- Email: [email protected]
Point of View
622 which
acknowledges that in the foreseeable future ecogrowth will have to take place without increased energy consumption.4 ment
Point of View
nomic
possible savings are surprisingly huge. 2. Even if savings of this order could not be achieved quickly (i.e., within 10 years) it is suggested that nuclear power could not significantly alleviate the problem within the time needed. There is tacit support for this viewpoint in a recent EEC docu-
The scale of the capital investment and diversion of needed if nuclear energy is to become a substantially larger contributor to world energy needs is certainly daunting. By pre-empting these huge capital, material, and human resources, a massive nuclear programme might make things worse in the next crucial decade. The economic and logistic objections to an expanded nuclear power programme are cogently argued by Amory Lovins.5 Nuclear power produces electricity -and only baseload electricity at that. This can account for only 10% or so of total primary energy and can only rise in this proportion. In turn this requires economic growth, the one thing we cannot have because we live in a world dependent for growth on oil, a fuel for which nuclear power is no substitute in the time under consideration. Lovins argues that an insurmountable cost barrier prevents substitution of oil by nuclear energy and concludes that not only is nuclear power logistically incapable of filling the existing gap, it will also prove a positive hindrance to rational policies. In such circumstances, all the other arguments against nuclear power, important as they are, become relegated to supporting roles. These objections, in particular to the next stage of nuclear development-the fast breeder reactor-are set out in the Flowers Report.6 There is a long list of unresolved problems-of nuclear proliferation, the dangers of nuclear wastes, the problems of civil liberties, the ever-present threat of simple malfunction leading to a disaster of the type which nearly happened at Harrisburg, and the still unknown consequences of persistent low-level radiation. The medical profession would find the epidemiological evidence on effects of radiation on workers in nuclear plants and the uncertainties about the effects of more widespread radiation of particular interest. Everyone, but perhaps especially the medical profession with its long tradition of respect for privacy and individual freedom, must be alarmed at the kind of security controls that would seem inevitable to prevent small amounts of plutonium reaching the wrong hands. Finally, it is necessary to return to the more fundamental philosophical question-whether the sort of growth envisaged by the nuclear proponents, and even in the Leach analysis, can continue indefinitely. There is no physical mechanism for indefinite expansion. Sooner or later the rate of material consumption must level off.7 The forced slowdown of economic growth which will inevitably result from the current energy crisis might be seen by some as a golden opportunity to change gear toward a level of consumption compatible with a sustainable economic system. It may be that the uncoupling of "standard of living" from rising material consumption and energy use will become the most vital need of our time. It is the attempt to escape from these dilemmas which is leading towards a major expansion of the nuclear pro-
1. Meyer N, Noigord J, Blegaa S, et al. Report of the DEMO Project, 1977-79—Fysisk Lab III, Danmarks Tekniske Hojskole, 2800 Lyngby. 2. Groupe de Bellevue—"Projet Alter", 1978—85 boul de Port Royal, 75031,
4. EEC Background Report ISEC/B32/79 Energy: Concern about Oil 1979 4 5. Lovins A. Is Nuclear Power Necessary? Friends of the Earth, Energy Paper
Paris. 3. Leach G, Lewis G, Romig G, Foley G, van Buren A. A Low Energy Strategy for the United Kingdom-Science Reviews and International Institute for Environment and Development. 1978.
6. Nuclear Power and the Environment. Sixth Report of the Royal Commission on Environmental Pollution. Cmnd 6618. H.M. Stationery Office, 1976 7. Davoll J. Review of ref. 3 Conservation News. 1979, no. 73, p.3.
The latest oil crisis and the nuclear mishap at Harrisburg have intensified the debate on energy needs and supplies. We asked Dr Taitz, chairman of the Conservation Society and consultantpadiatrician, to set down his own thoughts.
