News Review

Side Effects of the Pill

The Royal College of General Practitioners’ 25 year-long follow-up study has shown that ten years after stopping taking the Pill, women have no greater risk of dying of heart disease or Pill-associated cancers than those who have never used it. However, it was confirmed that the risk of developing heart disease, strokes, cervical and breast cancer is higher for those women who are on the Pill and the risk remains high for the first few years after cessation. The use of the Pill (which currently accounts for about 25% of all contraceptive use) seems to keep abortion rates at lower levels; during the last Pill scare of 1995, when women stopped using it, the abortion rate surged to its highest level since records began (The Telegraph 1999; 8 January).

Male Pill within five years

An effective birth control pill for men could become a reality within five years. Doctors at St Mary’s Hospital in Manchester have launched a trial of the new contraceptive: testosterone is given as an implant that lasts six months and a prolactin pill (that switches off a hidden secondary sperm-production mechanism) is taken every day. Current male contraceptives are only 70-80% reliable, and it is hoped that the new contraceptive will be on a par with the female Pill (99% effective)(The Telegraph 1998; 26 October).

Abortion in Bavaria and Ireland

The Catholic state of Bavaria in Germany has been forced to lift its abortion restrictions after Germany’s highest court ruled that they were unlawful. Five doctors who together perform more than half of all Bavarian abortions brought a petition against the abortion laws to the court, and also aim to overturn the ruling preventing a doctor from earning more than 25% of his income from abortions (BMJ 1998;317:1272, 7 November).

The number of Irish women travelling to Britain for abortions has reached its highest level ever. Abortion is illegal in Ireland unless doctors judge the pregnant woman to be suicidal. A recent survey has shown that attitudes towards sex before marriage are becoming much more liberal, especially among the young (BMJ 1999;318:77, 9 January).

Teenage and Unmarried Pregnancies

Recent research by the Government has revealed that the conception rate for teenage girls has risen by 11%. The survey, Birth Statistics 1997, has shown that three quarters of the pregnant girls were 15 years old, and more than half had had abortions. There has also been an increase in the number of children born outside marriage from 23% ten years ago to 37% now (The Telegraph 1998; 12 December).

Boots, the chemist chain store, has set up the first family planning clinic in a Glasgow pharmacy. This is part of an attempt to reduce the number of teenage pregnancies by making services more accessible. It is hoped that emergency contraception will be available over the counter at such clinics, reducing the number of abortions. However, pro-life groups are unhappy and suggest that this will encourage teenagers to have underage and premarital sex (BMJ 1998;317:1612, 12 December).

The Family Planning Association has launched a new initiative to get the message of safe sex across to university students. About £1000 worth of ten pence pieces have been scattered in 96 union bars, and when picked up, the coins are found to have a sticker describing the dangers of unprotected sex on the back. The combination of cash and beer has proved to be successful, and many students have found the coins and read the message (The Telegraph 1998; 11 December).

Fetal faces on ultrasound

Recent advances in ultrasound scanning will soon allow parents to see the faces of their unborn children. The new technique was presented to obstetricians in Edinburgh last year; it will improve diagnosis of fetal abnormalities, and may also allow doctors to perform keyhole fetal surgery instead of potentially dangerous invasive surgery. Pro-life groups have welcomed the advance, and a member of Life suggested that doctors should allow women who want an abortion to see the faces of their unborn babies, ‘so that they fully understand what they are doing’ (The Telegraph 1998; 11 December).

Single Cell Genetic Fingerprinting

A new single-cell genetic fingerprinting test has been developed at Leeds University which is a thousand times more sensitive than current DNA tests used to catch criminals. Embryos created during infertility treatment will be subjected to this test to screen for a wide variety of disorders: those with defects will be discarded. This has caused uproar in pro-life groups, who view it as a search-and-destroy procedure and have condemned it as degrading the value of human life. St George’s Hospital is applying for a licence to use the test to select only healthy embryos for implantation, and hence increase the chance of a successful pregnancy (The Telegraph 1998; 29 November).

Cloning Update

In December, Government advisers recommended that human embryos a few days old could be cloned for research purposes only in order to develop treatments based on cloned tissue and organs. This would facilitate the development of treatments for mitochondrial diseases. However, the cloning of human beings for reproductive purposes would be banned. The Human Fertilisation and Embryology Authority (HFEA) has suggested that only cell nucleus replacement techniques should be permitted.

