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The second creation

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DOI: 10.1038/429348a

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reviews
BOOKS • CD ROMS • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS • MINERVA
Virus: The Co-Discoverer
of HIV Tracks Its Rampage
and Charts the Future
Luc Montagnier, Stephen Sartarelli
(translator)
W W Norton, £18.95, pp 224
ISBN 0 393 03923 4
Rating: ★★
H
IV has generated a huge amount of
literature in the relatively short
period of time since AIDS was first
described. Investigators quickly discovered
the aetiological agent of this new and deadly
The Second Creation
Ian Wilmut, Keith Campbell, Colin Tudge
Headline Books, £12.99,
pp 362
ISBN 0747275300
Rating: ★★
I
found the media reaction to Dolly the
sheep decidedly depressing. As a pub-
licly funded scientist in a democratic
society, I acknowledge my obligation to
explain what I am doing. If I worked on
quarks or black holes—things far beyond
normal human experience—I would expect
some odd comments about my work. But
surely not clones? Everybody knows a
human clone. Half a million walk the streets
The BMJ Bookshop will endeavour to obtain
any books reviewed here. To order contact the
BMJ Bookshop, BMA House, Tavistock Square,
London WC1H 9JR.
Tel: 020 7383 6244, Fax: 020 7383 6455
email: orders@bmjbookshop.com
Online: bmjbookshop.com
(Prices and availability subject to change by
publishers.)
966
disease, established its main genotypic
determinants, and found an effective
treatment—an amazing record in the field of
virology. With such an enormous amount of
information, which includes several journals
devoted exclusively to the virus and its
related conditions, the history of HIV is well
documented. So who better to write the
definitive story than the man who discov-
ered it, Luc Montagnier?
Virus is a detailed account of the work of
the investigators at the Pasteur Institute in
their search to find the cause of AIDS. Mon-
tagnier gives his personal insights into HIV
epidemiology, treatment, and prevention,
including vaccine development. He also dis-
cusses future directions in HIV research and
measures that should be taken to curb the
spread of the virus in developing countries.
But beyond the scientific discussion lies
an autobiography. The author discusses
some episodes of his childhood, his initia-
tion into research, and his extraordinary
career. The personal account, however,
of Britain. Yet, despite our everyday familiar-
ity with them, popular culture persists in
seeing clones as some sort of semi-human
programmable zombies. After all the hype,
we need to get back down to earth. In this
book the science writer Colin Tudge joins
Ian Wilmut and Keith Campbell in a careful
explanation of how Dolly was cloned, why
she was cloned, and what it might mean.
The authors work hard at stripping away
the hype—so hard that they risk stripping
away the interest as well. After the witty pas-
tiche of Leonardo da Vinci on the dust
jacket, I struggled through pedestrian expo-
sitions of basic genetics and cell biology.
One of those adult cartoon books would
have put it over so much better. However,
when the story moves on to the cloned
sheep—Megan and Morag cloned from fetal
cells, Dolly cloned from an adult mammary
cell, and her successor, Polly, cloned from a
genetically engineered fetal fibroblast—the
pace and interest pick up. The authors have
good fun at the expense of journalists who
wrote stuff like: “when you do something to
anger her, she looks at you with those
intense red eyes—eyes full of hate.” Once
again, as in every public pronouncement
from Wilmut et al, they stress their
opposition to human reproductive cloning.
One thing I learnt from the book is that
Dolly, as an expression of remarkable mam-
mary potential, was named after Ms D
Parton. This raises the question, what will the
diverts attention from the more interesting
and important aspects of the book. Montag-
nier peppers the book with criticisms of US
investigators and institutions, particularly of
Dr Robert Gallo from the National Institutes
of Health. These criticisms come out of the
controversial debate, widely publicised in
the media, about which group was the first
to identify the virus and the serological test
to detect HIV infection
The most compelling story in Virus is
the chronological account of the race
against time to identify the cause of an
emerging, rapidly spreading, and lethal
disease. The story has an upbeat ending,
which counterbalances the difficulties faced
by Montagnier and his team of laboratory
researchers. As the author points out,
researchers have to fight constantly against
disappointment, since most of their experi-
ments come to little or nothing.