THE CASE FOR A NON-NUCLEAR FUTURE
THE natural interest of the medical profession regarding nuclear power is directed towards questions of possible present and future health hazards of radiation and the genetic consequences of a progressive increase in the amount of radioactive material in the environment. One of the main arguments offered against expansion of nuclear energy has been that not enough is yet known about these effects. Lately, however, opposition to the development of nuclear power has shifted to two even more basic questions-whether the future demand for energy need be as high as proponents of nuclear power claim, and even if it was, whether nuclear power would be the right way to obtain it. The orthodox view, held by the present British Government, is that a shortfall. in energy supply, resulting from a fall in world reserves of oil, can be met in good time by alternative sources, principally nuclear energy. Other sources such as solar, wind, and wave power are considered too problematical, and will take too long (until the next century) to be practicable. Coal, of which this country has an abundance, is believed to have dangerous political disadvantages. At the basis of these conclusions lie the suppositions that growth in material consumption must and will continue to rise as a prerequisite to rising living standards and social equity, and that such growth implies a corresponding rise in the demand for energy which can be met only by more nuclear power.
The first
supposition raises major philosophical and ecological questions. Let us first examine the second, which has been questioned on several grounds. 1. From several countries comes evidence 1,2 that, such is the slack created by the wastefulness of present energy usage, conservation measures alone could increase effective energy use to allow for real increases in living standards without the need for major new sources of energy. The most important work in Britain has been done by a team led by Gerald Leach.3 Simple or well-established measures, it is argued, including better home insulation, slightly lower temperatures in homes, savings by industry, and fluidised-bed combustion would lead to massive reductions in energy consumption. These findings conflict with official projections of energy demand. The discrepancy arises from the fact that, while orthodox forecasts depend on extrapolating into the future historical relationships between economic growth and energy need, the Leach study examines discrete areas of energy consumption in the economy and identifies areas where savings are possible. The magnitude of such
resources
3, 1979.
623
Having built our industrialised society on the assumption of an infinite supply of cheap and easily available oil, we now find that it is no longer cheap and will soon not be easily available at any price. Prudent oil-producing countries cut back extraction (sometimes euphemistically called production when it should be called destruction) and eke out their diminishing reserves. Only Britain seems poised to take a different tack, to use up North Sea oil as fast as we can in order to maintain present rates of consumption. Such a course would seem lunatic if there was not the implicit belief
mount.
that another energy source will fill the gap. Yet the difficulties of such substitution are immense, particularly in a static economy. Indeed this economic stagnation due
16 Nethergreen Road, Sheffield S11 7EJ
gramme.
Occasional Survey RANDOMISED COMPARATIVE STUDIES IN THE TREATMENT OF CANCER IN THE UNITED KINGDOM: ROOM FOR IMPROVEMENT? HELEN C. TATE
JANET
B. RAWLINSON
M.R.C. Statistical Research and Services Unit, University College Hospital Medical School, London WC1
LAURENCE S. FREEDMAN M.R.C. Cancer Trials
Office, Addenbrooke’s Hospital,
Cambridge The basic details of randomised clinical studies in cancer treatment under way in the United Kingdom were ascertained in a postal survey. The cancers of major interest were those of lung, breast, colon and rectum, and lymphomas and leukæmias. In general, only a small proportion of cancer patients are entered into clinical studies; and most of the individual studies aim for a small number of patients, with patient entry over a long period.
shortage, which cannot be prevented now, may prove a stumbling block to the modest proposal (economic growth without increased energy consumption) of the I.I.E.D. Report.4 More drastic changes of life-style in the medium term seem inevitable. The crucial question is whether nuclear-power expansion, with all its known and unknown hazards, is the appropriate response to our difficulties or merely the reflex response of collective vertical thinking. The need for to
the world oil even
be aware of the nature of the dilemma is paraThe decision cannot be left in the hands of vested interests. all
men to
entfy
had been completed; and in which patients lowed-up after were randomly allocated to one of two or more "treatment" groups. These "treatment" groups might involve no treatment or the administration of a placebo. We contacted international, national, and regional organisations, and individuals known to have an interest in cancer investigations. Anyone identified as being a clinical study organiser was requested to complete a short postal questionnaire which asked 6 basic questions concerning : disease definition, site, histological type and stage of disease; the number of patients already in the study and the total aimed for; the hospitals or regional-health-authority areas from which patients were drawn; the date of entry of the first patient into the study; details of the study organisation, funding, and day-to-day running (and, in particular, about the involvement of the statistician in the design, data collection, and analysis stages) and the treatments involved. A specimen copy of the protocol was also requested.
