Sunday, February 17, 2008

Still on Ljubljiana - you can also listen to several of us discussing our book on cancer in Europe in a podcast.

Sunday, February 10, 2008

Ljubljana - 7th February. Slovenia is the first of the countries that joined the EU in 2004 to hold the rotating Presidency of the EU. Each country uses the Presidency to promote an issue that it sees as important, in the hope that it will be able to influence policy across the EU, either through the legislative process (a long term goal) or by recommendations from the Council of Ministers (easier). The Slovenian government chose cancer as its priority and, as with many of the previous Presidencies, we have been helping to bring together the relevant evidence.
Over the past year, with my colleagues Michel Coleman and Delia Alexe, at LSHTM, and Tit Albreht, from the
Institute of Public Health in Ljubljana, we have been editing a book on cancer in Europe. Of course there is an enormous number of books on various aspects of cancer already available but this differs in several ways. First, it covers the entire range of issues related to cancer, from research and drug discovery through screening and cancer plans, to psychological aspects of cancer and palliative care. We were extremely fortunate to get contributions from many of the leading authorities on these topics, including researchers, practitioners, and representatives of patients. Unbelievably, we pulled the whole thing off in just over a year!
The book provided the basis for a major conference on cancer in Europe. We had actually launched the book to the media two days earlier, getting some coverage on the
BBC and elsewhere, but what had been overlooked when putting the timetable together was that this coincided with Super Tuesday in the US presidential race. Clearly, we have some way to go to become experts in spin! (sorry, media relations).
The conference was held in the Brdo conference centre, newly built for Slovenia’s presidency. Slovenia is a stunning country and the conference centre is ain a great location, with a backdrop of snow-covered mountains.
It was my task to sum up the meeting. This is always difficult as much of what needs to be said already has been. I did, however, draw out some lessons. We first need to decide, in each country, whether we really do want to do something. You could argue that the existing systems sort of work. Most people get treated, and for some cancers outcomes are not too bad. However, the evidence we had heard over the past two days was that this was not good enough. There are still large variations in incidence and survival from cancer across Europe. In many countries, care is highly fragmented and patients face long delayed in accessing effective treatment. Only a few countries, such as the UK, have really embraced palliative care on any scale, and even there it could be strengthened. So something really must be done. But what?
Whatever is done, there is a need for co-ordination and, ideally, integration. Rifat Atun, from Imperial College, provided an overview of cancer plans in Europe, noting how many countries have yet to put anything in place while others are still quite limited. Inevitably, given that many of the authors of the plans were in the audience, his sparked considerable debate, as people claimed that there was more written between the lines! Yet that surely misses the point. There is little point in having a plan if you need inside information to understand it.
We talk of a war against cancer but we forget that, in any war, if the forces at your disposal are fragmented then at best you lose the war and at worst you shoot yourself. “Friendly fire” is a perennial risk when some of your allies have complex and potent equipment that they don’t fully understand how to use. Yet, in some countries, politicians seem determined to make things worse, fragmenting systems further in their continuing ideological pursuit of “patient choice”.
It is far too easy to overlook the role of the patient. We were extremely fortunate that Lynn Faulds Wood, president of the
European Cancer Patients Coalition, and herself a survivor of colo-rectal cancer, agreed both to contribute to our book and speak at the conference. She reminded us that a diagnosis of cancer is the beginning of a long and complex journey. Our role, as researchers and practitioners, is to ensure that the patient has a map, signposts, pathways along which to travel and places to rest.