Scientists in the US have now successfully managed to harvest stem cells from human embryos. They have also created a variation on a human clone by fusing the nucleus of a human cell with a cow egg. This opens up the possibility of producing stem cells, which have the potential to divide forever, to grow a wide variety of other types of cell that make up the human body. Scientists predict that this research will one day allow brain cells to be harvested and grown to replace those lost in Parkinson’s and Alzheimer’s disease; muscle tissue and eventually whole organs could be grown (The Telegraph 1998; 11 and 19 November), ( BMJ 1998; 317:1337 14 November), (The Telegraph 1998; 8 and 10 December), (BMJ 1998; 317:1613 12 December).

Laboratory mice will be used as incubators for human eggs in new experiments in the US. Ovarian tissue from women cleared of ovarian cancer, Hodgkin’s Disease or leukaemia will be implanted in the mice, who will then ‘grow’ human eggs, which will be used to make test-tube babies. This may help to avoid the risk of reintroducing cancer to the patients. The aim is to restore the fertility of young women who have been subjected to chemotherapy and radiotherapy.

Similar experiments at Leeds University have shown that ovarian tissue from both cats and humans does begin to grow eggs in mice, although larger host animals (such as rabbits) are needed for the eggs to reach maturity (The Telegraph 1998; 5 November).

South Korean scientists claim to have produced a cloned human embryo by removing the nucleus of a donor egg and replacing it with a somatic cell nucleus. The scientists claim that if the egg had been implanted, a human child with the same gene characteristics as the donor would have formed. However, there is much scepticism about the validity of this work (The Telegraph 1998; 17 December).

Illegal Sterilisation in Peru

A state-sponsored campaign in Peru to reduce poverty by cutting family sizes has led to the sterilisation of more than a quarter of a million poor Peruvian women. Officials, doctors and health workers were set regional quotas by the Ministry of Health and were told their jobs were at risk if they failed to meet them. Some had themselves sterilised in order to fulfil requirements.

Women were told their health was at risk if they were not sterilised, that it was just a type of temporary contraceptive device, and some were threatened with removal of food aid or arrest unless they complied. Many of the women were illiterate, had never seen a doctor before, and had no idea what was happening to them. At least 15 have died from complications or lack of aftercare.

The US Government is investigating this abuse of human rights and the Peruvian President, Albert Fujimori, has attempted to distance himself from the sterilisation programme (The Telegraph 1999; 8 January).

Pakistani Discrimination against Women

Recent reports from Karachi have revealed that Pakistani society still attaches enormous importance to the well-being of male children, while daughters are regarded as a shameful burden. Mortality among children under four years of age is 66% higher in girls than boys, and the literacy rate for women is only 26% compared to 50% for men. This makes teaching about reproductive health very difficult. Forty-five percent of the population have no access to any form of health service, and investment in preventative health care and education is very poor. A huge population explosion is expected as over half the country’s population is between five and 20 years of age (BMJ 1998;317:1546, 5 December).

Abuse of Dutch Euthanasia Legislation

Dutch law allows euthanasia when the patient is undergoing intractable suffering and makes a voluntary request provided that the doctor reports each case to the local medical examiner. However, it has emerged that the regulation is being abused widely, with many cases of non-voluntary euthanasia coming to light. In 1995, 900 cases were recorded including many fully or partly competent patients who were killed without making any request for euthanasia. The problem may stem from the lack of palliative care facilities available, and many GP’s feel that they have no solution other than euthanasia for patients in great pain (BMJ 1998;317:1613, 12 December).

Doctors starve patients in Sussex

In England, the police are investigating the deaths of at least 50 patients in Derby, Surrey, Kent and Sussex. There have been accusations that the patients’ deaths were hastened by denying them intravenous fluids. The BMA’s ethics committee said that it seems that doctors have responded to the guidelines on withdrawing and withholding treatment by removing artificial hydration and nutrition even from patients who are not terminally ill, (eg those with dementia or serious strokes) (BMJ 1999;318:143, 16 January).

HIV Vaccines

American scientists may have made a major breakthrough in the development of HIV vaccines. By freezing the HIV viral machinery in the act of contorting itself to fuse with the DNA of a target cell, they have succeeded in producing 23 effective antibodies (out of 24 strains of HIV). However, much more testing must be carried out in monkeys before the vaccine may be tried in humans (The Telegraph 1999; 18 January).

