Woken up yesterday morning by a series of SMS messages – colleagues with the benefit of time differences had already heard the news from Ashgabat that Saparmurat Niyazov, the president of Turkmenistan, had died. Apart from a general interest in current affairs why, you might ask, should anyone want to share this news about the leader of a far away country with me? Some time ago, with my colleague Bernd Rechel, we tried to understand what was happening to the health of the population of Turkmenistan. Our problem was that the Turkmen government had stopped sending health data to the WHO in 1998. What data did emerge was barely credible, such as the admission that there were 2 (two) cases of HIV infection in the country, despite its location on the edge of the region with the fastest spreading epidemic in the world, despite the presence of a thriving sex industry, and despite the existence of extensive drug trafficking, with credible evidence that senior members of the regime were involved in it.
At that time Turkmenistan mainly attracted attention in the international media as a figure of fun (remember, this was before Borat drew attention to Kazakhstan). We occasionally saw pictures of the golden statues depicting himself that were adorning Ashgabat, or heard about his injunctions against beards, music on car radios, and gold tooth fillings. Indeed, there seemed no end to his eccentricities, including renaming much of the country after himself, or rather his adopted name Turkmenbashi, or leader of the Turkmens, and what he didn’t name after himself he named after his family – he was orphaned as a child. He published his thoughts in a book entitled the Ruhnama, which soon became required reading for all Turkmens. It is worth looking at for an insight into his deranged thinking. Yet there was a sinister side to his regime that was not reported. After a failed assassination attempt (or at least that was how it was portrayed – there is credible evidence that it was a setup) he launched a purge against opponents, or at least those he imagined to be opponents. Those unlucky to be caught up in his purges were tortured and many fled into exile. He then launched a sustained attack on the health and education systems, and indeed anything he didn’t understand. Other casualties were opera and ballet, which he described as “unnecessary”. Universities and the Turkmen Academy of Sciences were closed. His attack on health care was also severe. All hospitals outside the capital were closed and health workers were sacked, to be replaced by untrained military conscripts. We summarised all of this in a book, which we wrote by searching for snippets of news from the growing émigré sources, as well as information from some people who were working within the country in various organisations. We described a country in which outbreaks of serious contagious disease, including plague, were suppressed. Anyone seeking health care had to pay for it, often incurring catastrophic expenses. Health workers themselves struggled to survive. Many nurses drifted into sex work. Doctors demanded that women wanting immunisations for their children prove they were suitable mothers by undergoing internal examinations, which of course they had to pay for. Inevitably, Turkmenbashi was unwilling to share the privations being suffered by his compatriots. He knew he had heart disease and each year he flew in a group of German doctors to check him out.
After we published the book, Lucy Ash and Sian Glaesnner, two BBC reporters, went to Turkmenistan, posing as tourists. The programme they made was horrifying, allowing Turkmen people to recount the experience of everyday life. Shortly afterwards I went with Lucy and Sian to describe our findings to UN agencies in New York and to the State Department and USAID in Washington. We were accompanied by a Turkmen former journalist who described a graphic example of field epidemiology, in which he counted the growing number of gravestones for infants in a local cemetery. A number of international agencies used our work to exert pressure on the Turkmen government but there was little they could do when the leading western and ex-Soviet governments were unprepared to act.
So where now for Turkmenistan? The omens are not good. His deputy, Gurbanguly Berdymukhamedov, has been given the job of arranging the funeral and is acting prfesident, even though this is actually a departure from the procedure set out in the constitution. He is a former dentist and, in addition to being deputy prime minister, served as minister of health. Formally, he is ineligible to stand as president when the position is decided in a few months, although the constitution in Turkmenistan seems to be somewhat flexible. Another one to watch is Agageldy Mamedgeldyev, the defence minister. Unfortunately, neither has a reputation suggesting that they will depart from the policies of their predecessor. There is, however, another possibility, that Turkmenistan will fall victim to the tribal tensions that are just underneath the surface. Tragically, the precedents of what happens when a strong leader leaves the scene, in Iraq or Yugoslavia for example, are not encouraging.
One can only hope for a better 2007 for the people of Turkmenistan. Unfortunately I’m not optimistic.

14th December. Final trip of the year. The same as the first one last January, to Brussels on Eurostar. This time for the Steering Committee of the Observatory. This is our six monthly opportunity for all the partners to meet together. It has been an incredibly busy and productive year, measured not just in the books, articles, and policy briefs we have published but also the many interactions with policy makers. A highlight was our work to support the Finnish EU presidency in September and next year we will be working closely with the Germans and Portuguese. This time we had a staff retreat after the Steering Committee. Although we senior staff see each other regularly, often weekly in different countries, it is very easy for the people who do the real work to become isolated from one another when they are scattered between London, Brussels, and Berlin. It was an excellent opportunity for everyone to share experiences and to understand the scale of the operation. We are constantly amazed by how much our products are used, and where. However, we were somewhat puzzled by a recent request to translate our Health Systems in Transition report on Norway into Chinese! After dinner we all went for a stroll in the Grand Place, which was beautifully decorated for Christmas. A perfect ending to the working year (almost).
Home on Saturday (I’m catching up on this week’s blog on the train). Sitting in the Eurostar lounge I read in European Voice how the new member states will join the Schengen Agreement in 2008, so that I won’t need to go through frontier controls when I travel among them. Yet some things never change. After check in at Brussels I go through Belgian passport control, only to stand in line 10 metres further on to clear British immigration. Surely, you ask, could the two governments not find some way to combine their operations? Of course not. That would require the British government to concede that it really is part of Europe. And if it did that, the next step would be the adoption of the Euro….. And then, of course, the world would end…

Arrived at Heathrow Terminal 4 on Wednesday after a flight from Tel Aviv of over 5 hours. Given the consistency of my experiences here over recent weeks, it was little surprise to be told that we had to wait 40 minutes for the steps to be brought to the plane! I’m beginning to think it might be easier to take the Eurostar to Paris and fly from there when I travel (I’m actually writing this a few days later, by which time the Christmas rush has hit my favourite terminal – amazing how the Christmas holidays appear without any warning – and the news reports show queues snaking into the car parks – a marked contrast to Tel Aviv where it took less than 5 minutes to get through security, showing that security and endless queues don’t have to go together, but only if, unlike BAA, you can actually manage an airport).
This afternoon is one of the highlights of my year. The students on my course on Issues in Public Health have to present a strategy to prevent cardiovascular disease in another European country in the most informative and, especially, entertaining way possible. The goals are to get people from different cultures to understand where they each come from, to learn about somewhere else, and above all to realise that public health does not have to be boring (OK, I know it often is, but not what I do).
Once again, the students excelled themselves. The Austrian strategy was in the form of the TV quiz programme “The weakest link”. The Portuguese one had a football theme, with the group clad in Portuguese football shirts and a referee who shoed the yellow or red card to team members who persisted in smoking and eating unhealthy food. The Estonian group created an “Estonian Rhapsody” in which the elements of their strategy were accompanied by musical extracts from Queen. The French group offered a demonstration of healthy cooking featuring an extremely passionate (in all senses of the word) television cook (I wonder who she was modelled on – Nigella) supported by Zinidine Zidane, and accompanying by an attempt to bribe the judges with wine a cheese (an approach taken, in various forms, by several teams). Norway had an integrated programme featuring walking longships (instead of the more usual walking school buses, in which a children join a growing line walking past their houses to school) as well as a system of food labelling in which healthy foods get a Viking stamp while unhealthy ones get a troll stamp. The goal is to maximise the Viking: Troll ratio in shops! The Albanian strategy was built on the Matrix films, combating attacks from secret agents representing fat, tobacco, and alcohol. The Ukrainian strategy began with a health minister clearly modelled on Borat inviting the audience to a lard eating festival while complaining about public health experts who tried to stop vodka drinking and unsafe sex. His speech was interrupted by an ivasion of the stage by other students in orange boiler suits who launched the second Ukrainian revolution, in this case against cardiovascular disease, which would provide for oranges to be eaten by all. However the winner was the Bulgarian group. Who staged an e-mail exchange between a wealthy Russian magnate and a Bulgarian public health doctor he had met at a conference. His attempts to woo her involved offers of money, a diamond (which she gave to the local orphanage, hospitals (which she also rejected, pointing out that Bulgaria has enough hospitals already), and eventually €10,000 to all unhealthy Bulgarians. They finally agreed that he would support the construction of a public health institute (he offered 100 of them) and they finally met. Yet, as they embraced against a background entitled “the agony and the ecstasy” he collapsed with a heart attack!
I know the judges (Stig Pramming and Christine Hancock from the Oxford Health Alliance and my colleague Dina Balabanova (purely a coincidence that one of the judges is Bulgarian!) were really impressed, not only at the creativity and imagination shown by the students but also because, underneath the entertainment, they had really got to know the health problems and policy responses in the countries allocated to them. Who said public health is boring!

