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Rainsbury and Westwood state that because the chelate techniquecaused less damage to the antibody its performance was enhanced.This is highly unlikely. We think that there are two reasons why111In chelates may be preferable. Firstly, "In has two gammaemissions (171 and 247 keV) which are more suitable for detectionthan, the single 364 keV emission of 131 I. Calculation based on theefficiency of conventional LFOV gamma cameras8 indicate a

potential eight-fold higher count rate for III In than for 1311.Secondly, indium is stable within cells,9 unlike iodineio which isprobably rapidly stripped from protein and diffuses out.

Finally, monoclonal antibodies may behave idiosyncratically withrespect to the damaging effects of labelling procedures. This shouldbe borne in mind when results with different antibody systems arecompared.Immuno Diagnostic Research Laboratory,Department of Immunology,Medical School,University of Birmingham,Birmingham B 15 2TJ

D. S. FAIRWEATHERA. R. BRADWELLP. W. DYKES

8. Anger HO, Davis DH. Gamma-ray detection efficiency and image resolution in sodiumiodide. Rev Sci Ins 1964; 35: 693-97.

9. Thakur ML, Segal AW, Louis L, Welch MJ, Hopkins J, Peters J. Indium-111-labelledcellular blood components: Mechanism of labelling and intracellular location inhuman neutrophils. J Nucl Med 1977; 18: 1020-24.

10. Stern P, Hagan P, Halpern S, Chen A, et al. The effect of the radiolabel on the kineticsof monoclonal anti-CEA in a nude mouse-human colon tumour model In:Mitchell MS, Oettgen HF, eds Hybridomas in cancer diagnosis and treatment.New York Raven Press, 1982; 245-53.

Commentary from Westminster

Effective Prescribing and Promotional Costs

THE medical profession often feels irritated by the media’scapricious attitude to medical issues. One day all the nationalpapers and television get excited about transplants, cancercures, or drug prices, only to lose interest a few days later.Often the fuss does more harm than good, as it did to thesupply of donor organs. But there can be little doubt thatnewspapers and television have played a key role in forcingthe Government to publish the Greenfield reportl on

effective prescribing, which examines ways in which theN.H.S. could reduce its drugs bill. In 1980-81 generalpractitioners prescribed f866 million worth of drugs,chemists were paid 234 million in fees and allowances, andN.H.S. hospitals spent 185 million on drugs.The Social Services Secretary, Mr Norman Fowler,

received the report from one of his principal medical officers,Dr Peter Greenfield, exactly a year ago. It lay for ten monthsgathering dust in Mr Fowler’s office, and the D.H.S.S.plainly had no intention of acting on it. It became known thatthe report commended the idea of substitution bypharmacists of the generic equivalent of branded drugsprescribed by doctors, but there was still little pressure on theGovernment to publish the report. About two months ago thenational press started to take a concerted interest in the

subject of drug damage to patients, drug company profits,and the cost to the N.H.S. This, combined with Oppositionpressure in Parliament, finally forced Mr Fowler’s hand. Thereport is something of an anticlimax, since it sidesteps themost important implications of generic substitution. "Anysignificant reduction in the prescribing of branded drugs

1. Report to the Secretary of State for Social Services of the Informal WorkingGroup on Effective Prescribing. Department of Health and Social Security.Copies of the report are available from Mr David Caygill, Department ofHealth and Social Security, Room 618, Eileen House, 80/94 NewingtonCauseway, London SE1 6EF.

could have an adverse effect on the innovative sector of the

industry and so limit the money available for research anddevelopment," but, it adds, this is a matter for someone elseto deal with.

Opposition politicians of the Labour Party and the SocialDemocrats are clear in their belief that generic substitution issomething the drug companies will just have to live with. Butthe Government takes a different attitude. Mr Fowler,without saying so in plain words, is determined not to godown that road. Cabinet colleagues and Departmentaladvisers, as well as drug industry spokesmen, have pointedout to the Secretary of State that the drug industry employs70 000 people in Britain and exports C600 million worth ofpharmaceuticals each year. Nor should it be forgotten thatseveral drug companies make generous contributions to ToryParty funds (Glaxo gave £ 25 000 last year, and Beecham gave20 000, to name but two).Mr Fowler has no wish to become the scourge of the drug