Meanwhile, British, African and American scientists have launched two research programmes into a vaccine for HIV. They hope to produce a vaccine that is effective against strains prevalent in the developing world at an affordable price. Currently, many countries in Africa spend only £5 per person per year on health, while the annual cost of treating a patient with HIV in the UK is £7,000. So far, the only HIV vaccine in clinical trials is specific for the B subtype which is prevalent in the US and the UK but rare elsewhere (BMJ 1998;317:1543, 5 December).

Viagra Deaths

One hundred and thirty men have now died after taking Viagra to boost their sexual performance. The US Food and Drug Agency claims not to be unduly worried, because side-effects have occured in only a tiny fraction of the six million Viagra prescriptions. Seventy percent of the victims had one or more cardiovascular risk factors, and 16% had already taken nitrates. Sales of Viagra have slowed in the light of these events, paving the way for a new drug called Vasomax. This challenger to Viagra claims to be twice as quick, does not cause visual disturbances and is safe for men who need to take nitrates for pre-existing heart conditions. Vasomax contains phentolamine mesylate, an alpha-blocker that overrides the nerves that prevent erectile tissue from becoming engorged with blood, whereas Viagra (containing sildenafil) targets an enzyme that regulates blood flow to the penis (The Telegraph 1998; 3 December).

Tobacco Controversy continues

The American Medical Association has produced a report recommending that the nicotine in cigarettes should be reduced to non-addictive levels within ten years, and access to smoking cessation treatment should be improved. Seven health organisations in the UK have called for an overhaul of current testing and regulating of tar, nicotine and addictive agents in cigarettes. According to the director of ASH (Action on Smoking and Health), most tobacco companies still claim that nicotine is important for taste and is not addictive.

The BMA, ASH and the World Development Movement have urged the British Prime Minister Tony Blair to implement tough international controls on tobacco marketing on order to put an end to the companies’ aggressive tactics of targeting women and children in the developing world (BMJ 1998;317:1271, 7 November).

The Government’s White Paper, Smoking Kills, set out the new £100 million package aimed to reduce smoking in Britain. There are 20 initiatives to cut the number of smokers by 1.5 million over the next ten years.

From April, doctors in certain pilot areas will be encouraged to refer patients keen to give up smoking to new ‘cessation’ clinics, where they will receive specialist counselling. Also, a week’s supply of free nicotine patches will be given to smokers who are least able to afford them. The makers of the Nicotinell patches claim that three times as many people give up with the patches than by willpower alone. However, a course of twelve weeks is recommended and there is no evidence that patches are more successful than any other method in keeping smokers free of the habit in the long-term. The proposals have been clouded by allegations that the manufacturer of the nicotine patches spent £10,000 sponsoring the Labour Party conference in 1997.

The Government does not propose to ban smoking in public places or at work. However, a voluntary proof of age card for young people may be implemented. Shops will also be encouraged not to advertise cigarettes, and to site their vending machines in such a way as to reduce their use by children. Criminal sanctions against retailers who persistently sell cigarettes to underage children are being considered.

The Health Secretary has also announced a new £50 million advertising campaign directed at the young, warning them of the dangers of smoking. The ban on tobacco advertising on billboards and the media is being brought forwards to this summer (BMJ 1998;317:1405, 21 November).

The Australian spin-bowler, Shane Warne, has agreed to be paid £76,900 if he gives up smoking using Nicorette, a nicotine replacement treatment that has at least double the effectiveness of placebo gums and patches. This has provoked widespread media debate about the ethics of this arrangement. However, most people in the public health community are delighted that such a prominent person has agreed to be associated with giving up smoking. They believe this will have far more of an effect on young people than the extremely healthy role models used in past campaigns (BMJ 1999;318:9, 2 January).

Cigarette use has risen in universities in the US. Substantial numbers of students are both starting to smoke and trying to stop, according to a study examining changes in smoking rates among 29,000 students at 116 universities, reported in JAMA. Between 1993 and 1997, the prevalence of smoking rose by 28%, and more than a quarter of the smokers had begun smoking regularly at university (BMJ 1998;317:1405, 21 November).

Presumed Consent for Organ Transplants

The BMA’s ethics committee has approved plans to presume the organ donation consent of any patient who dies in hospital. Organs would be removed unless the patient has previously chosen to opt out, thereby hopefully easing the severe shortage of organs for transplant (The Telegraph 1998; 29 December).