To Jerusalem. Two reasons. The first is a meeting of the International Advisory Committee of the Israel National Institute for Health Policy and Health Services Research. This is an organisation established in the early 1990s, in preparation for the introduction of a national health insurance system in 1995. This introduced universal coverage with contributions paid from taxation and distributed according to a weighted capitation formula to one of four Health Maintenance Organisations (HMO). The full story of how this came about, despite opposition from powerful vested interests, is told in the Israeli Health System in Transition report. One element of this reform was the creation of the Israel National Institute for Health Policy and Health Services Research. It was funded by “up to 0.1%” of contributions to the HMOs. It is always important to get the wording of legislation absolutely correct, a point that the UK government consistently fails to grasp. In this case it was the “up to” that caused the problem as it was too easy for this to be clawed back when the economic situation was unfavourable. Yet notwithstanding budgetary cuts, the Institute has supported a wealth of mainly small but useful studies providing answers to practical problems. Looking ahead, the Institute faces the same issues as any policy-relevant research funder. Do you wait for investigator instigated research or do you take a more proactive stance, identifying emerging issues and seeking to encourage proposals that will address them in a timely way so that the answers will be available when needed.
The second reason was to speak at the Institute’s international conference on health care reforms. We had an almost complete participation from the European Observatory’s senior staff at the conference and there were lots of excellent presentations. I especially enjoyed Steven Schroeder’s critique of the US health care system and learned a lot from Naoki Ikegami’s presentation on long term care insurance in Japan. Hans Stein gave a superb speech on globalisation.
There were four parallel streams and I was giving the plenary introduction to the one on chronic disease. It had been organised superbly by Leon Epstein, with lots of really good papers (I leave others to comment on my own of course!). With my colleagues Ellen Nolte and Dina Balabanova, we have been thinking a lot about this over recent years. We have a new book coming out from the Observatory in 2007 and have contributed to the World Bank’s new strategy on non-communicable diseases in low and middle income countries. Complex chronic diseases are clearly the main challenge facing health systems in the 21st century yet many politicians simply don’t get this. They persist in their simplistic ideas of individual patients making one-off trips to a health professional for a self-limiting condition. Of course they never make this model explicit but it is clear that it underpins the paradigm they inhabit, dominated by attempted to measure individual encounters, patient treatment episodes, and the like, as well as, at least in England, to promote “patient choice” as a value above all others, including the more usual ones such as equity, effectiveness, and efficiency. Yet it is all too clear, from even the most superficial review of the literature, that the key to effective management of chronic diseases is integration, not fragmentation. Ellen Nolte and I have highlighted how, in a country characterised by fragmentation of care, the USA, outcomes, in the form of death rates from diabetes and other chronic diseases among young people, are many times higher than in Europe, although even here we could often do better. Yet bizarrely those advising English ministers seem determined to attract American providers of chronic disease programmes, persisting in this goal even in the face of recent evidence from the early examples in England that they are no better than what was already there.
Of course you need to do more than simply integrate services. You need to establish mechanisms that allow them to respond to patients’ needs, to adapt to changing technologies, evidence, and expectations, and to find ways to develop the new types of workers that will be needed for these changing models of care. Yet the introduction of market-based reforms in many countries is actually making this more difficult. Unfortunately, these reforms are driven by ideology rather than evidence. In my talk I drew initially on some examples from other sectors in the UK, where apart from the USA (and to a lesser extent, The Netherlands) this paradigm has taken root most firmly among the political elite. These were the break-up of the telephone directory enquiry service, long seen as a natural monopoly and run cheaply and efficiently by British Telecom. The government, in its wisdom, decided that the service would be improved by competition. There was a feeding frenzy as companies, many with no experience in telecommunications, moved into the market. Like any market there were winners and losers. The winners were the advertising companies who were the beneficiaries of vast campaigns to attract customers to the different providers. Of course everything has a cost and this was recouped by higher charges (albeit somewhat opaque as they developed incredibly complex pricing structures) and cuts in those providing the service. The result? Service quality and later calls to directory enquiries have plummeted and the leading provider is now abandoning its main product in favour of a computerised “voice recognition” model. Prepare to receive even more wrong numbers! The second example was railway privatisation, where the government’s subsidy to the private operators is now double what it was under state ownership. A reduction in expenditure on track maintenance was associated with some high profile crashes, in which people died. The company owning the track failed and was taken back under state ownership, since when quality has improved and it has turned a loss into a £750 million profit! Yet still we are told that market solutions are needed so that the private sector can sort out the inefficiencies of the public sector! Given that one of the UK Prime Minister’s former health advisers was also speaking at the conference, extolling the virtues of patent choice, it was perhaps a little insensitive of me to compare Mr Blair’s campaign of modernisation with Mao Tse Tung’s Great Leap Forward. However I leave it to others, especially those who have the misfortune of trying to implement the constant stream of contradictory initiatives emanating from Whitehall, to decide whether the analogy is valid.
The final reason for being in Israel was to move forward on our existing collaborations with Israeli colleagues. They have been developing an important new initiative entitled Healthy Israel 2020, in which a number of committees have been established to design a health strategy linked to achievement of health targets. A key goal has to be the reduction of smoking. There is a ban on smoking in public places but it is not enforced, something I called attention to in an op-ed in Haaretz where I argued for a smoke-free Israel earlier in the year. One obvious way forward is to levy large fines on bar and restaurant owners who allow smoking on their premises. At last it seems that the Knesset will support such a move. The next challenge is to get the Finance Ministry to provide the funds that are needed for the Healthy Israel programme to move forward.
I can’t finish a blog about a trip to Israel without addressing the political situation. A number of people invited to the conference refused to attend because of their political beliefs, a view I can understand, even if I disagree with it. After a lot of thought I’ve taken the decision to work with Israeli colleagues because many of those I work with have done a great deal to bridge the divide with their Palestinian colleagues. They are as horrified as I am by the atrocities by both sides in this ongoing tragedy. What’s more, I can hardly blame others for the actions of their government, given some of the things mine does. Unfortunately as in my own Northern Ireland, those advocating mutual understanding on both sides are in the minority.

