Thursday, October 18, 2007

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

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

Thursday, September 27, 2007

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

Sunday, September 23, 2007

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

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

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

Saturday, September 22, 2007

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

Sunday, July 08, 2007

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

Saturday, June 23, 2007

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

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

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

Tuesday, June 12, 2007

Back to South Africa… The final day of our course on health an human rights involved a series of extremely well designed site visits put together by the local OSI team. I joined the group going to Khayelitsha. This is a very large township on the outskirts of Cape Town, larger than many cities, but with many of its population still living in corrugated iron shacks, sharing a common water source. We began with a visit to an AIDS treatment centre, run joint by Médecins Sans Frontières and the Treatment Action Campaign. MSF is very well known globally but TAC may be less so. This was the organisation that spearheaded a legal campaign to force the South African government to make available prophylactic treatment for HIV positive expectant mothers. Their work encapsulates the case for linking lawyers and public health professionals to combine forces to work for health and human rights.
Needless to say, this was an incredibly inspiring visit. The team working in the centre combined idealism with realism and vision with pragmatism. Despite what others would see as insuperable odds, they had put in place a system that was delivering much needed anti-retrovirals to several thousand people. It had been a long struggle, in the face of long-standing denial by some senior South African politicians, supported by a range of individuals promoting the most bizarre ideas about the nature of AIDS and how to treat it. It was only because the authors of the South African constitution had included a legal right to health that it was possible to force the Health Ministry to make treatment available, yet another example of a health ministry that had lost sight of what should be it’s role in advancing the health of its people.
Our second visit, a short distance away, was to a rape crisis centre. Rape is all too common in Khayelitsha, as in many parts of South Africa. While an appalling act anywhere, its significance is even greater here because of the very high prevalence of HIV infection. The centre is staffed 24 hours a day, seven days a week and it provides all the essential services for the victim in a single building. A particular success was enlisting support of the local police, so that a dedicated detective is on hand to collect evidence and statements. The conviction rate remains low, but it is a start.
Then it was off to the University of Cape Town, where we met with
Prof Solomon Benatar at the University of Cape Town. A remarkable man, he had been Chief Physician at Groote Schuur Hospital but combined this with an outstanding publishing career in bioethics and human rights. It was absolutely fascinating to listen to his account of the transition in South Africa but also a little depressing as he shared his vision of the future, one that unfortunately seems to be shared by many of my South African colleagues.
Our final visit was to
IDASA, whose name recalls its origins as the Institute for a Democratic Alternative in South Africa. In particular, we learned about its Africa Budget Watch, which seeks to introduce a greater degree of transparency into government spending in the continent.
It was one of those days that was exhausting but inspiring, and grateful that there are so many people prepared to take on the really hard issues and make a difference.
The philosophy underpinning the NHS in England is one of patients exercising informed choice. To help them to do this, vast amounts of information are being placed on web sites. A recent example is a new NHS website proving outcomes of paediatric cardiac surgery. Intrigued by this development, I tried to think how it might help me if I was unfortunate to have had a child needing surgery. Not much, unfortunately. The most recent data relate to procedures undertaken in 2004/5, over two years ago. Such a delay is inevitable, given the need to wait until one year survival can be calculated and the data processed. However, in many centres both surgeons and techniques may have changed. Twenty of the procedures listed were undertaken fewer than twenty times in the entire country and even the most common procedure was undertaken an average of less than 28 times a year in each of the sixteen centres, so the numbers in any one centre will be very small and the observed differences are likely to be statistically insignificant due to chance variation. Furthermore, none of the figures are adjusted for risk, an important consideration as many of these children will have other problems. I am sure that those making these data available have the best of intentions but if, as is suggested, they are intended to help parents make choices, then some guidance from government ministers as to how precisely they are meant to do so would be helpful.

