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….

Sunday, April 08, 2007

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

The National Constitution Center, Philadelphia

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

Thursday, April 05, 2007

Another two trips this week (26th March). To Copenhagen on Tuesday for the European Advisory Committee on Health Research. As always, lots to discuss as we struggle with how to strengthen the evidence base for the work of WHO, where it is so important to take account of the context in which one is operating. Thursday it was back to Brussels (I’m getting to know Eurostar far too well). This time it was for a consultation on the 2008 WHO conference on health systems, which will be held in Estonia. It will be 12 years since the WHO European Regional Office discussed this topic, in Ljubljana in 1996. We were struggling with the question of how to measure health system performance and I was giving a presentation on our work on avoidable mortality. As always, Peter Smith (University of York) gave a superb overview, highlighting the challenges involved. His focus was at the level of performance of organisations delivering health care and he provided more warnings (as if they were needed) of the problems associated with public disclosure of performance data. Of course everyone is in favour of openness. The idea is that surgeons or hospitals that are getting poor outcomes will improve their practice if they are named and shamed. Unfortunately, people don’t always behave in the way that you would like them to. They stop operating on sick patients, they change the way they record data, and the net result, at least in one major study, is that patients who do not have severe illness obtain no benefit whereas those who do, do worse, as they miss out on operations that, although risky, might have brought them benefit.
Earlier in the week there was an excellent example of the problems in assessing health system performance. It is increasingly clear that it is almost impossible in many parts of England to register anew with a dentist, because of problems with their new contract. Which Magazine undertok a well-conducted survey in which their researchers phoned up dentists to try to register with them. A health minister commented that ‘The results were “deeply flawed” because they focused on the possibility of dentists taking on new patients, without looking at how many patients they were already treating', conveniently ignoring the fact that prospective patients couldn't care less how many patients were already being treated if they could not join them. Still, thanks to papers released reluctantly by the British Government under the Freedom of Information Act we now know what ministers mean when they describe something as "deeply flawed". This was a term used extensively by ministers to rubbish the paper in the Lancet reporting that the best estimate of lives lost since the invasion was 655,000. As the BBC and others have revealed, what one adviser told them was "The study design is robust and employs methods that are regarded as close to "best practice" in this area” while another reported that the methods were "tried and tested".
I can only hope that my research meets the high standard needed for a British minister to consider it "deeply flawed" too.
Started the week in Brussels, finishing it in Geneva. I’m here to talk to the African Medical Association. Doctors in Africa have been working for a long time to create a forum where their professional associations could come together to exchange ideas about shared problems. At last it has happened, in large part due to the hard work of two colleagues, Kgosi Letlape from the South African Medical Association, and Delon Human, formerly of the World Medical Association.
Although I don’t work in Africa I was there to talk about some work we have been doing on surveillance in fragile societies, which are all too common in Africa. It was really quite humbling to hear the accounts of the challenges that many of the delegates faced, in some cases even to get to the meeting. The health minister from Somaliland, a break away territory in the north of Somalia, had been waiting in Addis Ababa for two days to get a visa to attend the meeting. Contrast that with the ease with which our ministers travel the world.
One of the other speakers was Winnie Mandela. I had never met her before and I wasn’t entirely sure what to expect. I was obviously aware of the controversy that had surrounded her in the past but also knew that, in recent years, she has been speaking out against the policies of the South African government on the need to tackle HIV seriously. What was in no doubt was her ability to motivate the audience. She is clearly someone who can get people to listen. I’m just glad that, at least in the case of HIV, she’s on the right side!
Another incredibly busy few weeks, making it almost impossible to keep up the blog (Hurray, you shout). I need to go back to the 19th of March to pick up where I left of.
I was in Brussels to speak at the annual
European Voice conference. I’ve spoken at it before and it’s always a good opportunity to catch up with what is happening. My task was to contribute to a panel entitled “Can Europe’s health systems survive?” Actually, it was a fairly silly question. After all, we have tried to do without health systems before – it involves stepping over dead bodies in the streets and it’s really not very nice. However I guessed that the organisers wanted a rather more nuanced response. Perhaps we could rephrase the question to say what do Europe’s health systems need to do to adapt to future challenge? In fact we can be quite optimistic. Health systems have changed continually in the face of changing patterns of disease, changing expectations, and changing opportunities. Just think if what happened in the 1950s when, in industrialised countries, polio was being eradicated and tuberculosis was coming under control. Orthopaedic surgeons were running out of work as, until then, they had been kept busy with tendon transplants on children with paralytic polio and drainage of tuberculous spinal abscesses. So they invented the hip replacement, and then the knee and shoulder replacements. Chest surgeons lacking tuberculous lung cavities to operate on moved into heart surgery. There has been an enormous shift of care from hospital to primary care as changes in technology have challenged the basis for many of the services provided in the acute hospital. In other words, we will always have challenges to confront but there is no reason why they should defeat us. In fact, this was the broad consensus, which was a pleasant surprise because there is usually someone who is predicting loudly the end of the welfare state as we know it, summoning visions of catastrophe as we are overwhelmed by aging populations as our jobs disappear to the far east or some other low wage economy. It is certainly true that we need to respond to an aging population but the situation is much less worrying than it seems. First, people require a lot of resources not because they are old but because they are about to die. Just because 75 year olds cost a lot to look after it does not follow that 75 year olds will cost the same in the future. The highest costs are in the last year of life and there is even evidence that these fall if you die at an older age because you are treated less intensively.
Then there are worries that there will not be enough people in work to pay for those who are retired. Only if we keep the retirement age as it is. There is no good reason to do so (honest). A very small change would actually compensate for the predicted changes in longevity far into the future. And anyway, there is good evidence that compression of morbidity is really happening. In other words, while people are living longer, they are living even longer in good health. Yes, we do need to reconfigure health care delivery, to take account of the increased numbers surviving with multiple chronic diseases, but that can be done. It just requires a clear vision and some political will (ok, there’s not a lot of either about). All in all, Europe’s health systems can survive. They just need to adapt. That they can do, but only if they are allowed to by our political masters. Perhaps they are the greatest threat, predicting doom and then by their actions making sure it comes about. In the UK a favoured term in 10 Downing Street is “creative destruction” – the idea that if you push the public sector far beyond its limit something new and good will emerge. I can’t help feeling they are wrong, but if they are it will soon be too late to do anything about it.