To Taipei this week, to give the plenary speech at the 2006 Global Health Leaders Forum. This is the second year that the Taiwanese government have organised a major conference on health. My involvement with Taiwan came about in a very roundabout way. Last year I was Armenia, at a time when a gamily just across the border in Turkey was infected with avian flu. Turkey has an effective surveillance system, appropriate measures were taken, and the international community was soon alerted.
Yet the occurrence of a bird-borne disease in this part of the world raised important questions. Few people can be unaware of the war in Chechnya yet this was only one of a number of local conflicts that took place in the aftermath of the collapse of the USSR. The result has been that, in the Caucasus and Moldova, a number of territories broke away from the then newly independent republics. During our discussions in Armenia we were focusing on Nagorno-Karabach, an area populated by Armenians but entirely surrounded by Azerbaijan. Our question was what would have happened if an outbreak of avian flu had occurred there, or in one of the other enclaves in this region. This set us thinking because, of course, there are a number of places across the world that are not recognised as independent states but are not fully under the control of a government recognised by the international community. Other examples include Western Sahara, the Republic of Northern Cyprus, Kosovo, and the Palestinian Territories.
With my colleague Rifat Atun, from Imperial College, we set out to discover what arrangements were in place in these territories. The picture was very variable. In some, reporting channels of varying degrees of formality existed. For example, the Palestinian Authority works closely with the Eastern Mediterranean Regional Office of WHO. In others, such as the Trans-Dniestr republic that has declared its independence from Moldova, any information flows were intermittent at best. In most of these cases there were problems with both surveillance infrastructure within the territories and communication channels to the outside world.
There was, however, one exception among the places we were looking at. After the Chinese civil war at the end of the 1940s the government of China withdrew to the island of Taiwan, leaving the mainland under the control of Mao’s communist party, which declared itself the government of the new People’s Republic of China (PRC). [see Wikipedia for fuller description]. Until 1971 the government in Taiwan was recognised by most countries as the legitimate government of China but following the Richard Nixon’s rapprochement with China, this recognition was shifted to the government in Beijing. For reasons too complicated to go into here, Taiwan is considered as a province of China and the government of the People’s Republic is considered to represent it in international affairs. Why is this relevant to avian flu, you ask? Because the international surveillance system, co-ordinated by the WHO, is based on communications between WHO and the governments of its member states. Although the PRC government claims to be able to speak for Taiwan, it has no formal means of communicating with Taiwan and the WHO was unable to contact the Taiwanese authorities without getting permission from Beijing.
In the course of our research on these areas outside the global surveillance system we obtained a copy of a memorandum of understanding between the WHO and the PRC that set out the circumstances in which contact with Taiwan could take place. While it was an honest attempt by the WHO to make things work, the guidance was totally inappropriate for dealing with an emergency. Permission had to be sought from the Chinese contact point in Geneva 5 weeks in advance of making contact. The PRC contact point could decide which Taiwanese experts should be contacted. If Taiwanese experts were invited to technical meetings an expert of similar status should be included. Taiwanese citizens were not permitted to attend WHO meetings as members of NGO delegations. Most bizarrely, because writing “Taiwan” on an envelope (necessary if it was to reach its destination) would imply recognition of its independence in the view of the PRC, all paper communications had to be faxed.
This system was put to the test during the SARS outbreak, when e-mails from the Taiwanese authorities to the WHO went unanswered for weeks. This is a ludicrous state of affairs, not only because of the consequences in cases of emergency but also because it denies the very considerable Taiwanese expertise to the WHO.
So that is how I became involved with Taiwan….
Anyway, the conference was excellent, with some really thought provoking presentations. Among the most noteworthy were a set of presentations on migration of health workers, a huge challenge for many countries especially in sub-Saharan Africa. Yet there is some hope, and we heard about the integrated approach being taken by the government of Malawi to stem what has been a haemorrhage of skilled staff, so that this country of over 12 million people does not have a single cardiologist or urologist. The strategy described was multi-faceted; a core element was to raise salaries of health professionals and to improve their working conditions. Early results suggest that it may be working.
Others looked at a range of complex ethical issues. Barry Pakes, from the University of Toronto, discussed the many ethical challenges posed by pandemics, especially those arising from limited stocks of vaccine, while Alireza Bagheri, also from Toronto, discussed the challenges posed by the market for organ transplants in Asia. All in all, much to think about on the long flight home.

Another excellent ECOHOST seminar this week. Professor Larry Brown, a political scientist from Columbia University in New York, chose a deliberately provocative title: “Why does the US health system not just collapse”. As Larry noted, people have been predicting its collapse for decades yet it still managing to limp on. I stress “limp” because, not only is it ridiculously expensive, but as Ellen Nolte and I have shown, it achieves appalling outcomes, with death rates from chronic diseases (the real test of a modern health care system) about 4 or 5 times worse than in any western European country. In passing, this highlights the rClearly this was a question that many people wanted an answer to – while we are normally delighted if we attract 30 people to our seminars in Russia, in this case there was standing room only, with the audience spilling out into the corridor!
So what is the answer? One reason is that the picture most of us have of the US system, characterised by employer- or individual-funded insurance plans, is really quite misleading. About 15% of the population have no coverage but they are able to receive care (of a sort), mainly from publicly funded facilities. A further 40% of the population receive care through other publicly funded mechanisms, such as Medicaid, Medicare, and the Veteran’s Administration, as well as the S-CHIP plan that covers children that would otherwise be excluded. Thus, a full 45% of health care funding, covering 55% of the population, is from government sources. In other words, the system that we think of has failed, but the state has taken action to pick up the pieces.
However, that is not the whole story. We heard of examples where sophisticated private hospitals had stepped in to help rescue county hospitals facing financial problems, either by direct financial help or by lobbying for local taxes to support them. This seems strange behaviour in what we are led to believe is a competitive market. The reason is, of course, clear. Some of those county hospitals have the greatest experience with trauma and, while the wealthy wouldn’t go there for their hip replacement, they want to know that there is someone with lots of experience if they are unlucky enough to get shot. However, even more importantly, if those county hospitals closed then they would have to do something to help the uninsured, people whom their normal customers pay good money to stay away from (except when they need a gardener or a maid). In other words, the US health system is clearly failing its citizens but it is not being allowed to collapse. What will happen in the future? One person in the audience asked about the proposal by Massachusetts to mandate universal coverage. An interesting idea, but will it be feasible given the enormous costs in the US health care system?
While it was great having so many students from LSHTM present, the people who really need to hear this are some of those advising our Prime Minister, who seem to have some idealised vision of health care across the Atlantic and who seem determined to introduce their distorted vision here. Still, given their ability to hear the same messages as the rest of us but to interpret it in a way that is completely different, maybe it would just be a waste of time.
That leads me nicely to a series of conversations I have been having this week. Patricia Hewitt has confidently predicted that the NHS in England will be in financial balance this year. Maybe it will. Yet maybe that is not the question we should be asking. Rather, will it be in a form that is recognisable. OK, maybe the consequences of present policies won’t become entirely apparent this year, but unless there is a major policy reversal they certainly will in a few years.
The problem is this. For the past few years we have been putting in place a system of hospital financing that is unique internationally in its inflexibility. New developments funded by private finance require the hospital to pay (very) large sums of money for years in the future (mostly 30 years but in a few bizarre cases, for 60 years). Now think how much hospitals have changed even in the past decade. Unfortunately, the contracts are so tightly specified that any changes will be prohibitively expensive. In other words, the costs facing hospitals are to a large degree fixed.
In marked contrast, the new funding system is, in international terms, uniquely volatile and unpredictable. Hospitals will be funded on the basis of the numbers of patients treated (adjusted for their severity and complexity). Sounds simple. Of course, it is not. While lots of countries have such systems in place, none have ever introduced one so quickly, covering such a broad range of patients (from the relatively easy to categorise, such as simple elective surgery, to patients with multiple complex chronic diseases that defy simple categorisation), and with such a high proportion of total cost being variable (100%). Everyone else has introduced it incrementally, and has included lots of safety mechanisms.
The implications of fixed costs and unpredictable income, with both largely outside the control of hospital managers, seem fairly obvious, but clearly not to everyone.
As if that was not enough, the NHS governance systems are struggling to emerge from a wide-ranging reorganisation that has led to the early retirement of many talented staff and the almost complete loss of institutional memory. However, just in case the NHS might be able to survive this situation, a large number of privately owned independent treatment centres are being funded, many benefiting from highly preferential funding packages, in which, in some cases, they don’t even have to do the work they were contracted for to be paid.
The Secretary of State may be right that the overall NHS budget will be balanced by the end of the year but there will be many winners and losers, with specialist services, and in particular children’s and orthopaedic hospitals, the most vulnerable. I cannot help but be reminded of the quotation from a US Army Major in Vietnam after the destruction of the village of Ben Tre - "It became necessary to destroy the village in order to save it." It is difficult to avoid concluding that a similar mind set holds sway in Whitehall.

