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use private or voluntary homes. Ironically, last week’sdecision won’t save much money because the social securitytap will have to remain open and uncontrolled.The final insult was the Health Secretary’s purported

reason for the decision-the state of unreadiness at locallevel. No doubt the plans of most councils could beimproved, but a survey of social services directors found 94out of 95 wanting to start in April. No one has conducted asimilar survey of district health administrators’ reactions tothe NHS changes, but there is no doubt what they wouldsay: give us more time. What should be delayed is beingruthlessly pushed through; what should be pushed through,is being delayed.

Malcolm Dean

Round the World

USA: Proposition 65

Merchants in California are now obliged to warn customersif some of their products could cause cancer or birth defects.This obligation is mandated under a law passed by popularreferendum in 1986 following a consumer campaignfeaturing celebrities, including the actress Jane Fonda.Environmentalists say that the law, called Proposition 65, isfar superior to national legislation in Washington. That maybe true in theory, but the sober fact is that Governor GeorgeDeukmejian has removed the fangs. A Republican in themould of former California Governor Ronald Reagan, heand his administration have exempted from regulationmany important products-food, drugs, cosmetics, andpesticides. As he sees it, Federal regulation of these productsis good enough.Mr Deukmejian may be unable to make these exemptions

permanent. In March, 1990, a Superior Court judge inSacramento overruled him, and regulators in other Statesand in Washington are now following the effectiveness, in apopulous state, of a law that calls for a completely regulatoryapproach. Standard procedure requires regulators to gothrough an interminable process to establish proof of achemical’s hazards before restricting its use or banning it.Proposition 65 shifts the burden of proof to the companies.They must prove that the risk is trivial or warn the publicthat a cancer or reproductive hazard exists. David Roe, ofthe activist Environmental Defense Fund, says thatCalifornia in 12 months produced health-based standardsfor more than twice as many chemicals as the EnvironmentalProtection Agency had managed to set in 12 years.

This achievement is unlikely to impress Californiabusiness executives. They fought Proposition 65 before itwas passed and, along with the Governor (who is appealingagainst the ruling), they are dragging their feet now. Manymanufacturers have refused to print warning labels on theirpackages. Instead, they have posted signs in stores advisingcustomers to call a toll-free number in Omaha. Consumerswho did often found themselves sparring with companyrepresentatives in their efforts to get straight answers. If theyasked for the hazards of cigars as a generic class instead ofspecifying a brand, the company spokesman stone-walled.Ridicule is another favoured tactic. Michele Corash, aformer general counsel for the EPA, now in industry’semploy in San Francisco, once wondered whether

Proposition 65 was "just another novelty from the land offruits and nuts and sunshine".

Proposition 65 goes well beyond consumer products. It isalso supposed to ban discharges of cancer-causing chemicalsinto drinking water-a problem for farmers whose

pesticides can seep into groundwater. Here again, GovernorDeukmejian has managed to pacify his environmental

opponents. State authorities have announced that farmersare exempt if they meet existing regulations. Barred from themain action, supporters of Proposition 65 have had tocontent themselves with fringe achievements-warningsigns against the hazards of such carcinogenic or

reproductive hazards as tobacco, alcohol (including the winefrom California vineyards), water coolers, gasoline stations,and dry cleaning plants.

Proposition 65 is not a major issue in the current

Governorship contest between the Republican candidate,US Senator Pete Wilson, and the Democrat, DianneFeinstein, a former mayor of San Francisco. This time thedebate is over another popular initiative for the ballot this fallcalled "the Big Green." The referendum would phase out allcarcinogenic pesticides by the end of the century. It soundsambitious, even unrealistic. Unlike many of the rest of us,millions of Californians quietly go along with the

complaisant officials in Washington who don’t seem to careabout public health.

J. B. Sibbison

Caribbean: Dengue epidemicDengue viruses are now endemic in the Caribbean, as inmost of the tropical world. There are four known serotypesof the flavivirus that causes the disease, any one of which cangive rise to dengue haemorrhagic fever (DHF) and dengueshock syndrome (DSS). The prevalence of the virus in theAmericas has increased over the past 25 years, and in1977-78 an epidemic of type 1 infections appearedthroughout the Caribbean and Central America. In 1981 amajor epidemic of type 2 infections hit Cuba. Nearly350 000 people caught the disease, 24 000 of whom hadDHF, and there were 158 deaths.

In late 1989 dengue activity was reported from manyCaribbean islands and from Venezuela, Guyana, Surinam,and French Guiana on the South American mainland. InVenezuela a large outbreak began in December, 1989, andby March, 1990, over 9000 cases had been reported, with2600 cases of DHF and 74 deaths. Two-thirds of the casesand deaths were in children less than 15 years old. Denguetypes 1, 2, and 4 were isolated, primarily the last two.Elsewhere in the region, however, the pattern has beenshifting, type 1 becoming more common. In January, type 1was reported in Trinidad and Tobago for the first time since1985.The epidemic has now passed its peak, largely as a result

of intensified control measures. The vector in the Caribbeanis Aedes aegypti, which persists in most territories in theregion despite the efforts of the respective governments tocontrol it. In some communities over 70% of homes haveevidence of mosquito breeding-in water vessels, flowervases, and discarded household items that collect rainwater.The increasing use of plastic containers seems to be addingto the problem.

