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 late