There are far too few PhDs on public health in the former Soviet Union. This week saw a small but significant increase. Last Friday Kirill Danishevski, one of my students, successfully defended his thesis in London, on “Maternal health care in Russia: understanding clinical practice in an information poor setting.” In brief, Kirill was looking at the use of clinical evidence in Russia, a subject that I spoke about in the Cochrane Lecture earlier this year (“Cochrane on Communism”), where I benefited from Kirill’s insights. He chose obstetric practice because it was an area where the evidence on many aspects of care is clear, set out in the excellent book “Effective Care in Pregnancy and Childbirth”. Using this as a starting point, he looked at how far official Russian guidance was consistent with best evidence and then at how well actual practice complied with it. The answer was, unexpectedly, not very closely at all. The challenge then was to understand why and his research provided valuable new insights into this situation. This involved analysis of the correlates with different practices, detailed interviews with health professionals, and a statistical technique known as conjoint analysis, which uses case histories to reveal the principles underlying clinical decisions.
Some papers arising from the thesis have already been published; others are on their way. However, all in all they paint a rather worrying picture of the quality of clinical care in Russia today and remind us of how far we have to go to a situation in which ordinary Russian people can be sure that the care they get will at least do them no harm.
The second thesis defence was the same day, but in Stockholm. My colleague Andy Stickley was defending his thesis on interpersonal violence in Russia (See: http://www.diva-portal.org/su/theses/abstract.xsql?dbid=1331 ). Although I obviously wasn’t there, his opponent was my colleague from here, Ellen Nolte. PhD defences in Sweden and the UK are very different – in public in Sweden and in private in the UK. What’s more, in Sweden the opponent begins by giving a public lecture on the candidate’s thesis, to ensure that it can actually be understood I guess! Andy’s thesis was another superb contribution to our knowledge of Russia, using imaginative analysis of statistics going back to Tsarist times to track the changing nature of Russian society and, in particular, the role played in domestic life (and death) by alcohol.
The third defence was on Monday at Oxford – and this time I was the examiner. Dana Sumilo was defending her thesis on the epidemiology of tick borne encephalitis in the Baltic States, work she did under the supervision of Sarah Randolph, who is the expert on this disease. In 1993 there was an almost simultaneous and very dramatic increase in the incidence of tick borne encephalitis in Estonia, Latvia and Lithuania. The question was why? As always, one learns an enormous amount by examining theses and I now feel much better acquainted with the two species of tick found in European forests. This is a disease where one wonders how it ever survived. It needs very special climatic conditions and animals to feed on, and humans are really only at risk if they go into affected forests at certain times. The virus is spread from one generation of tick to another only when the conditions are right for the two forms (larval and nymphal) of the tick to feed together!
Inevitably, sorting out what was going on was incredibly complex, involving climate, agriculture, and human activity. I will leave it to Dana to describe what the findings were when she writes the papers on her research. However, for me an important message was how difficult it can be, with current epidemiological and related methods, to understand the health effects that arise from the changing world that we live in.

Back in London after an overnight flight from Cape Town. Heathrow, as always, seriously dysfunctional – this time it was a clogging up of the luggage delivery. It is now so obvious that it cannot cope with the volume of passengers, not helped by the British Airports Authority forgetting that hey are meant to be running an airport and not a shopping mall. Anyway, despite the intense irritations, still really enthused by events at the OXHA summit.
If you haven’t checked out the web site - http://www.3four50.com/ - don’t hang around reading this. I really liked the video and audio blogs – David Matthews – a quiet, apparently serious diabetologist at Oxford missed his vocation as a stand up comedian – great audio blogs, David! Eddie McCaffrey must be on track for an Oscar as a director of so many superb film clips! Trying to get chronic diseases on the agenda is a colossal task but this web site must be a key part of any successful strategy.
Anyway, back to the office and a lunch time seminar by Barbara Profeta, one of our research students. Barbara has been doing some fascinating work in the Altai region of Russia. This is in southern Siberia and has the dubious distinction of lying under the flight path of the Russian rockets fired from the Baikonur space station in Kazakhstan. Unlike the US launching sites, in Florida and California, where the fuel tanks fall into the sea, these ones fall on land, among the Altai people. As if it was not enough to have large chunks of metal fall from the sky, these things contain unspent and highly toxic rocket fuel. The health of the Altai people is dreadful, but then so is that of the other inhabitants of Russia. The difference is that many of the inhabitants of Altai blame their poor health on the rockets. There is, inevitably, a small problem – the toxic rocket fuel is undetectable in the environment.
I’ll leave it to Barbara to describe her own work but the fascinating story she tells raises lots of issues. Why is it that people so often focus on the wrong reasons for disease and ill-health? There are many reasons why the people of the Altai have poor health, not least the severe deprivation and heavy drinking, but falling rockets is not one of them. Similarly, ask 100 people about cancer in Ukraine and you can be sure many of them will blame Chernobyl, conveniently ignoring the ubiquitous cigarette smoke. That reminds me of a time many years ago when I was working in Northern Ireland, where there were concerns about radioactive releases from the nuclear reprocessing plant, Sellafield, just across the Irish Sea. These concerns were expressed at public meetings in rooms that contained highly toxic levels of tobacco smoke that seemed not to worry those protesting about the much smaller (and possibly only theoretical) hazard from radiation.
In a strange way, that takes us back to Cape Town. Faced with an enormous toll of death and disability from non-communicable diseases, the world’s political leaders are finally galvanised into action on health by …. Avian influenza, a disease that has so far afflicted less than 200 people. Yet as Derek Yach pointed out in Cape Town, while avian influenza kills 50% of those affected, so does smoking cigarettes. The different degree of urgency in tackling these two problems is striking.