companies, but at the same time he does not want to be seen tobe feather-bedding them, or allowing them to makeunreasonable profits out of the N.H.S. His strategy thereforeis to bypass the generic substitution issue and turn attentionto the Pharmaceutical Price Review Scheme. He prepared theground a couple of weeks ago, when his Under-Secretary, MrGeoffrey Finsberg, announced that the Government is toreview the way the PPRS works. The objective, Mr Finsbergtold Parliament, was to ensure a good balance between theinterests of the taxpayer, the patient, and the drug producer.It sounds impressive, but in fact the D.H.S.S. is apparentlyalready well satisfied with the present working of the scheme,as became clear when the Comptroller and Auditor General,Mr Gordon Downey, examined its workings on behalf of thebackbench Public Accounts Committee (which will give itsown opinions on the PPRS at the beginning of April}.The D.H.S.S. requires drug firms to submit audited annual

financial returns which break down sales, costs, profits, andcapital employed. If the Department thinks the profitsexcessive it can direct the firm to cut prices accordingly.Profits are supposed to stay within targets set by the D.H.S.S.The Department told Mr Downey that "on the basis of thecriteria agreed with the Treasury for the PPRS the

pharmaceutical industry did not earn excessive profits". ThePPRS itself "represented good value for money, furnishedgood quality and safe medicines at reasonable prices, fostereda healthy domestic industry, and contributed to a substantialexport surplus", Mr Downey was told. Such faith in thescheme leaves little room for Mr Fowler to make anyimpression on the N.H.S. drugs bill.But he will have to make a gesture of some sort, since the

Public Accounts Committee’s report on the scheme is not

expected to be particularly anodyne. When the committeeheard from a D.H.S.S. assistant secretary, Mr John Long,that the Department employs only one accountant to checkthe drug companies’ returns (though he has access to somehelp) the committee’s alert chairman, Mr Joel Barnett, askedifMr Long was satisfied that the D.H.S.S. was not sometimes"the victim of creative accounting"? Mr Long admitted hewas not satisfied. The committee will undoubtedly call for amore rigorous approach, and could well have some harshwords to say about the drug firms.Mr Fowler may announce, as his response both to

Greenfield and to any criticisms from the Public AccountsCommittee, that the D.H.S.S. is to strengthen its accountingteam. He may well add that drug companies are to be allowedto include less of their promotional costs in the sums allowed

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against profits. At the moment it is not too hard to add the costof a trip on the Orient Express or a visit to Henry Ford’s yachtin Liverpool Docks to the total legitimate promotional costsof a drug. To crack down on such ventures would modify thepopular press’s fascination with the subject without greatlyinterfering with the pharmaceutical industry’s profits.

A New Inquiry into N.H.S. Staffing and EfficiencyAnother inquiry into staffing levels and operational

efficiency in the N.H.S. has been announced by Mr Fowler.The managing director of Sainbury’s, Mr Roy Griffiths, willhead a team in the examination of how and how many peopleare employed in hospitals, community medicine, supplies,clinics, and medical teaching. The inquiry will cover all staff,from cleaners and porters to consultants. Mr Griffiths will

report to the Secretary of State by June. The D.H.S.S. insiststhat Mr Griffiths has not been given any target for reducingN.H.S. manpower, which increased last year by 4000, or0’4%. But in announcing the inquiry, Mr Fowler remindedParliament that 70% of the cost of the N.H.S. came from staff

costs, so "we need to investigate the best way of managingservices in order to provide the best value for money."

RODNEY DEITCH

Obituary

MARCOLINO GOMES CANDAU

M.D., F.R.C.P.

Director-General, World Health Organisation, 1953-73

Dr Candau died on Jan. 24, aged 71-the end of a lifededicated to the public health of the peoples of the world. Hewas the second Director-General of the World Health

Organisation. During his office the organisation came of agein many ways and remarkable successes were achieved ininternational public health.He was born in Rio de Janeiro and received his medical education

at the University there and later at Johns Hopkins. From 1934 to1950 he followed a successful career in public health and teaching

posts in Brazil. In 1950 he joinedW.H.O. as director of the divisionof the organisation of healthservices. Within a year he was

appointed assistant director-

general, and in 1952 he becameassistant director of the Pan-American Sanitary Bureau. Fromthis position he was electedDirector-General in 1953, succeed-ing Dr Brock Chisholm fromCanada.

