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Round the World

From our Correspondents

REUSABLE EQUIPMENT

IN July, 1983, I was on an elective in central Peru. Havingcompleted two years of medical school in New York, I was burstingwith the stuff of encyclopaedias, but had little notion of the realitiesof medicine. My lack of clinical skill and of Spanish meant thatobservation, rather than participation, was much more practical forme-and safer for the patients. Activities requiring little more thantwo hands offered exciting opportunities, and I participatedenthusiastically. In this poorly financed, remote hospital, housedwithin the school building of a former convent, I was astounded athow recyclable equipment could be: tongue depressors, emptyinfusion bottles, glass slides, lancets, and even heparinised capillarytubes and Foley catheters were all reused.One evening, I wandered into the emergency room where a

shabbily dressed young man lay comatose on the examination tablereceiving nasal oxygen. One intern asked me to help withcardiopulmonary resuscitation, telling me sternly not to use mymouth. I had a reputation for insisting on mouth-to-mouthbreathing on arrested patients. The interns strictly preferred theAmbu bag, but I, with the no-risk-is-too-great attitude instilled by 2years of seeing disease only on a blackboard, always went for themouth. I began cardiac compressions until the intern returned withan Ambu bag (the only two in the hospital were kept in thesterilisation room). I began the airflow while the first intern and twoothers who had arrived injected intracardiac adrenaline and startedan intravenous drip. The Ambu bag was, of course, impossible touse and one of the interns had forcibly to compress the mouthpiecein order to get a respectable seal. Disappointed that the intern hadtold me not to use my mouth (mouth-to-mouth being one of my fewskills), and disgusted with the inadequacy of the Ambu bag, I asked,"Porque no use mi boca?" The intern replied in English, "Use yourmouth, if you wish, but I think this man has TB". Suddenly theAmbu bag was working just fine.We were, nevertheless, unsuccessful. By the time the interns

decided to stop cardiopulmonary resuscitation, the hospital directorhad wandered in. As we were closing the jaw and eyes and removingthe drip the director asked what the case had been. "Tuberculosis,"replied an intern. The director looked over at me still holding theAmbu bag, his face suddenly growing furious. He threw up his armscrying, "He had TB and you used the Ambu bag? The bag is nowuseless!" Astonished, I looked up at him and managed to find thewords, "Este o que?" (this or what?). I took comfort in the

knowledge that I was not a real intern at the hospital, where, as in allPeru, senior doctors were addressed with the utmost respect andformality, and that I was directly responsible not to this doctor butto the regional director of health. The director stormed out of theemergency room leaving myself and the three interns flabbergasted.Later that night an acid-fast stain of the patient’s saliva turned outpositive. His mother told us that he had had symptoms foralmost a year. Like most of the patients I saw there, he had neverseen a doctor.

Sweden

COURT COMPELS DRUG AUTHORITY TO LICENSE

FENFLURAMINE PRODUCT

THE Danish company Benzon has for several years been trying toregister ’Ponderal’, its brand of the appetite suppressantfenfluramine. The Swedish regulatory authority, the NationalBoard of Health and Welfare, refused the application on thegrounds that the drug can cause depression severe enough to lead tosuicide and that its effect on appetite is short-lasting. Eventually thecompany took its case to court. The court chose to rely on theevidence of the experts called by the company, who denied a

significant risk of suicide. Its judgment last month required theBoard of Health to license the product. The law does not provide forappeals by the Board of Health, though a company does have theright of appeal. Ponderal is therefore being licensed, but underprotest. The Department of Drugs of the National Board of Healthis informing doctors of its assessment of the drug and is advisingthem not to prescribe it. To prevent such embarrassing conflicts inthe future, the Board of Health is proposing that the law be amendedto give it the right to appeal against decisions of the court.

United States

ACID SNOW AND ACID RAIN

THE widespread destruction of biota in many forests and lakes inthe US fits in all too well with acid rain falling in the North East andin the South West, which is now suffering severely from drought. Ifthe normal pH of rain is slightly acidic (pH 5 - 6), then the rainfalling in some areas is a very acid solution (pH 4 - 4); indeed a localscientist who tested the acidity of our last snowfall found an evenlower pH. Eastern Canada is possibly more affected, and its peopleare justifiably concerned.The cause of the acidity-sulphur emissions from industrial

chimneys in the states of the Midwest-can be identified withreasonable certainty, if not with absolute scientific proof. To reducethe emissions, let alone to eliminate them, will take a great deal ofmoney. Naturally, the industries responsible are unwilling to spendsuch money and the Administration, taking its tone from the

