In attempting a fair picture of this conference I am more than usually aware that it is impossible to do justice in a short report to all the nuances of science, medicine and sociology expressed by participants.
That said, it was inevitable that much of the debate should focus on AIDS. It was nevertheless noted that even to-day, though future trends were uncertain but alarming in the case of AIDS, the annual toll of deaths resulting from smoking and drink greatly exceeded deaths from drugs or AIDS (in the UK, for example, 100,000 died each year from smoking and 10-28,000 from drink, compared with 350 from drugs).
In all these issues, prevention must be distinguished from treatment. For prevention two things were needed: identification of the size and nature of the problem and education.
To take prevention first, in no area were statistics wholly reliable. For example figures for serious drug users were probably exaggerated; and figures for alcohol-related violence and death might be under-stated. In the case of AIDS, figures were extrapolations and several factors prevented the accumulation of adequate data - the relative unreliability of the commonest and cheapest test, and the high cost of the more reliable confirmatory test; the infectious “window” period during which no antibodies were detectable; the reluctance of those most at risk (e.g. homosexuals, intravenous drug-users, prostitutes) to be tested, partly because, there being no cure, they “would rather not know”, and partly because of the practical and social consequences that flowed, in the present state of public opinion, not only from an HIV positive finding but even from the fact of a test. It was agreed that anonymous testing, so far as possible of representative samples, was desirable, for epidemiological reasons. That should not raise civil liberty issues. Testing of certain categories, where anonymity would be impracticable if there was to be benefit (although confidentiality could be preserved), was also desirable (e.g. pregnant women, prostitutes), and some other categories where risk might be high by reason of the occupation (e.g. some surgeons or air-line pilots although the relevance of testing in such cases was disputed). Refusal to be tested might in such cases require that the individual be regarded as HIV positive.
Anonymous testing must be free, with easy access to centres, which should not be sited in police stations or courts. Counselling must be available. Practice in individual countries varied in detail but was broadly similar, except in Scandinavia, Canada perhaps having the most developed system of free anonymous testing, using both primary and confirmatory tests.
Compulsory testing was ruled out except in certain circumstances, e.g., blood donors, the army. (In France and Illinois, testing was required before marriage.) Employers should be forbidden by law from requiring tests, except perhaps for the special occupations referred to. Some argued strongly for compulsory testing in prisons, as a protection for prisoners themselves; but others argued equally strongly that to test and segregate, either the HIV positives or negatives, avoided the root cause, sexual abuse in prisons.
Opinion was divided over insurance for HIV positives, health insurance being distinguished from life. With the former the problem arose where there was no comprehensive health care scheme, e.g. in the US. As the WHO put it, the state had a duty to look after the health of its citizens: if private health insurance could not carry that burden, the state must. In the case of life insurance, the general but not unanimous view seemed to be that the insured engaged in a gamble: if he was HIV positive and knew it, there was no gamble. No insurer could insure against a certainty. If the state were to provide specially for the dependants of AIDS victims, above the general provision, it would be a political decision.
Testing as a requirement by some countries for admission was considered. As a means of control, testing was useless, but if, given public sentiment in some countries, it had to be accepted, the European Community’s policy was to persuade nations to accept certificates issued by the visitor’s own state, thereby reducing the risk to him of infection through dirty needles. The risk to receiving countries from fraudulent certificates was insignificant.
The problem defined, education must be the key: education of the general public, to bring about a generally healthier life-style, to encourage risk-reducing precautions and to combat discrimination against sufferers; but also education targeted at individuals and groups who for one reason or another (sexual habits, intravenous drug use, profession) might be at particular risk. To change behaviour would take time. Nor could education alone be expected to succeed: failing a cure for AIDS, it was necessary to be able to offer counselling and non-discrimination. The campaigns against smoking and drinking and driving had been relatively successful over a long period. There were no doubt several reasons for this, including the growing social unacceptability of the habits. Reduced levels of nicotine in cigarettes, with lower addiction rates, had also played a part. While governments probably had to give a lead (and would be criticised if they did not), the message was more readily received if it came from peers, by age or life-style. There were dangers, however. It was argued that drug education in schools by reformed addicts could carry the message that you could enjoy the habit without penalty. The media had a particular responsibility: the press thrived on, often exaggerated, scare stories; but responsible handling of the issues, particularly in radio and television (perhaps more effectively through drama than straight educational programmes) could have immense impact. Positive education must be backed by control of advertising (cf. the ban on television advertising of cigarettes). As satellite broadcasting spread, controls must be international. Above all the message must be consistent, truthful, adequately funded over a period, and designed to bring out the social contract between society’s duty to the individual and the individual’s responsibility to society. While it might be tempting to argue, with Mill, that nobody need be prevented from damaging himself so long as he did not damage others, the fact was that all the problems under discussion affected others and society in some degree.
