20th September 2008, Liverpool
I had been invited by Michael Marmot to speak at the annual meeting of the Academia Europaea. Michael had organised a session on Health and Wealth so I was presenting our work on the contribution of health to economic growth in Europe. It was my first opportunity to hear Michael speaking since the publication of the Report of the Commission on Social Determinants of Health, which he chaired.
The report begins by documenting, in great detail, the scale of the problem we face. Life expectancy at birth ranges from 54 to 82 years, not in the world as a whole but within a single city, Glasgow. The Commission states very clearly that "social injustice is killing people on a grand scale" and sets out a vision for closing the health gap between rich and poor in a generation.
The Commission made three broad recommendations:

• Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and die Equity from the start; healthy places, healthy people; fair employment and decent work; social protection across the life course; universal health care;
  
• Tackle the inequitable distribution of power, money, and resources—the structural drivers of the above conditions of daily life—globally, nationally, and locally Health equity in all policies, systems, and programmes; fair financing; market responsibility; gender equity; political empowerment—inclusion and voice; good global governance;
  
• Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

This is an ambitious but achievable agenda. The real question is whether the governments of the WHO’s member states will have the courage and determination to take it forward.

18th September 2008, Stockholm
To the European Centre for Disease Prevention and Control. This was my first visit to ECDC, although we do work closely with colleagues there, most recently in our new book on the health system response to complex communicable diseases (primarily, but not only, HIV and TB). Unusually, this time we looked beyond Europe, drawing lessons from both Europe and another region undergoing political and economic transition, Latin America and the Caribbean.
I was there as a member of an expert advisory group on migration. The 2007 Portuguese EU presidency placed the health aspects of migration on the policy agenda and the ECDC is in the process of preparing a report on its consequences for communicable disease.
In some countries, in particular the UK, migration has become a highly politicised issue. Even though the UK has benefited enormously from migration (whether as assessed by the number of foreign born “British” Nobel Prize winners or the army of unrecognised workers who care for the elderly and disabled in our society), there are still shrill voices calling for ever tighter restrictions. These calls have, regrettably, been heard by the current government which has put in place a draconian process to limit the number of highly skilled migrants, as well as quite disgraceful treatment of asylum seekers fleeing persecution in other parts of the world. It has come under particular criticism for its inhumane treatment of children in families seeking asylum. These points are worth recalling as it is easy to overlook the reality that the major threats that migration poses to health are to the health of the migrants themselves.
The report is due out at the end of the year. It will focus on three areas, TB, HIV, and vaccine-preventable disease. However, what became clear from our discussions was the need for an extensive preamble, defining and categorising different types of migration and providing a conceptual framework to understand the health consequences of migration.
A major challenge will be collecting the necessary data. In part reflecting differences in laws on citizenship (at the risk of over-generalisation, there are two approaches – jus solis , where citizenship depends on where you were born, and jus sanguis, where citizenship depends on the nationality of your parents) and constraints arising from data protection legislation.
At the end of our meeting I gave a lecture on migration and health, entitled threats and opportunities. You can see a short video on the ECDC website. It was an opportunity to recall that, even after the breaking down of barriers in Europe in 1989-91, we still live in a divided continent, inhabited by young and old and native-born and migrants. The European social system is, however, based firmly on solidarity. This solidarity owes much to the experiences of the 1940s, where even the most wealthy could be reduced to ruin when they became caught up in the conflict. Two recent books remind us that people of all nationalities suffered. These are Norman Davies’ Europe at War (in which he once again reminds us of the extent of Europe, in this case recalling the carnage on the Eastern Front), and Giles MacDonogh’s After the Reich (where he describes the horrors of the retributions visited on Germans after May 1945). The knowledge that you could go to bed rich but wake up poor ensured that the generation that survived would put in place arrangements to protect their fellow citizens from the consequences of illness and unemployment. This contrasts with the the USA, which has never managed to achieve universal health care coverage. There, those in power, who were overwhelmingly white, could be confident that they would never wake up black. The question we must face up to is whether our belief in solidarity is strong enough to survive the pressures of aging populations, increased migration (by those who are visibly different) and economic downturns. Unfortunately there are some worrying signs in many countries, with growth of extreme xenophobic parties. As Martin Niemoller reminded us over 60 years agoin his famous poem (First they came for...), this challenges everyone who believes in solidarity to speak out before it is too late.

17th September, 2008 Rotterdam
In Rotterdam for the initial meeting of our new EU-funded project Avoidable mortality in the European Union: towards better Indicators for the effectiveness of Health Systems (AMIEHS). Jointly led by Johan Mackenbach at Erasmus Medical Academy and us at LSHTM, with partners from France, Germany, Spain, and Estonia, it seeks to understand how the concept termed “amenable mortality” can be used as an indicator of health system performance.
The concept of amenable mortality was developed by Rutstein and colleagues in the 1970s. It was based on the premise that deaths from certain causes, and certain ages, that should not occur in the presence of timely and effective care. Subsequent work has expanded the list of causes of death considered amenable, reflecting advances in health care, and increased the upper age limit for these deaths, reflecting improvements in life expectancy. The concept has also been refined to include differentiation of causes amenable to the health care system and those to public health policy, while specific causes have been partitioned into the proportion to which reductions are attributable to primary, secondary, and tertiary actions.
In recent years, amenable mortality has undergone something of a renaissance. In part this reflects the much greater interest in performance of health systems, stimulated by the 2000 World Health Report, with improved tools being sought avidly by policy-makers seeking to determine whether they are getting value for money. An example was our study showing that deaths from amenable mortality in the USA around the year 2000 had hardly changed at a time when other industrialised countries were experiencing substantial declines.
In its original conceptualisation, amenable mortality included some conditions where medical care could do little to prevent death once the disease process had occurred but where the onset of the disease could be prevented by health promotion activities. This is exemplified by lung cancer, where, it was argued, health professionals could be effective in preventing people smoking or encouraging them to quit. However, assuming they were successful, the deaths that would then be avoided would occur several decades later. Clearly, this is incompatible with the idea that contemporary rates of amenable mortality reflect the current performance of health systems. Hence, only those deaths than can be prevented by contemporary interventions should be included. The definition of contemporary is inevitably somewhat arbitrary but a period of five years has the attraction of consistency with the period used to assess what is popularly considered as “cure” in analyses of cancer survival.
The original list of amenable causes included causes of death that could be prevented entirely by health care and those from which some deaths would be inevitable but the number could be minimised. The former is exemplified by vaccine preventable diseases such as measles; the latter by ischaemic heart disease, where even in the best performing health care system, some deaths will be sudden and unobserved. However, there are also many causes of death not considered to be amenable where, in some circumstances, health care can be life-saving. This is true of many cancers for which a small proportion may be identified early, making possible curative treatment. An example is cancer of the pancreas. This begs the question of what proportion of deaths from a specific cause should be preventable for the cause to be considered amenable. This issue has previously been addressed only implicitly but it is now time to make it explicit. The figure is, again, somewhat arbitrary but we propose that a 50% reduction has the benefit of simplicity.
There are, however, a number of considerations to be taken into account. In some cases, reductions in mortality in this scale will be achievable with a single intervention. The term “magic bullet” recalls the dramatic benefits of penicillin when it was first given to patients with severe staphylococcal infections in the 1940s. More often, health care will prevent deaths through a combination of interventions that were introduced incrementally, perhaps over decades. In these cases it will be necessary to look at changes in death rates over considerable time, introducing the problem of attribution as it is necessary to exclude other explanations for observed changes.
It will be necessary to draw on a variety of sources of evidence. In some cases, there will be randomised controlled trials. However, these are most likely to exist for single interventions; they are much less likely where a combination of interventions is involved. Randomised controlled trials also face the problem of external validity, as they often exclude both children and older people, those with co-morbidities, and historically, women. Hence, it will also be necessary to draw on natural experiments, where it is possible to determine when new treatments were introduced. An example is the introduction of HAART for patients with AIDS, where death rates fell very rapidly. In other cases, even where detailed data are unavailable, it may be possible to infer the impact of health care where there has been wider system change. An example is the political transition in eastern Europe around 1990. The opening of borders to modern pharmaceuticals and ideas of evidence-based medicine made it possible to provide treatment that was previously denied to sufferers from many chronic diseases. Thus, in countries such as Estonia, there was a rapid decline in mortality from stroke, almost certainly as a result of better treatment of hypertension, at a time when such deaths were increasing in neighbouring Russia. It may also be necessary to look at historical evidence. Thus, conditions such as acute appendicitis became amenable to health care once the introduction of asepsis and anaesthesia made intra-peritoneal surgery possible in the late 19th century. Treatment of hypertension has a shorter history but has still been possible since the late 1950s.
In all previous studies, the definition of amenable deaths has had an upper age limit, reflecting the view that “everyone must die of something”. The age limit has increased over time, from 65 to 75, but this creates certain problems. The first is that it is explicitly ageist, as it devalues curative care for those aged over 75. The second is empirical, first because life expectancy in some countries now exceeds this figure but, second, as there is growing evidence that many types of health care are very effective in older people. If, however, the definition of an amenable cause is one where health care can reduce the death rate by 50% or more, then there is no intrinsic reason to have an upper age limit. Yet, while conceptually attractive, this also poses problems of obtaining evidence, first because older patients are often excluded from trials but, second, because the absence of an observed decline in mortality at older ages at a time when an intervention was being introduced may simply mean that this population was not offered treatment.
So far we have not addressed one of the most difficult definitional issues in assessing health system performance, how to define the borders of the health system. The 2000 World Health Report adopted an essentially pragmatic definition as it was necessary to include all of the WHO’s 193 member states, the majority of which had no functioning system f vital registration and certainly no possibility of ascertaining causes of death. As a consequence, it defined the health system extremely broadly. This included a range of inter-sectoral actions. It is, however, difficult t justify holding the health system to account for actions that others must take. For this reason, we propose that the boundaries must be drawn more tightly, to include interventions delivered by those working what is unambiguously the health care system but also those developed by public health agencies, such as immunisations and screening for cancer.
This is a three year project. What I have described above is only the first step, as we then need to show whether changes in amenable mortality actually do correlate with innovations in health care. If we are successful, this should be a valuable contribution to the debate on health system performance.

16th September 2008, Velden, Austria
Carinthia is a stunningly beautiful part of Europe. Its lakes, mountains, and traditional towns and villages make it an ideal holiday destination. Unfortunately my stay was for just over 12 hours but long enough to put it on the list for future visits. Situated in the south of Austria, it borders Italy and Slovenia and, since the 2004 enlargement of the European Union enlargement, links across these borders have strengthened greatly. This is especially true in the health sector, with the Carinthian authorities establishing a formal system of collaboration with colleagues in Slovenia and in the Friuli and Veneto regions of Italy. I was speaking at the Austrian Health Economics Forum, sharing a session with my colleague Luigi Bertinato from the Veneto region. I was talking about the three way relationship between health systems, health and wealth (see Tallinn Conference) while he was discussing the changing nature of international health tourism. Veneto Region has been developing links with Dubai, where an international “medical city” is being built with the intention of attracting patients from across the world to what will be a first class medical facility.
Two weeks before I had been speaking about the Dubai venture on BBC World Service TV. I confess that I was not entirely optimistic. There is no doubt that there is a growing market for medical tourism but I’m not sure that Dubai can compete with the much lower costs in countries such as South Africa, India and Thailand. There is, of course, a potentially large American market, given the increasing unaffordability of care even for those Americans who have coverage. However, I’m not sure how many will be prepared to fly to he Arabian peninsula in the current political climate, especially when they can get care for rather less in Mexico.
Both in the presentations and discussions over coffee a key issue to emerge was that of quality of care. In Austria, as in many other countries with social insurance systems, it has proven extremely difficult t get the medical profession to engage in effective mechanisms to assess and improve the quality of the care they provide. There are, of course, lots of small scale individual efforts but there is still a lot of opposition to anything more systematic. As we have shown in our new book reviewing the mechanisms to promote quality in all 27 EU Member States, Austria is not alone.
This is becoming an important issue at a European level. The proposed framework directive on patients’ rights in relation to cross-border care will require that each country establish systems to ensure quality of care, and while they will be free to decide how to do this, future work is planned to monitor whether they are doing it (See our recent BMJ editioral). A further issue is the introduction, in a few countries of revalidation of the right to practice medicine. Again, this is something we have looked at in a recent paper and, in some more a detail, in a policy brief. Clearly this is an area where some discussion at a European level is needed, not least to ensure that the arrangements are workable (but also to ensure that they are not hijacked by bureaucrats who believe that the larger the pile of paperwork, the better the system (as seems to be happening in the UK)). Unfortunately, and as usual, the Commission’s DG Internal Market doesn’t agree. It invariably sees any attempt at regulation that would protect the public as a constraint on free movement. It is essential that its views are not allowed to prevail.

10-11th September, 2008 Tiberias, Israel
I was in Israel for a meeting of the International Advisory Board of the Israel National Institute for Health Policy and Health Services Research and for the international conference that followed it. The conference was on the Public-Private mix in health care. The discussions were fascinating, reminding us of the many semantic difficulties in health policy. Specifically, could we agree on what we meant by public and private? This is of particular relevance in Israel, where the sickness funds are private bodies but operating within a statutory framework. Most of those representing them do not claim to be private organisations, rather seeing themselves as fulfilling a public role. Perhaps the only way to resolve the issue is to accept that some organisations have public and private dimensions and which predominates depends on the specific circumstances!
All health care systems are a product of history and, if one was starting from scratch it is unlikely that anyone would design them as they are now. Much of the discussion inevitably focused on issues facing the Israeli health system. Revital Gross provided a remarkably clear explanation of a highly complex financing scheme, where everyone is covered through the social insurance scheme yet where 80% purchase supplemental insurance from the sickness funds while 38% also pay for complementary private insurance. However, this was simplicity itself compared with the new Dutch insurance system, presented by Wynand van de Ven, which left many of us relieved that we didn’t have the choice that it offered, as the complexity of the many packages on offer seemed to test the comprehension of most of those present, that vast majority of whom had the benefit of tertiary education!
The conference was held in Tiberias, on the Sea of Galilee Its banks are steeped in history, from biblical times to the 20th century (it is overlooked by the Golan Heights). Over 200 m below sea level, the surroundings are beautiful and the warm water is fresh and clear (and I did manage to find some time to swim in it). Yet it also provides a warning. It is surrounded by jetties and harbours whose walls now tower over the stones that line its shores. Although it is difficult to tell, it seems to be about 8m lower than it once was, serving as a reminder that, ultimately, the survival of this region is dependent on one scarce commodity, water.

18-22nd August, 2008. Auckland and Wellington, New Zealand
New Zealand holds a great deal of interest to anyone interested in health policy and living in the UK. In both countries the executive has almost unchallenged power to introduce laws, with no need to build supportive coalitions at other tiers of government or with civil society organisations. This has many attractions for politicians – after all, why explain your decisions if you don’t have to. However, the absence of detailed scrutiny also makes it easy to enact unworkable laws, and then to revise them with ever increasing rapidity.
New Zealand acted as a health policy laboratory in the 1980s and 1990s, introducing market reforms that went well beyond those then being contemplated in the UK. The word “hospital” was no longer acceptable, being replaced by Crown Health Enterprises. They were intended to work like businesses but to continue to be socially responsible. Inevitably, those running them failed to resolve the contradictions. Many chief executives left. Costs increased rapidly, as did waiting lists. By 1996 the Treasury concluded that ““The health reforms have yet to yield the original expectations. By a range of measures … the pace of performance seems, if anything, to have been weakened since the reforms.” However, lessons were learnt. Those bits of the system that had worked were retained, especially Pharmac, the pharmaceutical purchasing scheme that ensures that New Zealanders get low cost drugs. However the purchaser-provider split was abolished and a new system was put in place in which health care was delivered by 21 district health boards. The most important lesson was the destructive effects of what can seem like endless attempts at reform. Reform fatigue set it and even though there is widespread agreement that the current system is not perfect, there is little appetite for structural change.
I was in New Zealand for a series of meetings, concluding with a conference entitled “Building tomorrow’s health services”, held in a spectacular community and conference centre built in the form of an upturned Maori boat.
My trip included several meetings at the Minstry of Health in Wellington and a masterclass in Auckland. New Zealand’s health system faces many familiar challenges, including an aging population and the rise of complex non-communicable diseases, as well as some that are less familiar, such as a long-term redistribution of population, away from the South Island and into the greater Auckland area. It also experiences a high level of emigration of health professionals although, as we learnt, the emigration rate is not significantly different to other graduates. There is, however, a remarkably clear vision of what needs to be done, embracing prevention (and especially action to reduce the persisting inequalities between Maori and European populations) to integrated delivery systems.
In 1948 Aneurin Bevan, when asked to speculate about the forthcoming introduction of the National Health Service replied “do I need a crystal ball when I can read the book”. He was referring to the successful introduction of a health service in New Zealand a decade earlier. Could it be that English politicians will once again learn a lesson from New Zealand and place major structural chage on hold for a while to allow people to just get on with the job of delivering better care. Somehow I doubt it, but we can but hope.

3-8th August 2008, Venice
This year’s European Observatory summer school is on the “Hospital re-engineering: New roles, tasks and structures”. It draws extensively on our forthcoming book and we have, once again, been able to assemble a first class team to teach on the course, which is held in the idyllic setting of the island of San Servolo, close enough to Venice to be inspired by the view but far enough away from crowds of San Marco to allow for the reflection and contemplation necessary to exchange and absorb new ideas. As always, one of the greatest assets is the range of participants, collectively bringing a vast range of experiences that they are willing to share.

3rd July, 2008, London
Among the hundreds of thousands of words written about different health systems (and I confess that I can account for quite a few thousand alone) there is remarkably little describing what health professionals in different countries actually do. Although we have statistics on how long patients stay in hospital (themselves increasingly meaningless in a world dominated by ambulatory care), we know very little about what happens when a patient with a common medical or surgical problem comes into a hospital. Well, we know what happens in our own country but unless we engage in participant observation, either as health professionals or as patients, in a hospital in another country, we know almost nothing about how things are done elsewhere. Yet without this crucial information, it is difficult to see how we can say anything meaningful about how different health systems perform.
This was what prompted the organisation of a meeting by the NHS Confederation and the European Observatory that brought together health professionals from countries such as Sweden, Finland, France, Germany and Italy to talk through a series of scenarios such as acute myocardial infarction and deep venous thrombosis. As expected, there were many similarities in how patients are managed but also quite a few differences, reflecting the organisation of care in each country. In particular there were differences in the extent to which care was centralised in specialised hospitals or dispersed, in the roles of different health professionals, and the extent to which quality of care was monitored. This is only the beginning of what will be a long process. We will next be using this approach to understand the delivery of child health services at a workshop at the EUPHA conference in Lisbon in November. I hope anyone that is interested in these issues will join us there.

25-27th June, 2008, Tallinn
At last, the culmination of over two years’ work. Health ministers and their representatives from the 53 Member States of the European Region of WHO have come together in a major conference to discuss the links between health systems, health, and wealth. I’ve been involved in many aspects of this process, including writing some of the background reports, but here my task is to give one of the opening speeches, along with Mary Robinson, former UN High Commissioner for Human Rights and President of Ireland, and Uwe Reinhardt, from Princeton University. Both extremely hard acts to follow. If you want to see whether I succeeded you can watch a webcast of the speech on the conference website.
The framework underpinning the conference is a series of reciprocal relationships between health systems, health, and wealth. The first set of relationships are between health and wealth. It is obvious the greater wealth, whether at the level of the individual or a country, provides greater opportunities for health. People with more economic resources can make healthier choices in terms of what they eat, where they live, and how they spend their leisure. Countries with more economic resources can provide healthier environments. However, there is now a large body of evidence that healthier individuals and healthier populations contribute to greater economic growth. Healthy individuals are more productive and more likely to remain in the labour force. Historical studies show that much of the wealth of countries today is due to improvements in health over the last 200 years.
Health systems contribute to health, by preventing death and alleviating suffering. We can I quantify this through research using the concept of avoidable mortality, which measures the number of deaths that should not occur in the presence of timely and effective care. However better health also contributes to health systems, as healthier people have less requirement to use health care. This was the basis for at the analysis conducted by Sir Derek Wanless in his report to the UK Treasury, when he was asked to look at future expenditure on the National Health Service.
Wealth can contribute to health care as wealthier countries clearly have more resources to spend on modern medicine. On the other hand, health care systems can contribute to economic growth, especially at a regional level, where the provision of high-quality health care and support inward investment. Investment in health facilities can benefit the local economy, reducing unemployment, and thereby improving the health of the population, but only if it is structured in a way that enables local companies to bid for tenders on a level playing field with multinational corporations.
What we were trying to convey at the conference was not the detailed prescription for action, but rather a vision of where policy should be heading. We believe that it is possible to create a virtuous circle, with benefits for everyone.
Although there was a large attendance at the conference, and the background material is available on the Internet, we had recognized that there was a need to reach out to a much wider audience. Fortunately, as at the Oxford Health Alliance meeting in Sydney in February, we were able to enlist the invaluable support of Eddie McCaffrey and his team at JooseTV, who not only webcast the entire conference, but also produced a series of news bulletins at the end of each session and in-depth interviews with some of the key individuals who were at the conference. If you watch nothing else, check out the film shown at the end of the conference that really captures the atmosphere of excitement and enthusiasm there. Once again, I conducted many of the interviews and you can watch them on the conference website. The opportunities provided by webcasting also allowed us to connect with the European Health Management Association conference, taking place at the same time in Athens, with a specially tailored interview. If we really want to communicate messages to a wider world, this is definitely the way to go forward.

