Memorandum by the Institute of Biology
in conjunction with the Association for Clinical Microbiology
and Society for Applied Microbiology
1. The Institute of Biology is the independent
and charitable body charged by Royal Charter to further the study
and application of the UK's biology and allied biosciences. Its
15,000 members (January 2002) and over 60 specialist, learned
Affiliated Societies make the Institute ideally placed to respond
to the above consultation. The Institute of Biology is aware that
a number of the specialist biological learned societies within
the Affiliation are concerned with this issue and these include
the Association for Clinical Microbiology and Society for Applied
Microbiology who support this response.
2. This response's principal points include:
(i) Their Lordships in their consultation
are addressing an issue for which there is a growing likelihood
of great biological, human and economic impact.
(ii) We understand that the 2001 foot and
mouth outbreak prompted the question to be asked "what if
a similar scale of infection affected the human population"?
However, outbreaks of non-human infections can also result in
suffering and mortality among the human population (eg Irish potato
(iii) Resistance to anti-infective agents
continues to be a problem requiring holistic and novel approaches.
This Institute and a number of its specialist Affiliated Societies
recently (2002) appraised the way forward for anti-infectives.
(iv) If the UK were a PLC it would be obliged
to conduct a risk assessment.
(v) We are not convinced that the full investment
required by the new Health Protection Agency recommended in Getting
Ahead of the Curve are being made available.
(vi) With regards to the supply of scientists,
microbiology as a profession is perceived among bioscientists
(and we believe many clinicians) not to have the status that is
appropriate. Worse, the state of UK agricultural research (part
of which relates to infectious agents) is now almost beyond a
(vii) Governmental investment in science
R&D has not kept pace with the economy it innovates and protects
for the past one and a half decades. A number of Select reports
have noted that UK agricultural and systematics research has been
severely erodedresearch on fighting plant and animal infection
directly relates to human infections. Furthermore, investment
in surveillance-science managed by Departments and their agencies
has not kept pace with economic growth though there is more need
for it today than before.
This consultation focuses on human disease but
the topic is far broader than that
3. This consultation has a focus on human
disease but the topic is in reality far broader than that. First,
some human infectious diseases are shared with those of other
animals. Secondly, some plant infectious diseases have an adverse
impact on human well-being. Here frequent examples can be found
among crop pathogens where epidemics can have economic and direct
nutritional effects such as the role of mycotoxins in poisoning
(the Salem, US, incident) and delayed development of cancers (alfatoxins)
and famines (hence health) consequences (such as the Irish potato
famine). (Indeed, we understand that the 2001 UK outbreak of foot
and mouth disease was in part a factor behind their Lordships
choosing the topic of this consultation inquiry.) Third, there
are opportunistic microbial populations that are shared between
non-humans and humans that develop resistance to anti-microbials.
The question can then be seen to become one of our species' ability
to tackle global pandemics of infectious agents of humans as well
as of species of economic (hence frequently human well-being)
importance. A good current example is that pandemic strains of
the influenza virus originate in birds. The Institute of Biology
is currently considering whether it can usefully explore this
The risks of epidemics are growing
4. The topic of fighting infection is of
increasing importance. Your Lordships through this consultation
are addressing an issue for which there is both growing likelihood,
as well as probability, of great biological, human and economic
impact from epidemics of infectious agents. This is primarily
(i) The human population increased dramatically
over the last century (see Appendix 1) and for a time was growing,
not at an exponential but, at a super exponential rate. It is
currently just over 6 billion and by 2025 is expected to be around
the 8.5 billion mark.
(ii) Human population densities are increasing.
Here the UK and Western Europe has an above average population
density compared with the rest of the developed world (OECD nations).
(iii) Human mobility is increasing. Globally
international arrivals in 2000 were around 664 million and the
World Tourist Organization has predicted an 80 per cent increase
in travel to long-haul destinations between 1995 and 2010 (BMJ
(iv) The problem of resistance to anti-infectives
is increasing, as well as (where applicable) disease vectors are
becoming increasingly resistant to chemical controls.