Once again the Oxford Health Alliance (OXHA) summit has lived up to expectations. Some great presentations and lots of fantastic ideas. As you can read this blog on both my blog page and the OXHA one, if you are using the former then you really should check out the new OXHA one www.3four50.com It’s full of great ideas, stories, pictures and blogs. '3FOUR50' represents the 3 main risk factors (poor diet, lack of exercise and smoking) that cause four chronic diseases (cardiovascular disease, some cancers, chronic respiratory disease and diabetes), which in turn is estimated to be responsible for 50% of the world's deaths over the next two decades. Check it out!
We had a remarkably inspirational speech by Tommy Thompson – the former US Health Secretary. He showed what it is to be a great communicator, drawing on his personal experiences and framing the big issues in terms of how they affect ordinary people. He had obviously been moved immensely by a visit he made to a village in Uganda a few years ago where he talked with two families who had been afflicted by AIDS, as well as by the experience of administering polio vaccine to babies in India. This is a lesson for public health professionals – we need to remember that the statistics we so often present represent thousands, or even millions, of individual lives.
Parallel sessions pack a lot in but mean that you can’t get to everything. This morning there were four equally enticing sessions – healthy workplaces, the economic case for investing in health, youth, and designing health cities. I was at the economics workshop – with lots of discussion about the relative emphasis placed by funders on treatment versus prevention, and infectious versus non-infectious disease.
Our starting point was a superb report on the economics of chronic disease in middle and low income countries written by a team led by my colleague Marc Suhrcke – see
http://www.oxha.org/initiatives/economics/chronic-disease-an-economic-perspective
We concluded that we need to break down the silos that seem to surround many groups, so that we see the production of health as a seamless whole, with prevention integrated with treatment and a balanced and sustainable production of the people who deliver care and the things they need to do it, including pharmaceuticals. In particular we need to break down the barriers between infectious and non-communicable disease – in practice the management of AIDS and diabetes have a lot in common – both are complex diseases requiring life-long treatment involving many people including trained health workers and informed and engaged patients and their families. We returned to the WHO/ HAI report on drug pricing I referred to in my last posting. It is clear that governments are making a lot of money from tariffs and taxes on essential medicines – maybe we need to start promoting the simple message “Don’t tax the sick”. After all, governments can get the money from other sources in ways that might even promote health, for example by taxing cigarettes, or maybe even unhealthy food.
Listening to the feedback from the other workshops, they all sounded great, especially the healthy city design one, which started with maps of cities using Google Earth.
Finally, we had an afternoon session on how the www.3four5.com website might develop – of course we don’t know because it is user defined, like Wikipedia. Still, it all sounds very exciting!

Spent the weekend cocooned in a hotel near Stellenbosch, in the middle of the wine region of the Western Cape province of South Africa. The reason – a meeting of an advisory council convened by Johnson & Johnson to discuss some of the major challenges facing health care globally and what different actors can do about it. It was a somewhat diverse group, including Derek Yach from the Rockefeller Foundation, Kgosi Letlape, president of World Medical Association, Tommy Thompson, former US Secretary of Health and Human Services, Stig Pramming and Christine Hancock from the Oxford Health Alliance, Delon Human and Nigel Majakari from Health Diplomats, a company based in Geneva which looks at ways in which health professionals can build alliances that can tackle some of the issues where the politicians have failed. We had a wide-ranging discussion – there are a lot of challenges! However we homed in on a few key issues.
One was what is, for many countries, a crisis already facing the health workforce. This was highlighted in the 2006 World Health Report. Several points emerged. One is the need for new types of health workers, and in particular nurses with enhanced skills who, with the benefit of newly emerging technology such as miniaturised testing kits will be able to take over many of the tasks currently undertaken by doctors or, more often, not undertaken at all because there is no-one to do them.
Of course this is critically dependent on the ability to retain skilled staff in each country’s health workforce. One problem is migration. Here a major driver is the failure of the USA to train enough nurses. Although things are now improving a bit, if there is not a dramatic increase in recruitment of student nurses in the US that country could suck in an enormous proportion of the next generation of nursing graduates from across the developing world.
A second problem is retention. We were told that the number of qualified nurses living in South Africa but not working as nurses exceeds the number of South African nurses working abroad. It is obvious that much needs to be done to improve the rewards and working conditions for health professionals. So far this is stating the obvious, but we were able to explore a number of ways in which these issues might begin to be addressed.
Clearly there is no point in having skilled workers if they don’t have the tools to do the job. And often they don’t. In many countries drugs are either unavailable or unaffordable. We discussed the recent excellent report on access to drugs - http://mednet3.who.int/medprices/CHRONIC.pdf - . This confirmed the problems that people with chronic diseases face in accessing the pharmaceuticals they need to function and, in many cases, to stay alive. However, a critical finding from their assessments was the extent to which the cost of drugs was driven by mark-ups in country, such as taxes, tariffs and, particularly, mark-ups along the distribution chain. However, there are other problems. In some countries, such as Russia (which I know best) there is an enormous amount of inappropriate prescribing of drugs sold at inflated prices, simply because doctors are getting back-handers from the pharmacists from whom patients must buy their drugs. Yet the situation is even worse because, in many countries, there are substantial numbers of counterfeit drugs – it was estimated that 26% of all drugs prescribed in South Africa were counterfeit, with even higher levels in many other parts of Africa. Yet we also learned that there was no room for complacency even in developed countries and we heard about a patient in the USA who was deteriorating unexpectedly while on chemotherapy. Her nurse checked out the drugs she was getting from the local pharmacy and discovered they were counterfeit and ineffective. We also learned of an initiative to raise awareness among nurses worldwide about this problem, so that they would at least think of it when the response to therapy was worse than expected. Again, things can be done. There was consensus that the responsible pharmaceutical industry must understand the ways in which its products get to people across the world. It is not enough just to put a product on the market and hope that it will get to those who need it. There is also a need for global action on counterfeit drugs, something that will require the creation of new alliances linking many different players.
Health is everyone’s business. The benefit of meetings such as this is that we can draw on experiences from people who have experience in government, international agencies, the private sector, academia, and NGOs. Of course we need to do much more than talk but I did feel that this group has the potential to catalyse actions that can begin to address some of these challenges, as well as to enable others to understand the challenges we all face in bringing our own communities with us as we move forward.

Another bad experience at Heathrow. Landed from Geneva on time and then spent 40 minutes waiting for a parking place. The same thing happened last time I came in from Geneva. This airport is barely functioning. Rapid dash through flight connections where an Australian couple in front of me had their empty drinks container taken from them and thrown into a large bin by the security staff. It reminded me of the time when I was going through Heathrow just after the latest inexplicable security restrictions came in. I dutifully obeyed the instruction to remove my laptop from its bag, only to be stopped by a guard because I now had two pieces of hand luggage – the laptop and the bag. He insisted I put it back in the bag and walk past him and then remove it again for screening! Insane or what?
Anyway, just caught my flight to Cape Town, where I have two meetings – Johnson & Johnson’s Global Health Advisory Committee and the annual conference of the Oxford Health Alliance. After an overnight flight I finally get to my hotel and unpack my bags, to be reminded of where I had just come from. In Switzerland I had gone out to dinner in a local restaurant which, like nearly all Swiss restaurants was full of cigarette smoke. Even though the ban on smoking in public places has yet to enter into force in England, it is already seen as unacceptable in many restaurants to smoke. Not so in Switzerland. From out of my suitcase came the strong smell of stale smoke. I wonder whether smokers ever realise just how awful their clothes smell. Or maybe the damage that the smoke does to their nasal epithelium means that they just don’t notice it.