President, who in the first campaign seemed to think the treesthemselves were the main cause of air pollution, is reluctant tocoerce or even to investigate the causes and effects of acid rain, andCongress seems equally unwilling. Government and industry alikeare too keen to suggest fires, ozone, and forest pests as culprits forthe ecological disasters of the North Eastern forests.Damaged foliage has now been found in the Ohio Valley on a

variety of trees in both urban and rural areas and has beenattributed to sulphur emissions and possibly to ozone. There seemsno doubt that the damage is most severe where there is a heavyconcentration of coal-burning power stations lacking the equipmentto reduce emissions, and Ohio State has a reputation as a source ofpollution. Moreover, it seems that the forests of the south fromArkansas to the Atlantic Ocean are also in peril because of sulphuremissions, which are expected to increase considerably withindustrialisation in this area.As is usual, officials of the bodies responsible for pollution are

denying both the existence of the damage and its causation.Whether such an attitude is a wise one remains to be seen, but it

certainly has ominous indications. As recent decisions have shown,to correct the damage of pollution can be a vastly expensiveundertaking. It might have been wiser to deal differently with toxicwaste chemicals than dump them in the notorious Love canal, or tocontain such toxins as the PCBs rather than let them pollute thewaterways or render villages uninhabitable. The issue is politicallargely because all Bills so far introduced into House or Senate havebeen bitterly opposed by the Administration and the industriesconcerned, but if they strike one of our acid fogs in the North East(pH 2 - 8) their attitude may change. It had better be before we findwe are driving in battery acid.

It is not only the Administration’s indifference to the problemsbut also its unwillingness to support research which has angered somany. At least the Administration has not claimed that life in theNorth East is good for achlorhydrics.

SCIENCE BY JUDICIAL DECREE OR COMPROMISE

SocIETY seems to have reached a stage where scientificconclusions are established not by experiment or consensus

amongst a majority of scientists conversant with the evidence, butby judicial decree. Cancers in Nevada, southern Utah, andnorthern Arizona have been attributed to radioactive fallout fromthe test atomic explosions in Nevada in 1951-62. Persons living

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in these areas were not warned of the potential hazards and severalhundred lawsuits have been brought by cancer victims and

surviving family members. Evidence was produced that theMormon population in these areas had 50% more cases of cancerthan Mormons in non-affected areas. Another study purported toshow that rates of childhood leukaemia increased in southern Utah

during, and after, the tests. Both studies have been severelycriticised especially by statisticians from the National CancerInstitute.In the first ever lawsuit connecting low-level radiation with

cancer, the judge accepted that the testing and subsequent fallouthad been the likely cause of cancers in 10 litigants (8 cases ofleukaemia, 1 thyroid cancer, and 1 breast cancer). He rejected 14other claims on the grounds that evidence was inadequate. Inarriving at his decision, the judge suggested that in cases of disputedevidence resolution demanded rational judgment rather than

perfect evidence.The decision may assist uranium miners, sheep ranchers,

veterans, and others who have claims against the Government, butthe outcome for the 14 claimants will not help the 375 other victimsin whom similar cancers have developed. Many of these victims hadhoped that they also would be eligible for compensation, but theyhave been discouraged, especially since Government attorneys havestated that each case will be fought separately and that the judge’sdecision will be subject to appeal.In another attempt to settle a huge set of lawsuits, 7 chemical

companies manufacturing the so-called Agent Orange (thenotorious defoliant), with dioxin as the suspect toxic contaminant,agreed to set up a fund of$180 million to compensate veterans fromthe Vietnam war claiming both personal injuries and deleteriouseffects on their children. The veterans’ lawyers dropped damageclaims against the companies, all of which denied liability. The fundwill accrue interest of$21 million per year and is intended to last 25years to compensate both the veterans and their children. However,it is unclear how the claims will be dealt with and this may lead to anew outburst of litigation. Nor is the US Government happy,because it is still liable for paying millions of dollars in

compensation, and it is the target of the suits involving radioactivecontamination.The Government is also in the background of the lawsuits arising

from the growing number of cases of mesothelioma associated withasbestos. Litigation was nearly brought to a standstill when theManville Corporation declared bankruptcy to evade the claims.Apparently the legal expenses incurred by the asbestos firms havesurpassed the funds set aside for the Agent Orange settlement.Major battles have been going on between the asbestos companiesand the insurance firms with the result that only a small number ofclaims have been settled. However, an agreement between 16asbestos companies and 12 insurance firms to set up a fund of severalbillion dollars to compensate affected workers is near completion,and the scheme should be in operation by the end of the year. Thus,the aim of companies in the above instances has been to cut costs andlimit and equalise awards.Cigarette smoking and lung cancer is another legally sensitive