Summary
INTRODUCTION a Medical Research Council conclinical studies in cancer, in 1978 we did a postal survey of the randomised comparative studies of cancer treatment then in progress in the United Kingdom.* No comprehensive information existed: the Union Internationale Contre le Cancer1 and the U.S. Department of Health, Education and Welfare2 had published international lists of randomised studies, but these proved to include only a small proportion of the U.K. work The Breast Trials Co-ordinating Committee (B.T.C.C.) had compiled a list of breast-cancer studies and kindly supplied us with the names of the organisers (and we in turn were able to inform them of three studies of which they were unaware). So far as we know, no other siteoriented group has made a similar list.
IN
preparation for
ference
on
METHODS
The survey included only studies into which patients were about to be entered, were being entered, or were being fol*The survey included
two
studies in the
Republic
of Ireland.
L. S. TAITZ Chairman, Conservation Society
RESULTS
obtained for 211 studies and we ascertained that a further 20 studies were in progress though the questionnaires for these were never returned.
Complete questionnaires
were
Site and Incidence Rates
About a quarter (49 out of 211) of the studies were concerned with breast cancer, almost all being organised under the auspices of the B.T.C.C. Lung cancer attracted much interest (21), as did lymphomas (30) and leukaemias (25). Table i shows the number of clinical studies now entering patients, in relation to estimates of national incidence rates; the fourth and fifth columns give estimates of the total number of patients being entered per year (calculated from the total currently entered divided by the time interval since the entry of the first patient) and the percentage of the national incidence. There may be excellent reasons why a patient should not be entered into a particular study; for example, the histological type may not be relevant; the stage may be too advanced; or the patient may not be fit enough to undergo the treatment under investigation. We doubt, however, whether these are the main reasons for the very small proportion of patients being entered in controlled studies. Rate of
Entry
For this part of the analysis, the studies have been divided into two categories-local/regional (patients
acknowledges that in the foreseeable future ecogrowth will have to take place without increased energy consumption.4 ment
Point of View
nomic
possible savings are surprisingly huge. 2. Even if savings of this order could not be achieved quickly (i.e., within 10 years) it is suggested that nuclear power could not significantly alleviate the problem within the time needed. There is tacit support for this viewpoint in a recent EEC docu-
The scale of the capital investment and diversion of needed if nuclear energy is to become a substantially larger contributor to world energy needs is certainly daunting. By pre-empting these huge capital, material, and human resources, a massive nuclear programme might make things worse in the next crucial decade. The economic and logistic objections to an expanded nuclear power programme are cogently argued by Amory Lovins.5 Nuclear power produces electricity -and only baseload electricity at that. This can account for only 10% or so of total primary energy and can only rise in this proportion. In turn this requires economic growth, the one thing we cannot have because we live in a world dependent for growth on oil, a fuel for which nuclear power is no substitute in the time under consideration. Lovins argues that an insurmountable cost barrier prevents substitution of oil by nuclear energy and concludes that not only is nuclear power logistically incapable of filling the existing gap, it will also prove a positive hindrance to rational policies. In such circumstances, all the other arguments against nuclear power, important as they are, become relegated to supporting roles. These objections, in particular to the next stage of nuclear development-the fast breeder reactor-are set out in the Flowers Report.6 There is a long list of unresolved problems-of nuclear proliferation, the dangers of nuclear wastes, the problems of civil liberties, the ever-present threat of simple malfunction leading to a disaster of the type which nearly happened at Harrisburg, and the still unknown consequences of persistent low-level radiation. The medical profession would find the epidemiological evidence on effects of radiation on workers in nuclear plants and the uncertainties about the effects of more widespread radiation of particular interest. Everyone, but perhaps especially the medical profession with its long tradition of respect for privacy and individual freedom, must be alarmed at the kind of security controls that would seem inevitable to prevent small amounts of plutonium reaching the wrong hands. Finally, it is necessary to return to the more fundamental philosophical question-whether the sort of growth envisaged by the nuclear proponents, and even in the Leach analysis, can continue indefinitely. There is no physical mechanism for indefinite expansion. Sooner or later the rate of material consumption must level off.7 The forced slowdown of economic growth which will inevitably result from the current energy crisis might be seen by some as a golden opportunity to change gear toward a level of consumption compatible with a sustainable economic system. It may be that the uncoupling of "standard of living" from rising material consumption and energy use will become the most vital need of our time. It is the attempt to escape from these dilemmas which is leading towards a major expansion of the nuclear pro-