20th June, 2008 Leiden, The Netherlands
I was privileged to be asked to speak at a conference of the EUPHIX consortium. This team, led by colleagues at RIVM in The Netherlands, has done a remarkable job in creating a portal for information on health in Europe. In my speech I asked, somewhat tongue in cheek, whether with EUPHIX we needed Interail to see Europe’s rich diversity. The portal is much more than a directory of information. It includes software for mapping data (down to regional level) and manipulating it graphically. However, crucially, it is supported by extensive guides, helping users to understand the strengths and limitations of the data they are using.

18th June, 2008 Belfast
In Belfast for the launch of the new Centre of Excellence in Public Health, led by Frank Kee at Queen’s University, Belfast. As a graduate of Queen's University, have been delighted to see the remarkable progress in academic public health under Frank’s inspired leadership. I was particularly delighted to see that the launch conference was opened by Northern Ireland’s Deputy First Minister and Health Minister, two individuals from different political parties who, not so many years, would not have spoken to one another. The Centre’s research programme recognises the importance of interlinkages between different disciplines and the need to translate research into policy. This is just what Northern Ireland has needed for a long time and it is certainly something to watch.

8-10th June, 2008 Washington DC
This year’s AcademyHealth conference was held in the sweltering heat of Washington in June, a city where summer is always hot and sticky but which this year was experiencing what was, for it, a heatwave. A strong disincentive to leave the conference venue! With my colleague Bernd Rechel, we had organised a session based on our forthcoming book on hospital. This is the product of a collaboration between the European Observatory and the European Health Property Network.. After introducing the scope of the study, which draws on the most innovative ideas in hospital configuration and design from across Europe, we looked in detail at some of the most interesting examples. One was Northern Ireland’s regional hospital plan, which will create a network of hospitals offering different levels of care, primary care and rehabilitation facilities, and care in patients’ homes. Another was the Orbis Medical Park, near to Maastricht, in The Netherlands, where a new hospital is being designed to support clinical pathways and processes rather than, as is more usual, ignoring them. The third was the Alzira Hospital in Valencia, Spain, which has implemented a new financing model that was initially quite problematic but is now working well, in contrast to the UK’s Private Finance Initiative, which is now suffering what seem to be terminal death throes.
As always, many of the presentations at the conference focused on the problems that arise when you fail to provide universal health coverage. A growing number of states are now taking initiatives themselves, typically by requiring people (and their employers) to purchase insurance schemes. However, for a European the overwhelming impression is of just how complex these schemes are, and also how many holes there seem to be in them. It is difficult to see how any of them will ever really work without addressing some of the reasons why health care is so expensive in the USA, in particular the high cost of pharmaceuticals and the huge administrative costs of maintaining a multi-payer system.
There is, of course, an election coming up but it is not obvious that either candidate has a solution. What’s more, we heard that health reform is not high on the concerns of ordinary Americans, and is training far below where it was when Hilary Clinton attempted to do something in the early 1990s. Instead they are concerned about the economy and the wars in Iraq and Afghanistan. Yet this may change, as manifest by the growing evidence that people are having to cut back on expenditure to meet health care costs. Something must be done sometime, but I suspect things will have to get a lot worse before they get better.

4-5th June, Izhevsk, Russian Federation
Izhevsk, a city on the European side of the Urals, is the setting for a major Wellcome-funded study we are undertaking to understand the high level of adult mortality in Russia. Readers of this blog will be familiar with our earlier work highlighting the role of alcohol. In our current work, and in previous work in other parts of Russia, it has become clear that we are facing an enormous problem of untreated hypertension. The Soviet Union never managed to deal effectively with chronic diseases. It never developed a modern pharmaceutical industry and, even if it had, it would never have been able to distribute the drugs that those in the west take for granted and which, when taken regularly, can be life-saving. Now the drugs are available and the distribution system is in place, but we still face two problems. First, those taking drugs as outpatients have to pay for them. As they are often much more expensive than in the west because of mark-ups along the supply chain they are often effectively unaffordable. Second, there are very low expectations as to what can be achieved, so that physicians seem content to leave patients untreated even with what we would consider dangerously high pressures. This should be an entirely soluble problem but I suspect it will take some time to resolve it.

27th May 2008, Lausanne
This was my second year teaching on the course run by Alberto Holly in Lausanne. The title of this year’s course was “Mastering the new challenges of health care”. There is a wonderfully diverse mix of students, making the discussions especially rich. My sessions were on health system performance and the future of health care. These are both topics I have spoken about many times before. Predicting the future is never easy. A few have managed it successfully, such as Jules Verne and HG Wells, but even they recognised their limitations and, as far as I know, never staked their fortunes on the outcome of a horse race! Yet there is one thing that we can be fairly certain about, and that is that health care in the future will be much more complex than it is now, with aging populations suffering from multiple disorders, each interacting with one another, with their ability to function secured by a complex mix of medicines that have never been tested in combination, and especially in people with impaired liver and kidney function. This poses real challenges for modern health systems, something Ellen Nolte and I will be looking at in our new book on the health system response to chronic disease, due out in September.

I’ve been thinking a lot about two words, governance and stewardship, recently. In part this is because, with Josep Figueras, I’ve been working on the text for the Tallinn Ministerial Conference but also because I’ve been teaching about it to our MSc students. I’m grateful to one of my PhD students and to my MSc seminar group for the examples I’m going to use in a minute.
The problem with both of these words is that everyone seems to use them differently. A quick search on Google reveals dozens of definitions of governance; stewardship, a term that came into widespread use following publication of the 2000 World Health Report, has received less attention but it is also clear, listening to it being used, that it can mean all things to all people. As always with health policy, I take comfort from Lewis Carroll’s book, Alice’s Adventures in Wonderland, where Humpty Dumpty says “words mean what I choose them to mean”.
Yet maybe we can turn it round. We may not know what (good) governance and stewardship are but we do know when they are absent. Hence the two examples from my students. One concerns a new EU member state. As with any newly acceding country, its accession was conditional on putting in place an extensive body of modern laws. One of these laws concerned mental health. Yet although the law was passed, no resources or personnel were made available to implement it. No-one was accountable for failing to implement it. Indeed, it was very clear that it was never meant to be implemented. Simply passing it served a purpose and it could now be ignored. This is a failure of governance.
The second example is from the UK. A previous English Secretary of State for Health was confronted with a situation where, having put in place a new system of postgraduate medical training, it was clear that a flood of applicants from outside the UK would leave several thousand British doctors with no job. She issued an instruction that non-EU doctors would be ineligible to apply. The British Association of Physicians of Indian Origin sought judicial review and in a scathing judgement the Law Lords supported them. They noted that the Secretary of State had it within her power to change the rules by bringing a motion before parliament. Clearly wanting to avoid controversy, she failed to do so, instead simply placing a notice on a web site of the NHS Employers organisation. This, Lord Bingham noted “was to suggest a degree of official formality that was notably lacking”, going on to state that “it is for others to judge whether this is a satisfactory way of publishing important government decisions with an impact on people’s lives”. This too is a failure of governance (and as I have argued before, far from exceptional in the UK in recent years).
Of course, these are not unique, and maybe we need to think about assembling a collection of such examples from across Europe. Even if we are unable to define what good governance and stewardship are, we will at least be able to know when they are missing.

Copenhagen, 30th April

To Copenhagen, for the European consultation on the forthcoming Ministerial Conference on Health Research that will be held in Bamako, Mali, this November. I’ve been engaged with this process for a while, through WHO EURO.
The conference follows on from one held in Mexico City in 2004. It will be important as it will contribute to the agenda for global health research in the next number of years. Hence, it is essential to get it right.
My concern is that we risk losing sight of the fact that it is a global conference, albeit one that is, in part, focused on Africa. I don’t want to diminish for one second the enormous need for health research in Africa and, in particular, the importance of building research capacity there, but we should not forget the needs of the rest of the world.
Last November, we organised a consultation on European priorities for Bamako at the conference of the European Public Health Association (later published in the Eur J Public Health). We highlighted three priorities for research in Europe (on top of the ones that will be included anyway because of their global reach, such as tobacco and HIV). These were migration, aging, and alcohol, while we also flagged up the contribution that Europe could make to the rest of the world in research on complex chronic disorders, which will be the real challenge for everyone in the future, whether we are talking of diabetes or HIV or something else.
This time we were looking more widely, and the Danish Foreign Ministry had brought together what seemed to be over 100 people in their very attractive conference on the sea front in Copenhagen. I was arguing, in a panel discussion, that the health systems framework we will be using in the forthcoming Tallinn conference bears closer inspection. It highlights the beneficial reciprocal relationships between health systems, health, and wealth. Beyond that, I think we have three questions about capacity that are of concern to those of us working in Europe.

• First, how can we get the basic data in place, by which I mean regular health examination and health interview surveys, that are comparable across all of Europe? These are being developed but we are already so far behind the USA.
• Second, how can we establish better links between research and policy? Obviously I would say that the European Observatory is a good model but we also need to learn much more from the Canadians with their knowledge brokers.
• Third, how can we build up research capacity in our own neighbourhood. Research capacity in many parts of the former Soviet Union or in the Middle East or North Africa is far weaker than in countries like Uganda or Tanzania.

So at Bamako I hope that Africa does get attention – it deserves it. But we should not forget the rest of the world.

April 29th
To the Royal College of Physicians for their conference on Global Health. I was asked to speak about international trade and health so I chose as my title “Opium, tobacco and alcohol: the evolving legitimacy of international action”. My argument went as follows. We all agree that, in most cases, international trade brings great benefits. Each country does things where it has a competitive advantage. I enjoy mangoes but it would be a bit silly of me to try to grow a mango tree in my garden in north London (although with global warming you never can tell). Yet there is a down side. The problems arise when what are being moved around the world are not the usual “goods” but rather “bads”. Few people really think that flying tons of AK-47s into the Democratic Republic of Congo is a good idea (except of course those doing the flying and those supplying them from places like the Trans-Dneister republic – see Misha Glenny’s new book - McMafia: Crime Without Frontiers ). Similarly, landmines are now fairly universally regarded as a “bad”. But what is it that changes a “good” into a “bad”?
I began by looking at one of the best known examples. In the middle of the 19th century British forces went to war with China (twice) to protect our right to sell opium to China. China certainly didn’t want it – it realised that it was causing harm to its population and even threatened to retaliate by banning exports of rhubarb to Britain, in the hope that this would inflict widespread constipation. Yet it was the opium harvest that lay behind the economic success of now British Bengal. Over a century later we were still at it, as Christopher Bayly describes in his excellent book on the British withdrawal from SE Asia, as we imported massive amounts of opium to ensure that the Malayan population kept working even though there was no food. Yet now the Royal Navy patrols the high seas, interdicting cocaine smugglers in the Caribbean (and anywhere else it can find them). What turned us from a trafficker to a policeman?
The same sort of change is taking place with tobacco. Here we have a product that has killed more people than all the wars of the twentieth century yet we (or at least our political leaders) still treat the manufacturers and distributors in the same way as people who make things that actually benefit us. It really is remarkable. These people are peddling their deadly products to children all over the world in a way that is really no different to the traffickers who hand around school gates trying to hook kids on heroin. Yet while no-one would invite the drug traffickers to be photographed with our political leaders, there seems to be no barriers for tobacco company executives. In the past, when countries such as Thailand stood up to the USA and said that they didn’t want tobacco imports, the USA threatened trade sanctions. Imagine what would happen if Bolivia took the USA to the World Trade Organisation for blocking exports of cocaine (although, again, anything is possible).
Except, there are some signs of hope. The Framework Convention on Tobacco Control does make clear that tobacco is not just another product and that governments can put in place a range of measures to counteract the aggressive marketing of tobacco without being accused of erecting non-tariff barriers. So tobacco is steadily being transformed from a bad to a good.
What of alcohol? Obviously this is more difficult as moderate consumption is clearly good for you, providing you are at risk of heart disease (if you are under 40 you are just kidding yourself – the net effect is harmful, sorry). Yet the alcohol industry seems to be doing everything possible to move into the corner with the makers of “bads”. Recently (as I described in an editorial in the BMJ) when discussions on a European alcohol policy were taking place, the Brewers of Europe published a remarkable report purporting to show that there really was very little evidence that alcohol was at all harmful. They commissioned it from the Weinberg Group, a consulting firm that had previous tried to convince us that the health effects of smoking were exaggerated and that Agent Orange was not such a bad thing after all. Their report argued that that "there is not enough evidence to substantiate a link between alcohol advertising and consumption," raising the question of why the industry spends so much money promoting its products, and that "violence is a subjective term which is fairly nebulous and elastic," a view unlikely to be shared by someone scarred by a bottle wielded by a drunk. Clearly, if the alcohol industry continues with tactics such as this, it cannot be surprised if we begin to consider the need for concerted international action, building on the experiences with narcotics and tobacco.

My second trip to Brussels this week. I was with my colleagues Christian Haerpfer and Alexander Chorostov to begin negotiations with the European commission on our new FP7 project, Health in Times of Transition: Trends in Population Health and Health Policies in CIS Countries. This is a follow-up to our earlier project entitled Lifestyles Living Standards and Health. In it, we conducted household surveys in eight former Soviet countries, providing important new information on topics such as tobacco and alcohol consumption, access to safe water, and use of health services. In the new study, we will be expanding the household surveys to 11 countries, covering the entire Commonwealth of Independent States with the exception of Turkmenistan. We will also be undertaking a number of community profiles to understand better the circumstances in which people live, in particular their access to different forms of food, the extent and nature of tobacco marketing, and their access to healthcare. We are hoping that the project will begin in November 2008 with the first survey data being collected in early 2010.

Footnote: I read that the UK government is planning to introduce a new facial recognition system “to reduce delays at immigration in British airports”. This news simply confirms to me that the Home Office is viewed as an incredibly soft target by anyone with a computerised gizmo that no-one else is stupid enough to buy. When it was introduced, I enrolled in the IRIS system, which was a complete waste of time. The system is frequently out of order and, even when it is working, it is so slow that it is quicker to use the ordinary queue. I was reading about the new system as I was getting on the Eurostar at Brussels, where one must show one’s passport to Belgian officials and then again, about 10m further on, repeat the entire process with the British (only more slowly as it is clear that their computers are creaking under the weight of data from the new biometric passports. If the government really is interested in reducing queues at immigration, there is an obvious solution. Join the Schengen Agreement like the rest of Europe!

To Brussels, for a meeting of the steering committee of the European Observatory. It has been an incredibly busy year, beginning with the publication of our book on cancer in Europe and continuing with intensive preparations for the Ministerial Conference on Health Systems in Tallinn in June.

It is always nice to know that one is appreciated, so it was a great pleasure for us all when the Observatory was recognized in an award schema that had been launched by the World Bank for initiatives that improve the lives of people living in Europe and Central Asia. A total of 19 awards were made, most for projects within countries, such as the restoration of the famous bridge in Mostar, in Bosnia, that was destroyed during the war, or an AIDS control project in Moldova. The Observatory was recognised by a multi-country award. The picture shows Armin Fidler, who had previously accepted the certificate from the president of the Bank, in Washington, handing it on to Charles Normand, the chair of our steering committee, and accompanied by Josep Figueras, Director of the Observatory.

17-18th April 2008, Riga, Latvia
We are here for a meeting of the EURO-PREVOB project. This is seeking to develop a methodology to map policies, both “on the books” and “on the streets”, that can address the increasing problem of obesity in Europe. We are interested in policies that influence both energy intake and expenditure, in other words, nutrition and physical activity. With support from the WHO, we were joined by many of the leading experts on food and physical activity from across Europe, who provided extremely valuable inputs into our thinking.
We began with a series of presentations that brought us up to date with developments in this field. Liz Dowler reminded us that, as we think about access to healthy food, we need to think about whether it is culturally appropriate food in an increasingly multi-cultural Europe. Mike Rayner reminded us that marketing involves 4 Ps: product, promotion, place, price. Effective action must address all of these. A key issue we need to address is food labelling. Although almost everyone has signed up to the need for labelling to inform the public, some companies are working hard to avoid the use of traffic light systems – red for danger, green for healthy – for the obvious reason that their products would have a line of red splodges. Instead they are pushing for more complex labels, often on the back rather than front of packs, that the public finds confusing (see link for UK Food Standards Agency evaluation). Mike also reported some very interesting evidence on the effects of so-called “fat-taxes”, or more generally increased taxes on unhealthy foods. In fact, in the EU, many foods are already taxed – in the UK there has been a very interesting legal action recently to decide whether a marshmallow is a cake or a biscuit, with very considerable financial implications for the Treasury. The question is whether the existing somewhat confused and contradictory regime can be refined to incorporate a health dimension. What the research showed was that simply taxing unhealthy foods would actually increase deaths. What is needed is an integrated policy that is linked to subsidies for healthy foods.
Tim Lobstein then took us through the tactics that are being used increasingly to market food to children. He reminded us of a study that looked at the range of foods marketed to children. Some products were low in fat (but high in sugar), some were low in sugar (but high in salt), so that only 1% of products were actually low in salt, saturates, fat and sugar. In other words, virtually all food aimed at children is junk.
Any parent will be familiar with some of the more obvious methods used to persuade children to consume energy dense foods, such as McDonalds’ Happy Meals, otherwise known as “edible entertainment”. Many of these products give away sets of toys, with the sets changing regularly to encourage children to eat enough to get the whole set. Then there are the links to “good causes” where companies distribute tokens that can be exchanged for school sports equipment and the like. We were reminded of Cadbury’s tokens, whereby, if one managed to consume 20,000 kcal of chocolate, one could get a netball. Then there are the companies offering free logos and ringtones for mobile phones, and of course once the numbers are logged, the children can be bombarded with advertising text messages. Or the books where children learn to count by placing M&Ms on pictures, no doubt eating a few as they do. It is clear that the regulators are many steps behind the industry.
So what is to be done? We were meeting in Latvia, a country where, unusually, the government has taken a strong stance against additives and colouring in food aimed at children. Leaving aside the emerging evidence that some additives may have harmful effects on children’s behaviour, we are faced with a situation in which colourings are used very extensively simply to make otherwise unattractive (and unhealthy) food attractive to children. There seems a strong argument for banning their use in food aimed at children.
So back to the project. Essentially, if we want to understand existing policies in a country, how they relate to needs, and the scope for further development, we need quite a lot of information. We will be focusing, first, on the “law on the books”. The idea is to identify a national focal point in each country who can convene a group of knowledgeable informants who can tell us about what policies are in place. Of course, that is just the first step, so we need them to tell us not only whether a policy exists but also whether it is written down , whether there are financial and human resources identified to implement it, and whether there are systems for monitoring, evaluation and accountability. The second focus is on “law on the streets”. Here we have to develop a means to capture what is happening in reality. Do the foods on sale in shops have nutritional labels? Can people afford to eat a healthy diet (and can they get to the shops that sell it)? Does the layout of the streets force people to use their cars or to walk of cycle? Finally, drawing on Marx’s comment that “the philosophers have only interpreted the world, in various ways; the point is, however, to change it”, we need to identify who the key stakeholders in a potential new policy might be, what their positions are, their interests, and their influence. We have a lot of work ahead of us!

17th April 2008, Flying from Tallinn to Riga
A short flight down to Riga. The Baltic States are now in the Schengen zone so no need to go through immigration, unlike the ridiculous situation when entering the UK, whose government continues to emphasise its semi-detached relationship with the rest of Europe.
I read in the in-flight magazine an article by Bertolt Flick, the CEO of Air Baltic, that there is some prospect that the EU might get rid of the ban on liquids in hand baggage. He writes that he has serious doubts that they ever contributed to safety. So he should. As anyone with a moderate knowledge of chemistry will know, this policy is devoid of any basis in evidence (surely if it was so easy to make explosives from household liquids we would be seeing bombs going off in European capitals every week?). We must thank the European Parliament, whose members have been asking some quite penetrating questions (even if the European Commission has failed to answer them, citing secrecy – the argument of the truly desperate). The Parliament is pushing through long-awaited legislative measures to bring some basic common sense to the often bizarre array of security measures that simply serve to make air travel in Europe even more awful than it would otherwise be. However, I am not holding my breath. This will involve some governments admitting that they got it seriously wrong and, given that some still believe there are WMD in Iraq (and also presumably fairies at the bottom of their gardens), this may take some time.

15-16th April 2008 – Tartu, Estonia
Estonia has, in many ways, had a very successful transition from communism. Its economy is growing rapidly (somewhat faster than its neighbours Latvia and Lithuania), it has maintained a high level of fiscal stability, and its markets are now closely integrated with the rest of the EU. It has made remarkable progress in reforming its health care system, introducing a very effective system of primary care, it has managed to restructure its hospital system very successfully, and has a health insurance system whose income and expenditure are in balance. These largely reflect the efforts of a number of extremely talented young Estonians (hope you are reading this, Maris and colleagues). Their achievements stand out in a region that has struggled, often unsuccessfully, to bring about much needed changes to health care systems.
Yet there is still some way to go, both in terms of economic progress but more importantly in terms of health. Life expectancy at birth for Estonian women lags behind that in Sweden by over 4 years; for men the corresponding figure is a massive 11 years!
Things are improving. Indeed, Estonia has managed to achieve sustained increases after 2005 at a time when Latvia and Lithuania have experienced what are hopefully only temporary setbacks. One area where there has been a marked improvement is in deaths from stroke, almost certainly reflecting the reform of Estonian primary care and resulting improvements in the treatment of high blood pressure. This is at a time when Lithuania has actually seen a slight worsening in death rates. There have been other achievements, most notably the successful implementation of a ban on smoking in public places (something I argued for in the Estonian paper Eesti Päevaleht in December 2004 (Tubakasuits tuleb laiali ajada. Eesti Päevaleht). Yet there is one area that stands out because of the complete absence of a policy – alcohol. Like all countries that emerged from the USSR in the early 1990s Estonia has long had a problem with alcohol. Spirits are cheap and easily available (despite some local efforts to reduce the possibility of buying them late in the evening). As we showed in a recent study, aftershaves and medicines containing high concentrations of alcohol are sold widely, in the knowledge that they are being drunk. In a second study we showed that the main outlet is street kiosks, which sell an eclectic mix of aftershaves, pet food, washing powder, and condoms. One result is that, at a time when mortality overall has been falling, deaths from liver cirrhosis have been rising, to a level that is now three times higher than in 1990!
This provides the rationale for one of our research projects in Estonia. Working with Katrin Lang, Marika Väli, and Kersti Pärna and other colleagues at the University of Tartu, we are trying to understand better the role played by alcohol in premature deaths in Estonia and, in particular, the role of alcohol in sudden cardiac death, something that is still imperfectly understood. We should begin to have enough data to draw some conclusions in about 18 months.