All of these factors individually work to increase
the potential size of an epidemic. Together their effects are
Populations, and population densities, of species
of economic importance are increasing
5. Secondly, as the human population has
increased, this has largely (but not strictly) been mirrored by
the growth in populations of species of economic importance (for
example the UK chicken flock is far bigger at the beginning of
this century than it was in the last). The mobility of individuals
within these population has also increased. One only has to go
down the supermarket aisle to see just how far many of the raw
food products have travelled. Indeed, the mobility of UK cattle
was cited as one example as to why the 2001 foot and mouth epidemic
was so great. This means that epidemics affecting species with
large populations and highly mobility (irrespective of whether
they also affect humans) are likely to be potentially greater
than previously with smaller populations. Also, in addition to
the spread of disease, the spread of undesirable infectious agents
is more likely. An example of this last is the number of instances
of the spread of antimicrobial resistant strains among some domesticated
The risk literally has never been as great as
6. Taken togetherhuman demographics
and those of species of economic importancethe risk (be
it in terms of human health, economics and/or health of other
species) from pandemics of infectious agents has literally never
been as great as it has today. These factors have a synergistic
effect. They are not simply additive but combine to be more than
the sum of their parts.
The hazard from infectious agents is complex and
some aspects are getting worse
7. The hazard from infectious agents is
more complicated. Treatments in the form of anti-infective agents
are available. Yet again the effectiveness of some of these is
being undermined. For example, the rise in resistance to anti-infectives
is a major problem. Bacterial strains are becoming resistant to
the present antibiotics and fungal crop pathogens to existing
fungicides. Finally disease vectors are also showing increased
resistance to the chemicals used to control them. With regards
to human health it is worth remembering that globally, in terms
of the proportion of total causes of death, only AIDS and tobacco-related
cancer are growing. Of these, AIDS results from the infection
with the Human Immunodeficiency Virus, an infectious agent.
The UK bioscience community recently produced
a policy alert on resistance to anti-infectives (see appendix
8. Concern among the UK bioscience community
as to how to address the question of resistance to anti-infectives
manifested itself earlier this year (2002) in the form of a two-day
symposiumAnti-infectives: The Way Forwardwhich
was run by this Institute with other learned and professional
scientific bodies, the support of industry and the endorsement
of a Government Department and one of its Agencies. This symposium
in turn resulted in a policy alert called Pharmageddon Now
which was launched to Parliamentarians in the House of Lords in
October by the Institute of Biology and the Royal Pharmaceutical
Society of Great Britain. Pharmageddon Now included some
suggestions as to how we might begin to address the question of
the rise in resistance to anti-infectives. The Pharmageddon
Now policy alert is reproduced in Appendix 2: we draw your
attention to this as there is little value in duplicating its
suggestions here in the main body of this response.
Historically there have been major epidemics the
question is not "if" but "when"
9. The UK population has in the past suffered
epidemics and pandemics of infections. Historically there is the
well-known Black Death. In more recent times there was the 1918-9
influenza pandemic which claimed 25 million lives Worldwide and
around 228,000 in Great Britain. We concur with the DH's Chief
Medical Officer's report Getting Ahead of the Curve (2002)
that the question is not one of whether there will be another
severe influenza pandemic but when? We need to decide now what
measures and investment are required to combat such a pandemic.
There are plenty of examples to illustrate the
need to ensure we invest in infection control and get the best
out of such investment
10. Currently there are a range of infectious
agents of concern. For example, Escherichia coli O157,
Salmonella enteritidis, and Legionella pneumoniae
causing Legionnaires' disease. Then there are the emerging infectious
diseases such as new variant CJD, as well as those with the potential
to emerge in the UK such as West Nile Virus. Taking this last
as an example of an infectious agent expected to be of low risk
for spread to the UK, the principal vector is the Culex
species of mosquito which is present in this country.West Nile
is found in southern Europe but may migrate north towards the
UK with global warming. Its spread to the US and Canada was thought
to be either by the importing of an infected bird, an infected
migratory bird or human traveller; this again illustrates the
increasing risk due to greater population mobility cited above.
Such current and potential threats from infectious agents demonstrate
that we need to ensure that we are getting the best out of our
investment in surveillance and treatment and if needs be appraise
as to whether the investment being made is appropriate.
If the UK were a PLC it would be obliged to conduct
a risk assessment. Government Departments are encouraged to undertake
11. Policy-makers sometimes view the UK
in terms of a hypothetical UKPLC: no doubt because they have to
balance the costs and benefits of policy against the nation's
economic requirements. It is interesting to note that if the UK
were a PLC it would be obliged to conduct a risk assessment under
the UK Financial Services Act. This Act determines that PLCs must
follow the "Combined Code" which itself adopts Turnbull
Guidance that recommends companies undertake risk assessment exercises.