There is still a great deal to be done in cancer prevention. The past few years have seen enormous progress against tobacco, with increasing numbers of countries banning smoking in public places. Yet many of these bans still have exceptions that will have to be tightened in the future and some countries have yet to do anything. Worryingly, the tobacco companies are working hard to subvert the bans. Their worry is that, given most smokers do want to quit, they will use the opportunities offered by the bans to wean themselves off their addiction to nicotine. The industry needs to find ways of ensuring that people remain addicted. It is doing this in several ways. First, it is campaigning to legalise sales of snus, a form of oral tobacco, across Europe. It is currently sold only in Sweden and Norway. As we show in a
recent paper, the industry’s claims for its effectiveness as an aid to quitting are without foundation. Second, it is producing mini-cigarettes, so that smokers can pop out for a few minutes and get a quick nicotine fix without having to smoke a whole cigarette. At the same time, other companies are producing electronic devices that extract the nicotine from tobacco without producing smoke (something the tobacco industry is less keen on because it clearly highlights the role of nicotine as an addictive drug). During the conference a Dutch court ruled that the last of these products, the electronic device, could lawfully be regulated as a drug. This is an extremely important decision as it now opens the way for regulating all nicotine products sold in Europe just like any other pharmaceutical product.
Screening is a key element in secondary prevention. Witold Zatonski, from Warsaw, compared the highly effective, population-based, and carefully managed Finnish cervical cancer screening programme with the much less effective, opportunistic, and essentially unmanaged German model. Finland has brought deaths from cervical cancer down to a very low level while in Germany the death rate remains about twice as high as in Finland. Yet while a typical Finnish woman will have 7 cervical smears in her lifetime, a typical German woman will have 50. Yes, five zero! The explanation? Hardly a surprise – German doctors are paid for each smear taken, while the insurance funds do almost nothing to promote evidence-based care. Clearly, many countries still have a long way to go.
Cancer control is critically dependent on information. Cancer registers have contributed enormously to our knowledge of what works and what doesn’t. Yet too many EU Member States have failed to put in place effective registration systems. What is worse, a few that once had excellent registers are damaging them irreparably> one of the worst examples is Estonia, where the Parliament enacted legislation based on an early version of the EU Directive on Data Protection, before it had incorporated protection for research and health monitoring. With my colleague Mati Rahu, we will be describing the worrying consequences of the Estonian legislation in a paper to be published soon in the International Journal of Epidemiology.
What is most remarkable is that governments that seem keen to use concerns about data protection to impede the war against cancer while they are equally prepared to abandon any pretence at safeguarding privacy in the “war against terror”. Every time we travel to the USA, our governments send over 50 items of information to the US authorities and while this doesn’t include religion it does include whether we have ordered a halal or a kosher meal! Our movements are tracked constantly from our mobile phone records and, in case this is not enough, the UK has more closed circuit televisions than the rest of the EU combined, with one for every 14 citizens at the last count. Many are now linked to facial recognition software. The UK also allows almost all public authorities to
bug phones and, as we have seen recently, the police seen to have no reservations about bugging the conversations of members of parliament. In these circumstances, it is difficult to avoid the conclusion that our political leaders might usefully consider their priorities.
The successes so far in the war against cancer have arisen primarily from research. Innovative treatments have made cancer at some sites, such as the testes, as well as some childhood leukaemias, curable in almost all cases. Yet there is still a great deal to be done, especially in areas such as health services research and the psychological aspects of cancer. Too many countries have failed to invest in the research that is needed to determine what models of care are most appropriate for their circumstances, or to put in place the infrastructure that allow as many of their citizens as possible to contribute to new forms of treatment by participating in clinical trials. As Richard Sullivan, from LSE, reminded us, “Research is a necessity, not a luxury”.

