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As inauguration day approached, Clinton, slow in makingsub-cabinet appointments throughout the Government,asked Bush to leave behind a senior official or two in each

agency. Bush, apparently peeved by his successor’stardiness in attending to appointments, announced that allthe clean-sweep resignations had been accepted and that, asof noon January 20, his appointees were out of office. IfClinton wanted to employ them, the Bush camp suggested,he could nominate them for office and commence the

process of confirmation with the advice and consent of theSenate-a cumbersome undertaking that normally takesweeks if not months. Or, it was suggested, Clinton couldtake another bureaucratic route, appointing the resignedagency heads as government consultants and sending themback to their old desks, though with circumscribed

authority.At the last minute, however, Bush relented and agreed to

ignore or cancel-there is uncertainty-the resignations ofsome 40 officials, Healy among them, as well as DavidKessler, head of the Food and Drug Administration. Theweek after inauguration, many at NIH expressed confusionabout Healy’s status. Healy, however, says there’s nothingto wonder about. She’s carrying on as director of NIH, withnothing changed, she insists. Has she discussed the

possibility of indefinitely remaining in the Clintonadministration, an outcome she has openly sought? Yes, butshe will say no more on that subject.

Daniel S. Greenberg

Round the World

WHO: Letter of discontent

"... whichever side may call itself the victor, there are nowinners but all are losers." The aphorism, though referringto war, seems apposite for WHO as a whole in the aftermathof an election campaign that has cost the organisationdear-both in man-hours diverted from the purpose forwhich the WHO exists and in lost repute. The atmosphere isheavy with forebodings that Dr Hiroshi Nakajima’s victorymay prove to have a hollow ring where WHO’s ultimategood is concerned.

Before the 31-nation executive board opened its two-week meeting on Jan 18, a reliable Japanese estimate wasthat the director-general was assured of a minimumtwo-vote lead. A factor in the actual outcome (18-13) wasthe 16-strong Japanese delegation-setting, doubtless, apermanent record numerically. It was instantly off the markin lobbying, just in case a board member or two might haveforgotten implicit previous understandings.

Apart from deploying individuals to follow up visits thatNakajima had made to member developing-countries,WHO’s own re-election task squad kept an eagle eye onactivities of opponents within the secretariat, some, it mustbe said, no less active than the Japanese themselves.Distribution of an open letter by the staff association wasblocked by the secretarial administration because it voicedconcern at the amount of public attention directed to thetotal preoccupation with the election campaign evidentwithin WHO itself. "Never before has health been so

adversely politicized in press reports", the letter said. Whilethe staff committee was taking no position on the election,"it is incompatible with our status as international civilservants to actively lobby governments at the behest of

candidates ... we ask all staff to re-commit themselves tostandards commensurate with WHO’s ideals".The letter cited World in Need of Leadership: Tomorrow’s

UN (the study by Sir Brian Urquhart and Erskine

Childers): "In a few worst cases, Secretariat members havebeen instructed to campaign for re-election of theirexecutive heads". The reason given for withholding normaldistribution of the association’s open letter, signed by Dr JanStjernsward, staff committee chairman, was that its content"appeared" to refer to the election: "The Legal Counselpoints out that staff may not take actions that might appearto influence elections". Where the Administration and itstask squad themselves were concerned, this observationlooked like a particularly ironic example of belatedly closingthe stable door. The staff committee saw it as an outrightinfringement of their right of association.

Swallowing their chagrin, executive board

representatives from countries who supported DrMohamed Abdelmoumene were determined after the voteto hold Nakajima to his expressed resolve to improveWHO’s overall performance and efficiency. Preliminarydiscussion on first results in the working group concernedwith this objective were being assessed by the board duringthe week. A full report is to be presented at its May sessionimmediately preceding the World Health Assembly.

Alan McGregor

India: Guineaworm eradication programmeHealth policy makers continue to ignore the value of

mechanical extraction of guineaworm from the patient, eventhough a specialist team from the All India Institute ofMedical Sciences and a medical adviser from the PlanningCommission have recommended it as the method of choicefor the management of guineaworm disease before the wormemerges from the skin. The 15th meeting of the NationalGuineaworm Eradication Programme’s task force on

Janl9-20 focused on strengthening surveillance of guinea-worm infection. At last year’s meeting the presentation ofthe project in Rajasthan that uses mechanical extraction ledto no change in the National Institute of CommunicableDisease’s (NICD) statement that "The hazardous

procedure of manual/surgical extraction of guineawormshould NOT be practised in any area as it is not

recommended in the National Guineaworm Eradication

Programme". The statement still holds.Patients may be incapacitated by pain for several weeks as

the mature female worm emerges from the skin to release itslarvae. Many patients immerse the part (usually the lowerleg, ankle, or foot) in cold water to induce bursting of theblister produced by the worm as it emerges from the skin.Winding the worm round a stick with gentle tension hastensextraction. In many patients the worm’s subcutaneoustracks can be delineated before blister formation. Vaidyas(practitioners of traditional medicine in India) relax themuscles of the affected part by active and passivemovements and massage to aid mechanical extraction of theworm. B. L. Sharma, trained in ayurvedic medicine,removes the worm from its subcutaneous track through atiny surgical incision, made under local anaesthesia, besidethe midportion of the worm. Cleaning the skin with alcoholmakes the worm stand out. The blunt end of a sterile needleis used to withdraw the worm from the subcutaneous areaand another needle is used to free it from tissue adhesions.The operator then grasps the worm with his fingers andextracts it by steady traction; gentle massage of the affected

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part or even a second incision beside another part of theworm may be necessary to free it totally from adhesions. Thecrucial aspect of the procedure is not to allow the worm tobreak, to prevent tissue reaction and anaphylaxis. Breakageis more likely if extraction is attempted after the worm startsto emerge on its own.