Indeed Lord Sharman's report, The Review of Audit and Accountability
for Central Government (2001), that all Government Departments
and central government bodies, should undertake risk assessment
as defined by Turnbull Guidance.
DEFRA and the Department of Health might benefit
of assessing the risk from major epidemics
12. Typically risk assessments undertaken
by companies identify threats. They usually include both an identification
of the threats (hazards) and estimation of the likelihood of each
threat becoming manifest as well as of impact. History and biology
can combine to indicate both a likelihood of an event and severity
of its outcome, it suggests that such a risk assessment would
point to the requirement for UK PLC management action. We are
suggesting it is possible to argue that the appropriate governmental
body undertake a risk assessment of a severe epidemic in the UK.
With the human population in mind this might be a severe influenza
pandemic as per 1918-19 but could more appropriately be any infectious
disease with the potential to spread rapidly through the population.
Though there have been risk assessments by Government Departments
(such as recently by DEFRA in to foot and mouth disease), we are
not aware of a general risk assessment being made in economic
terms. It should be noted here that risk assessments are made
in advance of anticipated events. Given the potential impact of,
for example, an epidemic a major crop pathogen on DEFRA's area
of remit, or of an aggressive strain of influenza on the Department
of Health's area of remit, it would appear that such risk assessments
would be valuable.
Risk assessments would help ensure that key questions
regarding the value of prevention strategies would be answered
13. Such an assessment should help ascertain
the magnitude of investment required for surveillance, control
and treatment. For example, would it be worth regularly vaccinating
the working population on an annual basis against less virulent
strains of influenza? This would have a direct economic benefit
of reduced lost days at work. It would also have the benefit of
ensuring that the mechanisms were in place and practised for the
vaccination of a large and economically important proportion of
the economy if a suitable vaccine strain were available in time.
The other important consideration is the use of antivirals, which
have been available for the last thirty years to treat or act
as prophylactics against influenza. These are but some of the
strategic questions that might be addressed by such an exercise.
Are all the costs for the new Health Protection
Agency being met?
14. In "fighting infection" much
will depend on the success of the new Health Protection Agency
(and its eventual counterparts in devolved parts of the UK). We
are not convinced that the full investment required by the new
Health Protection Agency recommended in Getting Ahead of the
Curve are being made available. In the recent Department of
Health consultation document on the new Agency (to which this
Institute responded), there was constant reference to the proposals
being cost neutral. While we believe this to be true within the
scheme of things for the nation as a whole (there are economic
benefits from having a healthier work force and improved health
among the population generally), this will not be true of the
Agency's immediate financial costs. There are increased costs
associated with co-ordination at a strategic level and further
downstream costs associated with working to standard specifications
determined at the strategic level. The fact that the nation benefits
over all in terms of improved human-wellbeing and over all economically,
will not prevent the Agency from costing more to establish as
well as run.
There are concerns for the Public Health Laboratory
15. There are also fears that the Public
Health Laboratory Service (PHLS) may lose resources when the network
is broken up and transferred to local NHS Trusts. Then eight specialist
laboratories will become part of the new Health Protection Agency.
Possible problems include the current interdependency of PHLS
labs as well as the element of national level work that a number
undertake. This would mean that they will not function well within
local NHS Trusts unless firm and clear arrangements are made at
local and national levels.
Investment in the PHLS has been declining
16. Then there is also the major problem
of the real-term decline in Government investment in the PHLS.
Government R&D investment has declined
as a proportion of GDP since the mid-1980s. DEFRA research has
been hit particularly hard and a proportion of this, including
topics such as systematics, has a bearing on infection control
17. This is part of a longer-term problem
in real-term decline in Government Department investment in R&D
over the past one and a half decades. This funding problem has
been recognised by the House of Commons Select Committee for Science
& Technology in their reports Government Expenditure on
Research and Development (2000) and Are we Realising Our
Potential? (2001). MAFF/DEFRA R&D has been hit particularly
hard. We suspect that this is because of pressure from the Treasury
and that the Treasury does not value the agricultural sector that
only contributes 1 per cent of GDP. However it also needs to be
appreciated that the food and drink sector (which takes forward
the products from the agricultural sector) adds another two per
cent, and then there is tourism and other rural economies that
benefit for operating in a managed landscape. Altogether this
adds up to a not insignificant proportion of GDP. However DEFRA
R&D does include research into animal and plant infections
and these have both a direct and in-direct bearings on human well-being.
