Sunday, March 11, 2007

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

Photos of odekolons bought in Russia

There are also very encouraging signs from some individual cities in Russia. We heard a fascinating story about the so-called “sober cities” in Sverdlovsk region, where a NGO has taken the lead, essentially forcing the police to take action. They knew that this would be difficult when, just after they started working, they diverted a truck full of surrogate spirits to the yard of a police station late one night. They checked it in and returned the next morning to ensure that the police were acting on it. The truck was gone and none of the police could “remember” seeing it. Now they are much more careful.
The path ahead will be very difficult, but it is a pleasant change to fly out of Moscow with a real sense that things are changing for the better.
I seem to be starting too many blogs with the phrase “you couldn’t make it up”. Unfortunately, it so often seems to be the only thing to say. This time it was the revelation, in a previously classified report, that in 2002 the UK Ministry of Defence had spent £18,000 on a study to see whether psychics could discover what was in sealed brown envelopes. Strictly the study was compromised because the original protocol specified that the subjects should be “known” psychics but unfortunately when they contacted people who advertised their possession of these skills they were reluctant to put their skills to the test. The Ministry then recruited some “normal” volunteers. They promptly failed comprehensively to discover what was in the envelopes. What a surpise! It rather reminds one of the cartoon of the fortune teller’s stall bearing a sign “closed due to unexpected illness”.
Of course, it is not only the British Defence Ministry that engages in bizarre studies such as this. A recent book by Jon Ronson revealed the existence of a once secret US military unit engaged in a major programme of psychic and (pseudo-) psychological research. His book was entitled “
The men who stare at goats” because of the extensive use made by the researchers of goats whose vocal cords had been severed to stop them bleating. The idea was that if you trained yourself sufficiently intensely then you would be able to kill a goat (or in fact any other creature, including a human) simply by staring at it. Of course the military unit that dreamed this idea up didn’t stop there. One of its senior officers was convinced that if he could only get his mind into the right state he could walk through walls. He tried repeatedly but, amazingly, only ended up with a headache and a bruised nose.
It is, however, unfair to single out the armed forces in the US and the UK. Ronson’s book makes clear that many of these crazy ideas were taken up by large corporations, paying large sums of money to consultants, many of whom seemed positively certifiable, to motivate their staff.
This resonates with the 2006 Cochrane Lecture, which I gave at the UK Society for Social Medicine in September (to be published shortly in the International Journal of Epidemiology). The theme should in some way relate to Archie Cochrane, whose bequest endowed the lecture. He suggested that, if one plotted on a map of the world the number of randomised controlled trials, the lightest shading would be in countries that were communist or catholic. Coming from Northern Ireland I decided to leave the religious bit for someone else but I was able to examine the legacy of Soviet science for medicine. Briefly, science in pre-revolutionary Russia was vibrant and progressive. It survived the revolution for about a decade, until Stalin unleashed his new model of Soviet science. This rejected basic concepts such as a fair test and equipoise. After all, if the foundations of all knowledge had been set out by Marx and Engels, you could never begin from a position of uncertainty. The consequences were calamitous, especially in agriculture where Trofin Lysenko rejected modern genetics. Yet medicine was also badly affected. I argue that this actually suited the Soviet leadership because they never managed to create a modern pharmaceutical industry, instead relying on bizarre machines emanating light, x-rays, and the like. These had the advantage that they gave the impression that something was being done. They only needed electricity, which the USSR could distribute to its people, even if it couldn’t manage pharmaceuticals (or even sugar or jam…). Introducing concepts of evidence-based practice in this setting would have been disastrous! The trick, as it the men who stare at goats, is to exclude open peer review. Yet this is still going on. A seminal
report prepared under the chairmanship of Congressman Henry Waxman (D, CA), when he was minority leader of the House Committee on Government Reform catalogues the distortions of science under the administration of George W Bush. His report is frightening but it is also essential reading for anyone trying to make sense of today’s world.