Five years ago the University of Crete established a postgraduate training course in public health. I’m here at the invitation of the course director, Professor Anastas (Tassos) Philalithis, to join in a review of the course, accompanied by colleagues from the UK, Sweden, and Canada.
Public health has not, traditionally, been strong in Greek universities (the Athens School of Public Health is part of the Ministry of Health, not Education). The creation of the course was therefore a very welcome development. In the short time that it has been going, it has attracted large numbers of students (and also attracted some very talented staff who had been working abroad). The Medical School here at the University of Crete has a spectacular modern campus, with a view of the mountains and sea that must inspire great thoughts! Although we are only half way through the process, we have had a chance to talk to the extremely motivated students and to look at their dissertations , all of which are very impressive.

Crete has a special place n the geography of public health. Cretan researchers participated in the landmark Seven Countries Study. The study recruited men aged between 48 and 59 and followed them up from 1958 to 1970. At that time, remarkably little was known about the causes of cardiovascular diseases. The Seven Countries Study was far ahead of its time, using standardised data instruments and analyses. It included countries with some of the highest and lowest mortality rates known anywhere at that time. By comparing risk factors in Karelia with those in Crete, the research team discovered the key role played by diet, in particular lipids, in the genesis of this disease. In due course this study, along with others, would confirm the status of the traditional Cretan diet, with its olive oil and high levels of fresh fruit and vegetables, now considered the healthiest anywhere in the world.


Of course, Crete is a Mediterranean island, benefiting from the Mediterranean climate and culture. The main square in Heraklion has a reminder of this shared culture, with a bust of one of it’s most famous sons, Doménicos Theotokópoulos, better known as El Greco. Although born here, he spent time in Venice and Rome before finally settling in the Spanish city of Toledo, where many of his greatest works were painted.

Unfortunately, as in other parts of the Mediterranean, the traditional Cretan lifestyle is under threat from the forces of globalisation. The diet is giving way to fast food, the growth of motor vehicles is reducing the amount of physical activity that people take (and leading to an enormous number of premature deaths from traffic injuries, in part because of a widespread rejection of the concepts of seatbelts and motorcycle crash helmets), and obesity rates are increasing rapidly. However, perhaps the greatest problem, and the one that can be addressed most easily, is the high rate of smoking.

I watched someone smoke three cigarettes, one after the other, at breakfast in the hotel yesterday morning. Every bus shelter has large advertisements for cigarettes, clearly designed to attract new smokers among Cretan adolescents. As the pictures here show, there are health warnings but they are very difficult to see. The result – death rates from cardiovascular disease and cancer are now rising in Crete and, as we showed in a recent paper looking at regional patterns of mortality in the Mediterranean countries, in many other places that traditionally had a health advantage.

The tragedy is that many Greek politicians do not seem to have understood what is happening to the health of their population. The public health service remains focussed on traditional hygiene. There is still no proper career structure for public health professionals. Although there are some world class public health researchers, they have so far had to go abroad for their postgraduate training and many have not returned. There are few funds for research training, except those available from the European Union. The health insurance funds, that might be expected to show some interest in preventing illness and ensuring that the care they pay for is effective, take little interest as, when faced with rising costs, they simply increase their deficits and from time to time ask the government to bail them out. Until now the gods have been kind to the Greeks, blessing them with a long life expectancy. It was easy to believe that a modern public health workforce was a luxury. Hopefully, before it is too late, Greece’s political leaders will realise that it is not. When they do, the University of Crete is well-placed to rise to the challenge.

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One of the things I enjoy about Greece, as a non-Greek speaker, is spotting the many words of Greek origin that have made it into English. The emergency exits in the university bear signs labelled “exodus”. The labels on the fire extinguishers begin with “pyros”. The wings of the university building are Pteriga (as in Hymenoptera – bees and wasps – or Pterodactyl (wing/ fingers)). I was therefore fascinated to learn from Tassos that, back in the 1950s, Xenophon Zolotas, an eminent Greek economist, had developed the art of making speeches to the international financial bodies, ostensibly in English but using virtually entirely words of Greek origin. One of his speeches, to the IBRD, is reproduced here. Another can be found by clicking on his name above.
I always wished to address this Assembly in Greek, but realized that it would have been indeed "Greek" to all present in this room. I found out, however, that I could make my address in Greek which would still be English to everybody. With your permission, Mr. Chairman, l shall do it now, using with the exception of articles and prepositions, only Greek words.
Kyrie, I eulogize the archons of the Panethnic Numismatic Thesaurus and the Ecumenical Trapeza for the orthodoxy of their axioms, methods and policies, although there is an episode of cacophony of the Trapeza with Hellas. With enthusiasm we dialogue and synagonize at the synods of our didymous organizations in which polymorphous economic ideas and dogmas are analyzed and synthesized. Our critical problems such as the numismatic plethora generate some agony and melancholy. This phenomenon is characteristic of our epoch. But, to my thesis, we have the dynamism to program therapeutic practices as a prophylaxis from chaos and catastrophe. In parallel, a Panethnic unhypocritical economic synergy and harmonization in a democratic climate is basic. I apologize for my eccentric monologue. I emphasize my euharistia to you, Kyrie to the eugenic and generous American Ethnos and to the organizes and protagonists of his Amphictyony and the gastronomic symposia.

12th March: Ljubljana

Slovenia will have a general election in September. Health care is rising rapidly on the political agenda, largely because of the high share (about a third) of health expenditure now being paid directly. The Slovenian health financing system has a large co-payment element, which many people cover through complementary insurance but others pay out of pocket (See HiT profile).

I was invited to talk about the roles of planning and markets in health care, with particular reference to the UK. My host was the Friedrich Ebert Stiftung, a German foundation that supports dialogue on public policy issues.

The starting point was that markets have clearly delivered many benefits. No-one now would want to go back to the centrally planned system for distributing food in the Soviet Union. The question is whether the conditions for markets to operate apply in health care? Another issue to consider is the differing goals of the various actors. Governments seek to improve the health of their populations, to respond to their legitimate needs, and to do so fairly (or at least they should – this is the WHO definition). Private companies are legally obliged to maximise the returns to their shareholders. These goals may overlap, but it is unlikely that they will overlap completely.

Health care is not a commodity like baked beans, apples, or widgets. It has certain features that make it special. Many people who need care don’t realise it. Even if they know they need something, they may not know what. They are easy prey for unscrupulous providers. This is what we call information asymmetry. It is not only people who are ill who have an interest in being treated. The rest of us also have an interest. This is obvious where they are suffering from infectious diseases, which may infect us, or mental health problems that may lead them to harm us. But simple concern for others also leads us to want to see their suffering relieved – what we call externalities.

Then there is the changing nature of disease. Markets are fine where the transactions are simple, as was once the case in medicine, where an individual patient would go for a single visit to a doctor, who would make a diagnosis (often wrong) and prescribe treatment (often ineffective). The patient either got better or died. The situation now is quite different. A typical older patient may have arthritis, Parkinsons Disease, heart failure, bronchitis, diabetes, and depression. They go to their family doctor. They are then referred to a series of medical specialists, nurses, other health professionals, all working together in a network, collaborating with each other. They receive multiple powerful and effective medicines, all of which are affected by their organ function and by the other drugs they are taking (which will never have been evaluated in combination). They remain under continuing review for the remainder of their now active and fully engaged life. This is seriously complex and someone has to manage it. Unsurprisingly, private providers will run a mile from patients like this. Instead they concentrate on straightforward non-urgent surgery, where the costs are largely predictable, and if they do venture into chronic disease management, they select those people who only have one disease and are otherwise healthy. The public sector picks up the rest – what we call cream-skimming.

But does this matter, as long as everyone can get treatment somewhere? It can do. Think of situation where a family is injured in a high speed car crash. They arrive at an emergency department. There is no paediatric service – it has been moved into the community. Their eye injuries cannot be treated as the ophthalmologists have been relocated to an independent treatment centre to concentrate on waiting lists for cataracts. The complex hip fracture cannot be treated, because the orthopaedic surgeons have been relocated to an independent treatment centre to concentrate on waiting lists for knee replacements. There is no microbiologist to speak to about the wound infection because the service has been privatised and moved 200 km away.
However, perhaps the greatest challenge relates to preparing for the future. As Donald Rumsfeld famously said “there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know. And … it is the latter category that tend to be the difficult ones.” So when we are thinking about the competing strengths of public and private provision, a key issue must be which allows more flexibility to adapt to future challenges. Then there are the things that we can predict, such as the need to train the next generation of health professionals and the need to engage in research and development to generate new knowledge. Again, we need to ask which is better at investing in these future needs.

Taken with the conventional questions such as value for money, this then gives us a framework for looking at two of the developments that have taken place in the UK, the Private Financing Initiative (PFI) (as a means of funding new hospitals) and Independent Sector Treatment Centres.

It is now apparent to all but the most ideologically driven commentators that the UK PFI scheme has been a failure. Allyson Pollock has provided most of the evidence in a series of papers, in the process exposing herself to vicious personal attacks from the supporters of PFI (or in some cases from backbench Members of Parliament who probably never understood the issues but were doing what they thought might be appreciated as they sought to advance their careers). She has shown how the procurement process is expensive, complicated, and prolonged. One result is that several projects have been abandoned at an advanced stage, wasting millions of pounds. Several of the hospitals that have been completed have suffered major quality problems. However, for us the real problem is the inflexibility (see our paper in the Bulletin of the WHO). Because the contracts are negotiated in so much detail, it is virtually impossible to change the specifications, even though we know that the nature of health care is changing rapidly. One example is the ratio of operating theatres to beds. With short acting anaesthetics and minimally invasive surgery we need more of the former and less of the latter. Yet some recently completed hospitals (including one close to where I work) are already obsolete in his respect by the time they open. The accompanying picture illustrates the problem. Given the declining need for beds, a newly built hospital now may have too few (an example is the now notorious Norfolk and Norwich hospital PFI scheme). However, in 30 years time it will have too many. The situation is worse for schools. There are now quite a few examples of schools built under the PFI scheme that are now surplus because of falling birth rates (see article in the Guardian). Yet the local governments still have to pay for them to be maintained for the next 30 years, at a cost of millions of pounds each.

The Independent Sector Treatment Centres raise different issues. Here the evidence is rather less, largely because they have consistently failed to supply the data that were required from them. Consequently, a cartoon accompanying one of Allyson Pollock’s paper in a recent issue of the BMJ compared them to a black hole, with money and patients being swept into them but no idea what happened afterwards. One problem is cream-skimming. They only take the straightforward cases, leaving the NHS to look after the rest. Yet bizarrely, give the lower costs that result, the government pays them 11% more per case! (and this is on top of various other subsidies plus a guarantee to buy back the premises at the end of the contract). It then doesn’t even check whether they have performed all the procedures they have been paid for – a reasonable estimate is that they have performed about 70% of the contracted work but of course they received 100% of the payment.

Now I am not saying that markets have no place in health care. Of course they do. All that we have to do is ask whether, in a particular set of circumstances, the prerequisites for a market exist and then whether it will actually deliver what it promises. Fortunately, I don’t have to answer that question for the Slovenian population!

Footnote 1: Credit where credit is due. On Tuesday evening I passed through Terminal 2 at Heathrow. This is normally a deeply unpleasant experience, reminiscent of Douglas Adams’ comment about being drunk, as experienced by a glass of water. Amazingly, I got through security in only a few minutes because there was a security supervisor who was actually managing the process. No-one should underestimate the importance of this development. Could it be that the executives of the British Airports Authority have finally realised that they are meant to be managing an airport, rather than a shopping mall? Somehow I doubt it. Terminal 5 opens in a few weeks and we already know there will only be enough seats for about two jumbo jets’ worth of passengers, presumably with the intention of forcing people wanting a seat to buy food and drink from the many commercial outlets. No. I suspect that this was just an individual who takes pride in his job. I fear he won’t last long.

Footnote 2: I returned through Terminal 2 at Frankfurt. A 20 minute queue to get through security, having been screened only 90 minutes earlier at Ljubljana. It’s close, but in the competition to become the most incompetent airport operator, Frankfurt seems to be drawing ahead.

6th March: Brussels

In June, WHO is organising a ministerial conference on health systems in Tallinn, Estonia. The theme is “Health Systems, Health and Wealth”. The concept underpinning the conference is that all three are mutually linked. Health systems can contribute to better health and to economic growth. Better health reduces the burden on health systems while supporting wealth (economic growth). Wealthier populations are healthier and can afford better health systems. The challenge is to create virtuous circles in which each reinforces the other.


The European Observatory is producing the background material for the conference. This includes a set of policy briefs and two books, one on health system performance, edited by Peter Smith and Elias Mossialos, and one on Health Systems, Health and Wealth, edited by Josep Figueras, Nata Menabde and myself. We were in Brussels for a workshop with the authors of our book.
Many of the elements are already there. Marc Suhrcke, Lorenzo Rocco and I have now published extensively on the contribution that good health makes to economic growth through greater productivity and higher labour force participation. Ellen Nolte and I have shown, in our work on avoidable mortality, how health systems contribute substantially to better health (unless, as in the case of the US system, they are highly dysfunctional – see blog entry of 8th January 2008). The challenge is to bring it all together.



There are, however, some gaps. Although collectively those of us in the room have a great deal of direct experience of health policy in Europe, it is really difficult to find anyone who has made a comparative study of how health policies are made (or not made). One of my favourite quotations is Bismarck’s saying that “two things should never be made in public, laws and sausages”. It may be that the experience of observing policy being made is so awful that few people want to watch it twice! Whatever the reason, there is a desperate need for politician scientists with a comparative perspective who would like to study European health policy (aspiring PhD students please get in touch).



The book will not, however, just be a rehash of what is already there. One of the most interesting areas is the relationship between the health system and the macroeconomic environment. We are often told about the need to ensure a profitable pharmaceutical industry because of its contribution to the economy. But given finite resources, is this really the best use of money? On the available evidence, the jury is still out. On the other hand, there is growing evidence of other ways in which health systems contribute to the economy. Peter Smith cited evidence from China where, especially in rural areas, the health system has largely collapsed. As a consequence, families are hoarding money as a form of insurance against ill health. This is sucking huge sums out of the economy, with serious macro-economic consequences - a warning, for those who seek to shrink the scope of publicly funded systems.

25th February, Sydney
To Sydney for the annual summit of the Oxford Health Alliance. The Alliance brings together participants from industry, academia, NGOs, and governments to tackle the epidemic of chronic disease. They come from many backgrounds, not just public health but the law, the media, the built environment among others. The message is simple – 3four50:

• 3 risk factors – smoking, poor diet, lack of physical activity, lead to


• 4 diseases – heart disease, type 2 diabetes, lung disease, and many cancers, accounting for


• 50% of deaths in the world.

We were allocated to groups, at tables, and asked to discuss the issues raised in a series of plenary presentations (speeches, panel discussions and video clips). OXHA has always had a strong emphasis on understanding (and changing for the better) the environments that people live in and how they impact on their health. This year we focused on cities where more than half of the world’s population now lives. A key theme, developed in particular by

Tony McMichael, was the issue of sustainability. Too often policies create sick people and sick environments. Greater car use leads to obesity, heart disease and diabetes and pollutes the immediate environment while contributing to global warming.

Of course, even in an audience that is committed to tackling chronic diseases, there is scope for disagreement. One area of contention was about how much evidence is enough. Should we delay calling for action until we have all the evidence? Or should we adopt the precautionary principle, even though we may occasionally be wrong? Those favouring the former highlighted the danger of unintended consequences, while the latter reminded us that that it was many years after the original epidemiological studies before we understood, at the biological level, of how tobacco causes lung cancer but it would have been a disaster if we had waited until we had it before acting to reduce smoking.

My role was two-fold. The first was to speak on a panel on getting evidence into policy, something I have spoken about many times. It was an exceptional panel and I was accompanied by Larry Gostin, Fiona Adshead, and Simon Chapman. You can hear commentary on the session by Richard Smith on the conference web-site (click on the Day 2 pm tag). I was arguing that we need to understand where politicians come from, recognising their personal agendas and trying to find win-win solutions. Yet that does not mean that we should not challenge how the political process works. In recent years there has been an enormous amount of soul searching by researchers about issues such as interpretation of evidence and research fraud. This is entirely justified. Yet the sins of a few researchers pale into insignificance in comparison with much everyday politics.

Unfortunately, few health-related decisions are subject to the scrutiny that we need to understand how they came about. Instead, we need to look for insights from other areas of policy. Our sources are some recent books, such as Anthony Seldon’s biography of Tony Blair. Bob Woodward’s State of Denial, and Carl Unger’s The fall of the house of Bush. These well-referenced books remind us of the importance of personal relationships. Unger shows how many of George W Bush’s policies were driven by his determination to go down in history as a greater president than his father. Woodward describes how the decision to go to war in Iraq took place in a US cabinet where, when Donald Rumsfeld was speaking, Colin Powell ignored him and vice versa, while George W Bush seemed incapable of understanding what either was saying. In the UK, Seldon describes graphically how policy making was dominated by the visceral and mutual hatred of each other by supporters of Tony Blair and Gordon Brown, to the extent that some of their senior advisors would not even sit in the same room. The relation was summed up best by Gordon Brown’s now famous remark to Tony Blair that "There is nothing you could ever say to me that I could ever believe."

It is, however, when we get into the detail of the decision-making process that we can really understand how some politicians understand the concept of evidence. The best described example is, of course, the case for invading Iraq. Here our sources are Woodward and Unger. It is now apparent that the “uranium from Niger” story was manufactured by the Italian security services to ingratiate them with the Americans. The flaws in the story, such as the fact that the French authorities were in complete control of the Niger mining operation and the story required that 500 tons of uranium ore be transferred between ships on the high sea (if not impossible certainly extremely difficult) was conveniently overlooked by the US and UK security services. The mobile chemical weapon factories, later found to be trucks for filling weather balloons with helium, were known to be harmless from the beginning. Interestingly, we now know, from an analysis by Ronan Bennett, that it was not French obstruction that prevented a UN resolution in favour of an invasion of Iraq but rather the role of the Mexican Ambassador to the UN, Adolfo Aguilar Zínser, then on the Security Council, who was the only one not to be taken in by the “intelligence” and to ask serious questions. One was whether there was any correlation between how well hidden weapons were and the speed with which they could be deployed. The admission that this was true suggested some contradiction between the two arguments being made that a) the weapons were so well hidden that they could not be found yet b) they could be made ready within 45 minutes! He was not persuaded, and as a result, neither were the ambassadors of the other undecided countries. At this stage, French support would have been irrelevant. So how was this peer-reviewer rewarded for his diligence in exposing this appalling example of research fraud? The US authorities put pressure on the Mexican government and he was recalled. While of course we need to continue the struggle against fraudulent researchers, we should not let politicians get away with the same crimes.

I did, however, have a second role. OXHA has been at the forefront of exploiting the opportunities offered by the media, thanks to the expertise of an extremely innovative production company, Joose TV. The summits are web cast live and, if you have followed the links above, accompanied by webcast commentaries. In an innovation this year I did a series of interviews with some of the participants: Larry Gostin, Srinath Reddy, Judith Mackay (Bloomberrg Tobacco Initiative), Abdullah Daar (leader of the Grand Challenges project), Claire Lyons (Pepsico Foundation), Viliani Tangi (Health Minister of Tonga), and Christine Hancock (OXHA). You can view them on the 3four50 site.

18th February: Izhevsk, Russia
Not an auspicious start. Shortly after we arrived at Moscow airport it was announced that our Izhavia flight was delayed two hours, then another two hours, and then a few more. Izhavia only has a few planes and several of them were out of order. Our Yak 42 that should have left at 7pm finally took off, in heavy snow, at 3 am. The joys of travel…
We have been working with colleagues in Izhevsk, an industrial city near the Urals, for about 5 years. It was there that we undertook the research showing the major role played by surrogate alcohols (aftershaves, fire lighting liquid and the like) in the Russian mortality crisis. In our earlier work we reported that these substances were drunk regularly by about 8% of working age men and their consumption was very strongly associated with premature death, even after taking account of consumption of other forms of alcohol. There are, of course, a few sceptics who are unconvinced of their importance but the evidence is now overwhelming.
The obvious next step is to do something about this problem. In fact, the Russian government did introduce a package of measures in 2006 that reduced supply of these substances, mainly by making it more difficult to get licences to sell them and the monitoring equipment needed to assess tax on them. Since then, life expectancy has increased markedly although it is still too early to say if it is a direct result of the new legislation or not.
Our current research involves following up those men who were the controls in our earlier study, to see how they have fared since we last spoke to them. We are also inviting them to come for health checks, where we can advise them about problems such as high blood pressure – a major problem in Russia. Those who are drinking heavily are being invited to participate in a randomised controlled trial of motivational interviewing, a brief intervention that has been effective in changing behaviour elsewhere.
By coming back to the same place for several years it is possible to see how things are changing. When we first came to Izhevsk we stayed in a trade union hotel for health workers that had changed little since Soviet days. Like other buildings of the period, no two steps on the stairs were the same height, something that we tend to take for granted in the west. Now we stay in a lovely little hotel that could easily have been transported from Vermont, with its beautiful wood panelling, comfortable bedrooms, incredibly helpful staff, and even WiFi. But it is not the only thing that is changing in the city. This time we got stuck in a traffic jam, something that was previously unimaginable. We heard that there are now quite a few Porsche cars in Izhevsk and there are now some very up-market cafes serving food from around the world. Yet many people still live in the wooden barracks built before WW2. This is definitely a society in transition.
On the way back, I took a brief trip into Moscow to catch up with colleagues at the Open Health Institute. With funding from the Bloomberg tobacco initiative, they have created the Russian Antitobacco Advocacy Coalition (Ataca), something I described a few weeks ago on this blog, following my last trip here. Ataca has already made enormous progress. The Russian government is well on the way to ratifying the Framework Convention on Tobacco Control and a much strengthened law on tobacco advertising has just been passed. There is a long way to go but it is great to see so much happening so quickly.

