

correctly identify the roots of some of the problems. Theproposals of grant-giving bodies, such as the Medical

Research Council, the Royal Society, and the WellcomeTrust, which support young scientific and medical graduates,are an imaginative way of using resources at a time ofeconomic pressure. Without the entry of youth, researchwould suffer severely. Organisation within medical schoolsand their associated hospitals could improve the situation Ihave outlined above.Most important of all, however, is for students to

remember the needs of the patient as a whole. They must seethis continually demonstrated in the medical care given bytheir teachers. The reborn professor of medicine should beone who gives the lead amidst all the specialised divisions,and this synthesising role does not necessarily mean that hisenergies are dissipated by being spread too widely, so long asthe institution he serves is not too vast. A twin birth may,however, be necessary to match breadth by depth.

It would be the greatest indictment of all responsible for thehealth of medicine if, at a time of the greatest expansion ofknowledge, and by far the greatest opportunities ever knownfor application of research to the care of patients, solutionswere not sought with the greatest sense of urgency. Brightyoung people need positive encouragement to take part inwhat seems to me to be the most exciting era of academicmedicine ever known. Therefore, in order not to end on toostarry-eyed a note but one which is eminently practical, I haveto say that merit must be seen to be rewarded for achieve-ment, to mark out recipients as clearly different from theirfellows who have merely survived.

REFERENCES

1 Peart WS Death of the professor of medicine. Lancet 1970; i: 401-02.2. Mitchell JRA The unkindest cut of all a view of the U.G C. cuts from Britain’s first

20th-century medical school. Lancet 1982; ii: 540-45

Round the World

From our CorrespondentsIndia

MISUSE OF AMNIOCENTESIS

Despite the government ban of July, 1982, on the use of amnio-centesis for selective abortion of female fetuses, women’s groups inIndia have called for a concerted campaign against its continuedmisuse. Investigations last December by Women’s Centre, a

Bombay based organisation, showed that in one large publichospital in that city there had been 7800 requests for amniocentesisin the past five years. Only 507o were for detection of genetic defectsand about 1% of women wanted to get rid of a male fetus: all theothers sought amniocentesis with the express purpose of abortingfemale fetuses.Last July two doctors in Amritsar attracted- adverse Press

publicity for advertising amniocentesis as a service to women whodid not want to give birth to daughters. There is great pressure onIndian women to bear male heirs while daughters are considered aheavy economic burden because of the exorbitant dowry system.Significantly, the Amritsar affair might never have attractedattention but for an error which resulted in the abortion of a malefetus. The anger of the couple to whom this happened resulted in anewspaper report and heated questions in Parliament. It then

emerged that what had been done blatantly in Amritsar was

happening on a wide scale in all the major cities of the country, inprivate practice as well as in public hospitals. The only differencewas that the hard-sell technique (using hoardings and distributingleaflets) adopted by the Amritsar doctors was not resorted to in otherparts of the country. In response to pressure from opposition MPs.the Health Minister announced a ban on amniocentesis for sexdetermination. However, the ban has one large loophole.

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Amniocemesis can always be recommended ostensibly for thepurpose of detecting genetic defects and sex-linked diseases. In theprocess the sex of the fetus becomes known. After that, sinceabortion-on-demand is legal (and is encouraged by the governmentthrough advertisements), the selective abortion of female fetusesremains technically and legally feasible. Investigations by women’sgroups show this to be a very valid possibility. Doctors in centreswhere amniocentesis is done have become tight-lipped whenactivists seek information. Many gynaecologists see selectiveabortion as a medical solution to a social problem and find nothingunethical in it. In the aftermath of last July’s exposure, doctors havebeen heard to express the view that if abortion is legal why shouldselective abortion be condemned. Significantly, neither the IndianMedical Association nor the Medical Council of India has so fartaken a public stand on the issue.In India many couples go on having babies in the hope of

producing a son. Sex determination is therefore regarded by many asa scientific tool for limiting the family while encouraging people totry again for a boy. What feminists and other concerned people fearis a sex imbalance in the population. India already has a high male tofemale ratio (1069 males to 1000 according to the 1981 census). It isalso felt that, despite the ban on sex selection, the official attitudemay be to turn a blind eye when violations are reported. Evidence ofviolations may become more difficult to obtain because patientswho seek sex selection do so because they desperately want it. Andsome ofus remember that in 1974 Dr D. N. Pai was reported to havesuggested, at a population conference in Stockholm, that selectiveabortion of female fetuses through amniocentesis could be animportant part of India’s population control programme. He waspresumably voicing the views of the government of the day.