The question of communicating the HIV positive result to the patient’s partner was considered. While practice varied from country to country (in France communication was forbidden) the trend seemed to be towards communication.
This led on to care and treatment. For AIDS, the highest priority should be given to finding a cure and a vaccine, but that could be many years off. All administrations were aware of the urgency. The question of trials arose. While trials in parts of Africa where the disease was most prevalent would be sensible, they might not be politically acceptable unless conducted also in the developed world; and results might in any case not be reliable for different populations. The problem was best left to the drug companies.
Meanwhile, society must provide care. In the case of alcohol and drugs, organisations such as Alcoholics Anonymous had emerged to fill gaps in orthodox medical care. Similarly with AIDS there was a vital role to be played by private bodies. While there was a case for providing care outside hospital, that was not necessarily always true. Costs would be high - the cost of terminal care of an AIDS patient was put on average at £27,000. Public support for the provision of care and the necessary funding must form part of the general educational programme. Greater coordination was needed between all those organisations and individuals operating in this and related fields - a role for the Community Care officer, who should have a budget from which to fill gaps.
With drugs, it was noted that there was a shift away from a demand-led situation to stimulation of demand by producers (notably with “designer-drugs” where media hype played a malign part). While fatalities might be relatively low, the social consequences of wide-spread use of illegal drugs were serious, even destabilising. International action against the traffic and the traffickers’ funds was necessary and in hand; but the conference saw no realistic possibility of rolling back the problem, only of controlling it. Again, education was the key. Legalisation even of the softer drugs would only lead to increased use and if a country went that way, without international agreement, it would merely attract addicts from elsewhere.
While some held that legislation (e.g. to make condoms available) should not be constrained by moral or religious scruples, it was forcibly argued that it was morally unacceptable to say that, since governments could not remedy all the underlying causes of drug and alcohol abuse, bad housing, unemployment etc., they should act merely to mitigate the social effects while conniving in the supply of “opiates” to the people.
Moreover governments derived much income from alcohol and tobacco; and while smoking, for example, though still a problem, had declined in many Western societies, as noted above, the export of strong cigarettes to the third world by companies continued, and was no doubt encouraged by third world tobacco producers. While education about the dangers of alcohol abuse was having some effect, the sale of alcohol to the third world and the installation of breweries and distilleries continued. In both cases, the West was open to the charge of hypocrisy when it complained about narcotics.
No specific agreed conclusions were drawn. It was the general view however that as regards AIDS and some of the other issues addressed, we were only on the threshold of understanding the extent and nature of the problems and how to treat them; that the adjustment of behavioural patterns took time; that the problems raised serious economic and financial considerations and would require greater funding; that further thought needed to be given to regulatory regimes; that medical and clinical efforts must be given high priority and the necessary funding; and, more tentatively, that there was a need for continuing informal international exchange of experience.
This Note reflects the Director’s personal impressions of the conference. No participant is in any way committed to its content or expression.
