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bologna Naloxone supplied to Italian heroin addicts
DISPATCHES
WASHINGTON
NIH’s big budget gains face new uncertainty
on’t assume that Washington is immobilised by the spectacle of the president dodging impeachment while undergoing moral convalescence. It may seem that way. But the great American government grinds on, albeit slowly, because of the extraordinary distractions. The new fiscal year commences on Oct 1, and, as often happens, Congress is behind in its appropriations work, and eager to get away for the Nov 3 elections. For biomedical research, the omens are favourable, unless the time and energy of Congress are depleted by inquiries into the president’s difficulties. If a new budget is not produced by Congress and signed by the president by the dawn of the new year, the next best choice is the continuing resolution, which permits agencies to spend at the previous year’s level until a new money bill has been enacted. Without such resolutions for unbudgeted agencies, the government would shut down, as it did 2 years ago, to the public-relations detriment of the reigning Republicans. They vow it will not happen again. A budget based on a continuing resolution would penalise the National Institutes of Health (NIH). While most other government agencies must make do next fiscal year with reductions, the same funds or, at best, modest increases, NIH is different. Starting from this year’s base of US$13·6 billion for NIH, the President proposed an increase to $14·8 billion, counting on a windfall of tobacco-settlement money that never arrived. No matter. With or
D
BOLOGNA
without tobacco money, it was not enough for NIH’s House Appropriations Committee, which voted for $14·9 billion. Piddling, said the Senate appropriations committee, voting for $15·6 billion—a $2 billion increase over current funding. The votes for those plump figures are not the equivalent of money in the bank. Under the Congress’s tight budgeting rules, the House increases were achieved by cutting programmes for the poor, which brought warnings of a presidential veto; and the Senate increase may be vulnerable because it is the product of inventive accounting wiles to elude the
“The glut of new money will be accompanied by political complications for the managers of NIH” supposedly rigid “caps” on spending. The essential message is that there’s a powerful urge to spend a great deal more on medical research. The glut of new money will be accompanied by political complications for the managers of NIH. While generous with dollars, the Congress is of mixed mind on whether it should select diseases for NIH’s attention. Congressionally “earmarked” appropriations, specifying projects and performers, are common in defence, agriculture, and energy research. But, cautioned that the heartfelt preferences of politicians are not a useful guide to medical-research priorities, the legislators have generally main-
tained a hands-off approach in recent years. Prodded, however, by disease lobbies that claim NIH is neglecting their particular disease, members are becoming more aggressive. Last year, the Parkinson’s disease lobby scored a budget gain. The budget for the coming year contains a directive to increase spending on prostate cancer, from $114 million to $175 million. The instruction comes from Senator Ted Stevens, Republican of Alaska, a survivor of prostate cancer and chairman of the Senate Appropriations Committee. Meanwhile, NIH is responding, though reluctantly, to recommendations for wider consultation with the public in establishing health-research priorities. The recommendations came from a committee created by the Institute of Medicine at the command of Congress, which, in turn, was responding to the complaints of disease lobbies. On Sept 23, NIH director Harold Varmus will hold an inaugural meeting with the recently established Director’s Council of Public Representatives. And each of the institutes at NIH will establish a public liaison office. NIH was cool to these innovations, and some of the disease lobbies—determined and well-financed—have voiced skepticism of NIH’s intentions. However, NIH and the lobbies need each other. NIH dominates basic biomedical research. And the budget that permits it to do so is regularly boosted by the agitations of the disease lobbies. Daniel S Greenberg
Naloxone supplied to Italian heroin addicts
M
easures aimed at containing the rising number of heroin overdose deaths in the Italian region of Emilia-Romagna have been launched by Celeste Franco Giannotti and Gianluca Borghi of Bologna’s regional administration. The measures include education and distribution of the opioid antagonist naloxone to heroin users. Emilia-Romagna, with 4 million inhabitants, has more than 9000 heroin users enrolled in public programmes, but their total number may be three times as high. In this region in 1996 (the last year for which complete data are available) there were 170 heroin-overdose deaths, up from about 120 in each of
THE LANCET • Vol 352 • September 19, 1998
the 2 previous years. More than 80% of those who died were men, two thirds were aged between 25 and 35 years. Data for 1997 indicate that overdose was the leading cause of death among addicts, ahead of HIV infection, which is declining. Naloxone vials (0·4 mg in 1 mL) contained in a key-ring will be distributed, along with instructions, to heroin users attending addiction facilities. Vials will also be available to non-enrolled addicts via “street units” which already offer needleexchange facilities. Mila Ferri, a physician coordinating the programme, told The Lancet that it seems to be the first experiment of its kind in the public sector.