1. Meyer N, Noigord J, Blegaa S, et al. Report of the DEMO Project, 1977-79—Fysisk Lab III, Danmarks Tekniske Hojskole, 2800 Lyngby. 2. Groupe de Bellevue—"Projet Alter", 1978—85 boul de Port Royal, 75031,
4. EEC Background Report ISEC/B32/79 Energy: Concern about Oil 1979 4 5. Lovins A. Is Nuclear Power Necessary? Friends of the Earth, Energy Paper
Paris. 3. Leach G, Lewis G, Romig G, Foley G, van Buren A. A Low Energy Strategy for the United Kingdom-Science Reviews and International Institute for Environment and Development. 1978.
6. Nuclear Power and the Environment. Sixth Report of the Royal Commission on Environmental Pollution. Cmnd 6618. H.M. Stationery Office, 1976 7. Davoll J. Review of ref. 3 Conservation News. 1979, no. 73, p.3.
The latest oil crisis and the nuclear mishap at Harrisburg have intensified the debate on energy needs and supplies. We asked Dr Taitz, chairman of the Conservation Society and consultantpadiatrician, to set down his own thoughts.
THE CASE FOR A NON-NUCLEAR FUTURE
THE natural interest of the medical profession regarding nuclear power is directed towards questions of possible present and future health hazards of radiation and the genetic consequences of a progressive increase in the amount of radioactive material in the environment. One of the main arguments offered against expansion of nuclear energy has been that not enough is yet known about these effects. Lately, however, opposition to the development of nuclear power has shifted to two even more basic questions-whether the future demand for energy need be as high as proponents of nuclear power claim, and even if it was, whether nuclear power would be the right way to obtain it. The orthodox view, held by the present British Government, is that a shortfall. in energy supply, resulting from a fall in world reserves of oil, can be met in good time by alternative sources, principally nuclear energy. Other sources such as solar, wind, and wave power are considered too problematical, and will take too long (until the next century) to be practicable. Coal, of which this country has an abundance, is believed to have dangerous political disadvantages. At the basis of these conclusions lie the suppositions that growth in material consumption must and will continue to rise as a prerequisite to rising living standards and social equity, and that such growth implies a corresponding rise in the demand for energy which can be met only by more nuclear power.
The first
supposition raises major philosophical and ecological questions. Let us first examine the second, which has been questioned on several grounds. 1. From several countries comes evidence 1,2 that, such is the slack created by the wastefulness of present energy usage, conservation measures alone could increase effective energy use to allow for real increases in living standards without the need for major new sources of energy. The most important work in Britain has been done by a team led by Gerald Leach.3 Simple or well-established measures, it is argued, including better home insulation, slightly lower temperatures in homes, savings by industry, and fluidised-bed combustion would lead to massive reductions in energy consumption. These findings conflict with official projections of energy demand. The discrepancy arises from the fact that, while orthodox forecasts depend on extrapolating into the future historical relationships between economic growth and energy need, the Leach study examines discrete areas of energy consumption in the economy and identifies areas where savings are possible. The magnitude of such
resources
3, 1979.
623
Having built our industrialised society on the assumption of an infinite supply of cheap and easily available oil, we now find that it is no longer cheap and will soon not be easily available at any price. Prudent oil-producing countries cut back extraction (sometimes euphemistically called production when it should be called destruction) and eke out their diminishing reserves. Only Britain seems poised to take a different tack, to use up North Sea oil as fast as we can in order to maintain present rates of consumption. Such a course would seem lunatic if there was not the implicit belief
mount.
that another energy source will fill the gap. Yet the difficulties of such substitution are immense, particularly in a static economy. Indeed this economic stagnation due
16 Nethergreen Road, Sheffield S11 7EJ
gramme.
