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initially failed to credit the questions raised about the Cellpaper and rose to the defense of Dr Imanishi-Kari.

However, it is difficult to comprehend his maintaining thisstance as the evidence mounted that serious problemsexisted." Dr Baltimore told the New York Times that beforethis report came out "I was quite confident that the paperreflected the data as it unfolded". The new report, he said,raises issues "serious enough to ask carefully whether therewas misconduct here".The star in the report was Margot O’Toole, the

postdoctoral fellow at MIT who first contended that thecentral claim of the paper might not be supported byexperimental evidence. Rebuffed by her superiors at MITand Tufts and finally fired, her complaints led to the Dingelland NIH investigations. "Dr O’Toole’s actions were heroicin many respects", the report said. "She deserved theapprobation and gratitude of the scientific community forher courage and her dedication to the belief that truth inscience matters." She is now a scientist with the GeneticsInstitute of Cambridge, Massachusetts.Like Dr O’Toole, Representative Dingell also seems to be

vindicated. The NIH panel that investigated the Cell paper,chaired by Joseph M. Davie, president for research anddevelopment at Searle Laboratories, had previouslyconcluded that there was no evidence of scientificmisconduct. It was only after Mr Dingell providedadditional evidence that the current investigation wasconducted at all. At least in this case, Mr Dingell’scontention that scientists don’t always respond adequatelywhen a whistle-blower cries "foul" has proved to bejustified.

J. B. Sibbison

Italy: GPs’ new agreementThe terms for general practice within the Italian health

service are supposed to be negotiated between theGovernment and the doctors’ unions every three years. Thetalks for the period from June, 1988, to May, 1991, began atthe end of 1989 and ended in the spring of 1990, and theagreement was endorsed by the President in September,1990. Part of the agreement came into effect in November,1990, only six months before the expiry date, and some of itsprovisions are still not operative.As in the last two agreements, GPs are required to retire

from the health service at age 70, but few have ever compliedor are likely to do so now. Most septuagenarian GPs haveresorted to litigation that has taken them almost to theireighties, if not to the grave, still clinging to their patients’lists. This, of course, has enraged young unemployeddoctors, who are sitting by, waiting for their aged colleaguesto give up their practices.The new agreement provides for financial incentives to

GPs who own personal computers and modems. Theobjective is to promote a booking system for laboratoryinvestigations and specialist consultations at health-servicefacilities, to be operated directly from GP surgeries. Oddly,the incentives are to be distributed to only one in four GPs,though how the choice is to be made has not been stated.Even harder to understand is how the link will be

established, since no health-service laboratory or centraloffice has either modems or programs for linking up withGPs’ computers.Another vagary is the rule, reminiscent of Fascist laws,

that a GP not wishing to take part in a doctors’ strike calledby a union (not necessarily his own) must give notice to the

local health authority within 24 hours of the start of thestrike. Failing that, he will lose his pay for as long as thestrike lasts. Obviously this means that GPs will pay moreattention to union bulletins than to scientific literature.

In the new agreement the number of GPs that can be

accepted in any district is to be calculated by dividing theresidential population by 1000. But an individual GP mayhave up to 1500 patients, which means that in a town of, say,15 000 people there may be fifteen GPs, ten of whom havefull lists and five idle away on the dole. More often, however,doctors compete furiously for patients and thus tend toaccede immediately to any request a patient may make.

Since the Government had unashamedly violated earlieragreements, doctors pressed this time for a provisionforbidding it to do so again. But only a few weeks hadelapsed before the Government yielded to temptation.Contrary to the agreement, on Feb 1 the Ministry of Healthissued a decree compelling GPs to memorise a list of 59diseases and relevant officially permitted drugs and to certifyon any prescription whether the medicine was on the officiallist. Since any of the 59 diseases gives the patient the right toexemption from his or her contribution to the prescriptioncost of the approved drug, doctors who make mistakes areliable to be prosecuted.

A. Attanasio

Kashmir: Bloodshed in paradiseOn May 21, 1990, Prof Abdul Ahad Guru, chairman of

the department of surgery at the Institute of MedicalSciences in Srinagar, issued a statement alleging that he wasbeing pressured by the Government to understate thenumber of casualties that had resulted from the action of the

security forces in the city that morning.A muslim leader had been assassinated at his home in

Srinagar, and it was alleged that when his body was releasedfrom hospital the crowds accompanying his funeral werefired upon by the security forces. In his statement, ProfessorGuru said that 65 bodies had been taken to his institutealone, and other hospitals in the city had reported a further89 deaths. He reported that the nature of the woundsinflicted suggested that the firing was "meant to kill".

In response to this statement, and to widespread reportsof violation of human rights, Physicians for Human RightsUK (PHR [UK]) organised a fact-finding mission to

Kashmir in January. The aim was to investigate suchallegations and the effect of the unrest on the provision ofhealth care. PHR (UK) released its report earlier this week.The day the team arrived the city was very tense following

a shooting incident between security forces and militants theprevious day. It was alleged that 19 civilians had been killedand many others wounded. The military presence in the citywas very evident, with soldiers at most crossroads and acurfew imposed from 7 pm to 5 am daily.A visit to the Bone and Joint Hospital in Srinagar that

week confirmed that a number of civilians had been shot and

seriously wounded in recent incidents. The High Court BarAssociation in Srinagar provided the delegation with

documentary evidence, including photographs of namedindividuals, which supported the allegations of widespreadand almost routine use of torture by the security forcesagainst detainees.During the delegation’s visits to community health clinics

it became apparent that the civilian population is findingtravel difficult, because of searches, prolonged curfews, and