Julio Collazos department of infectious diseases,
Hospital de Galdakao, Spain
first animals cloned from spleen or colon
cells be called? I think we should be told.
Why is Dolly important? We don’t need
fancy technology to make lots of sheep—this
weekend the Lake District was full of frisking
lambs, all strictly organic. Dolly refuted the
common belief that adult cells are irrevers-
ibly programmed. Technically, she points the
way to genetic engineering of animals.
“Pharming”—making animals that produce
valuable proteins in, say, their milk—
becomes much more controllable if they can
be cloned from cells manipulated in vitro.
Dolly was the only success out of 277
attempts, and some cloned animals have
unexplained abnormalities, so the technol-
ogy still has some way to go. But now we
know it can be done the problems will surely
be solved.
As for human cloning, no doubt
somewhere in the poorly regulated US com-
mercial sector, laboratories are already
working to give spurious immortality to
some self obsessed billionaire. Sooner or
later they will succeed. So what? I pity the
clone, but no more than I pity any child of
ambitious parents who think they can
programme its life. Actually, the clone might
well have the last laugh. Suppose he did
resemble his self centred progenitor. Would
he meekly follow a predetermined blueprint
for his life? Surely he would turn on his pro-
grammers with intense red eyes, full of hate?
Andrew P Read professor of human genetics,
University of Manchester
BMJ VOLUME 321 14 OCTOBER 2000 bmj.com

Global Challenge of
Healthcare Rationing
Eds Angela Coulter, Chris Ham
Open University Press,
£19.99, pp 288
ISBN 0 335 20463 5
Rating: ★★★
I
n 1995, when Alain Juppé, the French
prime minister, tried to reform the
healthcare system and to introduce
explicit rationing, the country went on strike
for five weeks and was almost totally
paralysed for that time. Healthcare rationing
is indeed a challenge for policymakers, and
few dare to do it explicitly.
The Global Challenge of Healthcare
Rationing presents a clear inventory of
what healthcare rationing means and of
why and how it should be done. The
introductory chapter refers to the Oregon
experiments, which dealt with explicit
priority setting rather than rationing. Here,
Tobacco War: Inside the
California Battles
Stanton A Glantz, Edith D Balbach
University of California Press,
£12.50, pp 496
ISBN 0 520 22286 5
Rating: ★★★
K
arl von Clausewitz wrote: “War is
nothing more than the continua-
tion of politics by other means” (On
War). The dictum is faultless, but its applica-
tion can be problematic. The devil, as always,
is in the detail.
Normally, a war’s protagonists are well
identified, and the combatants carve their
bloody path from the political chambers to
the battlefield. The usual presumptions do
not always apply, however, a point that is
forcefully argued in Tobacco War by Stanton
Glantz, lead author of The Cigarette Papers
and a professor of medicine at the
University of California, San Francisco, and
Ratings are on a 4 star scale, 4=excellent
BMJ VOLUME 321 14 OCTOBER 2000 bmj.com
the objective was to extend health insurance
coverage while deciding what services pub-
lic insurance would cover. The Oregon
experience with priority setting is, to my
knowledge, the only case in the world where
the exercise has been brought to its logical
conclusion: funding healthcare services
according to priority ranking, assessing the
effects of this policy, and adapting it in
return each year—for five consecutive years
to date.
The rest of the book focuses on papers
presented at two international conferences
on priority setting. These papers were given
by academics and not those presently in
charge of health services, with the exception
of the Israeli authors, which is both an asset
and a liability. The advantage is that we can
enjoy the good quality of research presented
here and its completeness, particularly in the
chapters that describe techniques for prior-
ity setting. On the other hand, the articles
perhaps do not give enough consideration
to the practical difficulties of implementing
rationing and dealing with the reality that
some people will be denied some kind of
care. This may be because, apart from the
state of Oregon, only Israel has actually car-
ried out a rationing scheme at a state or
country level.