Still on Ljubljiana - you can also listen to several of us discussing our book on cancer in Europe in a podcast.

Ljubljana - 7th February. Slovenia is the first of the countries that joined the EU in 2004 to hold the rotating Presidency of the EU. Each country uses the Presidency to promote an issue that it sees as important, in the hope that it will be able to influence policy across the EU, either through the legislative process (a long term goal) or by recommendations from the Council of Ministers (easier). The Slovenian government chose cancer as its priority and, as with many of the previous Presidencies, we have been helping to bring together the relevant evidence.
Over the past year, with my colleagues Michel Coleman and Delia Alexe, at LSHTM, and Tit Albreht, from the Institute of Public Health in Ljubljana, we have been editing a book on cancer in Europe. Of course there is an enormous number of books on various aspects of cancer already available but this differs in several ways. First, it covers the entire range of issues related to cancer, from research and drug discovery through screening and cancer plans, to psychological aspects of cancer and palliative care. We were extremely fortunate to get contributions from many of the leading authorities on these topics, including researchers, practitioners, and representatives of patients. Unbelievably, we pulled the whole thing off in just over a year!
The book provided the basis for a major conference on cancer in Europe. We had actually launched the book to the media two days earlier, getting some coverage on the BBC and elsewhere, but what had been overlooked when putting the timetable together was that this coincided with Super Tuesday in the US presidential race. Clearly, we have some way to go to become experts in spin! (sorry, media relations).
The conference was held in the Brdo conference centre, newly built for Slovenia’s presidency. Slovenia is a stunning country and the conference centre is ain a great location, with a backdrop of snow-covered mountains.
It was my task to sum up the meeting. This is always difficult as much of what needs to be said already has been. I did, however, draw out some lessons. We first need to decide, in each country, whether we really do want to do something. You could argue that the existing systems sort of work. Most people get treated, and for some cancers outcomes are not too bad. However, the evidence we had heard over the past two days was that this was not good enough. There are still large variations in incidence and survival from cancer across Europe. In many countries, care is highly fragmented and patients face long delayed in accessing effective treatment. Only a few countries, such as the UK, have really embraced palliative care on any scale, and even there it could be strengthened. So something really must be done. But what?
Whatever is done, there is a need for co-ordination and, ideally, integration. Rifat Atun, from Imperial College, provided an overview of cancer plans in Europe, noting how many countries have yet to put anything in place while others are still quite limited. Inevitably, given that many of the authors of the plans were in the audience, his sparked considerable debate, as people claimed that there was more written between the lines! Yet that surely misses the point. There is little point in having a plan if you need inside information to understand it.
We talk of a war against cancer but we forget that, in any war, if the forces at your disposal are fragmented then at best you lose the war and at worst you shoot yourself. “Friendly fire” is a perennial risk when some of your allies have complex and potent equipment that they don’t fully understand how to use. Yet, in some countries, politicians seem determined to make things worse, fragmenting systems further in their continuing ideological pursuit of “patient choice”.
It is far too easy to overlook the role of the patient. We were extremely fortunate that Lynn Faulds Wood, president of the European Cancer Patients Coalition, and herself a survivor of colo-rectal cancer, agreed both to contribute to our book and speak at the conference. She reminded us that a diagnosis of cancer is the beginning of a long and complex journey. Our role, as researchers and practitioners, is to ensure that the patient has a map, signposts, pathways along which to travel and places to rest.
There is still a great deal to be done in cancer prevention. The past few years have seen enormous progress against tobacco, with increasing numbers of countries banning smoking in public places. Yet many of these bans still have exceptions that will have to be tightened in the future and some countries have yet to do anything. Worryingly, the tobacco companies are working hard to subvert the bans. Their worry is that, given most smokers do want to quit, they will use the opportunities offered by the bans to wean themselves off their addiction to nicotine. The industry needs to find ways of ensuring that people remain addicted. It is doing this in several ways. First, it is campaigning to legalise sales of snus, a form of oral tobacco, across Europe. It is currently sold only in Sweden and Norway. As we show in a recent paper, the industry’s claims for its effectiveness as an aid to quitting are without foundation. Second, it is producing mini-cigarettes, so that smokers can pop out for a few minutes and get a quick nicotine fix without having to smoke a whole cigarette. At the same time, other companies are producing electronic devices that extract the nicotine from tobacco without producing smoke (something the tobacco industry is less keen on because it clearly highlights the role of nicotine as an addictive drug). During the conference a Dutch court ruled that the last of these products, the electronic device, could lawfully be regulated as a drug. This is an extremely important decision as it now opens the way for regulating all nicotine products sold in Europe just like any other pharmaceutical product.
Screening is a key element in secondary prevention. Witold Zatonski, from Warsaw, compared the highly effective, population-based, and carefully managed Finnish cervical cancer screening programme with the much less effective, opportunistic, and essentially unmanaged German model. Finland has brought deaths from cervical cancer down to a very low level while in Germany the death rate remains about twice as high as in Finland. Yet while a typical Finnish woman will have 7 cervical smears in her lifetime, a typical German woman will have 50. Yes, five zero! The explanation? Hardly a surprise – German doctors are paid for each smear taken, while the insurance funds do almost nothing to promote evidence-based care. Clearly, many countries still have a long way to go.
Cancer control is critically dependent on information. Cancer registers have contributed enormously to our knowledge of what works and what doesn’t. Yet too many EU Member States have failed to put in place effective registration systems. What is worse, a few that once had excellent registers are damaging them irreparably> one of the worst examples is Estonia, where the Parliament enacted legislation based on an early version of the EU Directive on Data Protection, before it had incorporated protection for research and health monitoring. With my colleague Mati Rahu, we will be describing the worrying consequences of the Estonian legislation in a paper to be published soon in the International Journal of Epidemiology.
What is most remarkable is that governments that seem keen to use concerns about data protection to impede the war against cancer while they are equally prepared to abandon any pretence at safeguarding privacy in the “war against terror”. Every time we travel to the USA, our governments send over 50 items of information to the US authorities and while this doesn’t include religion it does include whether we have ordered a halal or a kosher meal! Our movements are tracked constantly from our mobile phone records and, in case this is not enough, the UK has more closed circuit televisions than the rest of the EU combined, with one for every 14 citizens at the last count. Many are now linked to facial recognition software. The UK also allows almost all public authorities to bug phones and, as we have seen recently, the police seen to have no reservations about bugging the conversations of members of parliament. In these circumstances, it is difficult to avoid the conclusion that our political leaders might usefully consider their priorities.
The successes so far in the war against cancer have arisen primarily from research. Innovative treatments have made cancer at some sites, such as the testes, as well as some childhood leukaemias, curable in almost all cases. Yet there is still a great deal to be done, especially in areas such as health services research and the psychological aspects of cancer. Too many countries have failed to invest in the research that is needed to determine what models of care are most appropriate for their circumstances, or to put in place the infrastructure that allow as many of their citizens as possible to contribute to new forms of treatment by participating in clinical trials. As Richard Sullivan, from LSE, reminded us, “Research is a necessity, not a luxury”.

31st January - Moscow. I was joined by my colleague Anna Gilmore for the first international advisory board meeting of the new Russian Anti-Tobacco Advocacy Campaign. This initiative, funded by the Bloomberg Initiative, brings together a broad ranging coalition of non-governmental organisations to tackle the scourge of smoking related diseases in Russia. It is no secret that the international tobacco companies have invested vast resources in penetrating the Russian market, something that we have documented in papers previously. More recently, in another paper, we showed how the prevalence of smoking among Russian women, once low, has doubled in 15 years. Smoking already exacts an enormous toll of premature death in Russia and the recent trends among women mean that this will increase further in the future.
One of the orginal goals of the coalition was to get Russia to ratify the Framework Convention on Tobacco Control. That, at least, now seems to be happening, with the Cabinet sending the relevant legislation to the State Duma, where the majority leader has indicated that it will be supported (see story in Moscow News). Yet that is only the start.
The challenges are enormous but we were greatly reassured by the results of a new poll, conducted in a representative sample across Russia, showing a very high level of support for effective restrictions on smoking and, in particular, easy access to cheap cigarettes. The overwhelming majority believed that not enough was being done. So, there is much to do but considerable grounds for optimism.

8th January 2008 The new year started controversially. With my colleague Ellen Nolte we have been working for some time on the concept of avoidable mortality – identifying deaths that should not occur if health systems are working well. We all know that the US health care system is not working, but how bad is it? In a paper published in Health Affairs, we calculated the death rate from these causes in 19 high income countries, looking at how they had changed between the late 1990s and the early years of the 21st century. Most countries did well, with falls in death rates of about 17%. There was, however, one not entirely unexpected exception – the USA. It had improved hardly at all, going from near the bottom of the list to the very bottom. Many of the reasons are obvious:
a) the lack of universal coverage,. There is now a wealth of evidence that people who are without coverage delay seeking timely care and as a result are sicker when they do make it, often quite inappropriately to Emergency Rooms. There is also a lot of evidence that people with insurance face sever barriers to care because of the many obstacles put in their way by their payers.
b) a fragmented system, with high tech specialist care prioritised over family medicine. Barbara Starfield from Hopkins has been showing the problems this creates for the US for years
c) cost of drugs - the Commonwealth Fund has shown how US citizens are much less likely than those in other countries to fill prescriptions. One factor is the complexity of some pharmaceutical benefit plans such as Medicare. Another is the very much higher cost of drugs in the US than elsewhere because the US government is unwilling to impose price controls like almost everyone else does.
d) the sheer cost of getting care because of the inefficiency of the system. Multiple payers, high profits by payers and providers, the cost of malpractice insurance etc. all combine to make care far more expensive than in Europe, meaning that in a system where there are no guarantees of coverage, people cannot afford care.
Unsurprisingly, our findings revealed markedly differing views (with intensive discussions on the bulletin boards). Many people felt that our findings confirmed their own experiences. Given their comments, Michael Moore could make a sequence of sequels to his film Sicko. However, others totally rejected our views, questioning our motives (more anti-Americanism from those awful Europeans…).
The experience of reading the blogs and online comments was fascinating but extremely depressing, as we read once again of the many stories of individuals who have been unable to get timely and effective care but also we saw the total inability of a significant number of people who are totally unable to see that, for many people, the American dream is really a nightmare.

It’s back. After a ridiculously long break I’ve finally managed to regain the enthusiasm to relaunch my blog. It’s not that I haven’t been doing anything the past three months. Quite the contrary, as the brief round up below will show. The real problem is that I’ve been doing too much – with trips every week between October and Christmas, two doctoral students finishing their theses, lots of papers to write, and a ludicrously large number of books to finish. I normally write these entries on planes coming back from wherever I have been – for the past few months that time was used entirely for writing other things. What follows is a brief summary of events since mid-October.

15th October – Copenhagen. We had the second team meeting of our project on preventing obesity in Europe – EURO-PREVOB. This brings together partners from across Europe, including not just EU countries but also Turkey and Bosnia. The goal is to understand better how policies being pursued in Europe either help or hinder the fight against obesity. We all know that the decisions that people make when they choose how much and what they eat and how much they exercise are highly constrained. Governments can make a real difference, through policies in areas such as urban planning, agriculture, education, and transport. The challenge is how to assess these policies as a prelude to changing them. This is not easy. A report that would be published a few days later, by the UK Government’s Foresight Programme sets out the tasks ahead. This contains a diagrammatic representation of the pathways that lead to diet and physical activity. Readers may see some similarity with a plate of spaghetti! It has been criticised, for example by Andrew Jack (the FT journalist) writing in the Lancet as being over complicated. Politicians want simple solutions he writes. Yet the reality is complicated and maybe we need to tell them this before they launch yet another simplistic (and usually unworkable) policy based on an idea they had in the shower this morning.

26th October- Valencia. I was giving a plenary speech at the annual conference of the Association of Schools of Public Health in the European Region (ASPHER). In my speech I was asking the question “What are governments for?”. It is something I have talked about before, and have written about it in a piece for the Australian Medical Journal linked to the forthcoming Oxford Health Alliance meeting in Sydney. Essentially, I look at the differing perspectives on what governments should do. There is a minimalist view, set out in the pages of the Economist and the Wall Street Journal, that they should simply defend the borders of the state (from invasion and migrants) and promote the prosperity of its people (well some of them – I suspect no-one really believes any more in the trickle down effect of wealth distribution). In all other things they argue that the government should “get off the backs of the people”, cutting red tape and minimising legislation. Yet there are always some exceptions. They do want legislation that protects their property, be it intellectual (as in the cases of the entertainment and pharmaceutical industries), capital (as when companies invest in unstable countries abroad), and their safety (calling upon the armed forces to rescue them when they find themselves caught up in a coup). They want the state to cut taxes, especially on the rich, but what taxes are collected they want to see spent on subsidies for the basic research that gives them their intellectual property, or the infrastructure that enables them to operate. This leads to a paradox. Governments do intervene to save lives. After the events of September 11th “the world changed” . I don’t need to remind anyone of how the US government spun into action, leading to outcomes as diverse as the Patriot Act and the invasion of Iraq, a country that had nothing to do with what happened that day in September. Yet the response to another human disaster, Hurricane Katrina, was lamentable and successive governments have failed consistently to do anything about gun control, even though effective action might save the equivalent of 13 September 11th every single year. Our role in public health is to flag up the contradictions and hold politicians to account for their inconsistency.

2nd November – Rotterdam. The first project meeting for our new study, DYNAMO-HIA, to develop a dynamic model that can inform health impact assessment in the EU. Led by Johan Mackenbach, the task is to create a model that will allow us to predict the likely health effects of policies to ban smoking in public places, to increase the cost of alcohol or limit sales outlet, or to change diet. We are only at the beginning but it is already clear that the final result will be of great value to policy makers.

3rd November – Washington. This was my first time at the American Public Health Association. It exemplifies the super-size conference, with several thousand delegates, and is so large that only a few cities can host it. I was speaking at a session entitled “International challenges for Public Health, Policy and Politics”. The choice of sessions was enormous. Unsurprisingly, the overwhelming majority dealt with domestic US issues. The US health system certainly has no shortage of problems. Some of the most interesting ones I got to looked at the prospect for reform of the US health system. There are now several attempts by individual states to introduce universal coverage, typically involving mandates for employers to provide coverage, with other provisions for the self-employed and unemployed. However, when one hears the details, it is clear that they will, at best, be only a very partial solution. These sessions were profoundly depressing because it really does seem that the reform mountain is too steep. There are too many powerful vested interests, both providers and payers, who have an interest in keeping the system the way it is.

14th November – Seoul. After a few days back in London it was off to the Far East. First stop was in Seoul, to speak at a conference celebrating 30 years of the Korean national insurance system. Note to self – next time make sure I check what hotel you are in and buy a quad band phone so that, if I forget, you can phone someone! I was with my fellow research directors from the Observatory, Elias Mossialos, Reinhard Busse, and Richard Saltman. The Korean health insurance system is a real success story. I knew something about it, having previously examined a PhD on the policy processes involved in its creation and expansion, but learned a lot more.

17th November – Taipei. Back to Taipei for my annual visit to the Global Health Leaders Conference. Each year the Taiwanese bring together a fascinating mix of speakers to look at a small number of key issues. I was speaking in the stream on health care quality, presenting the findings of our recent study on quality assurance strategies across the EU. Our book, which contains detailed descriptions of the very mixed activities in all 27 Member States, will be published in mid 2008.

22nd November – Munich. Participating in a meeting of the IMAGE project (Implementation of a European Guideline and Training Standards for Diabetes Prevention). The project pulls together experts on diabetes (and a few others such as me) from across Europe to develop European practice-oriented guidelines for primary prevention of type 2 diabetes, supported by a curriculum for training people who can engage in prevention, as well as development of European standards to monitor the incidence and prevalence of type 2 diabetes and its known risk factors. A great deal has already been done but much more remains to be done.

29th November – Helsinki. The director of the Finnish Public Health Institute (KTL), Pekka Puska, had invited a group of us (3 Finnish academics and 3 foreigners – myself, Michael Marmot, and Daan Kromhout) to conduct an independent evaluation of the Institute’s work in Chronic Disease Prevention and Health Promotion. KTL is a remarkable institution – a superb example of what a national public health institution should be. KTL’s research output is well known to be world class but, as importantly, it maintains an invaluable research infrastructure in Finland, in the form of cohorts, registers, and biobanks. This, along with its extremely capable workforce, has allowed Finland to punch well above its weight in public health research.

6th December – New York. I was in town for a meeting of the Open Society Institute’s Global Health Advisory Committee. This committee brings together senior people with backgrounds in law and health, but all with a commitment t human rights. The debates are always fascinating, often juxtaposing the individual ethical perspective of the lawyers with the collective perspective of the public health professionals. The task is to balance autonomy with the collective good. Many things to discuss but the most interesting, if depressing, was on the situation in Burma, where the authorities had recently suppressed the protest movement led by the monks, with appalling violence. We were privileged to hear first hand from people with first hand knowledge of the situation and to have a preview of a major report on the situation there.

10th December – Brussels. Steering committee of the European Observatory. In between all the travel I have been editing a series of books, one of which, on cancer in Europe, had just gone to production. This was a time to reflect on what we had achieved and plan for the next cycle – hopefully a little quieter than the last one!

18th December – Rome. The final trip of the year. A EU ministerial meeting on Health in All Policies organised by the Italian government. My task was to participate in a discussion on the relationship between health and economic growth, drawing on our earlier work for the European Commission.

So that brings me to the end of 2007 – a completely crazy year. The next entry will be in 2008, and I’m already behind with that, but it will have to wait for my next flight (tomorrow).

Helsinki, 11-13th October
… for the Annual Conference of the European Public Health Association. An especially busy few days, with a plenary speech to give, as well as three shorter presentations and a workshop to organise.
The presentations were on topics I have spoken about many times before – the mortality crisis in the former Soviet Union, the health of the Roma people, and the relationship between health and economic development.
The workshop was something I had agreed to organise in my role as a member of WHO’s European Advisory Committee on Health Research. In November 2008 health ministers from around the world will converge on Bamako, in Mali, to discuss the state of health research world wide. The 2008 Global Ministerial Forum on Research for Health is a follow up to the 2004 conference held in Mexico. We wanted to make sure that, in this global discussion, Europe was not overlooked, both in terms of its interests and its potential contribution to the global health research agenda.
To my surprise, even though it meant missing out on lunch, about 50 people turned up and engaged in a lively and highly productive discussion. The key messages, which will appear later in a paper, were as follows.
First, we need to make sure that governments live up to the commitments they made in Mexico. There, they agreed:
* to commit to fund the necessary health research to ensure vibrant health systems and reduce inequity and social injustice,
* to establish and implement national health research policies,
* to promote activities to strengthen national health research systems, including the creation of informed decision makers, priority setting, research management, monitoring performance, adopting standards and regulations for high quality research and its ethical oversight, and ensuring community, nongovernmental organization, and patient participation in research governance, and
* to establish sustainable programmes to support evidence-based public health and health care delivery systems, and evidence-based health related policies.
It will be important to document what Europe’s governments have actually done in the intervening four years. The overwhelming consensus of those present was “not much”. Indeed, there was a widespread feeling that no new developments could be attributed directly to the Mexico meeting.
Second, while accepting the importance of issues such as HIV, tuberculosis, malaria, and tobacco control, it was felt that these will be identified by every region in the world. Were there any specific issues that Europe would like to see in a global health research agenda? Three issues emerged: aging, migration, and alcohol.
Third, what can Europe contribute to the rest of the world? Here we identified expertise on the epidemiology and health system response to complex non-communicable diseases. These are rapidly growing in importance everywhere but often receive far too little attention.
The title I was given for my plenary was “The future of public health in a unified Europe”. I took the liberty of adding a question mark. Europe (or at least some parts of it) is now clearly united. Ten former communist countries, divided from the rest of Europe for 45 years by the Iron Curtain, are now part of the European Union. Yet it takes more to unite a continent than to pull down a wall.
Europe’s population is changing. Most obviously, it is aging and, as a consequence, needs more young people to maintain its workforce. With birth rates at a record low, this can only occur through migration. For the past half century, western Europe has been based on a particular social model, with consensus on the need for the rich to support the poor, the young to support the old, and the well to support the ill. This is very different in the USA. One obvious reason is that rich white people have often been reluctant to pay for poor black people, something that was all too apparent in the images of the aftermath of Hurricane Katrina in New Orleans. As Europe becomes more ethnically diverse, will it place strains on our commitment to solidarity? The newspapers I read on the flight to Helsinki certainly did nothing to allay my concers (see picture).
Then, how will our children respond to the much greater numbers of older people, especially when they realise that we have been borrowing from them for decades, through unfunded pension schemes and ill-thought out public private partnerships, such as the build today, pay (many times over) tomorrow UK Private Finance Initiative. In my talk, which will also be published in due course, I argued that we need to think about these issues now, because the alternative of a fractured, unforgiving society, where everyone must fend for themselves, is not a world that any of us want to live in.