To Montreux, for the annual European Public Health Association meeting. This is the key meeting for public health professionals in Europe and I’ve only missed one in its fourteen years. I am only involved in the association fairly peripherally (I was a member of the executive board for a number of years). However it remains a great pleasure to see how well it is doing. This year saw a record attendance – 1,000 people from all over Europe as well as significant numbers from countries as far away as Korea, Japan, the USA and Nepal.
One of the most exciting developments has been the creation of special interest sessions. These cover topics as diverse as health services research, utilisation of medicines, chronic diseases, and child and adolescent health. Obviously it would be possible for all these groups to run their own conferences but bringing them under the umbrella of EUPHA creates so many opportunities for cross-linkages and for people who, while not focusing exclusively on these issues, can get a taster of the key contemporary issues.
As always there were many excellent presentations and the problem we now face is that, as the conference has grown, there are more parallel sessions so it is really difficult to choose which to attend. I was especially pleased to see several papers on health in the former Soviet republics of central Asia, a region that is too often ignored. I also listened to some excellent papers on social capital and health, including a fascinating study of the association between religion and suicide in Switzerland. It made use of the Swiss National Cohort, a unique database using probabilistic linking to match census and mortality records; it is apparent that this will be an extremely valuable resource in the future. Our team had quite a few papers on topics ranging from the impact of health care in Ukraine to the integration of health in hospital design and the problem of health surveillance in non-states. It was also good to see results from some of the Europe-wide databases, such as SHARE (Survey of Health, Aging, and Retirement in Europe). Europe is at an enormous disadvantage compared to the USA because of the failure to invest in the data resources that are needed to undertake the research it needs to inform policy. When we undertook our review of the contribution of health to the economy in Europe for the European Commission we had to rely disproportionately on American data sets. This is something that has to be addressed at a European level but it is far from clear who should do it, not least because most of the possible organisations are dependent on short funding cycles with no guarantee of continuity. DG Research is sympathetic but its role should only be to fund development work. DG Sanco must be involved but, especially after suffering drastic budget cuts, is in no position to do much. EUROSTAT would be a logical player but its track record is, to say the least, weak. Perhaps this is something that the European Parliament could look at?
Unfortunately, this year I could only stay for the first part of the conference as I have to go to South Africa for a weekend meeting. This meant that I missed hearing my colleague Nina Schwalbe give what will be the final Ferenc Bojan lecture, although I am grateful to Nina for sharing the text with me in advance – it will be an excellent presentation. The lecture was named in honour of a former EUPHA president and very close friend of mine who established the Hungarian School of Public Health but was killed in a traffic accident ten years ago. I was privileged to give the first lecture in his memory. Things have changed enormously in central Europe, with Hungary and its neighbours now members of the European Union, something that still seemed a long way off when Ferenc died. It is now time to move on and his memory will be honoured in other ways at future conferences.

A really early start – up at 4 a.m. for the flight to Copenhagen and the WHO’s European Advisory Committee on Health Research. We continue to struggle with the problem of how to contextualise evidence. We all know that you cannot simply take evidence from one setting and apply it uncritically in another. Yet we also know that it would be wrong to say that nothing can be applied in another setting.
Often the ability to contextualise evidence simply comes with experience. The more experience one has, the easier it is to discern patterns. Yet how do we help those who have less experience to know when evidence can be applied in different settings.
The problem is particularly great in the former Soviet Union. Although Russian science flourished in the early years after the October Revolution, Stalin’s great break soon brought progress to a halt. A new form of Soviet science, based on ideology, emerged. Soviet scientists became increasingly isolated from developments elsewhere. This meant that, although the Soviet health system achieved much by scaling up basic interventions until the 1960s, it faltered after that, as it was unable to develop a modern pharmaceutical and medical technology industry. This, in turn, meant that the concept of evidence-based health care never developed, something I addressed in my 2006 Cochrane lecture (Cochrane on communism: the influence of ideology on the search for evidence).
The Soviet Union is no longer with us, but its legacy remains. My collague Kirill Danischevski has shown how many aspects of obstetric care in Russia at entirely at odds with the evidence. Many health professionals still have very little access to international medical developments. The challenge is enormous….

From Geneva to Tallinn, in Estonia. I left behind a warm Swiss autumn to change planes in a freezing, snow-swept Helsinki, so different from how it had been when I was last here in September.
I was working with colleagues in Tartu, Estonia’s other main city, on a collaborative project seeking to understand the role of alcohol in the high death rate in this region.
Among other things, we were writing up a rapid situation analysis conducted in Tallinn.
Our focus was on aftershaves and a variety of technical spirits that, in practice, are sold for drinking. They come in 200 ml bottles and are a fraction of the price of vodka. They are sold in kiosks, whose owners seem to get most of their income from these products – the only other things they sell are petfood, washing powder and condoms. There is growing evidence from across this region that these cheap spirits are playing a key role in the high level of mortality, something that is the focus of our ongoing research in Estonia and Russia.

After a late evening flight I arrived at Zurich and took advantage of the wonderfully integrated Swiss transport system, with a comfortable train whisking me to Bern. I had been asked to speak at the conference of the Swiss Health Economics Association. The question they posed was “what is the best health system in the world?”. Not easy. So much depends on what each system wants to achieve. After reviewing the various approaches that had been taken to rating health systems, and showing how the results you get are sensitive to how you ask the question, I decided that, in my view, the best system is one that can anticipate how the world is changing and respond effectively to it.
One way that health care is changing is that it is becoming much more complex. Chronic diseases, such as diabetes, require inputs from a broad range of professionals and from informed patients. This requires organisation – it does not happen on its own. Consequently, we can look at the outcome of diabetes (here, the death rate among young people) as a measure of how systems adapt to this complexity. Some much criticised systems, such as the UK NHS, do very well, whereas others, most notably the US system, perform disastrously. Then there are other challenges, such as preventing the spread of antibiotic resistant bacteria or retaining health professionals. This provides a different way of looking at health systems but maybe wone that we should be adopting more widely.

An early morning Eurostar journey to Brussels and on to Ghent. Ghent is a beautiful city, with medieval buildings lining its canals. Yet it is much less crowded by tourists than its better known neighbour Bruges.
We were holding a conference to present the findings of a major European project that we had been working on for the past 3 years. The topic was one that had little visibility when we started but was now at the centre of the European agenda – patient mobility.
Europe’s governments had long guarded their responsibility for health systems. Yet a growing number of rulings by the European Court of Justice were making this position untenable, as patients were given the right to seek care abroad, paid for by their national health system.
Our contribution was to show that the situation is even more complicated, going far beyond the cases that have come before the court. It includes the development of shared facilities in border areas, people who live in tow or more countries (perhaps weekending in France and working during the week in the City of London), and a growing number of people who retired to another country.
We had come to Ghent because this had been the setting for an earlier conference, held under a Belgian presidency of the European Union, that had placed European law on health care firmly on the agenda. This meeting provided an invaluable opportunity to bring together researchers and policy-makers.

An overnight flight took me to Budapest, followed by a 3 hour drive to Debrecen, in eastern Hungary. This is a city that I have strong associations with. Its university hosts the Hungarian School of Public Health, led by my good friend Professor Roza Adany. I was privileged to play a role in its establishment in the early 1990s, working with Roza’s predecessor, Ferenc Bojan, who was tragically killed in a traffic accident. A reminder that the statistics we work with are the sum of a vast amount of human suffering.
My main reason for being here was to speak at a satellite symposium on health of the Roma people. This was linked to a major health promotion conference that had been taking place in Budapest earlier in the week. The Debrecen School of Public Health has played a leading role in working with the Roma community, training a new generation of Roma health professionals and conducting research that makes their plight more visible.
The rest of the weekend was spent working with my colleague Karolina Kosa. She has been working with a local Roma community who live in appalling circumstances, in derelict buildings with no water or electricity supply and with infestation by rodents. They are now threatened with eviction and Karolina and I were working on a paper that assessed the impact of this and possible alternative measures on their health and welfare, as well as the impact on the responsible agencies.
Once again, there was a reminder of how the shadow of history falls across this region. The following day was the 50th anniversary of the 1956 Hungarian uprising. This had rekindled strong emotions, not least because the Hungarian Prime Minister had recently admitted having lied, leading to large protests outside parliament. As a consequence, Budapest was eerily silent, with the major roads closed off. Fortunately, the next day’s events passed off relatively peacefully.

