Cerezox doesn’t yet exist, but give it a few years and something like it
will. Memory boosters are on the way, along with dozens of other supposedly
rejuvenating, beautifying and energising chemical aids for the ageing
baby-boomer. Goodies currently in the pipeline include a clutch of new appetite
suppressants, increasingly subtle mood-tweakers and, rumour has it, a
Viagra-style product for women.

And whether they live up to the hype or not, the demand they are likely to
generate won’t be limited to the clinically impotent, obese or depressed.
Already fuzzy, the distinction between pharmacology and cosmetic pharmacology,
between medicinal and lifestyle drugs, is about to blur still further.

Well, let it blur. For too long we have put up with experts drawing lines in
the sand to decide who deserves to be prescribed drugs, not to mention doctors
handing out pills to people as though they were children. And for what?

There is no compelling reason why drugs such as Viagra and Prozac should not
be sold over the counter and advertised like any other product. In fact, there
are good arguments why they should be. And while few of these arguments are
brand new, the sheer number of drugs in the pipeline, along with growing public
awareness, makes some sort of action imperative.

The problems we face if we don’t liberalise access to lifestyle drugs have
been looming for some time and can be seen most clearly in Britain where
ministers have already made clear that they will try to ration lifestyle drugs
or even ban their use by people who are not clinically unwell. If this happens,
demand for the drugs won’t vanish: people will simply buy them abroad or at
exorbitant prices (and possibly illegally) from mail-order outlets.

One way doctors have hung onto their prescribing monopoly is by convincing us
that we are too stupid to treat ourselves. But prescribing through doctors does
not necessarily curb drug excesses—barbiturate and benzodiazepine
addiction was created on a huge scale by doctors, not despite them. Until this
decade, when European Union regulations started to bite, people in Spain and
France were able to buy many prescription drugs, including tranquillisers, at
their local chemist. Reports of addiction and overdoses were no worse than
anywhere else.

Obviously, certain safeguards need to be tightened before powerful drugs
could go on open sale. Drugs for children, those with especially dangerous (and
expensive to treat) side effects and antibiotics, which could spread resistance,
should be restricted. But appetite suppressants, memory enhancers and other
potential lifestyle drugs should be sold at the buyer’s own risk, providing the
risk is made clear.

Warnings—not to mix them with alcohol or other drugs, or to avoid them
if you have heart or liver problems—need to be made unmissable. And
pharmacists should extend the existing schemes by which they issue smart cards
which carry information about other medications, so the issuing pharmacist will
be alerted to possible bad drug reactions and can warn the purchaser. Reckless
individuals who ignore such warnings are no more likely to heed the advice of
doctors. We don’t need a note from experts to buy other potentially risky
products such as alcohol, weedkiller, or skiing holidays, so why single out
drugs?

A healthy person simply shouldn’t need drugs, you might say, but this, too,
does not stand up to scrutiny. It is natural to get wrinkly as we get older; to
lose some memory capacity and libido. It may even be natural, given the
unnatural nature of modern society, to continuously fancy more food than we need
or to feel mildly depressed. But what is natural is not necessarily nice.

For centuries, we have sought pharmacological antidotes to nature’s nastier
manifestations—lifestyle drugs are simply the latest. The difference is
that, because they are called drugs (as opposed to herbs, unguents, or tonics),
we have allowed them to make us so nervous that we insist on people being
definably ill before they can have them. Thus we have relabelled shyness as
social anxiety disorder, unhappiness as sub-clinical depression, and night-time
raids on the larder as an eating disorder, buying into the myth that health and
illness are either/or states when they are on a continuum.

Viagra fiasco

But that outlook could disappear fast as a new generation of drugs that
people actually want looms on the horizon—and as the information
revolution gathers momentum. Already, anyone with a mouse can find out more
about their ailments than their real doctor is likely to know—and more
about so-called “off-label” uses for drugs: oral acyclovir, for example, an
expensive antiviral only available on prescription, is a far more effective
remedy for cold sores than the topical cream available at the chemists.

As the Viagra fiasco in Britain revealed, it’s futile to think you can stop
information getting out. For six months after the drug became available in the
US, Pfizer, its manufacturer, couldn’t even mention the drug’s name in Britain
because it was still awaiting its European licence. Yet during that time, people
could call up 20 000 sites and 140 000 web pages dedicated to the drug. The
licensing authorities eventually gave up and changed the rules.

