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.