issue. To date, the tobacco industry, despite its financial resources,has managed to evade all claims of damages. The latest suit has beenbrought by individuals claiming that cigarette manufacturers do notwarn that their products might cause lung cancer. Congress has nowinsisted that the current very mild warning on cigarette packs bestrengthened to give more impact. Meanwhile, the decision on low-level radiation, based on probability, should cause concern forcigarette manufacturers who have based their defence on the lack ofdefinite proof that cigarette smoking causes lung cancer. But wherewill reliance on probability lead us?Much larger issues are raised by these lawsuits. The evidence

linking cigarette smoking to lung cancer and asbestos exposure tomesothelioma is remarkably firm; the combination of asbestosexposure and cigarette smoking seems almost to guarantee lungcancer. Here the scientific evidence should be decisive in litigation.There is no doubt that radiation can cause cancer, especiallyleukaemia, but there are other known causes of leukaemia and todecide between these in an individual case would seem to call forSolomon’s judgment.

The Agent Orange settlement was made with judicial adviceand help and, solely to avoid great legal expense, it was reachedperhaps more on emotional grounds than scientific evidence.The possible effects of dioxin are very uncertain. There seemsgood evidence that it may give rise to chloracne, but childrenwere born with defects before dioxin was ever produced and despitethe facts about carcinogenicity in animals we still lack decisiveevidence in humans. Emotional statements and claims surroundingthe whole issue of Agent Orange exposure have obscured the lack ofscientific evidence. The veterans who were in Vietnam complain,with some justice, that both the Government and the public havetended to ignore their services, their sufferings, and their needs formedical and general assistance. They claim that the Veteran’sAdministration has been unsympathetic to their claims and

unwilling to study the disabilities of which they complain,especially those arising from exposure to Agent Orange. Olderveterans complain of indifference to claimed disabilities fromradioactive exposures.The complaints have been recognised by the Government. On

May 22 the Senate passed a Bill requiring the Administration toestablish guidelines for the compensation of veterans whoseillnesses could be traced to exposure to Agent Orange or fallout fromnuclear explosions. A previous Bill, passed in the House of

Representatives, had specified chloracne, porphyria cutanea tarda,and soft-tissue sarcoma as disorders resulting from exposure toAgent Orange, but the Administration is resisting these specificitiesand its proponents acknowledge that there is "no sound medical orscientific evidence" linking Agent Orange to these disorders.Those seeking evidence linking exposures to cancers will benefit

from a widely accepted report from the White House intended toguide Federal Agencies in the regulation of carcinogenicsubstances. It firmly supports the view that any substance that cancause cancer in animals should also be considered a human

carcinogen, thus underlining the Delaney Rule, and states that it isstill impossible to establish thresholds below which carcinogenicagents can be safely used. It assumes that any exposure to a

carcinogen, however low or long term, conveys a definite risk ofcancer.

But while sympathising with those who believe their injuriesare the result of specific exposures, the implications of all thisfor science are very great. If the public or officials think thatjudicial decisions or administrative decrees can establish causalrelationships in the absence of scientific proof, or in defiance ofscientific evidence, then we are in danger, for where will this processcease? Cancers affected man long before the creation of syntheticcompounds and the development of nuclear weapons. If what thesoldier said is not evidence, then the statements of judge or jury arenot scientific proof.

West GermanyDIOXIN POLLUTION IN HAMBURG

EARLY in June a television report spread alarm in the east ofHamburg, especially among pregnant women. It claimed that therehad been an increase in the number of babies born with majormalformations (a finding which has not been confirmed), and thatthis might be related to atmospheric pollution with dioxin from theBoehringer-Ingelheim factory in Moorfleet. The week before,Wolfgang Curilla, Hamburg Senator for the Environment, hadgiven the management an ultimatum: the factory would be closedunless they could show by June 18 that the waste productsof the manufacture of the insecticide ingredient HCH

(hexachlorocyclohexane, benzene hexachloride) contained virtuallyno dioxin. The factory has now been closed. The ultimatum becamenecessary because an official analysis of the waste products of HCHhad revealed a startlingly high dioxin content-500 g/kg wastematerial. The less toxic substance OCDD was present in much

higher concentration, 32 g/kg. It is encouraging that the Landgovernment acted on this finding without delay, without waiting forclear evidence of damage. In the absence of an obvious disasterprocrastination and compromise seem unfortunately to be the normfor official responses to pollution.