As soon as I gave my talk in Ireland it was back to Dublin airport for the 1.30 flight to New York, where I had a working dinner that evening.
I was attending the Global Health Advisory Committee of the Open Society Institute (the philanthropic organisation created by George Soros). I’ve been involved with OSI in various ways for about 10 years. Its ethos is based on the concept of an open society, as set out by Karl Popper and interpreted by George Soros, who was his student.
In the region where I work, eastern Europe and the former Soviet Union, it has been one of the very few NGOs working on health. this is remarkable because the former Soviet Union shares, with sub-Saharan Africa, the dubious distinction of being one of only two major world regions where life expectancy is falling. It also has the fastest growing AIDS epidemic in the world. However, the major donors have concentrated their efforts elsewhere so that, as my colleagues Marc Suhrcke and Bernd Rechel have shown, this region get very much less development assistance for health than it should do on the basis of either its economic or its health situations.
OSI’s work focuses on vulnerable populations – the people that are often invisible to the rest of society. They include prisoners, sex workers, drug users, the dying, and minorities such as Europe’s Roma population. OSI has achieved an amazing amount in the relatively short time it has been working in health and is now recognised as a global leader in harm reduction in relation to drugs.
So what were we discussing? A wide range of things, as always. However two stood out. One was the plight of the Roam population in eastern Europe. Some years ago, OSI joined with organisations such as the World Bank to establish the Decade of Roma Inclusion. Progress, especially in the area of health, has been far too slow. There are several problems. One is being able to describe the health problems that the Roma face. Restrictive data protection legislation has made it difficult to conduct the necessary research. However another problem is the legacy of distrust as much research in the past has focussed on the threat seen as being posed by the Roma people to the majority population, such as from infectious disease, rather than the threats that they face from poverty and environmental degradation. However the greatest challenge is how to support the development of Roma leaders who can engage effectively in the struggle to improve the health of their communities, a topic I will return to soon.
The second issue concerned HIV testing. Obviously this must only be done with the consent of those being tested. However should there be opt-out (in which it is assumed that, in certain settings testing will occur unless refused) or opt-in (in which the individual must ask explicitly to be tested). This is a very complex issue and, at its heart, lies the debate about individual autonomy and community responsibility. Op-in respects individual autonomy but will lead to a lower level of testing, with implications for both tracking the epidemic and the provision of treatment. Opt-out is seen by some as potentially coercive. We didn’t reach a conclusion, but what was most interesting was the way in which the issue divided the lawyers (focussing on the individual) from the public health professionals (focussing on the community). A difficult question….

This was to be a busy week. As soon as I finished teaching on the Tuesday afternoon it was off to Heathrow for a flight to Dublin. I was then whisked off to a hotel on the Irish border where I was giving one of the opening speeches the next day. Coming from Ireland, it was good to catch up with some old friends although, as is so often the case there, it was disappointing that so few public health professionals were participating.
The conference was on inequalities in health and had been organised (very well) by Owen Metcalfe and Jane Wilde from the Institute of Public Health in Ireland. Unusually, I had gone on holiday without a laptop in the summer, so I missed the e-mail arrived suggesting a title, but adding that if it caused any problems could I say so at once as the programme was about to be printed, until it was too late. As a consequence I had had to spend quite a lot of time trying to discover what does work in reducing inequalities in health! Still, it gave me a chance to update the lecture I give on this topic to my students, which I otherwise might not have done!
This is not an easy question. Perhaps the only think that definitely works is voting, with clear evidence that income inequalities narrow under left wing governments and widen under right wing ones. Otherwise the evidence is hard to come by. One reason is that the causal pathway between interventions and outcomes is slow complex and it takes so long for the results to become apparent. By this time it is almost impossible to separate the intervention from all the other things that had happened.
The usual source of evidence, the Cochrane Collaboration, was not, initially, much help – I got a message that “your search – inequality- did not match any documents”. However, it does contain a wealth of evidence on how to do something about the causes of inequalities, especially smoking. The Campbell Collaboration was much more helpful. This was the first time I had used it to any extent and I was struck by how much valuable material it contained. It has three strands: social welfare, education, and crime. Many of the reviews under these headings have considerable relevance to health.
In the end of the day, however, while it was possible to point to a large amount of evidence that could be used to design a strategy to reduce inequalities, I concluded that what you put in that strategy depended on what inequalities (social, ethnic, gender etc.) you wanted to tackle and what causes them to exist. What the ultimate result of such grand strategies will be is difficult to tell, and I found myself quoting Cho en Lai’s answer when asked whether the French Revolution was a good idea – “It’s too soon to say”. Perhaps the most important takeaway message is that when people do intervene, they should evaluate what they do so that others can learn from their experience.

I hadn’t been to Kiev for a while. The last time was before the Eurovision song contest – an event of enormous symbolic importance to countries on the periphery of Europe but, I suspect, to few others.
Kiev had changed enormously from how I remembered it. It is now a vibrant European city, with shops selling a vast array of luxury (and presumably, for most people, unaffordable) goods. The McDonalds restaurants were packed and despite the cold, the streets thronged with young people enjoying themselves.
The reason for being here was to attend a conference on demography in the former Soviet Union. The conference had been put together by colleagues from Ukraine, Russia and France and provided an opportunity to get up to date on the latest thinking about health in this region. The LSHTM team (Dave Leon, Susannah Tomkins, Ellen Nolte, Francesca Perlman and myself) were presenting papers on a range of topics including premature mortality and inequalities in Russia, health care in Ukraine, and translating evidence into policy.
There were many fascinating presentations, and much to think about. The demographic crisis facing this region was encapsulated in one slide showing the predicted population growth of Vietnam and the decline in Russia, so that by 2050 the population living in the small area that is Vietnam will exceed that in the vast territory of Russia.
However, some of the most interesting papers were on Ukraine, a country that looks both east and west, as we were reminded during the orange revolution. As expected, the geographical divisions are reflected in patterns of health.
On the final day of the conference we had a reminder of the importance of history. A small riot broke out in the main square between those who had fought with the communists and those who had fought with the Ukrainian nationalists during World War II. It was a stark reminder that Ukraine remains a divided country in ways other than its health.