Implementation of rationing is dis-
cussed in a chapter on ethical dilemmas.
Edith Balbach, director of the Community
Health Program at Tufts University, Med-
ford, Massachusetts.
The apparent focus of their book is
Proposition 99, the Tobacco Tax and Health
Promotion Act, a 1988 California ballot ini-
tiative that would raise over $600m a year
for health education and medical treatment.
Proposition 99 garnered 58% of the vote,
despite the tobacco industry’s 13 to 1 spend-
ing advantage ($21.4m to $1.6m) over
pro-99 coalition forces. However, the adop-
tion of Proposition 99 proved not to be the
resolution of a Manichaean conflict between
lily white public health professionals and the
dark forces of the tobacco industry. In fact,
Glantz and Balbach relate the voting results
in one undramatic sentence and, in an
otherwise impeccably researched book,
actually get the date wrong by a decade.
For the authors, the divided loyalties and
internecine feuds among tobacco control
advocates are as central to the story as are
their battles with the tobacco industry. The
book’s most shocking episode is the notori-
ous “Napkin Deal,” a 1987 pact whereby the
California Medical Association aligned its
interests with those of the tobacco industry.
Glantz and Balbach are unstinting in their
criticism of the association for its opposition
to Proposition 99 and similar initiatives.
The authors analyse the differing
approaches of the American Heart Associ-
ation, American Lung Association, and
American Cancer Society. Relying on
exhaustive interviews with the principal
reviews
This lists the questions that politicians do
not wish to address in most developed
countries. Who decides that care should be
denied to a population group? What are the
consequences of denying care? What are the
societal consequences of creating a two tier
medical system?
The presence of a chapter on priority
setting in developing countries makes the
book complete but is a bit awkward because
the issues differ so vastly. The chapter does
raise the issue of whether policymakers
should decide on healthcare priorities
within a fixed budget or be permitted, as in
Oregon, to trade off healthcare budgets
against other budgets like those for defence,
housing, or road infrastructure.
The topic of priority setting is likely to
remain important for a long time, as new
medical technologies provide consumers
with the means of getting closer to their
goal of eternal life and health, though at
increased costs. This means that today’s
conferences are likely to be followed
by others, which should include more poli-
ticians and heads of sickness funds, private
and public. I look forward to reading the
sequel.
Isabelle Durand-Zaleski chief of public health,
Santé Publique, Hôpital Henri Mondor, Créteil,
France
players, they reach a logical conclusion. The
only way to effect policy change, they argue,
is by turning to the public, where support for
tobacco control is both evident and politi-
cally potent. In short, it is necessary to adopt
“outside” rather than “inside” strategies.
Equally important, the authors say, is
that the change of one key player can mean
everything. For several years after the
passage of Proposition 99, funds were
illegally diverted from smoking prevention
by Republican Governor Pete Wilson,
abetted by Assembly Speaker Willie Brown,
a Democratic party politician heavily
financed by the tobacco industry. When Mr
Brown left office, the victories of the pro-99
forces finally translated into funding for
appropriately aggressive advertising and
educational campaigns.
California has a population of 33
million, more than Canada or Tanzania and
just less than Poland or Argentina. The
lessons from its ongoing tobacco war may
apply to as broad a range of countries and to
many public health issues. In the case of
tobacco control advocacy, the central mes-
sages are simple: the tobacco industry lies,
nicotine is addictive, and secondhand smoke
kills. In other areas of public health the mes-
sages may differ, but the same strategies are
effective. Glantz and Balbach argue that we
should keep the public engaged and should
not be afraid of controversy.
War may be hell, but some battles are
worth fighting.