In Britain, drugs companies have backed the status quo because its National
Health Service provides a guaranteed market and the medical profession makes a
wonderful sales force, with the added benefit that if things go wrong, it is the
doctor who is sued, not the maker. The companies have also been warned that the
cosy price-fixing privileges they currently enjoy could be jeopardised if they
push for deregulation too hard. And doctors like the set-up because they retain
their status and their power.

What will bring the whole thing tumbling down is when patients complete their
current metamorphosis into consumers, get organised and demand a change. It will
happen, but not without a fight.

But now a team of chemists in the US believes it has found out why only these
tumours are susceptible to cisplatin. If they are right, the finding should make
it relatively easy to make other cancers similarly vulnerable. It could also
pave the way to designing even more potent antitumour drugs.

Cisplatin forces tumour cells to self-destruct—a process known as
apoptosis. It begins by binding with the cancer cell’s DNA. This deforms the DNA
molecule but is not enough, alone, to trigger apoptosis. The nail in the coffin
occurs after the drug has attached to the DNA, and until now that mechanism has
been obscure. But John Essigmann at the Massachusetts Institute of Technology,
and his colleagues at the Kimmel Cancer Center at Thomas Jefferson University in
Philadelphia, claim they have found out how it works.

They have come up with two possible mechanisms, both of which involve a
protein called hMSH2. This molecule is abundant in testicular and ovarian cells,
but sparse in others. It is one of a team of repair proteins which fix
“mismatches” in DNA—glitches where the rungs in the helix have
misconnected, like crooked teeth in a zip. The normal role of hMSH2 is to seek
out and draw attention to mismatches by binding to the faulty DNA. Once in place
it attracts other repair proteins which then cut out and replace the damaged
section.

Essigmann’s team has discovered that hMSH2 latches onto the cisplatin/DNA
compound, apparently mistaking it for a DNA mismatch. However, as the deformity
is structurally different from a mismatch, the presence of hMSH2 prevents repair
rather than helps it, and it is this that kills off the cancer cells.

One of the mechanisms proposed by Essigmann is that the protein simply blocks
repair molecules, causing the cell to die. His second proposition is that hMSH2
attracts other repair proteins, but aborts the repair immediately after the DNA
has been cut out.

“Either way, the presence of hMSH2 is the crucial factor that makes cisplatin
so effective,” says Essigmann. “The next move is to start designing drugs which
have an even greater ability to bind with it.” Such drugs, he says, would be
effective in tumours with only low levels of hMSH2.

Researchers have known for several years that a small minority of people seem
to escape HIV infection despite repeated exposure to the virus. Now two separate
reports have identified one mechanism that allows them to do this.

HIV-1, the principal virus which causes AIDS worldwide, takes two forms in
the body. Viruses of one form tend to infect macrophages, the all-purpose
guzzler cells of the immune system, and are known as m-tropic. Viruses of the
second form tend to infect T cells, and are known as t-tropic. Most samples of
virus taken from newly infected people are m-tropic and scientists believe that
this is the form most likely to be spread by sexual contact. By contrast,
t-tropic viruses seem to emerge later, when the symptoms of AIDS appear.

For HIV to enter a cell, it needs the help of at least two handholds, or
receptor molecules, on the cell surface. The virus binds to the first receptor,
CD4, and then fuses to the cell membrane with the help of a second receptor. It
seems that the virus’s choice of its second receptor determines which type of
cell it infects. T-tropic viruses tend to use a molecule called fusin, while
m-tropic viruses mainly use a molecule known as CKR-5.

Now, two teams of researchers have found a mutation in the CKR-5 gene that
renders the molecule useless to HIV. The mutated gene codes for a form of the
molecule that lacks the chemical “handles” the virus needs.

Everyone inherits two CKR-5 genes, one from each parent. About one in five
people of Western European origin have one mutated copy, while 1 per cent have
two mutated copies. So far, the mutation has never been found in African or
Asian populations.