Friday, February 08, 2008

31st January - Moscow. I was joined by my colleague Anna Gilmore for the first international advisory board meeting of the new Russian Anti-Tobacco Advocacy Campaign. This initiative, funded by the Bloomberg Initiative, brings together a broad ranging coalition of non-governmental organisations to tackle the scourge of smoking related diseases in Russia. It is no secret that the international tobacco companies have invested vast resources in penetrating the Russian market, something that we have documented in papers previously. More recently, in another paper, we showed how the prevalence of smoking among Russian women, once low, has doubled in 15 years. Smoking already exacts an enormous toll of premature death in Russia and the recent trends among women mean that this will increase further in the future.
One of the orginal goals of the coalition was to get Russia to ratify the Framework Convention on Tobacco Control. That, at least, now seems to be happening, with the Cabinet sending the relevant legislation to the State Duma, where the majority leader has indicated that it will be supported (see story in Moscow News). Yet that is only the start.
The challenges are enormous but we were greatly reassured by the results of a new poll, conducted in a representative sample across Russia, showing a very high level of support for effective restrictions on smoking and, in particular, easy access to cheap cigarettes. The overwhelming majority believed that not enough was being done. So, there is much to do but considerable grounds for optimism.
8th January 2008 The new year started controversially. With my colleague Ellen Nolte we have been working for some time on the concept of avoidable mortality – identifying deaths that should not occur if health systems are working well. We all know that the US health care system is not working, but how bad is it? In a paper published in Health Affairs, we calculated the death rate from these causes in 19 high income countries, looking at how they had changed between the late 1990s and the early years of the 21st century. Most countries did well, with falls in death rates of about 17%. There was, however, one not entirely unexpected exception – the USA. It had improved hardly at all, going from near the bottom of the list to the very bottom. Many of the reasons are obvious:
a) the lack of universal coverage,. There is now a wealth of evidence that people who are without coverage delay seeking timely care and as a result are sicker when they do make it, often quite inappropriately to Emergency Rooms. There is also a lot of evidence that people with insurance face sever barriers to care because of the many obstacles put in their way by their payers.
b) a fragmented system, with high tech specialist care prioritised over family medicine. Barbara Starfield from Hopkins has been showing the problems this creates for the US for years
c) cost of drugs - the Commonwealth Fund has shown how US citizens are much less likely than those in other countries to fill prescriptions. One factor is the complexity of some pharmaceutical benefit plans such as Medicare. Another is the very much higher cost of drugs in the US than elsewhere because the US government is unwilling to impose price controls like almost everyone else does.
d) the sheer cost of getting care because of the inefficiency of the system. Multiple payers, high profits by payers and providers, the cost of malpractice insurance etc. all combine to make care far more expensive than in Europe, meaning that in a system where there are no guarantees of coverage, people cannot afford care.
Unsurprisingly, our findings revealed markedly differing views (with intensive discussions on the bulletin boards). Many people felt that our findings confirmed their own experiences. Given their comments, Michael Moore could make a sequence of sequels to his film
Sicko. However, others totally rejected our views, questioning our motives (more anti-Americanism from those awful Europeans…).
The experience of reading the blogs and online comments was fascinating but extremely depressing, as we read once again of the many stories of individuals who have been unable to get timely and effective care but also we saw the total inability of a significant number of people who are totally unable to see that, for many people, the American dream is really a nightmare.

Thursday, February 07, 2008

It’s back. After a ridiculously long break I’ve finally managed to regain the enthusiasm to relaunch my blog. It’s not that I haven’t been doing anything the past three months. Quite the contrary, as the brief round up below will show. The real problem is that I’ve been doing too much – with trips every week between October and Christmas, two doctoral students finishing their theses, lots of papers to write, and a ludicrously large number of books to finish. I normally write these entries on planes coming back from wherever I have been – for the past few months that time was used entirely for writing other things. What follows is a brief summary of events since mid-October.

15th October – Copenhagen. We had the second team meeting of our project on preventing obesity in Europe – EURO-PREVOB. This brings together partners from across Europe, including not just EU countries but also Turkey and Bosnia. The goal is to understand better how policies being pursued in Europe either help or hinder the fight against obesity. We all know that the decisions that people make when they choose how much and what they eat and how much they exercise are highly constrained. Governments can make a real difference, through policies in areas such as urban planning, agriculture, education, and transport. The challenge is how to assess these policies as a prelude to changing them. This is not easy. A report that would be published a few days later, by the UK Government’s Foresight Programme sets out the tasks ahead. This contains a diagrammatic representation of the pathways that lead to diet and physical activity. Readers may see some similarity with a plate of spaghetti! It has been criticised, for example by Andrew Jack (the FT journalist) writing in the Lancet as being over complicated. Politicians want simple solutions he writes. Yet the reality is complicated and maybe we need to tell them this before they launch yet another simplistic (and usually unworkable) policy based on an idea they had in the shower this morning.