Even a topic seemingly as remote from infection control as systematics
is in fact relevant as a population's genetic biodiversity is
inversely related to its susceptibility to epidemics.
Investing in cost avoidance avoids costs
18. Then again, the Treasury needs to be
aware of the need for investing in cost avoidance. The recent
foot and mouth outbreak demonstrated that MAFF expertise had been
allowed to erode and so when the Government's Chief Scientific
Advisor stepped in he brought with him researchers from the Science
Base. This clearly showed that the cost of failing to have a sound
surveillance programme, and failing to horizon-scan, is significant.
But these relate to a third failing in that having the scientific
and technical staff to horizon scan and undertake surveillance,
means that there are the expert personnel in place to fire-fight
emergencies when they arise. Investing in cost avoidance avoids
downstream costs. (Such investment needs to be long-term and as
such has been of concern to the Affiliated Societies who view
the balance of research investment and policy as being short-term.)
Departmental research beyond the DH can make an
essential contribution to fighting infections
19. The above is neither theoretical nor
unrelated to fighting human infection. Departmental research beyond
the Department of Health can contribute to fighting human infections.
For example, as this Institute is learning during our current
examination of the future for anti-infective agents, DEFRA R&D
can support research into antibiotic resistance populations among
farm animals and these have the potential to affect human microbial
populations. Returning to the previous example of West Nile Virus,
if we are to properly ascertain the threat we need to have sound
entomological knowledge of likely vectors and how the distribution
of these vectors will alter with possible climate change. Again,
such applied and policy-driven research requires Departmental
funding first and foremost, and secondly linkage with the Science
Base. (Though it needs to be perfectly understood that the Science
Base Research Councils are responsible for fundamental and blue
skies research, and not policy-driven and applied research which
is the remit of Departmental research programmes. Consequently
the Research Councils should not be imposed on to bear the brunt
of the research costs but can be relied upon to provide expertise
on a contract basis.)
DEFRA R&D is now critical
20. Despite the Commons Select Committee
concerns (see paragraph 17 above) the state of DEFRA (former MAFF)
R&D is now so low that to describe it as critical is literally
Science can contribute to the fight against infection
but will continue to find it increasingly difficult in an environment
of dwindling governmental investment as a proportion of GDP
21. With regards to Governmental level of
investment in science, the position is perplexing. Successive
Governments of the past one and half decades have enthused about
the UK becoming a knowledge-based economy. Yet until recently
Governmental investment in R&D has declined in real-terms:
in fact it has only recently (1998-99) been stabilised with some
marginal growth but is still behind where the UK had been in the
mid-1980s. In terms of research as a proportion of GDP, UK investment
in science has steadily declined and so it is almost inevitable
that addressing problems such as fighting infection will become
increasingly difficult. The signal sent to industry is that perhaps
it is not worth their while investing in near-market research
(which is the only research industry and commerce will for the
most part fund (though there are a few exceptions)). Indeed we
understand that some companies have taken their research into
anti-infectives out of the UK. While it is most laudable for their
Lordships' committee to look at "fighting infection"
and "the science underpinning conservation"to
take two recent worthy examplesthere can be little progress
until the UK has devised a long-term strategy for investing in
its science, engineering and technology. Genomics and cutting-edge
bioscience offers potential wonders in the fight against infection,
but will be impotent if there are not the skilled personnel on
the ground engaged in strategic surveillance in a co-ordinated
way as well as undertaking remedial action.
Microbiology's status is being eroded
22. Moreover, this Institute has been aware
of a growing trend that is undermining microbiology as a profession.
We are aware of microbiology being marginalised in some university
curricula. Furthermore, microbiology is perceived among bioscientists
(and we believe many clinicians) not to have the status that is
appropriate. The Department of Health needs to consider its supply
of scientists for professions allied to medicine and, we would
claim, especially microbiologists if the improved implementation
of infection control is to be a strategic goal. One fairly straightforward
measure would be for those within the Department of Health responsible
for professions allied to medicine to ensure that there is both
dialogue with, as well as financial support for, appropriate learned
and professional societies. (This would also chime with recommendations
in the House of Commons Select reports The Scientific Advisory
System (2001) and Government Funding of Learned and Scientific
Societies (2002).) At the moment this is not happening as
it perhaps might.