INJECTABLE CONTRACEPTIVES

Not that sex selection is the only population issue to be worryingIndian women’s organisations. Last month the Hyderabad branchof the Indian Women Scientists Association, many of whom aredoctors, wrote to the Health Minister urging him to desist fromimplementing the proposed liberalised distribution of the pillthrough village-level health workers on the grounds that such amove is wide open to abuse. The March issue of the Medico FriendCircle Bulletin (a forum for social conscious doctors) has called forthe general public to be made aware of the dangers of injectablecontraceptives. This was in response to announcements by theIndian Council of Medical Research that injectable norethisteronehad been successfully tested in clinical trials on 2600 women infourteen centres and would soon be introduced into the populationcontrol programme and that a hormonal implant was undergoingclinical testing in Delhi.Mindless pushing of birth control methods has backfired in India.

The IUD drive of the 1960s failed miserably because of poor back-up health services; the vasectomy programme of the 1970s ended inpolitical disaster for the Government of the day. The fear now is thatthe 1980s have been earmarked for hormonal injectables and pillsand that the major casualty in such a policy will be the health ofwomen.

On March 22, the Minister of State for Health, Mrs MohsinaKidwai, announced that the Government would decide on theintroduction of the injectable after it had received the results ofclinical trials. Critics feel that the go-ahead is a mere formality andthat the strategy may be to push it through before too manyquestions are asked. This is significant in the light of the possibilitythat the US Food and Drug Administration may soon approve’Depo-Provera’, thus circumventing the law forbidding the exportof any drug not approved for use in the USA. Journalists andactivists in India are trying to ensure a cautious, safety consciousapproach to any programme involving hormonal contraceptives.For example, the Centre for Education and Documentation inBombay has just released a 15-page booklet Injectables: ImmaculateContraception outlining the pitfalls of a mass programme withtimetables and questioning the priorities of a programme ofpopulation control at any cost.

ItalyTHE FILLING OF VACANCIES

In Rome, AD 1983, the oft-recurring word sanatoria is not theLatin plural of sanatorium, but it does have something to do withhealing. What are healed are not physical ailments but bureaucraticcancers. The word indicates an Act of Parliament that confirms in

. office Civil Servants who have been appointed without properselection procedures. This is now almost routine in our NationalHealth Service.To prevent favouritism in the selection of Civil Servants, the law

prescribes that every hospital vacancy must be advertised in thenational or regional legal announcement bulletin forty-five daysbefore the closing date for applications. Then a public meeting iscalled to choose the members of the selection committee, whosenames are drawn at random from hospital doctors, universityprofessors, and Medical Council members. As a rule, thiscommittee does not meet, because the prospective members nevervolunteered their services and the fee is too low to compensate forloss of professional income. A new committee must therefore beassembled, in one or more attempts, until persons are found who arewilling to give up their time. Finally, a date for the selection isagreed upon-perhaps a year or more after the day on which thevacancy was advertised. Meanwhile the hospital administrators fillthe vacancy by appointing a locum (a much faster and simplerprocedure).From time to time, as happens in physics with the beat

phenomenon, the vacancies build up to such an extent that some-thing must be done, and fast. (It may even happen that, meanwhile,new regulations have been issued, making the selection proceduresyet more complex and tangled.) And on top of it all there is the all-Italian concern for job stability; no-one really wants to send homedoctors who have worked in a given post for one, two, or more years.So Parliament is asked to pass an Act that entitles locums to stay onjust as if they had been selected according to the rules. At a guess,half the doctors now working in Italian hospitals come into thiscategory.

United StatesPOLITICS OF ENVIRONMENT PROTECTION

"They’ll overplay their hand and within two years they’ll beknown as the Cancer Party." Mr Ralph Nader said that aboutPresident Ronald Reagan and his colleagues after the 1980 election.Few heeded him. As this nation’s most famous unofficial advocate ofenvironmental protection, Mr Nader has been largely ignored inrecent years by the news media. His warnings have been drowned bythe rhetoric of a President whose priorities have been militaryexpansion and a dismantling of the welfare state.Now suddenly Mr Nader seems to have been vindicated. Even if

"cancer party" is putting it too strongly, the Reagan Republicans’interest in controlling environmental carcinogens is demonstrablyvery near zero. Nowhere is this neglect more obvious than in theaffairs of the Environmental Protection Agency. The principalcause of EPA’s present plight is a refusal to prosecute, with vigour,the corporations which have been dumping cancer-causingchemicals. In consequence, the Agency’s leadership has been fallingapart under heavy pressure from the Democrat-controlled House ofRepresentatives. First, the House cited the EPA administrator,Anne Gorsuch Burford, for contempt because she refused to turnover documents regarding the misdeeds of chemical dumpers.Then, as the bad publicity mounted, President Reagan fired RitaLavelle, the former corporation executive who headed EPA’shazardous dump clean-up programme. Next, after several lesserexecutives were forced out, EPA administrator Burford herself was

obliged to resign under goading from White House aides. Herdeputy and temporary successor, Dr John Hernandez, was noimprovement. Congressional investigators discovered he hadcollaborated with Dow Chemical Co to suppress the news that Dowwas contaminating the rivers near its plant in Midland, Michigan,with dioxin.What is new about all this is not that the Government is in

collusion with industry-both parties do this on a large scale-but