The teams’ findings are published in the current issue of the journal
Cell and in next week’s Nature. In the Nature paper,
researchers at Pennsylvania University Medical Center show that, in laboratory
cultures, blood cells taken from people with two mutated copies of the gene were
completely resistant to infection with m-tropic HIV-1. Their cells could,
however, be infected with t-tropic viruses. Cells from people with one mutated
copy of the CKR-5 gene were about 35 per cent less likely to be infected than
cells from other Europeans.

Ben Doranz, a member of the Pennsylvania team, says that t-tropic infection
usually happens only through direct blood-to-blood contact, such as
transfusions or shared needles. “So people who are resistant to the m-tropic
virus are unlikely to get infected in the usual way,” he says. However, he warns
that people with the mutation would not be able to forget about safer sex. They
might still succumb to infection with a t-tropic virus, and they might pass the
virus on to others, he says.

In the Cell paper, a team at the Aaron Diamond AIDS Research Center
in New York report on two men who escaped infection despite long-term and
repeated exposure to the virus. Both were found to have mutations in their CKR-5
genes.

Because the mutation seems to be harmless, Doranz thinks new drugs could
safely mimic it. “If you could design a drug which blocks production of [CKR-5]
it would stop infection without causing bad side effects,” he says. Such a drug
might not provide total immunity, because if m-tropic HIV is deprived of its
preferred receptor it may make use of others, suggests Thomas Schultz of the
University of Liverpool. It might, however, slow the virus down enough for the
immune system to keep it under control.

The medical establishment has been forced to recognise the benefits of
alternative medicine through the sheer number of people who use it and for whom
it works. In the US, visits to complementary therapists now outnumber those to
orthodox family doctors. In Britain, around five million people regularly use
alternative therapies, and the number of practitioners is increasing by an
estimated 10 per cent a year. “Even many conventional doctors are becoming
receptive,” says David King of the British Complementary Medicine Association.
“Some will refer patients [to alternative therapists] for particular conditions
if they find that conventional medicine has not helped.”

Sales of herbal remedies have increased dramatically in recent years.
Disillusioned with conventional medicine and its perceived emphasis on
potentially dangerous drugs and high-tech interventions, people are turning to
acupuncture, osteopathy, herbalism and other “natural” treatments which, they
believe, are safe and free from side effects.

Safety scares

However, two recent studies by Edzard Ernst, director of the Centre for
Complementary Health Studies at Exeter University and the world’s first
professor in the discipline, suggest that such beliefs may be misplaced
and that
some complementary medicines can indeed cause severe side effects (
Nature, vol 381 p 361). The first study, a poll of 386 readers of The
Guardian, found that 23 per cent had suffered adverse side effects from
manipulation, acupuncture, homeopathy or herbal remedies. The effects included
pain, fatigue and dizziness with manipulation treatments such as chiropractic
and osteopathy; aggravation, needle trauma and mental effects with acupuncture;
and digestive problems with homeopathy and herbal remedies.

In the second study, also by Ernst, a questionnaire was sent to every
general
practice in Devon and Cornwall. Of the GPs that replied, 38 per cent said they
knew of patients who had experienced problems with complementary medicine,
and a
few doctors reported cases of misdiagnosis by manipulation therapists that had
led to bone fractures or neurological damage.

Some alternative therapies have gone seriously wrong. A 40-year-old
woman was
killed in May last year when an acupuncture needle pierced her heart, and in
September a 32-year-old Nottingham man died after taking Chinese herbal
medicine. Other cases include a man who suffered a fatal stroke following
spinal
manipulation and two people who died from anaphylaxis—a catastrophic
allergic reaction—after taking royal jelly. Serious, nonfatal adverse
effects have included miscarriages brought on by aromatherapy; autoimmune
disease and kidney or liver failure associated with herbal concoctions; and
dangerous interactions between patent remedies and prescription drugs.

However, hard statistics on the real risks of complementary medicine do not
exist because the complementary medicine business—apart from osteopathy
and chiropractic—is largely unregulated. Anyone can set up in business as
a therapist, and no one knows how many are at work. “You could start a practice
without even having attended a training course,” says Jo Barnes, a
researcher in
Ernst’s department at Exeter. “This is worrying from a safety point of view. At
the basic level, any therapist should at least have knowledge about how
the body
·É´Ç°ů°ě˛ő.”

Barnes believes that all alternative therapies should adopt the policy of
osteopathy and chiropractic, which are regulated by official,
government-recognised schemes. The General Osteopathic Council, for example,
runs a register of trained practitioners and sets standards of professional
conduct.