In the absence of an effective dengue vaccine, vectorcontrol is the only means of tackling the disease. Control

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programmes relying on the use of insecticides have not beenvery successful, partly because the chemicals do not reachmosquitoes resting inside houses and partly because manymosquitoes are now insecticide resistant. Reduction of

breeding sites, the use of larvivorous fish, and healtheducation are now seen as vital elements of an integratedattack on the mosquito population.

Epidemiological data collected by the Caribbean

Epidemiology Centre (CAREC) suggest that the diseasepattern in the Caribbean is evolving in a manner similar tothat seen in South-East Asia in the 1960s, when DHF wasfirst recognised. Although DHF at first occurred

sporadically, it is now a leading cause of death amongchildren in South-East Asia. One ray of hope for theCaribbean, says CAREC, is that people of African originseem to have a lower risk of DHF and DSS, as is suggestedby incidence of these complications among people whobecame infected in the Cuban and Venezuelan outbreaks.

Unless a concerted effort is made to reduce the vector

populations in the Caribbean, says CAREC, there is littledoubt that the prevalence of dengue will increase, and alongwith it the risk of DHF and DSS. This would impose aserious public health burden on the region, says the

organisation, and could have adverse economic effects onareas that depend heavily on tourism.A fmal concern, says CAREC, is the seemingly inevitable

reintroduction into the Caribbean of dengue type 3, whichhas lately caused epidemics in the Pacific region. Thisserotype was last detected in the Caribbean in the late 1970s.If it reappears, all people born since that time-

approximately one-third of the population-will be

susceptible.A correspondent

Germany: Divided on abortionThe division of Germany in two parts will probably beended by the end of the year. Already both parts of thecountry use the same money, have the same social securitysystem, and have some laws in common. But there is still one

question that divides the country into two halves, althoughthe border does not follow the partition between East andWest: should all women be allowed to have an abortion untilthe 12th week of pregnancy?

In the German Democratic Republic abortion is possiblein the first 3 months of pregnancy. This law was introducedin 1972, at a time when women in West Germany werefighting against more restrictive legislation. It is thoughtthat the East German Government was stimulated by thecampaign in the West for a more liberal regulation.Although the parliament in Bonn voted to allow abortionwithin the first 3 months, this so-called "Fristenlosung"could not be established: in 1975 the Federal ConstitutionalCourt decided that such a solution would conflict with theWest German constitution.

Instead, women in West Germany are threatened withpunishment if they have an abortion in the first 12 weeks ofpregnancy. There are exceptions-if the mother’s health isin danger because of the pregnancy, if the child would behandicapped, if the woman became pregnant through rape,or if the birth of the child would cause a "social crisis". Sincethis last indication for abortion is rather vague and left to thedoctor’s interpretation, abortion is practised in many partsof West Germany according to the Fristenlosung, despite

the legal restrictions. In the catholic south, abortions arerarer than in the more liberal north, and the restrictionsmore severe. All women who want an abortion have to beadvised about public and private facilities for pregnantwomen, mothers and their children.

Opponents of "paragraph 218", which forbids abortion inWest Germany, hope that the strict regulation will beabandoned after reunification. Their hope is based on thepromises of the conservative Government in East Berlin thatit would not allow the introduction of paragraph 218 in theEast. Most conservative politicians in the West are stronglyopposed to the Fristenlosung, but the liberal party, theirpartner in the West German coalition government, seem tofavour it. Since the Federal Constitutional Court discardedthe Fristenlosung 15 years ago it cannot be reintroducedwithout another Court decision and even a change in theconstitution.Does a more restrictive law lower the number of

abortions? In the past year about 74 000 abortions have beenconducted in the East and an estimated 200 000 in the West.The ratio between births and abortions is about the same inEast and West 3:1. Thus paragraph 218 does not, as itsopponents point out, actually reduce the number ofabortions: if a woman seeks an abortion she will get it,whether legal or not, they say.The high number of abortions in the East is due partly to a

lack of knowledge about contraceptive methods, particularlyin young women. It is estimated that 20% of all girls under18 have been pregnant. Since the practice of abortion isliberal and free, counselling is never offered, and alternativesare never discussed. Abortion is often regarded as justanother contraceptive method.What will happen after reunification-one country, but

two abortion laws? The second state treaty will probablycontain a clause that the Fristenlosung can be practised inthe former German Democratic Republic for a definedlimited time-until an acceptable compromise can be foundfor the two parts of the country.

Annette Tuffs

Health Watch

Endemic or recurrent social pathology?There is an eerie sense of déjà vu in reading EnvironmentalPollution and Health in Katowice, by Irena Norska-Borowka (Lancet 1990; 335: 1392-93). Her account of healthin Upper Silesia today recalls the investigation of a typhusepidemic made by Rudolf Virchow 150 years ago. Shewrites of "increasing indices of infant mortality, a highpercentage of mentally and physically handicapped children... Socioeconomic factors such as poverty, smoking,alcohol, and drug abuse". Virchow’s 1848 "Report on theTyphus Epidemic" included similar circumstantial

descriptions. His portrayal of the miserable living conditionsand social disadvantages of the oppressed Polish-speakingpopulation of the then German province is a paradigm ofcritical social epidemiological insights and analysis, and themedical and social reforms that it generated remain the basisof social medicine teaching and philosophy today. Virchowshould be honoured as much for establishing a political rolefor medicine ("Medicine is a social science, and politics is