OF UK SURVEILLANCE
Given adverse population demographic trends effectiveness
of existing surveillance systems must be declining
23. As described in paragraphs four and
five, because of demographic and mobility changes the risks and
threats from infectious agents are increasing. Ipso facto
current effectiveness of existing surveillance systems are being
Declining funding undermines surveillance and
the development of new treatments
24. Declining Departmental R&D and declining
PHLS funding mentioned in paragraphs 14-21 only serve to undermine
surveillance and the development of new treatments.
Good long-term surveillance is vital
25. Our recent investigation of resistance
to anti-infectives (see Appendix 2) revealed that long-term surveillance
was fundamental to identifying resistant strains locally, hence
control and treatment. This linkage between surveillance and treatment
is fundamental to the management of infectious disease. However
there needs to be a continual programme of research to ensure
that only the best and cost-effective surveillance is adopted.
For example, to take a non-UK case used before in this response,
in Canada the spread of West Nile Virus is monitored through the
surveillance of birds (especially those found dead, and not the
virus' mosquito vectors.
Rapid diagnosis is vital to the successful containment
of an epidemic
26. Rapid diagnosis (early detection) is
critical when dealing with an outbreak. It is far harder (and
more costly) to contain an epidemic once it has had the chance
Good surveillance has proven itself in the past,
as has poor surveillance that has let us down
27. That surveillance enabled the detection
of a virulent strain of influenza in chickens in Hong Kong in
1997 provides an excellent example of how surveillance can effectively
prevent an epidemic. The failure of surveillance in the early
stages of the 2001 foot and mouth epidemic demonstrate how the
lack of surveillance and lack of expert personnel can lead to
a major epidemic and high societal costs.
Research is too expensive for any one country
to carry the cost
28. Relatively new infectious diseases such
as AIDS demonstrate that the cost of treatment is high, as a result
of the cost of research and clinical trials. Consequently these
costs are too great to be borne by any one nation. International
co-operation is required. As cited in Appendix 2, the cost of
developing new antibiotics is high and requires a new paradigm
in research funding.
Infectious agents do not respect borders so international
surveillance is required
29. Because infectious agents do not respect
political boundaries, international co-operation is required for
International co-operation as to the way anti-infective
agents are used is required
30. Aside from research co-ordination there
need to be greater international agreement as to the way infections
are treated and anti-infective agents are used. It has been demonstrated
that the rise of resistance to anti-infective agents in one country
can spread to another. The Foreign Office (as well as its Science
and Technology Unit) need to be fully aware of the need for there
to be a full role for foreign policy and diplomatic programmes
to help fight infection globally so that the same can be done
at home with maximum effect.
Those representing industrial and commercial management
and the work force have a role to play
31. Industry and commerce have a role to
play in ensuring the health of the work force. Representative
bodies for industry and commerce, as well as representative bodies
for the work force, need to be aware of the value of vaccination
and other measures to combat infection. There are other important
stakeholders within the public that need to play a part.
Media problems persist and an effective science
and society programme remains a priority
32. Media coverage tends to be sensationalist
and is likely to continue to be in countries that have a free
press. This question is too complex to address here and neither
policy makers nor the social science nor scientific community
have developed an effective science and society programme. Little
has changed since the House of Lords report Science and Society
(2000) although there is now good evidence to suggest that the
public is more appreciative of science and technology than that
Taking the benefits of improved health for
granted we have become complacent
33. Investment in public health and science
and technology have been allowed to slide. There are many reasons
for this. Partly this is because public health as well as science
and technology have been victims of their own success. People
now live over 20 years longer than at the beginning of the 20th
century and this has brought about with it a change in the nature
of health care and the growth in demand for health care for the
elderly. Science and technology have also revolutionised communication,
travel and entertainment and people want investment in access
to and the development of these goods rather than in health care
or the further development of science and technology for strategic
reasons. Because health care and science and technology largely
work very well, complacency has set in. Public health care and
the ability to combat infections (both old and new) requires on-going
investment. This simply has not taken place. We have become complacent.