J. L. K. writes:"During his four successive five-

vear terms directing the secretariatof W.H.O., the organisation really got to grips with itsconstitutional task as the directing agency for international healthwork. More and more it took the lead in steering and coordinatinghealth services development to the benefit of its member states inthe industrialised and in the developing world, acting as a bridgeduring an anxious time of cold war and decolonisation. His was thedrive behind setting up and recruiting for the historic and

eventually successful campaign to eradicate smallpox, and also thetougher, though less profitable, campaign against malaria, whichnevertheless had some remarkable achievements up to 1967.He had a striking combination of intellectual vigour, political

perspicacity, sound judgment, and attractive personality, coupled

with great powers of persuasion. He could quickly cut through tothe substance of the issues he faced, and either solve them himself orfind the best people available to do so. In this way he attracted someremarkable teams around him. But the best-remembered partner-ship was that which he formed with Dr Pierre Dorolle, who was hisexcellent alter-ego and in-house manager, serving as deputydirector-general throughout the twenty years of Candau’s leader-ship. They were an effective combination-technically,managerially, and personally-each potentiating the other."Candau’s contribution to the health of the world was widely and

richly recognised with honours and awards from many countries,universities, foundations, and organisations. They includedW.H.O.’s Leon Bernard prize (where he joined an illustrious line ofrecipients, including his friend, Sir George Godber), honorarydegrees from Edinburgh, Queen’s University, Belfast, and

Cambridge, and the Mary Kingsley medal of the Liverpool Schoolof Tropical Medicine. When he retired in 1973, his outstandingservices were recognised when the 26th World Health Assemblyappointed him Director-General Emeritus."In later years he remained very active. He accepted the task of

chairing the coordinating committee for the onchocerciasis controlprogramme and he undertook many other public health

assignments in Brazil and elsewhere. A typical anecdote of theseyears, mingling humour and parental pride, records that, whenspeaking of a success achieved by one of his sons, he was heard toobserve that where once his son had been known as ’Dr Candau’s

son’, now he himself was well content to be known as ’Mr Candau’sfather’." "

G. E. G. adds:"The death of Marcolino Candau has removed one of the out-

standing medical men of this or any other century. His early careerwith the Service Especial de Saude Publica, a cooperativeprogramme of the Brazilian Government and the Institute oflnter-American Affairs, working to improve health conditions in the leastsalubrious parts of Brazil, led him naturally to the work of W.H.O.in the region of the Americas. When a new Director-General wasrequired thirty years ago, Candau emerged as the young andunexpected compromise candidate, but that choice proved to havebeen inspired. In the next twenty years Candau transformed anorganisation dominated by the few medically advanced nations intoone with 130 member states in which, if not harmony, at least asense of common purpose prevailed. Although his team includedtwo remarkable lieutenants in Pierre Dorolle, his deputy, andMilton Siegel, his director of finance, Candau was unquestionablythe leader and the inspiration. Many distinguished professionals,medical and other, were content to serve in relatively obscurepositions in a secretariat so ably led."Any international agency becomes, to some extent, a political

forum, but Candau so skilfully kept the real health issues in the fore-ground that the damage caused by the occasional politicalconfrontations, even once leading to temporary Russian with-drawal, was minimised. He did this without allowing any party toattribute political or regional bias to himself or his staff. He enlargedthe interests of the organisation and broadened its participation inthe health and related social fields to an extent that made W.H.O. an

object lesson to medically dominated national health departments.He was fortunate in obtaining so much voluntary financial aid,especially from the U.S.A., in the relatively affluent years of hisDirector-Generalship, but he was able to guide the membershiptoward acceptance of a less expansionist policy as the years ofrestriction arrived."W.H.O. under Candau was not a mere relief agency and he made

it into the powerful guiding influence it now is, recognising thatcountries make their own health systems and must not have other

concepts thrust upon them. It may be that too much outside help hasgone into the creation of sophisticated centres in countries that needsimpler services, but Candau’s W.H.O. never lost sight of the firstneed to provide a sound and indigenous health infrastructure.There were also many contributions to the health of wealthiernations from coordinating action on the safety of drugs to familyplanning or the international health regulations-and more educa-tion than many of them would acknowledge. Rightly, the main