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expressed as a percentage of the total number of live birthsoccurring in West Sussex in each index year. The use of births(as the best denominator available) means that the percentagesexpressed are not absolute values. Nevertheless, since like is

being compared with like year by year, the technique does pro-vide information on trends.

RESULTS

From 1970 to 1976, more than 60% of children hadbeen immunised against diphtheria, tetanus, and polio-myelitis by the end of index year plus one (see accom-panying table). Similarly, the percentage immunised bythe end of index year plus two shows only slight fluctua-tion about the 90% level, with a further increment

(1-2%) in index year plus three. The results for measlesover the whole period repeat the stable pattern seen withdiphtheria, tetanus and poliomyelitis, albeit at slightlylower overall levels.

By contrast, whooping-cough immunisations declinedprogressively in immunisation years 1974, 1975, and1976. The percentage of children immunised by the endof index year plus one remained constant around the60% level for index years 1970 to 1973, falling to

around 40% for 1974 and 1975. Index year plus twoshows a slight fall in index year 1972 with further fallsto just over 80% in 1973 and below 60% in 1974. Thefigures for index year plus three of the 1972 and 1973birth cohorts also declined.

DISCUSSION

Our results show that the decline in whooping-coughimmunisation seen nationally was also experienced inWest Sussex. The decline began with immunisations car-ried out in 1974 and continued into 1975 and 1976.

Secondly, and in contrast to the national experience,levels of immunisation in West Sussex against diph-theria, tetanus, poliomyelitis, and measles remained

high throughout the period 1970 to 1976.

Clearly, the "ripple effect" from the controversy overwhooping-cough vaccination has been contained in WestSussex and has not affected levels of immunisation

against the other communicable diseases of childhood.Parents in West Sussex must have behaved differentlyfrom many elsewhere. Their attitudes and behaviour are

unlikely to have been more or less susceptible to nationalor local newspaper and television coverage of the im-munisation debate than those of parents in other partsof the U.K. Nor can they have been influenced by formalhealth-education campaigns on immunisation, sincethese were discontinued in West Sussex 15 years agowhen the success of the computer system made them

superfluous. Although advice from doctors and healthvisitors is an important influence on all parents, WestSussex general practitioners and health visitors are un-likely to be more persuasive than their colleagues else-where. However, they do have the advantage of a com-puter system which keeps an "immunisation diary" forparents and for medical and nursing staff.

Without removing from doctor or parent the finaldecision on the administration of a particular vaccine,the system greatly reduces the chance that a child will

not be fully immunised because of fallible adult memoryor remissness over attendance at immunisation sessions.Therefore it seems reasonable to conclude that in WestSussex the computer system was instrumental in main-

taining high levels of immunisation from 1970 to 1976against communicable diseases other than whoopingcough. If these findings are confirmed by other A.H.A.susing similar systems, there would be a strong case forextension of computer systems of this kind to all A.H.A.Sto combat the national decline in immunisation levels.

Requests for reprints should be addressed to A.L.B., West SussexArea Health Authority, Courtlands, Parklands Avenue, Goring,Sussex BN12 4NQ.

REFERENCES

1. Hansard (House of Commons) June 14, col. 240.2. Department of Health and Social Security. C.M.O.(77)7.3. Galloway, T. McL. Med. Officer, 1963, 109, 232.4. Saunders, J. Br. J. prev. soc. Med. 1970, 24, 187

Round the World

Australia

HUMAN TISSUE TRANSPLANTS

AT present, throughout Australia, there is no legislationwhich relates to human tissue transplants from living donorsapart from the common law, and the control of such trans-plants from cadavers varies according to the laws of the Statein which the operation is performed. Although all the Statelaws were originally based on the 1952 English Corneal Graft-ing Act, and are similar in their approaches both to the choiceof donor and to the formalities of procedure, there are impor-tant differences, and these effectively restrict the transferenceof organs from one State to another and hinder the develop-ment of beneficial projects such as the pituitary programme.

The Law Reform Commission was established in 1973 "forthe purpose of promoting the review, modernisation and sim-plification of the law within the Australian Capital Territory".Its chairman, Mr Justice Kirby, was appointed in 1975, andthe subject of human tissue transplants was allocated to hisCommission for inquiry and report. However, the Common-wealth Government lacks the constitutional power to enact anational law to regulate such transplants, and, in order toovercome this difficulty, the Attorney General included in theCommission’s terms of reference a request for proposals di-rected towards obtaining "uniformity between laws of the Ter-ritories and laws of the States ... and a national register ofdonors of organs and tissues". In so doing, the CommonwealthGovernment has paved the way for uniform adoption by allStates of the draft legislation entitled Transplantation andAnatomy Ordinance 1977, which was tabled in the federalParliament by the Commission, with its Human Tissues

Transplants Report, during September.

In both the United States and Canada, uniform laws havebeen achieved by the adoption of similar procedures, but in theU.S. and in three of the Canadian provinces the legislationdoes not yet extend to tissue transplants from living donors.The Australian Commission, by means of constant expert con-sultations and by hearing submissions from all interested

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members of the public, professional and non-professional,throughout the country, has tried to ensure that its recommen-dations will be acceptable to all States.