Conference Chairman: The Rt Hon Sir Patrick Nairne GCB MC
Recently retired as Master, St Catherine’s College, Oxford (1981-88); Chancellor, Essex University; Member, West Midlands Board, Central TV; a Governor and Member of the Council of Management of the Ditchley Foundation
LIST OF PARTICIPANTS
Ms Brenda Almond
Director, Social Values Research Centre, and Reader in Philosophy and Education, Hull University; joint editor, Journal of Applied Philosophy and Chair, the Society for Applied Philosophy; Editor, AIDS: a moral issue fin preparation)
Mr Paul Barker
Associate Editor, The Independent Magazine; writer and broadcaster
Dr Gareth Beynon
Director, European Strategic Planning and Regulatory Affairs, G D Searle & Co Ltd; author of papers on endocrine physiology and clinical hypertension
The Baroness Blackstone
Peer (Labour); Master, Birkbeck College , University of London; Chairman, General Advisory Council of BBC
Ms Ann Burdus
Director, AGB Research pic; Joint Deputy Chairman and Member, Health Education Authority
Mr David Fall
Head, Narcotics Control and AIDS Department, Foreign and Commonwealth Office (FCO), London
Mr Norman Hale
Under-Secretary, Department of Health; Head of Child Health, Maternity and Prevention Division, which includes health education, AIDS and drug misuse
Miss Dianne Hayter JP
Director, Alcohol Concern
The Lord Hunter of Newington MBE FRCP DL
Former Vice-Chancellor and Principal, University of Birmingham (1968-81)
Dr Iain Macdonald
Chief Medical Officer, Scottish Home and Health Department; Member, Medical Research Council
The Baroness Masham of Ilton
Life Peer (Independent); Vice Chairman, Parliamentary Drug Misuse Committee; Member, Parliamentary All-Party Disabled Committee, Penal Affairs Committee; a Governor, the Ditchley Foundation
Mr D B Money-Coutts
Chairman, Coutts & Co; Director, National Westminster Bank; Trustee, Multiple Sclerosis Society
The Revd Nicolas Stacey
Executive Director, Citizen Action AIDS Policy Unit; Chairman, Youth Call
Dr Thomas Stuttaford
Medical Correspondent, The Times; Medical Adviser, Rank Organisation
Mr Ben Whitaker
Director, The Gulbenkian Foundation (UK) (1988-); UK Member, UN Human Rights Sub-Commission; author, The Global Connection: The Crisis of Drug Addiction
Mr Robin Woodland
Secretary to the Ministerial Group on the Misuse of Drugs, Home Office
Dr David Walters
Director, AIDS Education & Awareness Programme, Canadian Public Health Association
Professor Jean-Marie Decazes
Assistant Professor of Immunology, H6pital Saint-Louis, Paris
Professor Gérard Dubois
Professor of Public Health, on secondment to the French social security system where he is responsible for preventative medicine
Frau Dr Elisabeth Pott
Director, Federal Office for Health Education, Cologne
Dr Joseph Davie
President (Research and Development), G D Searle & Co; Senior Vice President, Preclinical Research, Adjunct Professor, Microbiology and Immunology, Washington University School of Medicine, St Louis, Mo, Member, Medical and Scientific Advisory Board, Medical Biology Institute
Mr Dennis deLeon
Deputy Manhattan Borough President, City of New York
Mr Richard D Dunne
Chairman, National AIDS Network, Washington DC; Executive Director, Gay Men’s Health Crisis Inc; Consultant, AIDS Policy Group, Ford Foundation; Member, National Advisory Committee, AIDS Health Services Program, Robert Wood Johnson Foundation; Member National Committee National- Community AIDS Partnership
Dean Harvey V Fineberg
Dean, Harvard School of Public Health; Member, Institute of Medicine, National Academy of Sciences; Founding Member, and President, Society for Medical Decision Making
Dr Howard H Hiatt
Professor of Medicine, Harvard Medical School and School of Public Health; Senior Physician, Brigham and Women’s Hospital; Director, Center for Policy and Education, Harvard AIDS Institute
Mr Edward Jurith
Staff Director, US House of Representatives Select Committee on Narcotics Abuse & Control (Counsel)
Mr Bruce Kiernan
Director of Development, Federation of Protestant Welfare Agencies, New York; Senior Program and Development Consultant and Member, Board of Directors, International Parliamentary Group for Human Rights in the Soviet Union (IPG); Head, Office of Science & Human Rights, American Association for the Advancement of Science; Founder Member, California Rural Legal Assistance Foundation (1982); Special Assistant to Senator Charles H Percy; Trustee, World Institute on Disability; Fund-raising strategist for community based AIDS organizations
Mr Cliff Morrison
Deputy Director, The Robert Wood Johnson Foundation AIDS Health Services Program, Institute for Health Policy Studies, School of Medicine, University of California; Assistant Clinical Professor, University of California, School of Nursing, Department of Mental Health, Community and Administrative Nursing
Mr Michael Nerney
Director, Narcotics and Drug Research Inc
Dr Gary R Noble
Director, HIV/AIDS programs, Centers for Disease Control; Assistant Surgeon General
Professor Mark Siegler
Director for Clinical Medical Ethics, University of Chicago
Dr Robert M Swenson
Professor of Medicine and Microbiology, Temple University Health Sciences Center
Mr Gil Tills
Chief Operating Officer, American Red Cross
Mr Hans A Wolf
Vice Chairman and Chief Administrative Officer, Syntex Corporation, California