Washington, 7-8 October
I was in Washington for the annual meeting of the Institute of Medicine, to which I was (somewhat surprisingly to say the least) elected last year, along with my colleague Anne Mills (as there are only 84 foreign (non-US) members, we felt it was quite a nice surprise – and possibly a unique one- to have two elected from the same institution in a single year).
It was a rather imposing occasion, held at the National Academy of Sciences building just beside the State Department. The theme of the day was “Evidence-based medicine and the changing nature of health care.” It was at the same time interesting and depressing. Interesting, in that there were, as one would expect, some superb presentations. Depressing, in that so little seems to have changed in the US health system – at least in tackling some of the fundamental issues around quality of care - in the past two decades.
For me, the highlight was a paper by Elliott Fisher, from Dartmouth Medical School. You can listen to it online and download the presentation on the IoM site. The key message was that there are still enormous geographical differences in per capita Medicare expenditure. What was most interesting was the comparison between high and low cost areas. Rates of clearly effective interventions (e.g. reperfusion within 12 hours and aspirin on admission with a myocardial infarct or pneumococcal immunisation) and of interventions where patients can decide whether they want treatment, after balancing risks and benefits (e.g. hip replacement and CABG) were essentially the same in both areas. What differed was the process of care, with those in the high cost areas having more inpatient days, more visits to specialists, and more investigations. Importantly, there were few differences in outcome and, in all cases, where they existed, outcomes were better in the low cost areas. What explained the difference? One major factor was the ratio of specialists to primary care providers, a finding that was unsurprising in the light of Barbara Starfield’s excellent work over many years. Over-specialisation has profound implications for the US health system. Any solution will be difficult, but I was taken by Elliott’s observation that if 30% of the medical workforce in the US was to move to Africa it would improve the health of the populations in both continents!
While I was there I was greatly privileged to meet this year’s recipient of the Gates Award for Global Health, Mechai Viravaidya, the founder of the Thai Population and Community Development Association. The PCDA started out as an organisation providing family planning services to rural communities throughout Thailand that were not covered by government programmes. It worked through a network of village-based volunteers, with a strong emphasis on enabling women to take control of their own lives. When Thailand was confronted with the AIDS epidemic, it shifted gear. Mechai and his colleagues were the driving force behind a remarkable HIV prevention programme that is credited with much of the responsibility for an over seven-fold reduction in new infections between 1991 and 2003. Subsequently, it has expanded even further, into primary health care, water supply and sanitation, income-generation, environmental conservation, support for small-scale rural enterprises, and gender equality.
Listening to Mechai’s acceptance speech was one of those amazing occasions that will stay with me for ever. He took us on a remarkable journey, describing how the organisation had responded to emerging challenges. This is someone for whom there are no problems, only solutions. You felt that if anyone could sell snow to Eskimos, he could! He described how he had used humour to break down prejudices about sex, and in particular how he had tackled an unwillingness to use condoms. Indeed, in Thailand he is now often referred to as Mr Condom! He handed out T-shirts showing multiple sexual activities, each stating whether a condom was needed or not. He told us how his team worked to support young girls in rural areas who were being lured into the sex industry. And he told us how they had supported small scale enterprises so that villages could become economically self-sufficient, with benefits for health and education.
This was a truly humbling occasion – a quite remarkable man and a very well deserved recipient of this prestigious award.

Six years ago, Elias Mossialos, Rita Baeten and I were asked by the Belgian government to prepare a book on the consequences of European law for health services, as part of their preparations for their EU presidency. At that time many governments remained in a state of denial on this issue. They had signed the Maastricht Treaty, which made clear that health services were a matter for member states and not the EU. Yet they forgot that all those things that a health care system needs to function, from drugs to medical technology to health professionals, were subject to EU law. For example, for over 30 years, health professionals had enjoyed the right to move freely within the EU. Patients could also receive treatment abroad, should they become unexpectedly ill, safe in the knowledge that their health care payer at home would cover the bill. It was also possible for patients to go abroad to get treatment for an existing disease but their insurer had to give permission in advance, or so it was thought. Anyway, these things were at the margin. Very few health professionals did move from one country to another, save for a few traditional flows, many of which long predated the EU, such as Irish doctors moving to England. The number of people falling ill abroad was small and anyway most claimed on their travel insurance. It was hardly surprising that no-one seemed too fussed.
Of course, in 1998 it all changed. Two citizens of Luxembourg travelled abroad, in one case to obtain spectacles from Belgium, in the other to get orthodontic treatment for his daughter in Germany. When they returned, they presented their bills to their insurer, who refused to pay. A long time later, it was forced to by the European Court of Justice.
These rulings sent shockwaves through the corridors of health ministries. Spectacles and dental treatment were not a problem, but where was this leading to? Yet in many capitals, the shockwaves rapidly subsided. Ministries reassured themselves that the Court’s rulings did not apply to national health services, or to hospitals, or indeed beyond the precise circumstances of the cases. In contrast, a growing number of people, often with remarkably unusual conditions, spread out across Europe seeking to test the limits of the new legal situation. Progressively, the right to obtain care abroad was expanded, and it became clear that many of the safeguards that governments thought they had in place were not as safe as they thought.
At the same time, a few governments were waking up to the implications of what had, until then, been a rather obscure legal instrument, the Working Time Directive. This limited the hours that people could work each week, but it was widely believed that it did not apply to medical staff who were on call but not actually working. Once again, they were wrong. The consequences are profound and even now poorly understood by many people responsible for the delivery of health care. Small hospitals, with a few medical staff on a rotation, became unviable. The established system of medical training needed radical revision.
Back then, we actually exceeded our brief for the Belgian government, producing one authored and one edited book. We now realise just how important the two books were. While I am still not convinced that many people, except for the small group of Euro-policy wonks, actually read them from cover to cover, the fact that it was possible to write two entire books on a subject that many people had previously regarded as a non-issue did seem to make an impression.
Yet six years is a long time (in fact the books appeared in 2002) and a trickle of health-related cases before the European Court has turned into, if not a torrent, at least a respectable stream. Consequently, again with support from the Belgian government, a new book is on the way. This time it is edited by Elias and Rita, along with Tamara Hervey and Govin Permanend. My role is limited to co-authoring two chapters (although today I seem to have acquired a third!).
Today we (the editors, authors, and a few policy experts whose job is to make sure we are grounded in reality) were in Brussels to discuss our draft chapters. Readers will be familiar with the concept of authors’ workshops, which we use with all the Euroepan Observatory books.
So what has changed in six years? The law of course. The European Court has ruled on a substantial number of cases hat have variously clarified or obscured the situation. However, it is beyond doubt that the legal situation is now very different.
Awareness of its importance has also changed. Now, no-one who is at all informed maintains that EU law is irrelevant to health care (but see later). In the intervening years, governments have established a high level reflection group to explore the nature of its implications. An attempt to treat health care like any other service, in a general directive on services, was roundly defeated. Yet while there is now an acceptance that health care is special, it has been extremely difficult to square the circle of delivering socially inclusive, evidence-based care, in an internal market.
Another change is the number of academics working in this field. Six years ago, there were only a handful. Now there are well-established teams of legal researchers specialising in EU health law in a number of universities, mostly in Belgium and The Netherlands, but also in, for example, Sheffield, directed by Tamara Hervey.
Yet some thinks have not changed. Surprisingly frequently, questions were raised about the conformity with EU law of developments in one country, England. There, a bewildering array of quasi-market mechanisms have been established, often shrouded in substantial legal uncertainty. From the time they were introduced, ministers have maintained that contracts between NHS purchasers and providers are contracts, but not ones that are legally enforceable. Outside the parallel universe in which many of their advisors inhabit, this is not a concept that is widely recognised. Furthermore, as new structures, such as Foundation Trusts, are created, the legal situation becomes ever less clear. Now this situation offers endless scope for debate on issues such as what is an undertaking or what is a service of general interest. And of course, nothing is more engaging for lawyers than endless debate (academic lawyers excepted of course!). Consequently, one question that came up several times was why none of the private health care providers active in England had challenged decisions under EU law. The only plausible solution was that, despite all its flaws, the pickings were so rich that no-one wanted to rock the boat. Whether this will continue if the flow of money slows remains to be seen.

In the nineteenth century the world was transformed by the industrial revolution. In the twentieth century it was the turn of the information revolution. The scale and pace of change is truly amazing. In the 1940s, Thomas Watson, the head of IBM, is reported to have forecast that the total world demand for computers would be at most five machines! Today, the vast majority of families in high income countries are connected to the internet.
These technological advances are being used for many purposes. Some are clearly beneficial. It is a great advantage to be able to check one’s bank balance or book an airline ticket whenever you want to. Yet some are more problematic. This week it was revealed that the US Department of Homeland Security has been accumulating comprehensive details of all travel undertaken by American citizens (and presumably others as well). The European Commission is planning a similar system. The United Kingdom, a country where urban areas are already almost entirely covered by surveillance cameras, is proposing to introduce a biometric identity card that will track every encounter that an individual has with an official agency, in the same way that loyalty cards allow supermarkets to monitor individual’s shopping habits. Data protection laws seem simply to be ignored.
Yet, while every move that we make in high income countries is being recorded by someone, in poor countries people are still born, live their often short lives, and die without anyone ever recording anything about them. Worldwide, only about 70 countries have any reasonable data on deaths of its adult citizens.

This will probably come as a surprise to many people, familiar with graphs and tables that purport to show life expectancy in countries such as Liberia or Sierra Leone. In fact, these data are simply guesses, albeit guesses that are informed by some scraps of evidence (or what some people would call “estimates”).
What has happened is that standard life tables have been created, showing what is thought to be the probability of death at different ages in countries exhibiting certain characteristics. Then, data on deaths in infancy and childhood are identified, typically from surveys, and are fed into the life tables to give an overall life expectancy. Obviously, this is critically dependent on us having a good understanding of the relationship between deaths in childhood and deaths in adulthood, which we now realise we don’t have. In other words, we really have no idea about what is happening to adult mortality in much of the world.
This week I was invited to Seattle to join a small group of people to discuss what might be done. The meeting was organised by Chris Murray, who has recently moved from Harvard to the University of Washington, where he has established the Institute for Health Metrics and Evaluation. We had convened within the framework of Grand Challenge 13, funded by the Bill and Melinda Gates Foundation. The challenge is to devise new ways of accurately measuring population health.
We spent the first day looking at the problem of simply capturing data on how many people have died. As Alan Lopez reminded us at the end of our discussions, the gaps in our knowledge are a “scandal of ignorance”. There is little doubt about where we need to be. All countries should have effective systems of vital registration. Yet for many this is still at best a distant prospect, especially those where establishing even the most basic governance functions seems as far away as ever. There are, however, possible intermediate steps, such as sample surveillance, where data are collected from a sample of locations, in the hope that they will be reasonably representative of the overall population. This is what is done in India and China. Then there are the indirect methods, based on data from surveys. Yet none of these are perfect and we still face many unanswered questions about the validity of the methods we are using. A problem in many parts of the world is that many people do not know what age they are. This can lead to what is called heaping, where reported ages are concentrated in numbers ending in 5 or 10. However I was fascinated to learn, although I suppose I should have realised, that in societies where astrological correlates of birth dates are important, people are much better informed. Ken Hill told me that the distribution of ages in the 1953 Chinese census is perfect.
Day two looked at the even more difficult problem of collecting data on cause of death. Here, a degree of realism is needed in what can be achieved. Even in countries with the best possible systems, there will always be considerable uncertainty about the main cause of death in older people who have multiple disorders. Yet it is clear that even here we can do better, in particular by understanding the principles that are used in different countries in assigning a single cause of death where several co-exist.
Where vital registration systems don’t exist, an alternative is to use a “verbal autopsy”, where surviving relatives are asked a series of structured questions about the deceased. Yet here too there are many methodological issues unresolved about how best to allocate a cause of death. Computerised systems are consistent but not always correct. Physicians inspecting the data are less consistent, but may be more often correct. One interesting possibility proposed by Chris Murray was the use of a computerised model that would take the reported signs and symptoms and, based on a validated data set from the same (or a similar) location, allocate a probability to different causes of death. If combined with clinical judgement (i.e. the physician is presented with the probabilities of different causes and, using any additional information available, decides on the most likely cause) this could be a valuable way forward. Clearly the increasing availability of hand held computers offers considerable potential. This would also overcome the problem seen in many existing sentinel surveillance sites of piles of paper forms lying uncoded long after the events they describe took place.
There are other opportunities too. It was pointed out that we are coming up to the next round of censuses in many countries, typically conducted every ten years. It would be possible to include a question asking whether anyone had died in a household in the past year or so and, where this had happened, to follow it up with survey teams applying a shortened verbal autopsy instrument.
Of course, none of this will happen unless the world community begins to take adult mortality seriously, something that it has so far singularly failed to do. What efforts exist have focused on child and maternal mortality. It was even suggested that these efforts have diverted attention away from adult mortality. The problem, as is so often the case, is that we are in a vicious cycle. The priority for international development is the need to reduce child and maternal mortality rates, because these are often the only figures we have on population health in many parts of the world. Yet because these are the priority, no-one (except the Gates Foundation) is willing to invest in the collection of data on anything else.
But maybe there are solutions to the problem of resources. As I came back through Heathrow the iris scanning machine, designed to let frequent travellers pass through immigration a little quicker, was yet again out of order (as it had been last week too). As I noted above, the British government is about to spend billions of pounds (the exact amounts are shrouded in spin and obfuscation, as usual) on a system of biometric identity cards that is doomed to failure (the full account of the failings are in an excellent account by a team at the London School of Economics). If only a fraction of the resources being devoted by the British and American governments could be diverted from the almost entirely pointless and futile attempts to track every move made by their citizens, then maybe we might at least be able to move away from a position where our fellow human beings can live and die without anyone ever recording it. What is more, the much simpler technology required is at least likely to work.

Over the past few years I’ve been working with Marc Suhrcke, from the WHO office in Venice and Lorenzo Rocco from the University of Padua to understand better the relationship between health and wealth. The Commission on Macroeconomics and Health showed how important health was for economic development in poor countries. We have subsequently shown conclusively how this is also true elsewhere. Specifically, in the European Union, South East Europe, and Eastern Europe and Central Asia, those in poor health are less likely to be working, and when they do they work shorter hours and they are less productive.
There are, however, many middle income countries where, although we may reasonably assume that this is so, we have no direct evidence. And we also know that policy-makers like to see local evidence before acting.
For this reason we were asked by colleagues at the World Bank whether we could apply our work to the countries of the Middle East and North Africa. This is a region where, so far, there has been remarkably little health research. The opportunity for us to present some preliminary work was at a meeting of the newly created Middle East and North Africa Health Policy Forum, a grouping of academics and policy makers from across the region. I was joined by my colleague Josep Figueras, who was talking about our experience in the European Observatory in translating evidence into policy.
The meeting was held in Cairo on 8-10th September so it was logical that we should start by looking at some Egyptian data. In fact, there are quite a few household surveys from countries in this region that are suitable for the sorts of analyses we have been doing. There is clearly enormous scope to make use of them.
The first task was to get some basic understanding of the health situation in the region, and in Egypt in particular, given that this is not somewhere I am especially familiar with. The available evidence reveals that Egypt has actually been very successful in improving health. Under-five-mortality has fallen by more than half in two decades and data from the most recent Demographic and Health Survey suggest it has fallen to 46 per 1,000. Male life expectancy has increased from 52.7 years in 1976 to 67.9 in 2003, while the corresponding figures for females are from 57.7 to 72.3. Looking to the future, Egypt has much in its favour. A falling birth rate means that there will be a substantially greater share of the population in the workforce. Fewer children also means that there will be more resources available for their education, a clear priority for future investment. Yet there are challenges. Using a model we have applied elsewhere we were able to show that if adult mortality could be reduced by 3% per year then, by 2030, Egypt’s GDP would be about $8,500 per capita, compared to $6,900 if it stayed as it is now, all else being equal. Unfortunately, even keeping it as it is now may be difficult. We looked at data on body mass among young children. Although there is still some evidence of malnutrition, what is really striking is the very high level of obesity, with almost 14% of under threes overweight in 2000, compared to less than 3% in many otherwise comparable countries.
The health situation in this region is clearly very different from that in eastern Europe, where I do most of my work. However the problems are equally challenging.

This blog has been rather neglected over the summer. Colleagues sometimes ask me how I find the time to write it. Sometimes I wonder myself! Usually it is on planes back from wherever I’ve been but the past six weeks have been so hectic trying to clear the backlog of unfinished papers and books. I even discovered a new condition – shoulder injury from over use of the mouse pad on a laptop!
I did, however, take one short break from writing in August to teach on our new summer school. For many years the Observatory ran a very successful summer school in Dubrovnik, Croatia. It was, however, a huge amount of work to organise it and as the tourists returned to Croatia after stability returned to the region, it became impossibly difficult to sort out the flights and accommodation.
There was, however, an enormous demand to recommence the summer school and this year we decided to do so, moving across the Adriatic to Venice. Our colleagues in the Veneto region had identified a superb study centre, San Servolo, a short journey on the water bus from Saint Marc’s Square.
About 40 participants from across Europe, and even a few from beyond, came together to examine one of the most pressing issues facing health systems today - the people who work in them. The problem is simple. We never seem to have the right people in the right place at the right time. The solutions are much more elusive.
The first difficulty is knowing who is in the health workforce. Statistics are plagued by problems of comparability, especially where health systems are fragmented. There are always interface problems, especially where health and social care intersect. And the words don’t even mean the same things. Unfortunately, a nurse trained in one country may have a very different set of skills from one trained in another.
A second is how to keep pace with the changing nature of health care. Patterns of disease are changing. Complex chronic diseases are now by far the leading contributors to the overall burden of disease in industrialised countries. We need people with new skills and perspectives, who can work in multi-disciplinary teams and who can work in partnership with patients. In some countries we need to accept that doctors are not always the best people to manage chronic diseases. There is now compelling evidence that nurse-run clinics for conditions such as diabetes and asthma get better results.
A third is the increased movement of people across the globe. This is an especially acute problem in the European Union’s new member states, where wages are much lower than in the west.
There are no easy solutions. However, it is good to be able to take some time out, in a place that is so conducive to thought and contemplation, to learn from each other.
The next task is to decide what the subject will be next year!

It is estimated that 230 million people worldwide have diabetes. Some cope well with this disease, managing to live a relatively normal life. Many don’t. In large parts of the world the onset of insulin dependent diabetes is a death sentence. John Yudkin and David Beran, at the International Insulin Foundation, have done a tremendous job in raising awareness of the many people in developing countries for whom a diagnosis of insulin-dependent is a sentence of death. For these people, mostly young children, the situation is unchanged from what it was before Banting, Best and their colleagues discovered insulin in 1921. Steadily, over a period of about 18 months, they waste away and eventually die. Yet even in wealthy countries many people with diabetes face almost insurmountable problems. Death rates from diabetes among young people in the USA, with its fragmented health system and its failure to provide more than the most basic care to 40 million people, are many times higher than in the much better integrated European countries. And things do not always get better. We have previously shown how death rates from diabetes have increased in most former Soviet countries (with detailed studies in Ukraine and Kyrgyzstan) as once functioning (albeit at a basic level) systems fell apart.
For these reasons we have increasingly seen diabetes as a lens through which we can observe the functioning of health systems. In essence, if health systems are working well, then people with diabetes survive; if the systems fail, then they die.
This was the subject of a talk I gave in Oxford on the 28th June. I was speaking at one of the now famous seminars organised annually at Exeter College by David Matthews. I began by looking at the enormous variations in outcomes of diabetes among industrialised countries, drawing on our earlier work relating mortality to the incidence of diabetes, before describing the reality for people with diabetes a variety of dysfunctional health systems in the former Soviet Union. The problem we face is that you need to get a lot of things right if people with diabetes are to receive effective care. You need trained staff who actually understand diabetes, reliable supplies of drugs (and not only insulin) as well as all the equipment to administer insulin and to monitor control, systems of referral when complications arise, and social support so that people with diabetes are not thrown on the scrap heap. All of this is discussed in detail in a new analysis of the management of chronic diseases led by Soji Adeyi at the World Bank, to which we were privileged to contribute.
However, as I mentioned above, things are not so good even where resources are plentiful. As the picture shows, death rates vary enormously within the United States. Unsurprisingly, the situation is much worse for African Americans, although the racial gap in outcomes varies considerably among states, with some surprising results. It is relatively narrow in states such as Maryland and Mississippi but wide in Tennessee and Louisiana.
Of course, I was talking to an audience of experts in diabetes. Do these findings have a wider relevance? Yes, they do. I also showed the close correlation, among US states, between deaths from diabetes and those from overall deaths that could be avoided if there was timely and effective care, a concept that my colleague Ellen Nolte and I have been revisiting over recent years (see our book for more details). However, looking beyond this, it must surely now be apparent to those trying to scale up treatment of HIV/AIDS that they face exactly the same challenges as those trying to put in place effective care for diabetes. The two disorders are both complex chronic disorders. They both need certain basic drugs – insulin/ anti-retrovirals. But they both need a lot more, in terms of an integrated system to deliver care. Furthermore, both diseases exemplify the way in which the traditional divide between communicable and non-communicable diseases is breaking down. People with diabetes develop long term infectious complications, such as a higher risk of tuberculosis or infected foot ulcers. People with AIDS are increasingly developing vascular diseases because of the atherogenic effects of anti-retrovirals. So yes, diabetes is a lens through which we can view, and understand, the health system.
The good thing about speaking at seminars such as this is the opportunity it gives to hear other people. The other speakers were, without exception, superb and I now know a lot more about the mode of action, and thus the effects, both positive and negative, of the new oral hypoglycaemic drugs. I also know probably more than I need to about erectile dysfunction, thanks to some graphic slides by Jonathan Levy! However two rather different presentations stood out from the rest. The first was by Helen Lloyd, a former BBC producer and now oral historian. In a Wellcome Trust funded project with David Matthews, she had interviewed 50 people diagnosed with diabetes between 1927 and 1997. Their stories can be read, and heard in their own words, on a superb project web site. Those diagnosed before the creation of the NHS faced incredible obstacles, with their families scraping together the money for insulin. So many of the stories from the 1920s-1940s echoed those I had heard in the former Soviet Union. Several people described how, as children, they had been excluded from education. Even in the 1980s, people in the UK with diabetes were being discriminated against, excluded from many jobs that they could perfectly easily have done, recalling contemporary practice in the former Soviet Union where children with diabetes are educated separately and, as soon as they reach adulthood, are labelled as disabled and excluded from the workforce. Anyone interested in the human aspects of health systems really should visit this web site. The project is now in a second phase, interviewing those who cared for people with diabetes. We had a preview; the interview that struck me most was with Harry Keen, who described the realisation that insulin was not a panacea and long term treatment was associated with increased risks of cardiovascular and other diseases, an observation with much contemporary relevance given my earlier comments about the cardiovascular consequences of AIDS.
The other noteworthy presentation was by Sir Michael Hirst, former Chair of Diabetes UK and now vice-president of the International Diabetes Foundation. He described the struggle to get a United Nations Declaration on diabetes. Now of course a declaration about a disease is just that, no more and no less. Yet for those struggling to tackle this disease, these things are important and highly symbolic, not least because of the way in which diabetes and many other chronic diseases are often effectively ignored.
It is a story that I hope he will publish sometime. The heroes are the governments of Portugal and Ukraine. The villain was the British government. It is a story of intrigue, duplicity, and deceit. Fortunately, following the recent cabinet reshuffle, some of those involved are now on the back benches. However, it did have a happy ending as the other EU governments, mystified by the hostile position of the British, one by one moved from not understanding what it was all about to active support for the Declaration. This is a story that should be heard by anyone trying to get health on the international agenda in the face of apathy or worse (especially when it is from one’s own government) outright hostility.

