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.

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.

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!