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

Monday, June 04, 2007

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

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

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

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

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

Max Stäubli, Basel, 2007
Public health is, first and foremost, about ensuring that the widest range of policies work in ways that promote, rather than damage, population health. One set of policies that is critically important is transport. A society that is dependent on the car is fundamentally unhealthy. Cars pump out toxic fumes and greenhouse gases into the atmosphere. They cause injuries, either by driving over pedestrians, or by conveying their occupants at high speed into solid objects. They convey us from door to door so that we need never walk, and thereby use up some of the calories in the food that we used our cars to collect. The most extreme examples are seen in some American cities, where ubiquitous drive-thru banks, fast food outlets, shops, and almost everything else means that you never need to get out of your car…. ever. Some medieval Europeans believed that the Mongol raiders who appeared at the walls of their cities each spring were half-man and half-horse as they never saw the raiders dismounted. Similarly, a visitor from Mars could easily assume that people from Alabama were born with four wheels instead of legs.
Yet, for many people, cars are essential. They allow people to meet together and overcome social isolation. They support economic development, through their production, sale, and what they enable us to do, such as being tourists. The challenge is to find a way to use the car when we need to but use alternatives where this is possible. Yet this only becomes possible if there is a functioning public health system.
Sadly, this is not the case in England. It is possible to get a reasonably priced train fare but only if you book weeks in advance and are willing to travel at a time that is extremely inconvenient. The privatised train companies use financial incentives to encourage their ticket collectors to recoup as many penalty charges as possible, using highly inventive approaches – did someone use the word scams – to extract money from helpless people who have been mystified by the complexity of the fare schedules. Deregulation of buses has left many rural areas without any meaningful links. And despite some recent progress in places like London, we are years away from achieving an integrated transport system. Take the trip to Heathrow. The Heathrow express train, at £29 for a return ticket (even more if you buy it on the train) is the most expensive journey per passenger kilometre in the world. In fact expressed this way it is even more expensive than flying Concorde to New York was before it was retired. If there are two of you, it is much cheaper to take a minicab.
Against this background, it was a wonderful experience to spend the week before last in Switzerland. I had meetings in Lausanne, Berne, Basel, and Geneva, so I packed in a lot of travel. The trains were punctual, comfortable, and unlike many British trains, there were enough seats for everyone. However even my high expectations were exceeded when I arrived in Basel.

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

Saturday, June 02, 2007

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

Thursday, May 17, 2007

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

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

By now, if you are still reading, you may be asking what about the conference. The organisation was a triumph, with everything running remarkably smoothly, due, in large part, to the work of Paul Hui, who seemed to be everywhere at once and totally in control. We began with the usual opening speeches from dignitaries, albeit somewhat more visionary than is usual at major conferences. Then to the opening lectures. Mine addressed the question of how health systems can maximise health gain. It allowed me to bring together a range of themes I have been talking about recently under five maxims (familiar to regular readers of this blog). These are:
Prevention is better than cure – the first step is to prevent disease arising in the first place
Timely investment pays off – you need a balanced programme of investment in people, things, and knowledge
You can’t leave it to chance (or the market) – delivery of health care needs to be planned
Anticipate change – the world is changing and so must the delivery of health care, but equally, permanent revolution (cf Trotsky, Mao, and Blair) is not a good idea
Trust but verify – learn from experience elsewhere but don’t assume that ideas are instantly transferable, Evaluate their impact.
These ideas seemed to resonate with the audience, fortunately!
To Brussels on the 26th and 27th April to participate in two of the four workshops we are organising on behalf of the European Commission to explore the impact of its proposed new strategy on health services. The idea was to prepare a document setting out the current situation in Member States and then invite a group of senior policy makers to consider the implications of the Commissions proposals – which would have been fine except that the Commission doesn’t actually have any concrete proposals yet. Still, it was a very good opportunity to thrash around some very difficult questions that have defied the combined intellectual might of Europe’s health policy community for at least a decade.
The two I was involved with were on quality of care and patients’ rights. I had also been involved in preparing the report on quality of care. This was a combined effort by three EU projects, Europe for Patients (focusing on patient mobility), MARQuIS (on quality of care, and SIMPATIE (on patient safety.
A key question we had to grapple with was who should be responsible for the quality of care provided when a patient from country A is sent by his or her health authority/ fund to country B. One thing was clear – it could not be the patient as, given the major asymmetries in information, patients are simply not in a position to assess whether the care they get is of good quality. There are far too many examples of smooth-talking charlatans helping vulnerable patients to part with their money. Even with the (totally unregulated) internet, except for a small number of people with longstanding chronic illnesses, the fully-informed patient remains an aspiration. There was considerable initial support for the authorities in country A taking the lead, until it was pointed out that this would mean that, potentially, a hospital would need to comply with the standards in place in each of the 27 Member States – hardly practical. What’s more, we were able to draw on the experience of the contracts between the English NHS and hospitals in France, Belgium, and Germany. This had never been a serious project anyway, but rather an attempt by ministers to show British hospitals that there were alternative providers so they had better do something about waiting lists. The English authorities sent a small number of patients abroad, with the first batch accompanied by almost as many newspaper reporters. They specified in excruciating detail how the patients should be treated, including access to English newspapers and afternoon tea. Given the abysmal quality of food in most British hospitals compared to those in France, the patients may have wished the authorities had not interfered. Anyway, as one might have expected, the foreign hospitals soon got fed up with the mass of bureaucracy, not to mention the lack of co-operation from English referring hospitals, who knew that the whole initiative was simply a way to get at them.
So the obvious answer is that quality must be the responsibility of the country where the health facility is situated. This is already implicit in EU law. However, it also implies that any country sending someone abroad should be assured that their patients will get high quality care. The answer seems to be some form of EU legislation to require countries to put in place mechanisms to ensure quality and then let them get on with it.

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

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

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

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

Sunday, April 15, 2007

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

Thursday, April 12, 2007

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