Stan Shatenstein editor, Tobacco News Online,
Montreal, Canada
967
reviews

Ethnicity: An Agenda For
Mental Health
Eds Dinesh Bhugra, Veena Bahl
Gaskell (Royal College of
Psychiatrists), £25, pp 240
ISBN 1 901242 15
Rating: ★★
assembling a coherent picture from this col-
lection. Many of the individual contributions
are thorough and well written, but they vary
widely in aim and scope—from research
presentations to clinical discussions to
policy recommendations. Topics addressed
range from specific epidemiological issues,
such as postnatal depression among
Japanese women giving birth in England, to
broader discussions of health policy. Some
contributions resemble case studies of
particular UK ethnic communities, such as
Gujarati children in Manchester, while
others take a much more general view.
Unfortunately, the organisation of this
volume makes the diversity of topics and
perspectives a barrier rather than a strength.
For example, data from the fourth national
survey of ethnic minorities, a key to
treatment vary much more widely than do
rates of morbidity. In other words, linguistic,
cultural, political, and socioeconomic factors
probably have a greater influence on how
people present to and interact with the
healthcare system than they do on the
nature or symptoms of mental disorders. As
suggested by several of the chapters,
planning and policy must focus on remov-
ing language specific and culture specific
barriers to effective treatment. Improve-
ments in availability and acceptability of first
line treatments might reduce the need for
“late stage” treatments, which are typically
more restrictive and coercive. Reconciling
the need for diversity with the need for
accountability will be a central challenge for
mental health providers and administrators
in multiethnic societies.

T
he chapters in this book attempt to
address several timely questions: Are understanding differences in treatment For those with a specific interest in these
diagnostic categories developed in rates, are not presented until the penulti- issues, this collection will be an important ref-
Britain and the United States appropriate mate chapter. Solutions are sometimes pro- erence. Newcomers to the subject should
for other national or ethnic groups? Why posed before problems are clearly stated or probably look elsewhere for an introduction.
are certain ethnic groups overrepresented explored.
in secure inpatient facilities and underrepre- Given these shortcomings in the book’s Gregory Simon Investigator, Center for Health
sented among those receiving outpatient organisation, what can we conclude about Studies, Group Health Cooperative, Seattle, USA
care? How can the demand for diverse and the larger questions addressed? Several
non-traditional mental health services be chapters mention the problem of “category
reconciled with the mandate to provide fallacy,” in which diagnostic categories
services proved in randomised controlled described in Britain or the United States
trials? simply do not apply elsewhere, but available These articles scored the most hits on the BMJ’s
While the questions motivating this epidemiological data show more diagnostic website in the week of publication
book hold great theoretical and practical similarities between countries than differ-
interest, most readers will have difficulty ences. It seems safe to conclude that rates of
SEPTEMBER
1 ABC of breast diseases: Breast
cancer—epidemiology, risk factors, and
genetics
Smuggling tobacco Antitobacco campaigners have always been enthusiastic web 2000;321:624-8
28 473 hits
users: witness the tobacco control archives hosted at www.library.ucsf.edu/
2 ABC of breast diseases: Breast cancer
tobacco/ which gives pride of place to its archive of internal memoranda from
2000;321:745-50
the tobacco company Brown and Williamson. This week an article in the BMJ 28 086 hits
reviews evidence suggesting that the tobacco companies export cigarettes 3 ABC of breast diseases: Screening for
WEBSITE knowing that they may be illegally re-imported and sold untaxed. Much of the breast cancer
OF THE reference list of this paper is to materials on the web, such as Action on 2000;321:689-93
Smoking and Health’s (ASH) content rich site at www.ash.org.uk/smuggling 19 165 hits
WEEK
Unfortunately this page initially caused my browser to redraw the 4 Recent advances: Complementary medicine
page endlessly, which was irritating. 2000;321:683-6
14 797 hits