In other fields, therapists have set up their own “approved” bodies, such as
the Traditional Acupuncture Society and the British Homeopathic Association, to
which most trained practitioners belong, but these organisations have no
control
over nonmembers. In the US, alternative practitioners are more strictly
regulated, and anyone offering therapies there is required to have a licence.
Some have been successfully prosecuted for operating without one.

The lack of control in Britain is one of the main criticisms levelled
against
complementary therapists by conventional doctors. Another is the reluctance of
therapists to subject their treatments to scientific trials. Indeed,
enthusiasts
and sceptics unwittingly conspire to keep complementary medicine untried.
Sceptics say it is too absurd to be worth scrutiny, while enthusiasts
claim that
because their treatments are tailored to individual patients, and are mostly
holistic, they cannot be fairly tested by conventional methods. Most treatments
are so ancient, they argue, that the risks of any unexpected side effects are
practically nil.

“This is nonsense,” says Ernst. “You can’t assume that because something has
been used for centuries any bad effects would have shown up. It might have a
very rare but serious effect, which would not show up in a single
±č°ů˛ął¦łŮľ±łŮľ±´Ç˛Ô±đ°ů’s
lifetime. And saying something cannot be tested by trials simply betrays
ignorance of the scientific method—you can construct a trial to test
practically anything.”

Ernst recently wrote to 200 German companies which produce nonlicensed
medicines asking them for information about the efficacy of their
products. Only
four returned reprints of published papers. Ernst himself is attempting to
carry
out trials of various therapies but finds himself endlessly frustrated. “On a
dozen occasions we have set up trials with the cooperation of complementary
practitioners, only for them to withdraw when they realise there is a real
chance of the trial returning a negative result.”

Legal minefield

In the absence of adequate efficacy and safety data, it is difficult to draw
up the regulations which critics say are so badly needed. Any hint of
legislation turns the area into a political minefield. When in 1994, for
example, the government announced it was going to license all herbal medicines
to comply with a European Union directive, a well-orchestrated campaign quashed
the idea in months. Faced with up to 2000 letters of protest every day,
ministers declared that Britain was, after all, in full compliance with
European
law on the issue.

At least 80 per cent of “natural” health products are marketed in Britain as
food supplements, and as such do not need medicinal product licences and do not
come under the scrutiny of the government’s Committee on the Safety of
Medicines. In any case, full licences may not be in the best interests of
either
manufacturers or consumers. It costs a minimum of ÂŁ15 000 to license a
product and many small manufacturers would be unable to afford it. Their
products, many of them beneficial and safe, would either go underground or
disappear altogether.

But the absence of licences for such products means that some herbs and
dietary supplements are only found to contain toxic material after they go on
sale. Some of them are referred to the Traditional Remedies Surveillance
Project
based at the National Poisons Unit in London. Last year the project dealt with
more than 100 cases in which “natural” remedies were suspected of causing
adverse effects. This, according to project director Virginia Murray, is almost
certainly only a tiny proportion of the total.

“We know we are only scratching the surface,” she says. “This is a big
problem, and we think it must be getting worse because more of these products
come onto the market every year. We badly need to step up our surveillance, and
to take steps to get some of these remedies under some sort of control.”

The surveillance project’s office at New Cross Hospital contains an
assortment of weird, homely and alarming concoctions. Murray produces a small
lump of brown, Plasticine-like material —a Chinese herb ball. “We found
mercury in that,” she says. “Not in a form that is easily absorbable, but
enough
to mount up and give you a serious case of poisoning.”

The growth in exotic remedies makes the job of the surveillance project
especially difficult, because their ingredients are largely unknown in Western
Europe. Each batch may differ from the next, and many medicines are made up by
individual practitioners to their own recipes. Several people have died after
using Chinese herbs, and in Belgium and France 80 people needed kidney dialysis
after taking a Chinese slimming cure.

However, Murray is anxious that remedies based on systems of medicine other
than our own do not get a reputation as poisons. “We are in no position to
judge
these things because we don’t understand how they work,” she says. “We do not
necessarily want to restrict them, but we do need to know what is in them.”