One such proposal is that death by cessation of brain func-tion be defined as such by statute. The need for such an enact-ment in order to optimise the chances of success with certaintransplants is well documented, and, although there is wide-spread acceptance of this definition of death throughout theCommonwealth, a medical practitioner who proceeded accord-ingly and removed tissue could, under the present law, findhimself facing criminal charges.The report contains a number of other recommendations. It

is proposed that the expressed wishes of an individual (oral orwritten) should be paramount in determining the disposal of hisdead body. There are a few reservations concerning cadaversunder the jurisdiction of coroners. An adult over 18 of soundmind should be allowed to donate non-regenerative tissue foruse as a transplant provided that he has discussed it with hisdoctors and has given written permission, and that a "cooling-off" period of 24 hours has elapsed. Incompetents and minorsshould be prohibited from donating non-regenerative tissue(other than, in the case of minors, for exceptional familyneeds, and then only after the strictest judicial and medical in-quiries). The donating of regenerative tissue for research andother medical purposes should be permitted for all competentdonors, with parental and medical approval for minors.

Attention is drawn in the report to the rapid advances in im-munology that, it is anticipated, will make rejection less of aproblem, and will thus create a demand for increasingnumbers of donors. As a consequence, the issuing of donorcards or suitable identifying discs should now be carried out asa step towards a future national register of donors and tissues.

The Commission points out that the legal problems associ-ated with artificial insemination concerning legitimacy, inheri-tance, and so on are so involved that they justify a separate in-quiry and separate legislation. Accordingly, semen and ovashould be excluded from the published list of acceptable dona-table tissues to be controlled under the new legislation. Similararguments apply to fetal tissue. It is recommended, however,that transplantation of fallopian tubes and ovaries be coveredby law. The Commission urges that the sale of human tissueshould be prohibited, and that the law should forbid paymentto donors, that the procedures within anatomy schools shouldbe modernised, and that specific laws be introduced for theconduct of all necropsy examinations not carried out by cor-oners.

The report also discusses anticipated advances in the fieldsof heterografts and prosthetics; it points out that legal andethical problems are to be expected following the acceptance ofnew ideas on euthanasia, genetic engineering, and humanexperimentation, and that the public must face up to theseissues; and it advocates appropriate legal protection for themedical profession and provision for the privacy of donors andof their families. It is to be hoped that a national law will resultfrom the tabling of this report.

United States

THE BAKKE CASE

THAT great friend of the American colonists, EdmundBurke, once said that if he could not reform with equity hewould not reform at all-something that the descendants ofthose colonists seem to have forgotten. The truth of this is

depressingly evident in the Bakke case, which is now beingheard before the U.S. Supreme Court, to the accompanimentof the brayings of the demonstrators, and a flood of obfuscat-ing rhetoric (as well as personal attacks on Bakke himself)from the Press. The quality of much of the argument put up

inside the court is also, to say the least, uneven, and now it isrumoured that, in order that the whole issue may be ducked,at least for the time being, the case will be returned to the Cali-fornia Supreme Court for the determination of some prelim-inary points.

Perhaps the saddest aspect of the case is that it would neverhave arisen if previous Administrations and Congresses hadaddressed themselves to solving the urgent social problems thatconfronted them. As it was, they left it to the Judiciary toassume the burden of making decisions on social policy. Thisled to objections from some that the Judiciary was usurpingthe place of Congress, and to the call from others for the im-peachment of the Chief Justice. It has also meant that the pre-cise and inflexible tool of legislation has been called in to dealwith the enormous, multifactorial problem of social disadvan-tage. The argument presented for the University of Californiawas that it was a "vital necessity" that the disadvantagedsocial or ethnic groups in this country should be given theopportunity to advance themselves. Some have taken this tothe point of exact percentage equality. Thus if we have 2% ofRuritanians in the population then 2% of doctors, architects,lawyers, teachers, plumbers, and so on, must be of Ruritanianorigin. Just why this should be is not clear, although there isa currently fashionable theory that only a physician of Ruri-tanian origin, even if educated entirely in the U.S., is com-

petent to treat a Ruritanian patient and could understand thebackground to his illness. Most people, if asked to express apreference, say that all they want is a competent physician,whatever his creed or colour.

It is not enough, if one is to benefit from reverse discrimina-tion, to be an economically or socially disadvantaged .candi-date, for most of those who fit that description in this countryare White, though one such-an impoverished female of Rus-sian descent-has been admitted provisionally on this ground,under a court order, pending decision in the Bakke case. Thelegal argument for the University of California in the endboiled down to the arid technicality that a quota is not a quotaunless it specifies precisely the group against whom it operates.Thus since the University did not specify the group not to beadmitted, its keeping 16 places reserved did not constitute aquota. Some think the Supreme Court may make its decisionon this very narrow issue, but this will do nothing to resolvethe question of reverse discrimination, and it will not just goaway. A whole series of related suits have been brought beforecourts all over the country, involving denials of promotion, fail-ure to take account of examination results, layoffs of indus-trial workers, and so on, all of which are causing personal dis-tress and social antagonism.

The unhappy results of so-called affirmative actions canonly multiply. The legislative bankruptcy is demonstrated bythe fact that, should the court uphold Bakke, then, so it is

claimed, all the Government programmes to increase the

opportunities for the disadvantaged, particularly the Blacks,will have to be abandoned. We have had a century of freedomfrom slavery, and of educational opportunity-admittedlywith some discrimination and inequality, but the right hasbeen there. Many disadvantaged have, to their great credit,seized avidly on these opportunities and whole groups have ele-vated themselves. The Blacks who have done so now see them-

selves, because of affirmative action, as stigmatised.A final question that arises is why this generation should

bear the whole of the burden of the past-a question that isposed, with particular point, by the educated, qualified, butexcluded student. How is the burden of sacrifice to be distri-buted in our time? The Supreme Court is not likely to answersuch basic questions, whatever is the decision we now await,but they are questions which will have to be answered. Ifadmissions to any walk of life are to be by numerical quotas,then Burke would be convinced that the "sophisticators andthe calculators" had taken over another country.