AIDS, AFRICA, AND ACADEMICS

575 GUILT AFTER ABORTION

We cannot be sure that teenagers will practise safe sex even if they know the result of HIV testing: the number of babies bom to unmarried teenagers shows how little attention is paid to contraception. If we told our teenage patients would we be taking a useful step in preventing the spread of HIV infection, or would we be placating our own consciences? Haemophilia Centre, Royal Manchester Children’s Hospital, Manchester M27 1HA

D. I. K. EVANS

AIDS, AFRICA, AND ACADEMICS SIR,-Dr Seaman (Aug 8, p 339) expresses his concern at Edinburgh and Glasgow Universities’ advice to medical students undertake electives in certain African countries for fear of HIV infection. To this sad list must now be added the University of Aberdeen, which has included staff visiting these countries in respect of academic interests in their "very strong advice", and has produced a waiver for staff to sign. As Dr Greenwood points out (June 13, p 1374) the risk of acquiring AIDS during a trip to Africa as a result of emergency treatment with infected instruments or blood is remote; much more so than the health and travel risks to which students and staff are exposed in other elective activities. Two issues seem clear to us--one medical and the other academic. It is a contradiction of professional ethics that doctors (either those in the making or the finished article) should shrink from the sick. The academic judgment is more open to question. Many of us believe that by being members of a university we belong to a wider community of learning than is encompassed by our local campus, a community to which we owe an obligation as teachers. We feel a commonality of purpose and a duty to our colleagues in the universities of Africa. It is a remarkable coincidence that such controversial advice should have been issued simultaneously by three of the four Scottish medical schools. It is a pity that the Aberdeen advice was distributed during vacation time when few were available to benefit from the instruction and when an adequate response to it could not be organised. Perhaps the deans of the medical schools concerned should write to The Lancet to explain their stand and state how they expect members of their universities to respond to academic invitations from, for example, Uganda, Zambia, Kenya, Nigeria, and The Gambia, all countries with which we in this department have academic connections. To ask us to ostracise our colleagues in Africa is a serious matter. It marks a profound departure in university attitudes and policy. not to

Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen AB9 2XB

ARNOLD KLOPPER NICHOLAS M. FISK

SELECTIVE REDUCTION IN ASSISTED PREGNANCIES

SIR,-Dr Fishel and Mr Webster (Aug 1, p 273) mention the frequency of multiple pregnancies in their 81 successful pregnancies where three embryos had been replaced after in-vitro fertilisation (IVF); they omit to mention 21 lost embryos in the "twin" pregnancies, and 106 in the 53 "singleton" pregnancies, and the number of wholly unsuccessful attempts where all three embryos were lost. The realism they ask for should be applied to their own data. I doubt if realism will come until the Voluntary Licensing

Authority becomes a compulsory one, with all relevant clinical data being supplied on demand. If patients’ advisers were realists (rather than optimists, pessimists, or opportunists) and informed patients that three embryos would be created in the hope that one might become established fewer might be inclined to try this answer to their fertility problem. Predictably many of those who do opt for IVF will seek selective reduction if inconvenienced by the establishment of a multiple pregnancy. However, I am astounded that clinicians should believe selective reduction is not termination of pregnancy. Selective reduction is a euphemism, not a realism. Royal Samaritan Hospital for Women, Glasgow G42 7JF

COLUM O’REILLY

SIR,-Madeleine Simms (Aug 8, p 339), drawing attention to a Life questionnaire, points out that it fails to contain questions on instant happiness. The decision to abort has to be made rapidly, because time is short: yet life for the mother and father is long. My experience with the aged has made me realise that some elderly people suffer intense distress arising from actions they took earlier in life. Somehow, in some way that is unclear, illness in old age strips psychological defences and makes earlier actions reemerge to conscious level with severe guilt reactions. Sometimes the confidentiality of the doctor-patient relationship is sufficient for them to express their guilt. Others have to be given permission to forgive themselves. Research into the complex question of the management of guilt reactions is needed. The Life questionnaire seeks evidence of short-term distress, but it remains to be seen what the long-term psychological sequelae of legalised abortion will be. Department of Geriatric Medicine, St George’s Hospital Medical School,

PETER H. MILLARD

London SW17 0RE

PESTICIDES AND HEALTH

SIR,-May I comment on your note (Aug 8, p 348)? The chairman of the Agriculture Select Committee of the House of Commons, Sir Richard Body, produced a draft report which was not agreed or even collectively considered by the committee. One committee member characterised the draft as scaremongering, while another said much of it was based on hearsay rather than fact and would have been heavily amended before it could have emerged as a Select Committee report. It is perhaps not surprising, therefore, that, to use your words, the report "will go a long way to confirming much public unease about the hazards of intensive farming". Such reports create public unease and the unsubstantiated allegations which they feature sit uncomfortably with the quoted statement about not substituting emotion for science, and diminish the contribution made to open debate on a matter of public interest. Sir Richard’s attitude is exemplified by his recommendation on ’Temik’. The review he calls for has already been done and the Advisory Committee on Pesticides concluded that "the claim that aldicarb [the active ingredient in temik] posed a risk to the human immune system could not be substantiated". No change to the approved status of temik in the UK was recommended. Similar decisions were reached by the Canadian authorities and by the US Environmental Protection Agency. An opportunity has been missed to make a timely and significant contribution to pesticide regulation in the UK, now subject to statutory control. Although this Association would find it possible to agree with as many as two-thirds of the recommendations, I believe the industry I represent deserved better of the House of Commons Agriculture Committee. British Agrochemicals Association Ltd, 4 Lincoln Court, Lincoln Road, Peterborough PE1 2RP

TEARLACH D.

MACLEAN,

Director

PERIPARTUM CARDIOMYOPATHY

SiR,—Dr Phipps and colleagues (June 27, p 1500) report a patient in whom dilated cardiomyopathy presented with postpartum collapse. We report a patient who was admitted to this hospital in whom the possibility of acute dilated cardiomyopathy was recognised before the onset of labour. Despite appropriate and recommended management1,2 she had severe, rapidly progressive heart failure that required urgent cardiac transplantation. A 35-year-old woman presented to casualty in the 38th week of her first pregnancy with a 24 h history of palpitations. Examination was

unremarkable, and she

was

reassured and

sent

home.

Retrospective analysis of an electrocardiogram (ECG) obtained at that time showed tachycardia (120 beats per min) and left bundle-branch block. 5 days later she was admitted to the obstetric ward with increasing palpitations, dyspnoea, orthopnoea, and ankle swelling. There was no history of note and regular antenatal checks had revealed no abnormalities. She had been attending aerobic classes until the end of the second trimester. Examination revealed a