On the Mac, control-clicking over a
5 Recent advances: Palliative care
frame brings up a menu that offered
2000;321:555-8
“open frame in new window” (on a 13 864 hits
Windows PC you right-click). 6 Using the internet to access confidential
Selecting this, I left the troublesome patient records: a case study
javascript behind. Information in Practice 2000;321:612-4
This minor technical hiatus 9444 hits
exposes some interesting learning 7 Regular review: Improving the care of
points for would-be web adepts. Of patients with genital herpes
2000:321:619-23
course, all webpage authors should 7147 hits
test their work on a variety of
8 Clinical governance in primary care:
browsers and platforms, but campaigns on tight budgets might not be able to Improving quality in the changing world of
do it all themselves. Cogent reporting of bugs is one way to show you care primary care
about a site: use email, include the URL (web address) that gave you a problem, General Practice 2000;321:551-4
details of your browser and operating system, and a brief description of the 7038 hits
errant behaviour. 9 Clinical governance in primary care:
I wouldn’t take the trouble to do this for any of the many websites that offer Organisational development for clinical
governance
cigarettes for sale over the web (for example, www.qcigs.com), but the examples
General Practice 2000;321:679-82
I could find seemed to be legitimate mail order businesses. Not surprisingly, 6765 hits
Douglas
finding “duty not paid” cigarettes seems harder, though the Hong Kong 10 ABC of oral health: Dental emergencies
Carnall
BMJ government has obligingly posted a list of the streets where the trading of 2000;321:559-62
dcarnall@ contraband is common (http://www.info.gov.hk/gia/general/199812/02/ 6652 hits
bmj.com 1202106.htm).

968 BMJ VOLUME 321 14 OCTOBER 2000 bmj.com


PERSONAL VIEW
What happened to plain wickedness?
L
ast Friday someone burnt my house
down. He was not a patient of mine,
nor even an acquaintance. I can only
guess at his motive. I suspect it was a result of
something going on inside his own head
rather than anything to do with me or my
family. As far as ownership of the property is
concerned, I anticipate that it could just as
easily have been your house that was
torched to the ground as mine.
Nobody died or was injured. Even the
cats got out. We are “fully covered” by insur-
ance, although our broker has already told
us of inevitable discrepancy between theory
and practice.
I weep for my books, my wife’s loss of
her mother’s cut glass, and
all the family photographs
and trinkets. And the water- The metal frame
colours. And the little dolls of the piano looks
our daughter made by
painting faces on wooden bizarre without its
clothes pegs when she rosewood case
was 8.
It’s strange seeing the
upstairs in the downstairs. Not that any of it
is recognisable apart from the occasional
candlestick, a couple of Delft-ish vases on a
window sill (the window has gone and so
have all the walls and roof above it). The
metal frame of the piano looks bizarre with-
out its rosewood case. My mother’s chair is
simply a memory. The ground floor walls,
nine inches of solid heaven knows what,
still stand as they have for the past four
hundred years. Some of the principal
beams, old ship’s timbers, survived although
they look rather lonely, silhouetted against
the sky.
We shall, of course, rebuild and also take
the opportunity to put on a small extension
for a ground floor bedroom
and bathroom. Both my
parents lived into their 90s,
The internet
we ourselves have lived and now peppered
loved in the cottage for the
past 32 years, so we might
with information
just as well take this oppor- about me in
tunity to plan for our own
old age.
support
That should be the end accusation
of this distressing episode.
But I doubt it. In a couple of years the
perpetrator will more than likely be back in
the community, after “treatment,” and he
might do it again.
I weep for my son Robin. He, of all our
children, has loved the cottage all his life
with an unswerving passion. But the other
object of his desire has said that she
If you would like to submit a personal view please
send no more than 850 words to the Editor, BMJ,
BMA House, Tavistock Square, London WC1H
9JR or email editor@bmj.com
BMJ VOLUME 321 14 OCTOBER 2000 bmj.com
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doesn’t want to go back there. Mothers
are understandably protective of their
babies.