We always hope that the products of the European Observatory will be relevant to policy makers. One way we try to ensure that they are is by involving people who will have to use them at all points during their development. A crucial episode in the production of our books is the authors’ workshop, in which those contributing to the books present advanced drafts of their material to colleagues in governments and international agencies. A few weeks ago (I’m really behind with the blog…) we held the workshop to discuss our forthcoming volume on the management of chronic diseases. The project is led by my colleague Ellen Nolte. It was a fascinating two days, as we were joined by contributors from Australia, New Zealand, Canada, and many parts of Europe.
Chronic diseases will be the greatest challenges that health policy makers will have to confront in the decades to come. People are living longer but as they age they are accumulating increasing numbers of chronic diseases. A typical 85 year old might well have some osteoarthritis, some chronic airways disease, type II diabetes, hypertension and perhaps a touch of Parkinsons Disease. They can expect to be on five or more different drugs, in a combination that has never been tested together, and certainly not on older people with multiple disorders, precisely those least likely to be included in randomised controlled trials.
Fifty years ago, there was little that anyone could do about many chronic diseases. There were two exceptions: diabetes, following the isolation of insulin by Banting and Best in 1922; and heart failure, treated by digitalis obtained from Dr William Withering’s extracts of foxgloves. It was only in the 1960s that modern pharmaceuticals became available. Thiazide diuretics were later joined by beta blockers, bet sympathomimetics, ACE inhibitors, and many others. Steadily, at least in industrialised countries, death rates from many common conditions began to fall.
Yet even today, there is still a long way to go. As Ellen Nolte, Chris Bain and I have shown, most recently in a paper in
Diabetic Medicine, death rates from common diseases such as diabetes are very much higher in some otherwise comparable countries than in others. One of the worst performing countries is the USA which, despite spending enormous sums on health care, consistently achieves very poor outcomes.
Given this fact, it is hardly surprising that many of the more innovative ideas for managing chronic diseases have come from the USA. Perhaps one of the best examples is the Chronic Care Model, developed in Seattle, but there are also several similar approaches, albeit all variations on the same theme. We have found the Chronic Care Model to be very helpful in conceptualising the management of chronic disease, highlighting the importance of support for self-management, redesign of health systems, information systems, and better clinical decision-making. But do these approaches deliver what they promise? In fact, the evidence is quite equivocal. Clearly, they can work in the best circumstances but there is rather less evidence that they bring real gains when rolled out into the real world. The most recent example of where these schemes failed to deliver what they promised was the
evaluation of the application of the American Evercare scheme in the English NHS. Now as I have said often before, it is relatively easy, at least in theory, to achieve improvements in outcomes of chronic disease in the USA. Just adopt a European health care system…. any system will do. They all achieve far better outcomes. So why one would think that a US system would perform better than that already in place in England was rather a mystery (except, of course, when one remembers our Prim Minister’s fawning admiration for all things American). Now this should not for one minute be seen as anti-Americanism on my part, simply a call for a more balanced perspective.
The idea of the Evercare scheme was that frail elderly people would receive intensive, targeted services that would prevent a deterioration in their condition ad thus reduce the rate at which they were admitted to hospital. It results in more services being provided, which is probably good, but not a reduction in admissions.
This led us back to thinking about why these schemes have come about. Maybe, rather than a response to rising levels of chronic disease, they are instead a response to the contemporary fragmentation of health care? In the old days, a community in the UK would be served by a small number of general practitioners. Those GPs would know their patients intimately. They would also know their families, their jobs, their relationships, and how they spent their leisure time. They didn’t need complex information systems because they kept it in their heads. Now to be fair, there was a lot of information that they did not have, such as laboratory results. But maybe the patient was more concerned about how their illness affected what they could do than he or she was about the precise value of their blood cholesterol.
There is no doubt that the amount of information collected on patients is far greater than anything that existed in the past, especially in the UK where the government has an appetite for data, regardless of whether it means anything, that has not bee seen since the demise of Gosplan, the Soviet state planning organisation. But does the health professional helping a patient to manage their multiple diseases know as much relevant information as his or her predecessor before computers were in common use. I’m not so sure.