The European Summit has reached a conclusion. We will have a Treaty, but not a Constitution. The European Union has become a “legal person”, even if it is still constrained by the governments of its member states. It will have a president who remains in post for two and a half years, instead of rotating every six months. And ten years from now it will have a sensible voting system for the Council of Ministers.
Yet there are many measures that have fallen by the wayside. Some are purely symbolic, such as the official recognition of the EU flag and anthem. Others are more serious, such as the watering down of the French proposal to strengthen the social dimension of the EU.
This was, as no-one can fail to notice, Tony Blair’s final European Summit. He came to power promising to place Britain at the heart of Europe. Has he succeeded? You can judge from my open letter to him:

Dear Mr Blair,
Now that you are moving on to the American lecture circuit, where your talents will doubtless be better appreciated, I want to thank you for the way you have taken forward our relationship with our European neighbours. Thank you for:

• Your opt out from the Schengen agreement, so that I can have all that extra time to think great thoughts as I queue to get through passport controls. Oh, and also because this has ensured continuing employment for those British immigration officers working at the Eurostar terminals in Brussels and Paris – you know, the ones who check your passport five metres after they have already been checked by the French and Belgian officials.
• Your opt out from the single currency, so that I can continue to contribute large sums of money to the terribly hard up banks each time I change money.
• Your opt out from European Union provisions on criminal justice, even though you agreed an extradition treaty with the USA that allows British citizens to be extradited without the US authorities even presenting a prima facie case against them (of course the reverse does not apply – it would be inconceivable for the USA to extradite one of their citizens here, and certainly not those who have unlawfully killed British soldiers in Iraq with so-called “friendly fire”)
• Your refusal to sign up to the Fundamental Charter of Rights, lest we should get ideas above our station and ask for basic rights such as freedom of speech (you never know, we may want to protest about something in Parliament Square without fear of arrest under your terrorism legislation).
• Your continued opposition to anything that would strengthen the European Union in the area of foreign affairs, lest it should ever challenge our British status as an arm of American foreign policy.

I hate to think where we would now be if you had decided that you really didn’t want to be part of Europe!

Back to South Africa… The final day of our course on health an human rights involved a series of extremely well designed site visits put together by the local OSI team. I joined the group going to Khayelitsha. This is a very large township on the outskirts of Cape Town, larger than many cities, but with many of its population still living in corrugated iron shacks, sharing a common water source. We began with a visit to an AIDS treatment centre, run joint by Médecins Sans Frontières and the Treatment Action Campaign. MSF is very well known globally but TAC may be less so. This was the organisation that spearheaded a legal campaign to force the South African government to make available prophylactic treatment for HIV positive expectant mothers. Their work encapsulates the case for linking lawyers and public health professionals to combine forces to work for health and human rights.
Needless to say, this was an incredibly inspiring visit. The team working in the centre combined idealism with realism and vision with pragmatism. Despite what others would see as insuperable odds, they had put in place a system that was delivering much needed anti-retrovirals to several thousand people. It had been a long struggle, in the face of long-standing denial by some senior South African politicians, supported by a range of individuals promoting the most bizarre ideas about the nature of AIDS and how to treat it. It was only because the authors of the South African constitution had included a legal right to health that it was possible to force the Health Ministry to make treatment available, yet another example of a health ministry that had lost sight of what should be it’s role in advancing the health of its people.
Our second visit, a short distance away, was to a rape crisis centre. Rape is all too common in Khayelitsha, as in many parts of South Africa. While an appalling act anywhere, its significance is even greater here because of the very high prevalence of HIV infection. The centre is staffed 24 hours a day, seven days a week and it provides all the essential services for the victim in a single building. A particular success was enlisting support of the local police, so that a dedicated detective is on hand to collect evidence and statements. The conviction rate remains low, but it is a start.
Then it was off to the University of Cape Town, where we met with Prof Solomon Benatar at the University of Cape Town. A remarkable man, he had been Chief Physician at Groote Schuur Hospital but combined this with an outstanding publishing career in bioethics and human rights. It was absolutely fascinating to listen to his account of the transition in South Africa but also a little depressing as he shared his vision of the future, one that unfortunately seems to be shared by many of my South African colleagues.
Our final visit was to IDASA, whose name recalls its origins as the Institute for a Democratic Alternative in South Africa. In particular, we learned about its Africa Budget Watch, which seeks to introduce a greater degree of transparency into government spending in the continent.
It was one of those days that was exhausting but inspiring, and grateful that there are so many people prepared to take on the really hard issues and make a difference.

The philosophy underpinning the NHS in England is one of patients exercising informed choice. To help them to do this, vast amounts of information are being placed on web sites. A recent example is a new NHS website proving outcomes of paediatric cardiac surgery. Intrigued by this development, I tried to think how it might help me if I was unfortunate to have had a child needing surgery. Not much, unfortunately. The most recent data relate to procedures undertaken in 2004/5, over two years ago. Such a delay is inevitable, given the need to wait until one year survival can be calculated and the data processed. However, in many centres both surgeons and techniques may have changed. Twenty of the procedures listed were undertaken fewer than twenty times in the entire country and even the most common procedure was undertaken an average of less than 28 times a year in each of the sixteen centres, so the numbers in any one centre will be very small and the observed differences are likely to be statistically insignificant due to chance variation. Furthermore, none of the figures are adjusted for risk, an important consideration as many of these children will have other problems. I am sure that those making these data available have the best of intentions but if, as is suggested, they are intended to help parents make choices, then some guidance from government ministers as to how precisely they are meant to do so would be helpful.

Last week I exchanged the warmth of a European summer for a South African winter. I spent most of the week in Cape Town, in my role as a member of the Global Health Advisory Committee of George Soros’ Open Society Initiative. The OSI public health programme, with which I have been involved since its inception, supports the needs of a range of vulnerable populations. One group consists of people who are dying. OSI has played an important role in supporting the development of palliative care in many parts of the world, to reduce the number of people who die in unnecessary pain. Another group consists of those who are in prison, which in many parts of the world is effectively a death sentence because of the harsh conditions and the high risk of infectious diseases such as tuberculosis. Others include a range of people on the margins of mainstream society, so often overlooked by other NGOs, such as sex workers and drug users. OSI has been at the forefront of international efforts to implement harm reduction policies, such as clean needle exchange and the use of methadone. Then there is a group with which I have been particularly involved, the Roma (or gypsy) population of central and eastern Europe, a group that has been subject to appalling persecution for centuries and, as we have shown most recently in Hungary, continues to have much worse health status than the majority population. Even now, in some of the European Union’s newest member states, they are subject to severe discrimination. However, the older member states should not be complacent, given the now notorious episode at Prague airport when British immigration officials, who were briefly posted there to pre-screen passengers to the UK, refused boarding to a Roma journalist while allowing a colleague, whose circumstances were otherwise identical, to board the plane. The officials had to be withdrawn soon after, in part because the entire episode was filmed.The training course in Cape Town was a joint venture between OSI’s Public Health, Justice, and Human Rights and Governance programmes. Our aim was to explore how we could collectively use the expertise and experience from the different programmes to make the world a better place. Armed with a workbook and a substantial resource pack, which contained all you could ever want to know about a range of international legal instruments, we worked through the opportunities offered by combining law and health to address the issues of the various populations with which we were concerned. This was interspersed with a series of excellent panels and presentations drawing in particular on the way in which NGOs in South Africa had addressed the many recent challenges that country has faced. My role was to act as a resource person for the discussions on minority rights, providing background information on the Roma population. I was accompanied by Willem Odendaal, from the Legal Assistance Centre in Namibia. Willem’s expertise relates to the San people (sometimes referred to as Bushmen), who live in Namibia, Botswana, and (in much smaller numbers) neighbouring countries. He and his colleagues have been doing a remarkable job, providing much needed support for San people trying to uphold their legal and constitutional rights. Although the Roma and the San are clearly different in many ways, it was also striking how much they have in common, or rather, the extent to which mainstream societies have treated them in the same way. Both groups are seriously disadvantaged. Their communities are poorly served by basic health and educational facilities (graphically described, for the Roma, by the recent report “Ambulance not on the way”). They face widespread discrimination and often suffer gravely at the hands of the police. They are seen as in some way separate from the state, often denied the necessary paperwork to access services. The plight of the San is especially severe, as they face pressure to move off traditional lands to make way for game parks and diamond mining, among other things. Like indigenous people everywhere, they have terrible health problems, in particular alcoholism and tuberculosis. Yet when they queue at health clinics, which often can only be reached after long journeys, the majority population walk straight to the front of the queue, as if the San people didn’t exist. Some time ago, with Judith Healy, I edited a book looking at how health systems meet (or more often don’t meet) the needs of the diverse groups within society. Among the indigenous populations we included, along with the Roma, Native Americans, First Nation Canadians, Australian Aborigines, and New Zealand Maoris. From what I now know, we should clearly have included the San.
I am extremely grateful to Willem for helping me, and the other participants on the course, to understand the challenges that the San continue to face and to my colleagues in OSI for bringing public health, legal and human rights people together in a way that allowed us to learn so much from each other.

The reason I was in Basel (see last blog) was to speak at the annual meeting of the Swiss Medical Association (SGIM). The title I was given by Verena Briner, the Association’s president, was “Does longer life mean better life and better life mean longer life?”. Of course this was an impossible question, so it was necessary to break it down into a number of constituent parts. The first question related to what is happening with longevity. Life expectancy has increased enormously in developed countries in the past century, even though retirement age has hardly changed. What can we expect in the future?
Essentially, there are two views. One is that there is no reason why life expectancy should not continue to increase. The other was that we are now, at least in the countries where people are now living longer, reaching a biological limit. I was able to draw, in particular, on an excellent review of the evidence by Jean-Marie Robine, who is one of the leading European experts in this field. In essence, it seems that the maximum age at death is not likely to increase dramatically in the future, with the oldest people dying at about 110. However, many of those people who, in the past, died much younger, are now living to quite old ages, so that overall life expectancy is increasing.
But if people are living longer, will they be sicker? Almost 30 years ago, Jim Fries, at Stanford, proposed the concept of “compression of morbidity”, whereby the factors that allowed populations to age, such as reductions in risk factors such as smoking throughout life, would mean that those surviving to old age would be healthier than in the past. There is now considerable evidence that this is happening. However, older people are accumulating more chronic disorders, such as diabetes, Parkinsons Disease, and arthritis. Fortunately, the availability of modern pharmaceuticals is allowing them to remain active and engaged with society.
But does this mean that they will cost society more for their health care. Apparently not. What does cost money is not being old but being close to death. Indeed, paradoxically, the cost of dying is often less at older ages because health professionals intervene less intensively.
So the challenge is how to age successfully. This is an issue that is being examined by my colleague Yvonne Doyle. Using imaginative analysis of British surveys, she is showing how important it is not only to minimise exposure to risk factors but also to remain engaged with society and, in particular, to retain self-confidence. Essentially, you need to believe in yourself as you get older. The crucial thing is that you should not write yourself off when you retire.
Clearly, this was a more optimistic message than many of the audience were used to and it was nice to have such a positive reception when I finished. However, I then received a tribute that has, in my experience, quite unique when, at the dinner afterwards, one of the speakers read a poem about my talk that he had written in the intervening few hours. I am extremely grateful to Dr Max Stäubli both for writing it and for his permission to reproduce it below. I haven’t attempted to translate if from the original German as it would ruin the rhyme. However, if readers want to pass it through Google Translate, I won’t stand in their way, but of course I certainly won’t guarantee whether it still means anything when it comes out the other end!

Heisst länger leben besser leben,
den Standard immer höher heben?
Dazu muss man statistisch denken,
das heisst, den Blick erst rückwärts lenken:
die letzten 170 Lenze
stieg an die mittlere Lebensgrenze
aufs Doppelte, kam `s nicht zur Panne
verfrüht schon in der Lebensspanne.
Doch gilt die Regel wiederum
nicht für das Altersmaximum,
denn dieses in der gleichen Zeit
wuchs nur um eine Kleinigkeit.
Daraus folgt klar die Konklusion,
Wunschdenken nur und Illusion
ist `s wenn man glauben will, es werde
der Mensch stets älter auf der Erde.

Auch hier ist `s besser, Mass zu halten,
den Alltag sinnvoll zu gestalten,
Verpflichtung weiterhin zu wagen,
dem Raucherlaster zu entsagen
und immer kreativ zu bleiben,
vernünftig einen Sport zu treiben,
so wird auch kürzer jene Zeit
der Drittpersonabhängigkeit.
Die Alten alten so gesünder
im Kreise der Urenkelkinder.

In Japan sind die Mehrfachkranken
viel seltener, was sie verdanken
der Soja- oder Tofuspeise,
das heisst, der Grundernährungsweise.
Und immer öfter lassen Leiden
beim Älterwerden sich vermeiden,
sowie entsprechende Beschwerden,
die Wohlbefindlichkeit gefährden.
Ist über 90, wer verstirbt,
Herr *Couchepin `s [Swiss minister of health affairs] Budget nicht verdirbt,
denn in dem Falle klar ergibt sich,
man macht nicht alles, was mit 70,
man noch zu investieren neigt,
wenn sich die gleiche Krankheit zeigt.

Ist auf der Pyramidenspitze
man angelangt, braucht es die Stütze
durch unsere Lieben zwecks Bewegung,
für Botengänge und Verpflegung,
dass letztere nicht nur einerlei,
jedoch gemischt bekömmlich sei.
Wer insgesamt sich so bemüht,
auch noch mit 95 blüht,
trägt bei zum Sozialprodukt,
indem man seine Papers druckt.
Und das gelingt, wenn nimmermüd`
man bleibt auch ein Vereinsmitglied,
pro Jahr sich einmal SGIM-versammelt,
damit der Estrich nicht vergammelt.

Max Stäubli, Basel, 2007

Public health is, first and foremost, about ensuring that the widest range of policies work in ways that promote, rather than damage, population health. One set of policies that is critically important is transport. A society that is dependent on the car is fundamentally unhealthy. Cars pump out toxic fumes and greenhouse gases into the atmosphere. They cause injuries, either by driving over pedestrians, or by conveying their occupants at high speed into solid objects. They convey us from door to door so that we need never walk, and thereby use up some of the calories in the food that we used our cars to collect. The most extreme examples are seen in some American cities, where ubiquitous drive-thru banks, fast food outlets, shops, and almost everything else means that you never need to get out of your car…. ever. Some medieval Europeans believed that the Mongol raiders who appeared at the walls of their cities each spring were half-man and half-horse as they never saw the raiders dismounted. Similarly, a visitor from Mars could easily assume that people from Alabama were born with four wheels instead of legs.
Yet, for many people, cars are essential. They allow people to meet together and overcome social isolation. They support economic development, through their production, sale, and what they enable us to do, such as being tourists. The challenge is to find a way to use the car when we need to but use alternatives where this is possible. Yet this only becomes possible if there is a functioning public health system.
Sadly, this is not the case in England. It is possible to get a reasonably priced train fare but only if you book weeks in advance and are willing to travel at a time that is extremely inconvenient. The privatised train companies use financial incentives to encourage their ticket collectors to recoup as many penalty charges as possible, using highly inventive approaches – did someone use the word scams – to extract money from helpless people who have been mystified by the complexity of the fare schedules. Deregulation of buses has left many rural areas without any meaningful links. And despite some recent progress in places like London, we are years away from achieving an integrated transport system. Take the trip to Heathrow. The Heathrow express train, at £29 for a return ticket (even more if you buy it on the train) is the most expensive journey per passenger kilometre in the world. In fact expressed this way it is even more expensive than flying Concorde to New York was before it was retired. If there are two of you, it is much cheaper to take a minicab.
Against this background, it was a wonderful experience to spend the week before last in Switzerland. I had meetings in Lausanne, Berne, Basel, and Geneva, so I packed in a lot of travel. The trains were punctual, comfortable, and unlike many British trains, there were enough seats for everyone. However even my high expectations were exceeded when I arrived in Basel.

This beautiful old city on the Rhine has a remarkable tram system. Nowhere do you need to wait more than a few minutes for a tram and the very clear maps at every stop make it simple to find your way around. When you book into a Basel hotel you get a free transfer with your confirmation and, as soon as you check in, you get a ticket for unlimited travel covering the duration of your stay.
Unfortunately, it couldn’t last. I had to come back to London where a single journey on the tube costs £4 (€6) if you haven’t previously bought one of the prepaid Oyster card. This is nothing other than a legalised process of fleecing tourists.
Clearly, if we want people in the UK to use public transport, we need to emply a few Swiss transport advisers to sort our creaking system out.

Much of my work involves trying to ensure that policies are based on the best possible evidence. This is often far from easy. From at least the early 1960s (and indeed, if we look carefully enough, even before that) that smoking causes lung cancer. We have even known for about 30 years that breathing other people’s smoke is dangerous. Yet it will only be on the 1st of July that smoking will be banned in public places in England. Long after their position became ridiculous, the cabinet, and in particular the then Health Secretary, Dr John Reid, held out against a comprehensive ban. His favoured alternative would be to exempt bars that did not sell food, precisely the places where the most disadvantaged people congregated. The fact that this was entirely incompatible with the government’s stated aim of reducing inequalities did not seem to worry him, but then this is a government that has never had any difficulty in pursuing more than one mutually contradictory policies at the same time.
But what about the government’s position on evidence to inform other policies. Everyone is, of course, familiar with the notorious statement that the Iraqi regime, under Saddam Hussein, could prepare and fire a weapon of mass destruction in 45 minutes. Unfortunately, no-one in our so-called “intelligence” service seems to have subjected this claim to the simple test of seeing whether it was actually possible, even in the best of circumstances where you did not have weapons inspectors crawling all over you. This is reminiscent of the concerns about the missile gap in the 1960s, when the western powers were alarmed about the large numbers of missiles being built by the USSR, forgetting that the missiles took over 24 hours to prepare for firing and there were only a handful of launchers.
However, the one that causes me most irritation, because I spend so much time at airports, is the rule that you can only take liquids through security of they are in containers of 100ml or less, and they must all fit inside a small plastic bag. At Heathrow Terminal 4 it is common to have 11 people standing outside security handing out plastic bags while the queues build up inside because there is no-one to staff the scanners. We have all seen the ludicrous consequences – in this blog I previously mentioned the Australian couple who had to throw away a container used to contain water when hiking – with a long plastic straw incorporated in it – even though it was empty. It was still a container of over 100mls! However, what surprisingly few people seem to realise is that the scientific basis for this policy is, how shall I put it, entirely non-existent. Now I realise that some people (in fact anyone with a basic knowledge of chemistry and some curiosity) has known this for a long time. Yet I guess, like me, they were afraid to say anything. After all, it is all too easy to be locked away as a suspected terrorist these days. However, I now feel able to speak out – simply because someone far more famous than me has done so. In last Sunday’s Observer newspaper, Professor Richard Dawkins was recounting his recent travels and, obviously frustrated by the hassle he was experiencing, listed the web site where you can read all about the junk science underpinning this policy. I encourage readers to look at his article but I’ll leave you to follow his links (his fame may keep him out of trouble – I can’t be so sure about mine!).
I confess, when this policy came in last summer, I was not terribly surprised. After all, this is a government that never looses an opportunity to give the impression that it is tackling terrorism. What I never suspected would be that other European governments would be taken in by it. That was the real surprise. So am I pessimistic about getting evidence into policies in the health sector. Actually, no. We have made huge progress. Where I am worried is about the other areas of government that seem to have avoided concepts such as empiricism and peer review. There lies the problem.