Occasional Survey RANDOMISED COMPARATIVE STUDIES IN THE TREATMENT OF CANCER IN THE UNITED KINGDOM: ROOM FOR IMPROVEMENT? HELEN C. TATE
JANET
B. RAWLINSON
M.R.C. Statistical Research and Services Unit, University College Hospital Medical School, London WC1
LAURENCE S. FREEDMAN M.R.C. Cancer Trials
Office, Addenbrooke’s Hospital,
Cambridge The basic details of randomised clinical studies in cancer treatment under way in the United Kingdom were ascertained in a postal survey. The cancers of major interest were those of lung, breast, colon and rectum, and lymphomas and leukæmias. In general, only a small proportion of cancer patients are entered into clinical studies; and most of the individual studies aim for a small number of patients, with patient entry over a long period.
shortage, which cannot be prevented now, may prove a stumbling block to the modest proposal (economic growth without increased energy consumption) of the I.I.E.D. Report.4 More drastic changes of life-style in the medium term seem inevitable. The crucial question is whether nuclear-power expansion, with all its known and unknown hazards, is the appropriate response to our difficulties or merely the reflex response of collective vertical thinking. The need for to
the world oil even
be aware of the nature of the dilemma is paraThe decision cannot be left in the hands of vested interests. all
men to
entfy
had been completed; and in which patients lowed-up after were randomly allocated to one of two or more "treatment" groups. These "treatment" groups might involve no treatment or the administration of a placebo. We contacted international, national, and regional organisations, and individuals known to have an interest in cancer investigations. Anyone identified as being a clinical study organiser was requested to complete a short postal questionnaire which asked 6 basic questions concerning : disease definition, site, histological type and stage of disease; the number of patients already in the study and the total aimed for; the hospitals or regional-health-authority areas from which patients were drawn; the date of entry of the first patient into the study; details of the study organisation, funding, and day-to-day running (and, in particular, about the involvement of the statistician in the design, data collection, and analysis stages) and the treatments involved. A specimen copy of the protocol was also requested.
Summary
INTRODUCTION a Medical Research Council conclinical studies in cancer, in 1978 we did a postal survey of the randomised comparative studies of cancer treatment then in progress in the United Kingdom.* No comprehensive information existed: the Union Internationale Contre le Cancer1 and the U.S. Department of Health, Education and Welfare2 had published international lists of randomised studies, but these proved to include only a small proportion of the U.K. work The Breast Trials Co-ordinating Committee (B.T.C.C.) had compiled a list of breast-cancer studies and kindly supplied us with the names of the organisers (and we in turn were able to inform them of three studies of which they were unaware). So far as we know, no other siteoriented group has made a similar list.
IN
preparation for
ference
on
METHODS
The survey included only studies into which patients were about to be entered, were being entered, or were being fol*The survey included
two
studies in the
Republic
of Ireland.
L. S. TAITZ Chairman, Conservation Society
RESULTS
obtained for 211 studies and we ascertained that a further 20 studies were in progress though the questionnaires for these were never returned.
Complete questionnaires
were
Site and Incidence Rates
About a quarter (49 out of 211) of the studies were concerned with breast cancer, almost all being organised under the auspices of the B.T.C.C. Lung cancer attracted much interest (21), as did lymphomas (30) and leukaemias (25). Table i shows the number of clinical studies now entering patients, in relation to estimates of national incidence rates; the fourth and fifth columns give estimates of the total number of patients being entered per year (calculated from the total currently entered divided by the time interval since the entry of the first patient) and the percentage of the national incidence. There may be excellent reasons why a patient should not be entered into a particular study; for example, the histological type may not be relevant; the stage may be too advanced; or the patient may not be fit enough to undergo the treatment under investigation. We doubt, however, whether these are the main reasons for the very small proportion of patients being entered in controlled studies. Rate of
Entry
For this part of the analysis, the studies have been divided into two categories-local/regional (patients