The problem has not been that the UK requires to spend a growing
proportion of its economy on science and technology, the problem
is that such investment from Government as a proportion of GDP
over successive Governments has been allowed to slip. Irrespective
of the science there is no escaping this underlying conclusion.
34. The Institute of Biology, in line with
Government Policy on openness and the Lords Science and Society
recommendation for transparency, is pleased for this consultation
to be made publicly available. Should their Lordships have further
questions related to this response then they should feel free
in the first instance to contact. Jonathan Cowie, Science Policy
and Books, Institute of Biology, 20-22 Queensberry Place, London,
Human population growth for the past 2,500 years.
Re-produced from Climate and Human Change with permission of the
Pharmageddon Now Policy Alert
At the moment:
There are 5,000 deaths per annum
in the UK from infectious diseases contracted in hospitals.
There has been no completely new
class of antibiotic developed in the last 30 years.
Virtually all major pharmaceutical
antibiotic research has moved out of the UK.
New antibiotics take in excess of
12 years to bring to market at an approximate cost of £250
Any new antibiotics would be promoted
for use by companies seeking to recover development costs which
is counter to the desire to limit their use to treat resistant
In many countries, antibiotic availability
and use is so indiscriminate that resistance is a serious burden
Importantly in 2002 we are aware of these facts:
Parliamentarians understand how important
these issues are, and in 1998 the House of Lords published a report
on antibiotic resistance.
Antibiotic use as prophylactics in
agriculture is declining, with application as growth promoters
negligible in the UK.
We have the necessary scientific
and medical expertise to prevent the future scenario envisaged.
The bad news is that:
In 1969 the Swann Committee recommended
that Government address resistance, but the Expert Advisory Committee
on Antimicrobial Resistance recommended by Swann was only set
up in 2001.
Little progress has been made implementing
recommendations of the House of Lords Report issued in 1998.
Continuation of the national surveillance
system currently provided by the PHLS is in doubt.
Futurefact of fiction?
There will be more strains of bacteria
resistant to all antibiotics in our communities and within many
hospitals in the UK.
There will be strains of bacteria
resistant to some antibiotics in all hospitals in the UK.
Reliable surveillance data on the
various antibiotic-resistant strains of bacteria in either our
hospitals or local communities will not be available.
Numbers of intensive care patients
will rise (costing £1,000-£1,800 per patient per day)
resulting in a commensurate increase in NHS costs.
A marked increase in the number of
deaths per annum from infectious diseases will occur in the UK.
It is unlikely that effective new
antibiotics will be available to tackle the problem.
There will be few medical microbiology
specialists being trained at degree level, and new doctors will
have only a rudimentary grasp of infectious disease.
The UK will have returned to the
pre-antibiotic era and average life span will significantly decrease.
The UK must:
Ensure that the recently published
UK Antimicrobial Resistance Strategy and Action Plan is actively
adopted by all stakeholder departments and agencies. The Interdepartmental
Steering Group, and recently established Expert Advisory Committee
on Antimicrobial Resistance, must continue to press for widespread
acceptance of the strategy.
Develop a cross-departmental co-ordinated
funding programme, involving charities and industry as appropriate,
to stimulate efforts in antibiotic research, to facilitate effective
long-term surveillance of antibiotic resistance, and tackle the
growth of hospital-acquired infections.
Increase funding for academic research
focused on development of new therapeutics.
Provide a more favourable climate
for pharmaceutical companies to develop new antibiotics by extending
market exclusivity for these beyond the current 20 years from
patent registration, through changes to patent legislation, to
provide patent rights running 20 years from marketing.
Ensure that foreign policy champions
best practice for antibiotic use overseas, particularly in Europe,
with new products being given EU-wide licences.
Literature and advice required at
school level to encourage pupils to pursue careers in pharmaceutical
science and medical microbiology and related professions. Government
Departments should liaise with learned societies to this end.
Revise medical and veterinary curricula
to reflect the significance of infectious disease and the appropriate
use of antibiotics.
The science behind this policy alert was reviewed
and discussed at a symposium principally organised by the Institute
of Biology and the Royal Pharmaceutical Society of Great Britain
but with assistance of a number of learned societies within the
Affiliated Societies together with the Department of Health and
Medical Research Council. The symposium received some welcome
support from Bayer and AstraZeneca.