The last of this series of long delayed entries. I’ve been catching up with events during the past few weeks on the flight back from Tallinn, in Estonia. Building on our work in Russia we have recently been awarded a major Wellcome Trust grant to study in more detail the causes of premature mortality in Russia and Estonia.
As readers will be aware, this is not the easiest of times to be conducting research involving both Russia and Estonia, given the recent tensions between the two countries. When I logged onto the BBC before breakfast this morning one of the headline stories concerned an apparent attempt to block many Estonian internet sites (government ministries, banks etc.) with an avalanche of messages, some of which seem to originate from Russian state servers. Still, at least researchers can manage to transcend these political disagreements….
Given the easy availability in Russia of alcohol containing substances that, in theory, are not sold for drinking but in reality are, we had been interested to see whether they could also be bought in Estonia. In an earlier paper we showed that this was the case. These substances, such as aftershaves and firelighting liquids, are cheap and easy to buy and, as we showed last year, contain very high concentrations of alcohol. Our more recent work sought to understand the nature of the market for these products. A major source are the kiosks that can be found on many Estonian streets. Aftershaves seem to be their main product line, although they also sell washing powder, pet food, and condoms, a rather eclectic mix. We think we can link them all together but we are still speculating. Watch this space!

May began with a trip to Hong Kong, where I was giving one of the opening speeches at the Hong Kong Hospital Authority’s annual conference (plus another one later in the programme). As the conference began on a Monday I managed to arrive a little earlier and meet up with Sian Griffiths, now Professor of Public Health at the Chinese University of Hong Kong. A former President of the Faculty of Public Health, Sian has managed to escape the chaos that the English Department of Health has visited on the public health workforce. Indeed, as I write this, the comparison between the governments successive waves of NHS re (dis) organisation and the biblical plagues comes to mind. The most recent reorganisation, in particular, has led to the early retirement of almost an entire generation of outstanding health professionals. (I have since been reminded by Angus Nicholl, now at the European Centre for Communicable Disease Control, that a similar loss of Area Medical Officers a few years ago was followed by an epidemic of whooping cough as those with the expertise to respond to public concern about the vaccine had been lost from the system.) I wonder what disaster we can now expect.
Anyway, back to Hong Kong. On the Sunday Sian organised an outing for myself , Paul Corrigan (soon to depart as our Dear Leader’s health advisor), and Selena Gray (University of West of England) to Lantau – until recently an island but now joined to the mainland as part of the developments linked to the new airport, which was built on reclaimed land on the shores of Lantau. I had forgotten how easy it is to escape from the bustle of Hong Kong to some amazing beaches and stunning mountain paths. Wonderful…. Oh, and I also managed to squeeze in a trip to the Hong Kong Museum of History. One of its many excellent exhibitions takes you from the opium wars to the 1997 handover, through streets recreated to represent different stages in Hong Kong’s history. Don’t miss it!
My first visit to Hong Kong was about 25 years ago and in the intervening years it has changed beyond recognition, not always for the better as the authorities have frequently shown a scant regard for their historical heritage. This time there was one change that was extremely welcome – on the 1st January Hong Kong had gone smoke free. Admittedly there are some exceptions, such as bars, so there is still work to be done, but restaurants, karaoke bars (not that I am likely to be seen in one) and most other public places (and many open spaces) are now free from a carcinogenic haze. Much of the credit for this must go to my good friend Judith MacKay who has worked tirelessly to expose the tactics of the tobacco industry in this part of the world.

By now, if you are still reading, you may be asking what about the conference. The organisation was a triumph, with everything running remarkably smoothly, due, in large part, to the work of Paul Hui, who seemed to be everywhere at once and totally in control. We began with the usual opening speeches from dignitaries, albeit somewhat more visionary than is usual at major conferences. Then to the opening lectures. Mine addressed the question of how health systems can maximise health gain. It allowed me to bring together a range of themes I have been talking about recently under five maxims (familiar to regular readers of this blog). These are:
Prevention is better than cure – the first step is to prevent disease arising in the first place
Timely investment pays off – you need a balanced programme of investment in people, things, and knowledge
You can’t leave it to chance (or the market) – delivery of health care needs to be planned
Anticipate change – the world is changing and so must the delivery of health care, but equally, permanent revolution (cf Trotsky, Mao, and Blair) is not a good idea
Trust but verify – learn from experience elsewhere but don’t assume that ideas are instantly transferable, Evaluate their impact.
These ideas seemed to resonate with the audience, fortunately!

To Brussels on the 26th and 27th April to participate in two of the four workshops we are organising on behalf of the European Commission to explore the impact of its proposed new strategy on health services. The idea was to prepare a document setting out the current situation in Member States and then invite a group of senior policy makers to consider the implications of the Commissions proposals – which would have been fine except that the Commission doesn’t actually have any concrete proposals yet. Still, it was a very good opportunity to thrash around some very difficult questions that have defied the combined intellectual might of Europe’s health policy community for at least a decade.
The two I was involved with were on quality of care and patients’ rights. I had also been involved in preparing the report on quality of care. This was a combined effort by three EU projects, Europe for Patients (focusing on patient mobility), MARQuIS (on quality of care, and SIMPATIE (on patient safety.
A key question we had to grapple with was who should be responsible for the quality of care provided when a patient from country A is sent by his or her health authority/ fund to country B. One thing was clear – it could not be the patient as, given the major asymmetries in information, patients are simply not in a position to assess whether the care they get is of good quality. There are far too many examples of smooth-talking charlatans helping vulnerable patients to part with their money. Even with the (totally unregulated) internet, except for a small number of people with longstanding chronic illnesses, the fully-informed patient remains an aspiration. There was considerable initial support for the authorities in country A taking the lead, until it was pointed out that this would mean that, potentially, a hospital would need to comply with the standards in place in each of the 27 Member States – hardly practical. What’s more, we were able to draw on the experience of the contracts between the English NHS and hospitals in France, Belgium, and Germany. This had never been a serious project anyway, but rather an attempt by ministers to show British hospitals that there were alternative providers so they had better do something about waiting lists. The English authorities sent a small number of patients abroad, with the first batch accompanied by almost as many newspaper reporters. They specified in excruciating detail how the patients should be treated, including access to English newspapers and afternoon tea. Given the abysmal quality of food in most British hospitals compared to those in France, the patients may have wished the authorities had not interfered. Anyway, as one might have expected, the foreign hospitals soon got fed up with the mass of bureaucracy, not to mention the lack of co-operation from English referring hospitals, who knew that the whole initiative was simply a way to get at them.
So the obvious answer is that quality must be the responsibility of the country where the health facility is situated. This is already implicit in EU law. However, it also implies that any country sending someone abroad should be assured that their patients will get high quality care. The answer seems to be some form of EU legislation to require countries to put in place mechanisms to ensure quality and then let them get on with it.

25th April – launch of our new project, EU-PREVOB. ‘Tackling the social and economic determinants of nutrition and physical activity for the prevention of obesity across Europe’. Led by my colleague Joceline Pomerleau, it brings together 14 partners from 11 countries, from the UK to Turkey and from Latvia to Bosnia. The aim is to develop a better understanding of the factors underlying variations in diet and physical activity across Europe. Of course we already understand many of these – most obviously people have tended to eat what farmers around them produce, explaining why Cretans eat Greek salads and Mongolians eat fatty sheep’s tails. Similarly, if you live in rural Nepal you have little alternative but to walk if you want to go anywhere while if you live in Los Angeles you risk being arrested for suspicious behaviour if you try to walk on the streets. The challenge, which links closely to our work on the PURE project (see earlier blog) is to locate other settings on these scales and to assess their direction of travel. For example, Ireland was once closer (gastronomically) to Mongolia than to Crete but is moving steadily towards the latter. If we can develop an appropriate instrument then we should be able to obtain some fascinating results.

I’ve spent a lot of time over the past month thinking about hospitals. Ever since I was a junior doctor I have been convinced that most hospitals were designed by architects trained in the Central School of Dismal Apartment Block Construction of the Soviet Union. I trained in Belfast, where the new Belfast City Hospital, which was conceived about the same time as I was, finally opened when I was 31. It provides the most perfect case study of how not to design a hospital, ranging from putting the dialysis unit on the top floor but forgetting to check if the water pressure up there would be sufficient or creating acres of underground parking without thinking of where the pipe work would go, so that the clearance was reduced to about 1 metre. The red rectangle in the picture highlights a grey (originally brown) bit that seems to have been put in as an afterthought – as it was. This is the university floor as the original designers overlooked that this was a teaching hospital. Then there was the need to replace all the heating ducts as the contractors forgot to put in portaloos so the builders urinated down the ducts causing them to corrode. I could go on.

Belfast City Hospital

Anyway, a few years ago Judith Healy and I published a book on the future role of the hospital. Our basic premise was that as the world was changing so must hospitals. They should be designed in ways that allows them to adapt flexibly to changing circumstances. Fairly obvious you would think. And of course it is – except to those in charge of the hospital building programme in the UK who happily sign expensive and complex contracts, under the Private Finance Agreement, that make it prohibitively expensive to change even the number of electrical sockets for a period of 30 years.
We also made the fairly radical suggestion that hospitals should be designed in ways that smooth the path of patients through them, so that they do not have to follow complex paths that would defeat an experienced jungle explorer, and that they should promote health.

These are issues we have returned to in a new book that will be published later this year.
This, then, was the reason why a disparate group of people came together in London on the 16th and 17th April. It was the latest of the Observatory’s authors’ workshops, in which those contributing to the book discuss what they are writing with those who make up its likely audience. As always, it was an extremely valuable few days, allowing people from very different backgrounds to understand where each of them is coming from. One of the main challenges, which I am working on, is how to create a system in which about 80% of activity is routine and predictable but the remaining 20% is anything but, and where what you are dealing with is often only clear after you have dealt with it. That should keep me busy for a few weeks!
A week later I was talking about hospitals again, this time at the annual conference of the European Health Property Network, an organisation that does believe it is possible to build hospitals that actually make you feel better. They are partnering with us on the new book and their members have brought together a series of fascinating case studies from across Europe that give one hope that a better world is possible.
I was asked to set the scene for a debate on planning versus the market (in health care). I tried to be as balanced as possible, noting the great successes of markets compared with, for example, Soviet central planning. But of course the problems arise when you see the market as a panacea for everything, as the current British government does. As a consequence you get bizarre decisions such as that to break up the monopoly that was the perfectly acceptable British Telecom directory enquiries service. The result – dozens of new companies spending millions of pounds to advertise their services, which they then have to recover from far higher charges. Of course they can’t do this openly so they create cost structures that require the user to have a qualification in accountancy to understand them. Others simply cut costs by using voice recognition systems or untrained staff that give you the wrong numbers. A complete disaster. I won’t even begin to talk about the shambles that resulted from privatising the railways.
Unfortunately we never got to the debate. Even those who were meant to be speaking on behalf of the market didn’t do so, quickly conceding the need for planning. A pity as I was rather looking forward to the debate!

Finished the week in Istanbul. It’s a wonderful city – just a pity that I rarely manage to get time to see any of it! I was there for an investigators meeting on the Prospective Urban and Rural Epidemiology (PURE) Study. This is a really fascinating study and it is a great experience to be part of it. It has been put together by Salim Yusuf at McMaster University, in Canada, and involves many of the teams from his earlier INTERHEART study. The basic idea behind PURE builds on the results of INTERHEART. It showed that nine basic risk factors (smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, abnormal lipids, fruit & vegetable consumption, alcohol consumption, and regular physical activity) explained a very substantial proportion of the variation in myocardial infarctions in populations from all regions of the world. It was a remarkable study, managing to gather data on 15,000 cases of myocardial infarction from 52 countries.
It is, however, clear that exposure to many of these risk factors is changing rapidly in many parts of the world, and often not for the better. In particular, in many developing and middle income countries life is changing rapidly for people in rural areas and in the per-urban sprawl around many large cities. PURE is recruiting subjects in urban and rural areas in about 20 countries so far, with the aim of following them up over the long term to see how their environments and their lifestyles change, and what impact this has on their health. So far, there is participation from every continent, but the largest numbers are from India and China. Remarkably, despite the enormous problems in the country, we even have participation from Zimbabwe, where there is a quite exceptional team.
The basic design is a cohort study, collecting data on people now and following them up into the future. However, where it differs is that it is looking at the environment within which people live. We know that many people want to make healthy choices, in relation to things such as smoking, diet, and physical activity. Yet too often their environment shapes the choices they can make. To take a few extreme examples, if you live in the mountains of Tibet you have very little choice but to walk if you want to get somewhere while if you are in Los Angeles you have very little choice to take a car. Similarly, in California it is actually quite difficult to smoke, or at least to find somewhere where you can light up, while in China it is difficult not to inhale smoke, even if it is someone else’s.
While it is easy to locate the extremes of these scales, such as the extent to which an environment discourages smoking or encourages exercise, it is far more difficult to place the communities we are studying in between these two poles. Smoking is perhaps the easiest. We can measure the density of tobacco sales outlets and advertising billboards and the extent of advertising in print media. Armed with handheld GPS devices and cameras, we can even map and photograph them. We can also see what proportion of bars actually ban smoking. However other areas are more difficult, when you are trying to work on a global scale. For example, it is fairly straightforward to measure the density of McDonalds, Kentucky Fried Chicken, and the like if you are doing a comparison across the USA. It is much more difficult to define calorie rich fast food in countries where these chains are still relatively uncommon and where people instead get their fat and salt from street vendors. Anyway, this is what a small group of us, from McMaster, Harvard, and LSHTM, are trying to do. Any ideas will be gratefully received!

To Lisbon yesterday, for a meeting with colleagues in the Portguese Ministry of Health and others from the International Organisation for Migration and the International Centre for Migration and Health.
Portugal will take over the rotating presidency of the European Union on the 1st of July. One of the main themes of its presidency will be migration and the Health Ministry is co-ordinating a report on migration and health. We, along with the IOM and the ICMH are helping to write the report that will provide the evidence base for any new policies.
The task is extremely challenging. Migration is an enormously controversial issue in Europe, with anti-immigrant parties doing surprisingly well in a number of countries. In the UK, for example, some newspapers wage an almost continuous campaign against “asylum seekers and refugees” whose numbers they inflate to absurd levels and whom they represent as coming to Britain to live on state benefits and to engage in crime. In many countries, migrants, especially those from Africa and the Middle East, have been subject to sustained discrimination and violence.
Ironically, many of those who complain most about migration have themselves relatives who migrated in the early years of the 20th century to Australia or North America, in search of a better life. However, what they almost certainly do not realise is the extent to which the current and future prosperity of Europe depends on substantial migration. European birth rates have fallen dramatically, to well below replacement rate. In the absence of migration, Europe would have a much smaller and older population, creating enormous difficulties in paying the pensions of today’s workers. What is more, without migration, there would be insufficient people to care for them in their old age as the health and social care workforces are heavily dependent on migrant workers.
However, it is not just the political problems. Even trying to define who is a migrant can be difficult. It is true that here are official definitions but there is considerable untidiness at the edges. For example, citizens of British overseas dependencies, such as those illegally displaced from the Chagos Islands to make room for the US air base in Diego Garcia, are considered migrants when they come to the UK. In contrast, citizens of Frances overseas Departments coming to metropolitan France are not. Those living in the Netherlands Antilles fall into the same category as those in British Overseas Territories for now but will be the same as their neighbours in Martinique or Guadeloupe when they are absorbed into the EU in 2008.
Then there is the complex set of laws on citizenship in Europe. Broadly, some countries base citizenship on where one is born while others base it on who one is descended from, although many countries have recently changed their laws, taking features of both.
Finally, there is the problem that many migrants are effectively invisible in national statistics. There is remarkably little information on their health status outside a few countries such as the UK and The Netherlands.
Still, if all goes well, we will have an authoritative report ready for the Portuguese presidency conference at the end of September. A lot of work ahead….

I try to read the New York Times every day. I’ve found that if you know what happened in Washington yesterday you can have a good idea about what will happen in London today. Of course it’s easier when you are in new York, as I am today, as you can read the paper version more easily with a coffee.
Aside from the continuing problems of Alberto Gonzales, President Bush’s Attorney General, who seems to be hanging on by no more than his fingertips as the whiff of scandal surrounding him gets ever stronger, I was struck by a piece on American education policy, which follows on nicely from my last entry. Education is clearly an area that should be left to the states under the Constitution, yet with support from both parties, the No Child Left Behind policy has been enacted. This represents an unprecedented centralisation of power, with intense Federal oversight of schools across the country. It includes exacting standards, detailed testing, and tracking of children from school entry to graduation. Of course, this sounds like a good idea – after all, who wants to have children left behind? Yet, as always, the devil is in the detail. Schools in Arizona complain that they are being judged on tests conducted in English in schools with large numbers of recent Hispanic immigrants. Isolated rural schools in Utah, where the students numbers are of necessity very small, are penalised by a requirement that to teach a subject you must have a college degree in it. It now looks increasingly likely that states will be allowed to opt out of the provisions without loosing the federal money that comes with it. Given what I said above about winds of change travelling across the Atlantic, could this be the stimulus for the reassessment of the British government’s plans to expand greatly their already exhaustive (and exhausting) programme of testing, whose sole purpose seems to be to increase the already massive volume of information that they seem determined to keep on every citizen? We can only hope.

I’ve been in Philadelphia all week, as a Distinguished International Scholar at the University of Pennsylvania, where I have been hosted by my colleague Dr Julie Sochalski. It’s always useful to participate in the transatlantic exchange of ideas, as so many ideas from the US to Europe and it helps to have the inside story! It’s also really useful to have an opportunity to have discussions with American students. Although we have much in common, there is a surprising amount that divides us.
Despite a very heavy schedule, I did manage to get a few hours off and I went to see the new National Constitution Centre. It is really worth a visit.

The National Constitution Center, Philadelphia

It is on the edge of Philadelphia’s small historical quarter, the setting for the Convention that created the US Constitution in 1787. Although independence was achieved in 1776, at first the 13 states wanted to remain a loose confederation but it soon became clear that this was not working. In particular, the original confederation was not up to the task of resolving inter-state trade disputes. Many people who would later become household names, such as Benjamin Franklin, James Madison, and Alexander Hamilton, met together in secret session and in only five months they agreed a constitution (if only the European Union could do it so easily!).
A key principle was separation of powers, which ironically, was an idea that copied from Britain. Unfortunately, as I have noted elsewhere, Mr Blair is doing its best to eliminate any residual any residual separation of powers that might challenge his absolute executive, legislative, and increasingly judicial authority. The founding fathers of the USA divided power between the executive (the President), the legislature (Congress), and the judiciary (the Supreme Court), as well as between the states and the federal government. The legislature was separated into the House of Representatives, which represented the people, and the Senate, which represented the states (they got 2 senators each).
The Constitution was not perfect. For example, they couldn’t agree on slavery so it was simply not mentioned. And they also didn’t agree on a number of other issues relating to basic rights, although this was soon addressed in ten amendments, enacted in 1791 and subsequently known as the Bill of Rights. Thomas Jefferson, who had been abroad when the Constitution was agreed, was a key figure in pushing them through. The amendments included, for example, freedom of speech, of seizure, and of cruel and unusual punishment.
A visit to the Constitution Centre begins with a skilfully presented performance by an actor in a central auditorium, against a background of impressive audio visual wizardry. However it was the exhibit that surrounds the auditorium that is the most interesting (at least I thought so). It takes the visitor through the operation of the constitution and how it has changed, both substantively through amendments and in terms of how it is interpreted, through Supreme Court rulings. It is extremely balanced, presenting both the political successes and the failures, including the events leading up to the civil war. However, the abiding impression is that the system put in place by the people who drafted the Constitution did a remarkable job, finding a way that could ensure that no-one was above the law….. at least until recently.
As one reads the ways in which Congress and the Supreme Court stood against attempted abuses of executive powers, such as FD Roosevelt’s threat to stuff the Supreme Court with additional, sympathetic justices, or Richard Nixon’s initial refusal to release the Watergate tapes, one cannot help to contrast what happens then to the situation now. A sympathetic Court, Republican control of both houses, and almost total domination of the media by sympathetic forces, has allowed George W Bush to assume an unprecedented degree of executive power. The most obvious is the decision to authorise US agents to kidnap people in foreign countries, fly them to places where they can be held in secret, and subject them to whatever conditions they choose. By arguing that the places where they are held, such as Guantanamo, are outside American jurisdiction, the executive in Washington has so far managed to insulate them from any legal oversight.
Yet there are at last signs that things are changing. The Supreme Court has just held that it will not hear the cases of several Guantanamo detainees but a careful reading suggests that it really meant “not yet”. The recent legislation that set up the military commissions did establish a system, albeit deeply flawed, that gives the appellate courts in the District of Columbia some say, and that process has not yet been fully exhausted. It seems likely that Justices Anthony Kennedy and John Paul Stevens will support an engagement by the Court in these cases. It is even possible that the executive branch may welcome this, as the new Defense Secretary Robert Gates clearly recognises the incredible harm that Guantanamo’s continued existence does to the reputation of the USA. If the Court does decide to get engaged, they will have much to discuss. The case of the Australian, David Hicks, who is about to be released from Guantanamo really says it all. After five years in what must have been the most awful conditions, despite what is now quite obviously no evidence that he was guilty of anything except naivety, he has agreed to spend a further nine months in an Australian jail. The US authorities were unable even to keep to their own totally one-sided procedures during the Commission that “heard” his case and he was eventually dealt with through a deal between his defence counsel and the President’s staff. When he returns to Australia he will be forced to remain silent about what befell him until after the forthcoming election, conveniently for John Howard (not that there is any legal basis in Australian law for this to be enforced).
The tragedy is that the high ideals in the US Constitution, which as the exhibition reveals have been adhered to for over 200 years, seem to have been cast aside by the current White House. One can only hope that this will change – the signs are at least positive – and that in the future there will be a new display case cataloguing the transient aberration that, with events like the internment of Japanese citizens in WWII and Macarthyism in the 1950s, happen from time to time before the checks and balances in the Constitution restore life, liberty, and the pursuit of happiness for all.