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intimidation by the security forces. This has particularlyaffected the provision of preventive health care, such aschildhood immunisation and antenatal care. Although noofficial statistics are maintained, it is said that there has beena resurgence of diphtheria. Last November, 15 children inthe village of Bemina contracted the disease, and 10 died.Increasing numbers of cases of whooping cough and polioare also claimed.The Children’s Hospital in Srinagar has reported a sharp

fall in the number of admissions. This is thought to be due totravel difficulties and curfews. Delays in admission to thehospital are said to have increased the mortality fromconditions such as pneumonia and meningitis. According toa local paediatrician, half the children admitted with

meningococcal meningitis have died.The supply of essential drugs such as antibiotics and

vaccines has been erratic because of the disruption ofcommunication and business life. At present, however,essential supplies seem to be adequate, and the drop in thevaccination rate for children appears to have more to do with

parental fear of travelling than shortage of vaccine.Visits to various hospitals showed that the workload has

increased because of casualties from the unrest, but the

budget has remained the same. Staff have been harassedwithin hospitals and in some instances have been detained.In addition, many Hindu doctors and nurses have left theregion for their own safety. The remaining staff have had tocope with intermittent shortages of supplies and routinepower cuts, and morale is consequently very low.A number of senior medical staff have been detained for

questioning. The delegation met Professor Guru, who hadjust been released from detention. He was arrested on Sept11 at Delhi airport on his return from a pilgrimage to SaudiArabia. He said that he had been accused of collectingmoney for victims of the Iranian earthquake last year and forchannelling funds to Kashmiris who had suffered as a resultof the unrest. He had been detained for three months inconditions that he described as "appalling".

Other doctors described incidents of personalharassment, house searches, and frequent questioning,which were often related to their medical work. For

example, one senior doctor who lived in the centre ofSrinagar said that his house had been raided and he had beenquestioned at length about his reasons for keeping suppliesof drugs in his house. He was accused of keeping these inorder to treat militants.

Local human-rights groups were gravely concernedabout the ways in which detainees are being treated. Duringthe various waves of unrest, a large number of people havebeen arrested and detained. The Bar Association alleged thatmany of them are being held without trial and has providedthe delegation with names of people in this category. Frominformation provided it appears that there are over 3000petitions for habeas corpus pending before the Kashmirwing of the Jammu & Kashmir High Court. It is also allegedthat many detainees are being held in distant states such asRajasthan, Nagaland, and Tamil Nadu, which makes visitsby lawyers almost impossible.The violence in Kashmir and the abuses of human rights

are not one-sided. The militants are said to have been

responsible for the kidnapping and murder of a number ofpeople, including Prof Mushirul Haque, vice-chancellor ofKashmir University, and it is estimated that nearly 65 000Hindus have fled Kashmir for fear of their lives.

Peter Kandela

Conference

Double dealing with your dataThe Lancet publishes about ten articles and forty letters

each week--over 2500 contributions per year in all. Despitethe best efforts of editorial staff and peer review, how muchof this information can we expect our readers to believe? Canan individual who is deeply involved in bringing clinical trialdata into the public domain-sponsor, investigator, or evenjournal editor-ever be objective? Should a single trial aimto be the final arbiter of a specific scientific question, orshould the quest for truth be left to that burgeoning band ofinterlopers-the meta-analysts?

Clinical pharmacologists occupy the special position of"mediator" between an industry often intent on commercialadvantage and a public hungry for straightforward answersto their questions. Last week, at a Forum on Clinical

Pharmacology held at the Royal Society of Medicine for this"diplomatic service" of the profession, the question of whoshould take responsibility for clinical trial results was put,and the participants attempted to furnish some answers.

In 1987, Hampton and Julian expressed their concernsabout the relation between the drug industry and clinicalinvestigators.1 The often large financial contributions madeby companies make them less likely to cede complete controlto trialists. Hampton and Julian argued that the preservationof confidentiality must be ensured during collection of datarelevant to the main end-points of the trial. They suggestedthat an independent Data and Safety MonitoringCommittee was one answer to this potential difficulty.Despite some tetchy replies from the pharmaceuticalindustry,2,3 their recommendations are now standard

practice for most large multicentre studies.The process by which ethical approval of a trial protocol is

given also remains open to criticism. To what extent do localhospital ethics committees have the ability to judge themerits of a study? These committees often have insufficienttime to discuss the subtleties of the ethical questions posedby each application. Who audits the work of ethicscommittees? Should data monitoring committees review theethical conduct of the trial?A meeting about clinical trials without the presence of

statisticians is now unthinkable. Those present at last week’smeeting remorselessly exposed the mathematicalobfuscations that investigators introduce to portray theirresults in the most appealing light. A speaker ruefullypointed to the surprising fact that the Committee on Safetyof Medicines does not employ an independent statisticaladvisor to review product licence applications.A special difficulty is the small clinical trial that does not

have the power to overcome a type II (false-positive) error.The probability of finding a single positive result fromtwenty small trials is high, whereas the statistical power of alarger trial may make such chance effects unlikely. Thesesmall trials will undoubtedly continue to be sponsored andpublished and the incentive for the pharmaceutical industryto sponsor large studies remains poor. To combat thisdisagreeable trend, some individuals have argued vigorouslyin favour of meta-analyses or overviews. This form ofobjective assessment of both published and (moreimportantly) unpublished trials is intended to kill off thereview that is based on the experience of a reflective

specialist. Although critics have unkindly labelled this

approach as "garbage-processing", a compromise view maybe that meta-analyses offer a quantitative review rather than