Someone who knows me slightly—he
heard me speak at a meeting of the
Libertarian Alliance, a fringe political group
of peace loving anarchists—has pestered me
and my family and all sorts of other people
for the past five years. He is convinced that I
was involved in the murder by the KGB of
his sister and his aunt.
I did not know that he had a sister or an
aunt, let alone that they were murdered. I
cannot imagine what connection there
could ever be between me and the KGB
except that I am so far on the other side that
we might meet up in some
topsy-turvy Smileyesque
scenario. (I have patients in
Bywater Street, where Smi-
ley lived.)
The incessant tele-
phone calls and letters and
offers “to resolve the issue
once and for all” are a
nuisance, but I was not particularly con-
cerned when he reported me to the General
Medical Council, Scotland Yard, and the
FBI. Professional colleagues (he got their
names from the brochure of our treatment
centre) have been warned about their
association with me. One American profes-
sor was surprised to receive the warning in
the middle of the night when his informant
forgot the transatlantic time difference. I
hope that he was also surprised by the con-
tent of the conversation. The internet is now
peppered with information about me in
support of the accusation. I can live with
that.
What disturbs me about these two men
is the clinical diagnosis that
I understand each has been
is given: depression. Granted
that psychiatric diagnoses
are merely convenient
labels, rather than verifiable
facts, none the less it seems
to me that even the concept
of the of “psychotic depression” is
a fudge, deliberately water-
ing down a diagnosis that
might be considered politically rather than
clinically incorrect. Did paranoid schizo-
phrenia disappear with the first whiff of
genetic inheritance? For that matter, what-
ever happened to just plain wickedness?
Has the pendulum of psychiatric diagnosis
swung so far that patients are now abused as
much in one direction as they were
previously in the other? Are the concepts of
protection of disturbed individuals and pro-
tection of society necessarily in opposition
to each other?
Robert Lefever, general practitioner, London
reviews
SOUNDINGS
Staying put
She had had what is known in the trade
as a “fair innings.” It was 15 years since
my predecessor first raised the
suggestion that she would be more
comfortable in a residential home. She
had resisted. Long before it became a
standard package option for
octogenarians, she had negotiated
with a mortgage company to release her
assets, and paid for home adaptations
and a long string of live-in helpers.
Today, she was dying—in a triumphant
sort of way.
Five years ago, she had moved the
bed downstairs into an alcove in the
front room. From here, she could see
through the French windows into her
little garden. When I came to visit, she
always talked me through the plants’
latest ailments before starting on her
own.
Towards the end, I began to share
her concern that she would outlive
the clematis, which had never really
picked up since the winter frost. Her
gardener was kept busy to the last, and
when I told her she had pneumonia—
“That might be it, is that what you’re
saying, doctor?”—she made sure she put
an extra fiver in his envelope.
Her parlour was modestly but
comfortably furnished, with three
separate coffee tables and a selection of
not quite matching armchairs. Various
friends and neighbours gathered in
silence, reading her magazines and
drinking her tea. They knew they didn’t
feature in her will—she’d announced
long ago that she intended to leave it all
to charity—but when you have lived in
the same cul-de-sac for 40 years you
turn up to pay your last respects. At
one stage, I evicted them all into the hall
on the pretext of wanting to listen
to her chest, and asked if she would
prefer to be alone. “No, thank you,
doctor,” she gasped. “But can you make
sure they wash the cups up after I’ve
gone?”
The vicar came and went, twice,
and I popped in and out between
surgeries. Some distant nieces and
nephews phoned up. At 5 pm she asked
for tea in her beaker and sucked on
some toast. At a quarter past she
breathed her last.
The undertakers nodded a greeting
to me and began to load her up on their
portable stretcher. “Nice place,” they
muttered, indicating the view from the
window. “Did well to stay put, didn’t
she?”
Trisha Greenhalgh general practitioner,
London
969