Recognising the potential of the technique to reducedisability to a few days, UNICEF employed Sharma as aconsultant in SWACH, a safe-water project in Rajasthan, toteach his technique to other doctors and medical students.So far more than 7000 extractions have been done in

Rajasthan where, according to Dr Helen Patton of

SWACH, the project’s dual strategy of financialinducement for reporting a case and of surgical extraction ofthe worm has resulted in interruption of transmission from97% of all new cases of dracunculiasis identified during thepeak transmission season. SWACH project director toldthis year’s meeting of the task force that the work will becontinued in Rajasthan; the method is used in

predominantly tribal areas, where it is popular and

acceptable, and where patients may seek worm extraction bypeople untrained in the principles of surgical asepsis ifSWACH stopped its project.Unlike India, Ghana has been sufficiently impressed by

the work in Rajasthan to fly Sharma there to train healthworkers (see Lancet Nov 28, p 1322). The NICD’sreluctance to recognise mechanical extraction of the worm asa worthwhile measure is based on the fear of tissue reactionand anaphylaxis. Clearly, the All India Institute of MedicalSciences team, which evaluated the technique in July, 1991,disagrees. So does Dr Jon Rohde, senior officer at

UNICEF’s regional office for South Central Asia; he pointsout that experience in Rajasthan shows that adequatetraining and practice can make the method safe and, likevasectomy, it can be carried out by paramedical personnel.An important point that seems to have been overlooked isthat accommodation of all possible strategies is usuallycrucial for a disease-eradication programme as it approachesits finishing post, which is near the stage that India hasreached with dracunculiasis. The number of new casesidentified in 1988 was 12 000. It has dropped to 4798 in 1990and 1059 in 1992.

Bhupesh Mangla

Germany: Troubles in medical associationsAfter two people testified about his Nazi past last

Saturday, Dr Hans-Joachim Sewering stood down as

president-elect of the World Medical Association. Hisresignation had been demanded by the World JewishCongress and by medical groups in America (see p 298),Canada, and Israel. The week preceding his resignation sawincreasing opposition from German doctors, who madetheir views known in advertisements in leading newspapers.

Sewering had denied membership of the SS. He told theNew York Times that he had been a member of the S S youthcavalry, a group not associated with criminal activities, butin its latest edition the German news magazine Der Spiegelclaims that he was a member of the general SS. Allegationsrecently circulating had also been made in 1978, yetSewering had received two of the highest civilian honours inWest Germany, in 1981 and 1986. The main allegationswere that he knew of handicapped patients being sent fromthe Schonbrunn Hospital (near Munich) to Nazi euthanasiaclinics and that he had personally signed the papers for thetransfer of one of them, a 14-year-old girl with epilepsy. Last

week Nikolaus Osler, director of the Schonbrunn Hospital,and Sister H. Menigna Sirl, a nun who used to work there,decided they could keep silent no longer. They said that theycould provide documents and eye witnesses to show thatbetween 1940 and 1944 at least 909 handicapped childrenwere transferred from that hospital to euthanasia clinics.

Sewering, who had been a long-serving treasurer of theWMA and president of the German National Chamber ofPhysicians from 1973 to 1978, gave as his reason for steppingdown the wish to protect the WMA from the threatenedboycott by the World Jewish Congress. Dr Karsten Vilmar,president of the German National Chamber of Physicians,has issued a statement that Sewering’s resignation is not anadmission of guilt but only a gesture made in the interests ofthe WMA.The story has not ended there. The president of the

German branch of the International Physicians for thePrevention of Nuclear War, Prof Ulrich Gottstein, has nowdemanded Vilmar’s resignation, on grounds of Vilmar’ssuppport for Sewering. In backing Sewering, said

Gottstein, Vilmar has shown that he lacks the necessarysensitivity and judgment to be president of the Germanmedical ascociation at a time when right-wing radicalism,neonazism, and anti-semitism are re-emerging. Vilmarshows no indication of resigning and has not issued anyresponse to Gottstein’s demands.

Annette Tuffs

Europe: Focus on environment and healthDenmark has insisted that domestic political problems

will not weaken Copenhagen’s resolve to use the Danishpresidency of the European Community to focus Europeanattention on EC environmental legislation and health issues.After the collapse of the Danish Government only days intothe six-month EC presidency, MEPs at the EuropeanParliament’s January sitting in Strasbourg heard Danishforeign minister Uffe Ellemann-Jensen outline

Copenhagen’s priorities for the next six months. He stressedthat his cautiously worded comments had been cleared withall major political parties in his country, adding: "You cancount on the Danish presidency".Although the word "environment" cropped up only once

in his 14-page speech, he pointed to the presidency’s moredetailed supporting document, which committed the Danesto strive for "a high level of environmental protection" and"increasingly systematic integration of environmentalconsiderations in the Community’s activities", with greateremphasis on preventive measures. The new presidencywould also, said the document, "make as much progress aspossible with the proposals concerning voluntaryenvironmental review, integrated pollution control, theincineration of dangerous waste... and attach importance tofurther harmonisation within a series of clearly defined areassuch as air pollution and chemicals".On health, the declaration spoke of giving priority "to

establishing a better basis-including statistics-for futureinitiatives and to continue work concentrating on areas inwhich co-operation between the member states can helpimprove protection of the health of Community citizens".

Notwithstanding UK resistance to efforts to secure

EC-wide rules on health and safety at work, Ellemann-Jensen insisted: "The Internal Market must be

accompanied by steps to guarantee the environment andconditions of employees at the workplace".

Arthur Rogers