Each October Europe’s health policy community withdraws to two small towns in the Austrian Alps. The annual European Health Policy Forum alternates between the neighbouring towns of Bad Gastein and Bad Hofgastein, in the beautiful setting of Salzburger Land.
After an epic session last year, in which I gave six presentations, I sort of regained some control this time, with only three presentations but also facilitation of two workshops. Of course, while the formal sessions are always valuable, the real benefit of going is the amount of work that you can do outside them, catching up with what is happening and developing collaborative activities.
One of my talks was in a session on pandemic preparedness. There were some really great presentations, for example by Zsuzsanna Jakab, new director of the newly established European Centre for Disease Prevention and Control and from David Heymann, who heads the infectious disease team at the WHO. With my collague Rifat Atun, I had been looking at the situation in those parts of the world that lie outside the formal system of surveillance – the bits that are not independent countries but are de facto not part of anywhere else. In the present situation, what is striking is how many of them lie under the migratory routes of birds. They include those places that never quite managed to get sorted out at the end of the USSR, such as the Trans Dneistr Republic, a break away part of Moldova, as well as various places in the Caucasus. Others are Western Sahara, Palestine, and Northern Cyprus. Then there is Taiwan, which differs from the rest because it has a highly developed health system but its ability to interact with the global surveillance system is seriously constrained by its ambiguous relationship with China. Some time ago we obtained details of a secret memorandum negotiated by the WHO and China that at least made it possible for communication with Taiwan to take place (although no-one shared it with the Taiwanese) but it contains ludicrous restrictions such as requiring that communications be faxed because to write “Taiwan” on a letter would imply recognition of its independence!
However, much else was discussed, including the need to do something about alcohol in Europe. Regulations arising from European single market have forced some countries to dismantle their carefully though out alcohol policies. An example is Finland, which has had to dismantle restrictions on sales outlets. The result – a massive increase in deaths from cirrhosis. The European Commission is proposing a strategy that would allow governments to take some very limited steps to address this problem but it is clear that the alcohol industry is engaging in highly dubious tactics to block it. More later….

The new group of students have arrived. The joy of teaching postgraduates is that they all bring with them a wealth of experience and, in most cases, a real enthusiasm to learn and to apply their knowledge to real life situations. The challenge we face is how to maintain and even enhance that enthusiasm.
Each autumn term I teach a course entitled “Issues in Public Health”. It is designed to give students an idea of the broad scope of public health as well as some of the basic concepts, such as what we mean by inequalities in health and what we can do about it. The first lecture gives me the opportunity to indulge my conviction that we must learn from history if we are not to repeat our mistakes. Almost all the contemporary debates in public health have been rehearsed before. Take the role of the state – Thomas Hobbes, writing in the aftermath of the English Civil War warned how, in the absence of effective government, life was “solitary, poor, nasty, brutish, and short”. Then there is free trade and public health. The Venetian Republic introduced quarantine (keeping ships at anchor outside the port for 40 days) to prevent the spread of plague, yet as Shakespeare’s Merchant of Venice reminds us, a delay in a ship returning to port can also have adverse consequences for health!
It is an opportunity to recall that public health practitioners have not always been on the side of the angels, too easily lapsing into a role as agents of social control. For example, many public health professionals played an enthusiastic role in the Nazi Holocaust. Even today, there is a real danger that, in the “war against terrorism”, public health professionals become complicit in the growing tide of authoritarian legislation in the UK and the USA, a point I expanded on in my DARE lecture at the conference of the UK Faculty of Public Health in June, which is now published in the Journal of Public Health as “A crisis of governance”.

To Rome…
It is always a pleasure to catch up with old friends, in this case Professor Walter Ricciardi at the Catholic University of the Sacred Heart in Rome.
After a very pleasant dinner on Walter’s balcony, enjoying a warm October evening and putting the world to right, I left Italy to spend a night in a charming hotel in the Vatican City, just a few hundred yards from St Peter’s Cathedral. Stunning…
However my main reason for going was to speak at a conference on health and the economy. This gave me an opportunity to set out the arguments we developed (with Marc Suhrcke from WHO in Venice and Regina Sauto Arce, Svetla Tsolova, and Jørgen Mortensen at CEPS in Brussels) on the contribution of health to the economy in Europe. Essentially, we all know that being richer leads to better health (generally, as long as you don’t spend the money on cigarettes, alcohol, cocaine or fast cars) but the question is whether better health leads to greater wealth? We do know, from the report of the Commission on Macroeconomics and Health, that it does in low income countries but these differ from high income countries because:
a) physical strength is more important in agriculture, mining and the like
b) the things that can be done to improve health are relatively easy
We looked at whether healthier people would stay in the workforce longer and would earn more. They do. However the evidence that healthier people saved more (so contributing funds for investment) or invested more in their own education was not so easy to find, which doesn’t mean that it is not the case. We also showed that today’s level of economic development in industrialised countries owes much to the gains in health in the past.
So what odes this mean? Well, if governments accept the case for investing in education and transport infrastructure, then they should invest in health as well.

My trip to Kuopio did not begin well. A few weeks earlier the UK government had introduced new restrictions on hand baggage on planes for reasons that they have never adequately explained and which, given their record for getting things wrong (WMD etc.) left many people perplexed. The effect was predictable – complete chaos at British airports with anyone who could switching to flights through other countries (so causing British Airways to loose about £100m). I was changing planes at Helsinki and it was no surprise that I, along with everyone else who had come from London, found that our baggage had missed the transfer.
Anyway, at last we arrived in Kuopio. The reason for my trip was a conference under the Finnish presidency of the European Union. The European Observatory (where I am a research director) had produced a book on the conference theme – “Health in all policies”. Kuopio was a perfect setting for the conference. Aside from being in a beautiful setting in the Finnish lakes, which is enough to inspire anyone to better things, it has a strong track record of actually getting health into all aspects of life. The city authorities had developed a fully integrated public transport system, new housing developments were designed with health and social cohesion very much in mind (with shops and community facilities integral to the design), there were outstanding sports facilities, and the university has a strong focus on health.
My task was to give one of the opening speeches, on the potential for health gain in Europe. The approach I took was to highlight the enormous diversity that exists within Europe – simply look at the cookery section in any bookshop, where you can find advice on how to prepare dishes from every part of Europe, each with their own characteristics. What’s more, there is an enormous regional diversity in many countries. Of course, not everything appeals to everyone, but I decided against referring to the famous comments by President Chirac and Prime Minister Berlusconi on Finnish food – certainly what we enjoyed at the conference was superb!
This dietary diversity has profound implications for health – for example, death rates from heart disease in Spain are about one third what they are in the UK, something that is to a large part due to differences in diet. And of course, things get even worse as you move north, exemplified by the sale of deep fried Mars Bars in Scottish chip shops!
Of course it would be a pity if everyone in Europe adopted the same diet (in passing it is noteworthy how Europe contrasts with the USA, where the extent of regional diversity is very much less) but what would happen if each country to get its death rates down to the level in the country that was doing best. A few back of the envelope calculations show that the effect would be enormous – if everyone could reduce their death rates from ischaemic heart disease to those of the French then we would have a quarter of a million fewer deaths every year, including 40,000 fewer in the UK.
A key issue throughout the meeting was the importance of partnership. It is essential that we find ways of moving beyond the traditional players to include all those who can contribute to better health. Of course we have to recognise that many of these players will have different goals. The food and drink companies are required to increase their return to shareholders, which is fine. The challenge is to find ways in which we can work together so that they do so in a way that enhances health. Our goals will not coincide but they do overlap. What we need to do, as my colleague Josep Figueras noted, is to ensure that the overlap is as large as possible.
On the other hand, there are some that we cannot work with, exemplified by the tobacco industry, who have engaged in a long campaign to undermine scientific evidence. Unfortunately, as we have seen time after time, those researchers who become involved with them are either used or themselves become corrupted.

I’ve finally got round to doing it! Given my enthusiasm for speaking out on the many things that are wrong with this world, I have at last surrendered to those who have been suggesting that I start a blog, perhaps so that they no longer have to listen to my constant woes about life. If it works, I plan to reflect on the many issues that come up in what is actually a fairly interesting life as an academic working in international health. The challenge will be whether I can keep it up. Let’s see!