Despite the widespread use of herbal and other complementary medicines,
government funding for research is minimal. The Ministry of Agriculture,
Fisheries and Food, which finances Murray’s project, has told her that no more
money will be forthcoming. So next March, when the original five-year plan
comes
to an end, the project will probably shut.

Unlike the 1994 threat to introduce licences for herbal remedies, its
closure
is unlikely to cause much of a stir. People will continue to buy exotic herbs
and flock to alternative therapists regardless of how untested or unregulated
they are. As Ernst suggests: “Perhaps people need a little magic in their
łľ±đ»ĺľ±ł¦ľ±˛Ô±đ.”

Jonathan Hore of the University of Western Ontario asked 10 people who played
baseball regularly to hurl tennis balls at the centre of a grid of small squares
3 metres away. The pitchers had electric coils taped to their fingers, hand, arm
and collar bone, so that their movements could be tracked using a magnetic
sensor. They also had a microswitch attached to their middle finger, which was
triggered the moment they let go of the ball.

Variations in the speed or pattern of the movement of their elbow, shoulder
and wrist joints did not strongly affect accuracy. The difference between throws
that hit the spot and those that went wide of the mark was almost entirely
explained by split-second variations in the timing of the ball’s release. If the
pitcher let go too early the ball struck above the target, too late and it fell
below (Journal of Neurophysiology, vol 75, p 1013). This is because the
hand moves in an arc during a throw. In previous experiments, Hore’s team found
that people who play baseball for fun can time ball release to an accuracy of
about one-hundredth of a second, so professional baseball pitchers must be
capable of much more accurate timing.

“This should be useful for sports coaches,” says Hore. “At the moment many of
them may be convinced that their players’ problems are to do with the way they
are rotating their shoulders or their wrists.”

But other experts warn that subtler factors may also be at work. Barry
Cripps, a sports psychology consultant in Totnes, Devon, has found that darts
players perform better when they are part of a well-motivated team, even though
throwing is an individual activity. “We don’t understand why, but the team is
more than the sum of its parts,” he says.

The magic solution that would allow the vast majority of terminally ill
people to die in relative comfort is not expensive or dangerous. It is one of
the oldest medicines known: morphine. For the past twenty years the use of
morphine and related drugs to relieve pain has been strongly recommended by the
WHO.

But because morphine is a narcotic and associated with heroin—a
derivative of morphine—it has gained a reputation among the medical
profession and the public as a dangerous drug. Care workers and experts in
palliative medicine complain that too many patients in Europe are being denied
the most effective painkiller available because doctors are scared of
prescribing it. Indeed, in some European countries restrictive legislation makes
it almost impossible for them to do so.

In 1994 Julia Addingtonhall, a psychologist at University College London,
published a survey of the relatives of 2000 recently deceased cancer patients.
It showed that 88 per cent of those patients had experienced chronic, and
sometimes severe, pain before they died. Addingtonhall claims that the chances
of a terminally ill patient obtaining adequate pain relief in a hospital in
Britain are little better than if they were treated at home by their GPs.

“If you are tucked away in a general ward in some small district hospital,
the chances of dying painlessly are probably no better than they were in the
mid-Sixties. In some ways the pain is more tragic now because expertise in this
area has increased phenomenally and there is no need for people to suffer.”

Doctors’ reluctance to prescribe morphine centres on a trio of enduring
myths, say pain experts. The first is that morphine, even when used as an
analgesic, is addictive. The second is that the dose has to be continuously
increased to maintain the same effect. The third is that narcotics used for pain
relief can hasten death. These beliefs are widely held by doctors, nurses,
patients and governments, even though they were debunked long ago.

Minimal risk

“It hardly matters if a person on the brink of death becomes addicted,” says
Mike Harmer, senior lecturer in anaesthesia at the University of Wales College
of Medicine. “But even if it did, I would say the risk is practically nil. We
sometimes give patients in severe pain massive doses of narcotic—sixty or
seventy times the usual amount. When the pain subsides they turn down the next
dose you offer, walk away, and that’s it.”

A paper in The New England Journal of Medicine in 1980
revealed that the risk of creating addiction in a patient treated with morphine
for pain relief is about 1 in 3000. Healthy people who take morphine for
recreational purposes, however, are much more likely to become addicted. This is
because narcotics work differently on people in pain. Patrick Wall, one of
Britain’s leading pain specialists at University College London, believes the
condition brings about a change in the brain which causes morphine to be “mopped
up” in a way that does not happen with healthy people.