Preliminary data have shown that all heroin users are generally ill informed about the risks and management of overdose. “Subjects at high-risk”, said Ferri “include addicts who resume injecting opiods after having stopped doing so for a while, for instance because of imprisonment or attempts at detoxication”. All opioid users will be given leaflets with simple safety advice. Planned epidemiological monitoring in Bologna and surrounding provinces in the next few months will investigate whether deaths can be avoided with such public health measures. Bruno Simini
967
WASHINGTON
NIH’s big budget gains face new uncertainty
on’t assume that Washington is immobilised by the spectacle of the president dodging impeachment while undergoing moral convalescence. It may seem that way. But the great American government grinds on, albeit slowly, because of the extraordinary distractions. The new fiscal year commences on Oct 1, and, as often happens, Congress is behind in its appropriations work, and eager to get away for the Nov 3 elections. For biomedical research, the omens are favourable, unless the time and energy of Congress are depleted by inquiries into the president’s difficulties. If a new budget is not produced by Congress and signed by the president by the dawn of the new year, the next best choice is the continuing resolution, which permits agencies to spend at the previous year’s level until a new money bill has been enacted. Without such resolutions for unbudgeted agencies, the government would shut down, as it did 2 years ago, to the public-relations detriment of the reigning Republicans. They vow it will not happen again. A budget based on a continuing resolution would penalise the National Institutes of Health (NIH). While most other government agencies must make do next fiscal year with reductions, the same funds or, at best, modest increases, NIH is different. Starting from this year’s base of US$13·6 billion for NIH, the President proposed an increase to $14·8 billion, counting on a windfall of tobacco-settlement money that never arrived. No matter. With or
D
BOLOGNA
without tobacco money, it was not enough for NIH’s House Appropriations Committee, which voted for $14·9 billion. Piddling, said the Senate appropriations committee, voting for $15·6 billion—a $2 billion increase over current funding. The votes for those plump figures are not the equivalent of money in the bank. Under the Congress’s tight budgeting rules, the House increases were achieved by cutting programmes for the poor, which brought warnings of a presidential veto; and the Senate increase may be vulnerable because it is the product of inventive accounting wiles to elude the
“The glut of new money will be accompanied by political complications for the managers of NIH” supposedly rigid “caps” on spending. The essential message is that there’s a powerful urge to spend a great deal more on medical research. The glut of new money will be accompanied by political complications for the managers of NIH. While generous with dollars, the Congress is of mixed mind on whether it should select diseases for NIH’s attention. Congressionally “earmarked” appropriations, specifying projects and performers, are common in defence, agriculture, and energy research. But, cautioned that the heartfelt preferences of politicians are not a useful guide to medical-research priorities, the legislators have generally main-
tained a hands-off approach in recent years. Prodded, however, by disease lobbies that claim NIH is neglecting their particular disease, members are becoming more aggressive. Last year, the Parkinson’s disease lobby scored a budget gain. The budget for the coming year contains a directive to increase spending on prostate cancer, from $114 million to $175 million. The instruction comes from Senator Ted Stevens, Republican of Alaska, a survivor of prostate cancer and chairman of the Senate Appropriations Committee. Meanwhile, NIH is responding, though reluctantly, to recommendations for wider consultation with the public in establishing health-research priorities. The recommendations came from a committee created by the Institute of Medicine at the command of Congress, which, in turn, was responding to the complaints of disease lobbies. On Sept 23, NIH director Harold Varmus will hold an inaugural meeting with the recently established Director’s Council of Public Representatives. And each of the institutes at NIH will establish a public liaison office. NIH was cool to these innovations, and some of the disease lobbies—determined and well-financed—have voiced skepticism of NIH’s intentions. However, NIH and the lobbies need each other. NIH dominates basic biomedical research. And the budget that permits it to do so is regularly boosted by the agitations of the disease lobbies. Daniel S Greenberg
Naloxone supplied to Italian heroin addicts
M
easures aimed at containing the rising number of heroin overdose deaths in the Italian region of Emilia-Romagna have been launched by Celeste Franco Giannotti and Gianluca Borghi of Bologna’s regional administration. The measures include education and distribution of the opioid antagonist naloxone to heroin users. Emilia-Romagna, with 4 million inhabitants, has more than 9000 heroin users enrolled in public programmes, but their total number may be three times as high. In this region in 1996 (the last year for which complete data are available) there were 170 heroin-overdose deaths, up from about 120 in each of
THE LANCET • Vol 352 • September 19, 1998
the 2 previous years. More than 80% of those who died were men, two thirds were aged between 25 and 35 years. Data for 1997 indicate that overdose was the leading cause of death among addicts, ahead of HIV infection, which is declining. Naloxone vials (0·4 mg in 1 mL) contained in a key-ring will be distributed, along with instructions, to heroin users attending addiction facilities. Vials will also be available to non-enrolled addicts via “street units” which already offer needleexchange facilities. Mila Ferri, a physician coordinating the programme, told The Lancet that it seems to be the first experiment of its kind in the public sector.
Preliminary data have shown that all heroin users are generally ill informed about the risks and management of overdose. “Subjects at high-risk”, said Ferri “include addicts who resume injecting opiods after having stopped doing so for a while, for instance because of imprisonment or attempts at detoxication”. All opioid users will be given leaflets with simple safety advice. Planned epidemiological monitoring in Bologna and surrounding provinces in the next few months will investigate whether deaths can be avoided with such public health measures. Bruno Simini
967