Another two trips this week (26th March). To Copenhagen on Tuesday for the European Advisory Committee on Health Research. As always, lots to discuss as we struggle with how to strengthen the evidence base for the work of WHO, where it is so important to take account of the context in which one is operating. Thursday it was back to Brussels (I’m getting to know Eurostar far too well). This time it was for a consultation on the 2008 WHO conference on health systems, which will be held in Estonia. It will be 12 years since the WHO European Regional Office discussed this topic, in Ljubljana in 1996. We were struggling with the question of how to measure health system performance and I was giving a presentation on our work on avoidable mortality. As always, Peter Smith (University of York) gave a superb overview, highlighting the challenges involved. His focus was at the level of performance of organisations delivering health care and he provided more warnings (as if they were needed) of the problems associated with public disclosure of performance data. Of course everyone is in favour of openness. The idea is that surgeons or hospitals that are getting poor outcomes will improve their practice if they are named and shamed. Unfortunately, people don’t always behave in the way that you would like them to. They stop operating on sick patients, they change the way they record data, and the net result, at least in one major study, is that patients who do not have severe illness obtain no benefit whereas those who do, do worse, as they miss out on operations that, although risky, might have brought them benefit.
Earlier in the week there was an excellent example of the problems in assessing health system performance. It is increasingly clear that it is almost impossible in many parts of England to register anew with a dentist, because of problems with their new contract. Which Magazine undertok a well-conducted survey in which their researchers phoned up dentists to try to register with them. A health minister commented that ‘The results were “deeply flawed” because they focused on the possibility of dentists taking on new patients, without looking at how many patients they were already treating', conveniently ignoring the fact that prospective patients couldn't care less how many patients were already being treated if they could not join them. Still, thanks to papers released reluctantly by the British Government under the Freedom of Information Act we now know what ministers mean when they describe something as "deeply flawed". This was a term used extensively by ministers to rubbish the paper in the Lancet reporting that the best estimate of lives lost since the invasion was 655,000. As the BBC and others have revealed, what one adviser told them was "The study design is robust and employs methods that are regarded as close to "best practice" in this area” while another reported that the methods were "tried and tested".
I can only hope that my research meets the high standard needed for a British minister to consider it "deeply flawed" too.

Started the week in Brussels, finishing it in Geneva. I’m here to talk to the African Medical Association. Doctors in Africa have been working for a long time to create a forum where their professional associations could come together to exchange ideas about shared problems. At last it has happened, in large part due to the hard work of two colleagues, Kgosi Letlape from the South African Medical Association, and Delon Human, formerly of the World Medical Association.
Although I don’t work in Africa I was there to talk about some work we have been doing on surveillance in fragile societies, which are all too common in Africa. It was really quite humbling to hear the accounts of the challenges that many of the delegates faced, in some cases even to get to the meeting. The health minister from Somaliland, a break away territory in the north of Somalia, had been waiting in Addis Ababa for two days to get a visa to attend the meeting. Contrast that with the ease with which our ministers travel the world.
One of the other speakers was Winnie Mandela. I had never met her before and I wasn’t entirely sure what to expect. I was obviously aware of the controversy that had surrounded her in the past but also knew that, in recent years, she has been speaking out against the policies of the South African government on the need to tackle HIV seriously. What was in no doubt was her ability to motivate the audience. She is clearly someone who can get people to listen. I’m just glad that, at least in the case of HIV, she’s on the right side!

Another incredibly busy few weeks, making it almost impossible to keep up the blog (Hurray, you shout). I need to go back to the 19th of March to pick up where I left of.
I was in Brussels to speak at the annual European Voice conference. I’ve spoken at it before and it’s always a good opportunity to catch up with what is happening. My task was to contribute to a panel entitled “Can Europe’s health systems survive?” Actually, it was a fairly silly question. After all, we have tried to do without health systems before – it involves stepping over dead bodies in the streets and it’s really not very nice. However I guessed that the organisers wanted a rather more nuanced response. Perhaps we could rephrase the question to say what do Europe’s health systems need to do to adapt to future challenge? In fact we can be quite optimistic. Health systems have changed continually in the face of changing patterns of disease, changing expectations, and changing opportunities. Just think if what happened in the 1950s when, in industrialised countries, polio was being eradicated and tuberculosis was coming under control. Orthopaedic surgeons were running out of work as, until then, they had been kept busy with tendon transplants on children with paralytic polio and drainage of tuberculous spinal abscesses. So they invented the hip replacement, and then the knee and shoulder replacements. Chest surgeons lacking tuberculous lung cavities to operate on moved into heart surgery. There has been an enormous shift of care from hospital to primary care as changes in technology have challenged the basis for many of the services provided in the acute hospital. In other words, we will always have challenges to confront but there is no reason why they should defeat us. In fact, this was the broad consensus, which was a pleasant surprise because there is usually someone who is predicting loudly the end of the welfare state as we know it, summoning visions of catastrophe as we are overwhelmed by aging populations as our jobs disappear to the far east or some other low wage economy. It is certainly true that we need to respond to an aging population but the situation is much less worrying than it seems. First, people require a lot of resources not because they are old but because they are about to die. Just because 75 year olds cost a lot to look after it does not follow that 75 year olds will cost the same in the future. The highest costs are in the last year of life and there is even evidence that these fall if you die at an older age because you are treated less intensively.
Then there are worries that there will not be enough people in work to pay for those who are retired. Only if we keep the retirement age as it is. There is no good reason to do so (honest). A very small change would actually compensate for the predicted changes in longevity far into the future. And anyway, there is good evidence that compression of morbidity is really happening. In other words, while people are living longer, they are living even longer in good health. Yes, we do need to reconfigure health care delivery, to take account of the increased numbers surviving with multiple chronic diseases, but that can be done. It just requires a clear vision and some political will (ok, there’s not a lot of either about). All in all, Europe’s health systems can survive. They just need to adapt. That they can do, but only if they are allowed to by our political masters. Perhaps they are the greatest threat, predicting doom and then by their actions making sure it comes about. In the UK a favoured term in 10 Downing Street is “creative destruction” – the idea that if you push the public sector far beyond its limit something new and good will emerge. I can’t help feeling they are wrong, but if they are it will soon be too late to do anything about it.

Finally catching up with the backlog of blogs – 3 in one day! it has been an incredibly busy few weeks, writing papers and book chapters almost constantly. Like the labours of Hercules, no matter how much you do there is always more. I did have a short break from writing the week before last, when Dave Leon, Vladimir Shkolnikov, and I went to Moscow to participate in a conference on alcohol in Russia. Our work has highlighted the very important role played by technical, or surrogate alcohols in the Russian mortality crisis. Readers will have to wait to read the full results in the Lancet but their importance is now beyond any reasonable doubt. These are things like aftershaves (odekolon), medicinal tinctures, and firelighting liquids. Shortly after we presented our initial findings to the Russian Presidential Administration, new laws were introduced to clamp down on the sales of aftershaves. These are sold in brightly coloured 250 ml bottles. Although labelled “for external use only” everyone knows they are really for drinking. Initial evidence suggests that the new law is working. It seems much more difficult to obtain the aftershaves. Unfortunately, it did address the sale of medicinal tinctures and it now seems that these are being consumed in larger amounts than ever. An unfortunate side effect was that people unable to get aftershave turned to antiseptics, many of which contained highly toxic substances (as we showed in an earlier paper, the aftershaves are pure 95% ethanol – a few contain some lemon scent but most don’t even have that).

Photos of odekolons bought in Russia


There are also very encouraging signs from some individual cities in Russia. We heard a fascinating story about the so-called “sober cities” in Sverdlovsk region, where a NGO has taken the lead, essentially forcing the police to take action. They knew that this would be difficult when, just after they started working, they diverted a truck full of surrogate spirits to the yard of a police station late one night. They checked it in and returned the next morning to ensure that the police were acting on it. The truck was gone and none of the police could “remember” seeing it. Now they are much more careful.
The path ahead will be very difficult, but it is a pleasant change to fly out of Moscow with a real sense that things are changing for the better.

I seem to be starting too many blogs with the phrase “you couldn’t make it up”. Unfortunately, it so often seems to be the only thing to say. This time it was the revelation, in a previously classified report, that in 2002 the UK Ministry of Defence had spent £18,000 on a study to see whether psychics could discover what was in sealed brown envelopes. Strictly the study was compromised because the original protocol specified that the subjects should be “known” psychics but unfortunately when they contacted people who advertised their possession of these skills they were reluctant to put their skills to the test. The Ministry then recruited some “normal” volunteers. They promptly failed comprehensively to discover what was in the envelopes. What a surpise! It rather reminds one of the cartoon of the fortune teller’s stall bearing a sign “closed due to unexpected illness”.
Of course, it is not only the British Defence Ministry that engages in bizarre studies such as this. A recent book by Jon Ronson revealed the existence of a once secret US military unit engaged in a major programme of psychic and (pseudo-) psychological research. His book was entitled “The men who stare at goats” because of the extensive use made by the researchers of goats whose vocal cords had been severed to stop them bleating. The idea was that if you trained yourself sufficiently intensely then you would be able to kill a goat (or in fact any other creature, including a human) simply by staring at it. Of course the military unit that dreamed this idea up didn’t stop there. One of its senior officers was convinced that if he could only get his mind into the right state he could walk through walls. He tried repeatedly but, amazingly, only ended up with a headache and a bruised nose.
It is, however, unfair to single out the armed forces in the US and the UK. Ronson’s book makes clear that many of these crazy ideas were taken up by large corporations, paying large sums of money to consultants, many of whom seemed positively certifiable, to motivate their staff.
This resonates with the 2006 Cochrane Lecture, which I gave at the UK Society for Social Medicine in September (to be published shortly in the International Journal of Epidemiology). The theme should in some way relate to Archie Cochrane, whose bequest endowed the lecture. He suggested that, if one plotted on a map of the world the number of randomised controlled trials, the lightest shading would be in countries that were communist or catholic. Coming from Northern Ireland I decided to leave the religious bit for someone else but I was able to examine the legacy of Soviet science for medicine. Briefly, science in pre-revolutionary Russia was vibrant and progressive. It survived the revolution for about a decade, until Stalin unleashed his new model of Soviet science. This rejected basic concepts such as a fair test and equipoise. After all, if the foundations of all knowledge had been set out by Marx and Engels, you could never begin from a position of uncertainty. The consequences were calamitous, especially in agriculture where Trofin Lysenko rejected modern genetics. Yet medicine was also badly affected. I argue that this actually suited the Soviet leadership because they never managed to create a modern pharmaceutical industry, instead relying on bizarre machines emanating light, x-rays, and the like. These had the advantage that they gave the impression that something was being done. They only needed electricity, which the USSR could distribute to its people, even if it couldn’t manage pharmaceuticals (or even sugar or jam…). Introducing concepts of evidence-based practice in this setting would have been disastrous! The trick, as it the men who stare at goats, is to exclude open peer review. Yet this is still going on. A seminal report prepared under the chairmanship of Congressman Henry Waxman (D, CA), when he was minority leader of the House Committee on Government Reform catalogues the distortions of science under the administration of George W Bush. His report is frightening but it is also essential reading for anyone trying to make sense of today’s world.

We always hope that the products of the European Observatory will be relevant to policy makers. One way we try to ensure that they are is by involving people who will have to use them at all points during their development. A crucial episode in the production of our books is the authors’ workshop, in which those contributing to the books present advanced drafts of their material to colleagues in governments and international agencies. A few weeks ago (I’m really behind with the blog…) we held the workshop to discuss our forthcoming volume on the management of chronic diseases. The project is led by my colleague Ellen Nolte. It was a fascinating two days, as we were joined by contributors from Australia, New Zealand, Canada, and many parts of Europe.
Chronic diseases will be the greatest challenges that health policy makers will have to confront in the decades to come. People are living longer but as they age they are accumulating increasing numbers of chronic diseases. A typical 85 year old might well have some osteoarthritis, some chronic airways disease, type II diabetes, hypertension and perhaps a touch of Parkinsons Disease. They can expect to be on five or more different drugs, in a combination that has never been tested together, and certainly not on older people with multiple disorders, precisely those least likely to be included in randomised controlled trials.
Fifty years ago, there was little that anyone could do about many chronic diseases. There were two exceptions: diabetes, following the isolation of insulin by Banting and Best in 1922; and heart failure, treated by digitalis obtained from Dr William Withering’s extracts of foxgloves. It was only in the 1960s that modern pharmaceuticals became available. Thiazide diuretics were later joined by beta blockers, bet sympathomimetics, ACE inhibitors, and many others. Steadily, at least in industrialised countries, death rates from many common conditions began to fall.
Yet even today, there is still a long way to go. As Ellen Nolte, Chris Bain and I have shown, most recently in a paper in Diabetic Medicine, death rates from common diseases such as diabetes are very much higher in some otherwise comparable countries than in others. One of the worst performing countries is the USA which, despite spending enormous sums on health care, consistently achieves very poor outcomes.
Given this fact, it is hardly surprising that many of the more innovative ideas for managing chronic diseases have come from the USA. Perhaps one of the best examples is the Chronic Care Model, developed in Seattle, but there are also several similar approaches, albeit all variations on the same theme. We have found the Chronic Care Model to be very helpful in conceptualising the management of chronic disease, highlighting the importance of support for self-management, redesign of health systems, information systems, and better clinical decision-making. But do these approaches deliver what they promise? In fact, the evidence is quite equivocal. Clearly, they can work in the best circumstances but there is rather less evidence that they bring real gains when rolled out into the real world. The most recent example of where these schemes failed to deliver what they promised was the evaluation of the application of the American Evercare scheme in the English NHS. Now as I have said often before, it is relatively easy, at least in theory, to achieve improvements in outcomes of chronic disease in the USA. Just adopt a European health care system…. any system will do. They all achieve far better outcomes. So why one would think that a US system would perform better than that already in place in England was rather a mystery (except, of course, when one remembers our Prim Minister’s fawning admiration for all things American). Now this should not for one minute be seen as anti-Americanism on my part, simply a call for a more balanced perspective.
The idea of the Evercare scheme was that frail elderly people would receive intensive, targeted services that would prevent a deterioration in their condition ad thus reduce the rate at which they were admitted to hospital. It results in more services being provided, which is probably good, but not a reduction in admissions.
This led us back to thinking about why these schemes have come about. Maybe, rather than a response to rising levels of chronic disease, they are instead a response to the contemporary fragmentation of health care? In the old days, a community in the UK would be served by a small number of general practitioners. Those GPs would know their patients intimately. They would also know their families, their jobs, their relationships, and how they spent their leisure time. They didn’t need complex information systems because they kept it in their heads. Now to be fair, there was a lot of information that they did not have, such as laboratory results. But maybe the patient was more concerned about how their illness affected what they could do than he or she was about the precise value of their blood cholesterol.
There is no doubt that the amount of information collected on patients is far greater than anything that existed in the past, especially in the UK where the government has an appetite for data, regardless of whether it means anything, that has not bee seen since the demise of Gosplan, the Soviet state planning organisation. But does the health professional helping a patient to manage their multiple diseases know as much relevant information as his or her predecessor before computers were in common use. I’m not so sure.

I did something that was, at least for me, very unusual this week. I signed an on-line petition. What was more surprising, however, was that the petition was against something that, in other circumstances, I would have supported. It was, of course, the petition on the Downing Street web site calling for the government to abandon its plans to introduce road pricing. So why did I sign it?
First, a few words about the site hosting the petition. Conscious of the growing tide of criticism that the government has been ignoring the voices of the British public, someone in Downing Street decided it would be a good idea to create a web site where those voices could be channelled, so that they could then be ignored while giving the impression that someone was paying attention. The idea was that anyone could post a petition for signature. It is fair to say that this idea was not greeted with universal enthusiasm in government, with one minister widely reported as having asked what “prat” thought it up. The problem was that what could have been a harmless diversion for a few people with too much time on their hands rapidly took on a life of its own. As I write this blog, over 1.5 million people have now signed the petition against road pricing, far outstripping the many others available for signature. Now it is important to point out that you can’t simply propose anything. The site is moderated, although it is possible to see the list of petitions rejected and the reasons for rejecting them. Actually, this list is more interesting than the list of petitions accepted. One submission calls for an enquiry into sales by a British company of booster rockets to increase the range of Iraqi scuds in the 1980s – clearly an interesting story behind that one. Others hold the promise of making British politics a little more interesting – such as the one calling on the Prime Minister to dance naked in the moonlight on midsummer’s day next. That one was rejected because “It was outside the remit or powers of the Prime Minister and Government”. Shame!
Anyway, back to road pricing. How have we come to a situation where I, as someone who rarely drives a car, who has no objection to paying road tolls in France, and who is totally convinced of the reality of global warming, would sign a petition against road pricing?
As always, the devil is in the detail. The solution that seems to be favoured by the government is a vastly expanded version of the London congestion charge. This involves positioning cameras equipped with automatic number recognition systems all over inner London. If a car that has failed to pay in advance passes one of the cameras, the registered owner is fined. This is, of course, entirely different from most other toll systems where you pay as you pass a barrier, either in cash or by deducting money from a pre-paid smart card on your windscreen. So what is the problem?
My first concern is the complexity. A nationwide system would be vastly more complicated than anything anywhere else in the world. Of course, the fact that a proposed computer system is more complex than anything ever attempted by anyone ever before is no barrier to our present government. Indeed, they view it as a challenge to be overcome. Unfortunately, they never manage to do so. One after another, major information technology procurement initiatives have run over time and budget or simply collapsed. The current National Health Service programme is just the latest example of a hugely over-ambitious programme that few expect ever to work as intended. The problem is that ministers seem to be entranced by IT companies offering a modern equivalent of the philosopher’s stone that, instead of turning lead into gold would turn raw data into meaningful information. Of course, the ease with which our ministers are entranced by glitzy sales packages promising the earth is not limited to IT schemes – think of how easy it was to convince them that super-casinos would be a good idea, totally ignoring the mounting evidence on the social cost of problem gambling (maybe I should see if they are interested in a bridge I have for sale in Brooklyn). Now even if the scheme ever did work, which I doubt, the sums payable to the company operating it would be so great that hardly any would be left over to support public transport, where investment is really needed if people are to get out of their cars. We should not forget that the reason so many people drive is because public transport in the UK is the most expensive in Europe.
My remaining concerns relate to the true motivation underlying the proposals. Clearly, a scheme of this complexity is not needed, so why propose it? It is intended that all cars will be tracked at all times, with their movements being fed into a giant computer system. The residents of the UK are already tracked more intensively than in any country in the world, with the possible exceptions of Myanmar and North Korea. The government’s Information Commissioner has warned that we are “sleepwalking into a surveillance society”. The UK now has more closed circuit television cameras than any country on earth, and more than half of all those in place in the entire European Union. At present, there is one camera for every 14 people in the country, and someone walking around London can expect to be filmed about 300 times in a single day. An increasing number of cameras have facial recognition software and some have microphones attached. And this is only the start, as the government is planning to introduce an incredibly complex system of identity cards, based on biometrics, that will track every encounter with any source of authority.
So what, you might say. If you are innocent, you have nothing to fear. Well, not exactly. The technology is far from proven. There are already a growing number of cases where entirely innocent people have had their lives ruined because the technology went wrong. Take the Oregon lawyer whose fingerprints were mistakenly thought to be on the Madrid bombs. Or the Scottish policewoman charged with lying because her fingerprints were misidentified at a crime scene that she denied having entered. The problem is that statistics such as “the match is one in a million” is fairly meaningless when your database holds 60 million fingerprints. And what if some future government decides that it will not uphold the human rights that are now in place? After all, almost uniquely in Europe, the present government has opted out of as many of the provisions of the European Convention on Human Rights as it can, justifying this by the “war on terror”. Das Leben der Anderen (The lives of others) is new film about the way in which, at the behest of the Stasi, tens of thousands of East Germans spied on their friends and neighbours. Think what it would have been like if the Stasi had the technology now available to the British government.
However, my final concern about motivation arises from a statement by the Treasury early this year. The Chancellor, Gordon Brown, stated that he would increase the tax on flights departing from the UK. Airlines would have to collect between £10 and £80 on each departure, depending on distance and class of travel. There was the minor technical issue that the charges would be levied before parliament had a chance to pass the relevant law, but then, as the old Russian saying goes “the law is like a door in the middle of a field – you can use it if you want but you don’t have to”. A number of airlines (and their passengers) complained that this was unfair on those who had already booked and paid for their tickets. Here, the Treasury had a chance to show its real intentions. If, as it had implied, the tax was designed as a disincentive to individuals intending to travel, then it should say “sorry, the passengers simply have to pay it” – although even then there was a contradiction as it could not possibly act as a disincentive to a decision already taken (and irreversibly so, given that most tickets are non-refundable). Instead, it sought to shift the burden onto the airlines, saying that they should simply absorb it. In other words, this was simply viewed as a means of increasing government revenue, with no real intention of changing individuals’ behaviours.
So why did I sign this petition? First, it is unlikely to work. Second, if it does it will rotationally threaten my human rights. And third, because I simply don’t believe that the government is being honest about why it wants to do it.