“If you give morphine for the first time to someone who is not in pain they
will feel nauseous and headachy,” he says. “These side effects are quite rare in
people in pain—the pain itself seems to protect them against most of the
undesirable actions of the drug, including the ability to induce addiction.”
Wall also dismisses the second myth—that it must be given in increasing
doses. He claims that if morphine is being used for pain relief “there is no
need to up the dose unless the pain gets worse”.

The most potent and widespread myth of all—that medicinal morphine can
cause early death—is also largely groundless, according to Harmer. He
claims a fairly small dose could kill a person who is not in pain, but that with
someone in chronic pain who has been taking morphine for some time “you can pump
the stuff in almost without limit and not do them any harm . . . If anything,
opiates will lengthen a terminal patient’s life, because pain relief will allow
them to eat, sleep and function better.”

For the past two decades these findings have been trumpeted by pain
specialists, the hospice movement and the WHO. But ridding morphine of the
“demon drug” image has proved an almost impossible task in the face of the
campaign against addictive recreational drugs with which, in many minds,
morphine is inextricably linked. Bruno Simini, an Italian pain expert at
Hospedale Generale Provinciale, Lucca, believes the drug will be adequately
prescribed only if its name is changed. “Morphine evokes ideas of immorality,
illegality, addiction and death,” he says. “The very word is an obstacle to its
±č°ů±đ˛őł¦°ůľ±±čłŮľ±´Ç˛Ô.”

Even when doctors are not hampered by prejudice about narcotics, their
patients often are. A Gallup Poll carried out in 1994 found that one in two
adults would not want to take opiates for pain relief, even if they badly needed
them. Some doctors, confronted with a terminal patient who is reluctant to start
taking morphine, may hesitate before trying to persuade them for fear that they
may be accused of euthanasia after the patient has died.

But the law in Britain on this subject is remarkably clear. Doctors are
entitled to do whatever is necessary to ease suffering. Even if drugs were found
to have “incidentally shortened life”, provided they had been used primarily to
ease pain a doctor could not be convicted of manslaughter.

If this does little to reassure GPs, the position in hospitals is no better.
According to Ilora Finlay, chairman of the Association of Palliative Medicine,
narcotics are often so tightly controlled in hospitals that staff cannot get
them when their patients most need them. “Nurses are terrified of making errors
with these drugs,” she explains. “Some of them seem to be more worried about
getting into trouble with their administrators than about having patients in
pain.” And yet, she adds, nurses are often better placed than doctors to monitor
patients’ pain because they see them the whole time.

One solution is to hand over control for dispensing morphine to the person
who is actually feeling the pain. Patient-controlled analgesia (PCA) allows the
sufferer to self-administer drugs according to need by using a small
button-activated device connected to a drip. Studies have shown that PCA
patients usually take less than they might otherwise have been given.

“Doctors tend to go for total pain relief and may end up with pain-free, but
semiconscious zombies,” explains Chris Wells, director of the Pain Research
Institute in Liverpool. “Left to themselves patients are often prepared to
accept some pain in order to stay clear-headed. PCA also allows them to match
the dose precisely to their needs, so you get better pain relief for the same
amount of drug.” PCA has revolutionised postoperative analgesia, but it is
rarely used in terminal care, partly because each device costs about
ÂŁ2000.

Finlay believes that pain relief comes low on the list of priorities in most
hospitals in Britain, because they gauge their performances in terms of cures
rather than quality of life. “We have got the expertise but the knowledge is not
getting down to the doctors and nurses who need it,” she says. “There are
hundreds of pain experts, but most patients don’t realise that referral to one
is possible, so they suffer in silence. Things are getting better, but we still
have a long way to go.”

Belief v relief

Elsewhere in Europe the situation is getting worse. In Catholic countries,
where suffering is strongly associated with martyrdom and religious redemption,
pain relief is seen as unimportant compared with the need to stop drug abuse.
Morphine is therefore controlled so tightly that even doctors find it difficult
to get hold of.

In Italy, Spain and Portugal doctors have to apply to the authorities in
person to get the special forms needed to write narcotics prescriptions. In
Spain and Portugal they even have to pay for the forms. Information and
legislation on morphine varies remarkably from nation to nation, as does the
frequency with which it is prescribed. A UN survey published in 1991 found that
doctors in Denmark hand out an average of 3000 daily doses of morphine per
million people, while those in Greece prescribe just 30 doses per million.
British doctors distribute an average of 1450 daily doses.

Michael Zenz of Bergmannsheil University Hospital in Germany published a
survey last year showing that between September 1990 and August 1993 only 2 per
cent of terminally ill cancer patients in Germany were given morphine. “If their
doctors had followed the WHO guidelines, 98 per cent of them would have got it,”
he says.

British legislation is remarkably liberal compared to the rest of Europe,
though few doctors are prepared to take advantage of it. Any doctor can write
any patient a prescription for morphine on an ordinary form. A special licence
is required only if they are prescribing for addicts. “Your system is the envy
of the world and we would dearly love to adopt it here,” says Zenz. “But
although we have demonstrated that there is no link between free opiate
prescribing and drug abuse, our authorities do not seem to be convinced.”

There are fears that the German phobia about narcotics could eventually
dominate European practice to the extent that Britain would also have to adopt
stronger restrictions on morphine. A working party in the Netherlands is holding
talks about harmonising prescribing policy within the European Union. “Germany
has the strongest voice in Europe,” says Zenz, “and it
is—correctly—determined to continue the war against drugs. What is
deeply tragic is that dying cancer patients should turn out to be the unwitting
victims of that war.”

The research team, led by Uta Frith of the Medical Research Council’s
Cognitive Development Unit in London, recruited five dyslexic and five
nondyslexic adult volunteers of above-average intelligence. While the volunteers
performed linguistic tests, the researchers studied brain activity using
positron emission tomography (PET), which reveals which parts of the brain are
most active by measuring blood flow.

The people with dyslexia had problems creating spoonerisms from familiar
combinations of words: converting “John Lennon” to “Lohn Jennon”, for example.
The PET scans revealed differences between the two groups in a part of the brain
called the left perisylvian area—a chunk of cerebral cortex just above the ear.
This contains Broca’s and Wernicke’s areas, which are involved with processing
words, plus a lump of tissue called the insula.

Wernicke’s area is thought to be involved in the recognition of complete
written words, says Frith, while Broca’s breaks the same words down into
segments and creates a mental image of their sound. Until now the function of
the insula was unknown, but the PET scans suggest that it forms a crucial bridge
between the two areas. In the nondyslexic volunteers, the insula and both
language areas lit up together during the linguistic tests. In the dyslexics’
scans, however, the insula did not light up and each language area was activated
in isolation (Brain, vol 119, p 143).

“Each of the language areas deals with a specific aspect of word processing
and in normal people the insula synchronises this work,” says Frith. So when
most people see a written word they automatically “hear” it in their head at the
same time. “In dyslexics the areas are disconnected so instead of knowing
instinctively what a written word sounds like they have to think about each word
they see and consciously translate it from one form to another,” says
Frith.

This translation may be easier in some languages than in others. Languages
that rely on picture-like symbols, such as Japanese, can be easier to read
because each symbol represents a whole word (żěè¶ĚĘÓƵ, Science, 20
January, p 14). But English words often need to be broken down into segments,
and can only be processed normally if the insula is fully functioning.

Nevertheless, many dyslexics get round the problem by using other pathways in
the brain, so the condition often only shows up under stress. But being able to
cover up dyslexia may be a mixed blessing because it means that as many as half
of all sufferers remain undiagnosed.

“Dyslexic children have to put much more mental effort than others into work
that involves using language, and this inevitably puts them under terrific
strain,” says Frith. “If their dyslexia is not recognised they may be wrongly
diagnosed, or marked down as being of average ability when they are in fact
much, much brighter.” She hopes the new study will lead to better and earlier
diagnosis, and appropriate education for dyslexics.

PET scans are never likely to be used for routine diagnosis. Because they
rely on people consuming small quantities of a radioactively labelled sugar,
radiation from each scan is equivalent to 10 X-rays. But researchers are now
developing a sensitive variant of magnetic resonance imaging, which examines the
behaviour of the brain’s constituent atoms in a strong magnetic field, and will
also measure brain activity.