26th October- Valencia. I was giving a plenary speech at the annual conference of the Association of Schools of Public Health in the European Region (ASPHER). In my speech I was asking the question “What are governments for?”. It is something I have talked about before, and have written about it in a piece for the Australian Medical Journal linked to the forthcoming Oxford Health Alliance meeting in Sydney. Essentially, I look at the differing perspectives on what governments should do. There is a minimalist view, set out in the pages of the Economist and the Wall Street Journal, that they should simply defend the borders of the state (from invasion and migrants) and promote the prosperity of its people (well some of them – I suspect no-one really believes any more in the trickle down effect of wealth distribution). In all other things they argue that the government should “get off the backs of the people”, cutting red tape and minimising legislation. Yet there are always some exceptions. They do want legislation that protects their property, be it intellectual (as in the cases of the entertainment and pharmaceutical industries), capital (as when companies invest in unstable countries abroad), and their safety (calling upon the armed forces to rescue them when they find themselves caught up in a coup). They want the state to cut taxes, especially on the rich, but what taxes are collected they want to see spent on subsidies for the basic research that gives them their intellectual property, or the infrastructure that enables them to operate. This leads to a paradox. Governments do intervene to save lives. After the events of September 11th “the world changed” . I don’t need to remind anyone of how the US government spun into action, leading to outcomes as diverse as the Patriot Act and the invasion of Iraq, a country that had nothing to do with what happened that day in September. Yet the response to another human disaster, Hurricane Katrina, was lamentable and successive governments have failed consistently to do anything about gun control, even though effective action might save the equivalent of 13 September 11th every single year. Our role in public health is to flag up the contradictions and hold politicians to account for their inconsistency.

2nd November – Rotterdam. The first project meeting for our new study, DYNAMO-HIA, to develop a dynamic model that can inform health impact assessment in the EU. Led by Johan Mackenbach, the task is to create a model that will allow us to predict the likely health effects of policies to ban smoking in public places, to increase the cost of alcohol or limit sales outlet, or to change diet. We are only at the beginning but it is already clear that the final result will be of great value to policy makers.

3rd November – Washington. This was my first time at the American Public Health Association. It exemplifies the super-size conference, with several thousand delegates, and is so large that only a few cities can host it. I was speaking at a session entitled “International challenges for Public Health, Policy and Politics”. The choice of sessions was enormous. Unsurprisingly, the overwhelming majority dealt with domestic US issues. The US health system certainly has no shortage of problems. Some of the most interesting ones I got to looked at the prospect for reform of the US health system. There are now several attempts by individual states to introduce universal coverage, typically involving mandates for employers to provide coverage, with other provisions for the self-employed and unemployed. However, when one hears the details, it is clear that they will, at best, be only a very partial solution. These sessions were profoundly depressing because it really does seem that the reform mountain is too steep. There are too many powerful vested interests, both providers and payers, who have an interest in keeping the system the way it is.

14th November – Seoul. After a few days back in London it was off to the Far East. First stop was in Seoul, to speak at a conference celebrating 30 years of the Korean national insurance system. Note to self – next time make sure I check what hotel you are in and buy a quad band phone so that, if I forget, you can phone someone! I was with my fellow research directors from the Observatory, Elias Mossialos, Reinhard Busse, and Richard Saltman. The Korean health insurance system is a real success story. I knew something about it, having previously examined a PhD on the policy processes involved in its creation and expansion, but learned a lot more.

17th November – Taipei. Back to Taipei for my annual visit to the Global Health Leaders Conference. Each year the Taiwanese bring together a fascinating mix of speakers to look at a small number of key issues. I was speaking in the stream on health care quality, presenting the findings of our recent study on quality assurance strategies across the EU. Our book, which contains detailed descriptions of the very mixed activities in all 27 Member States, will be published in mid 2008.

22nd November – Munich. Participating in a meeting of the IMAGE project (Implementation of a European Guideline and Training Standards for Diabetes Prevention). The project pulls together experts on diabetes (and a few others such as me) from across Europe to develop European practice-oriented guidelines for primary prevention of type 2 diabetes, supported by a curriculum for training people who can engage in prevention, as well as development of European standards to monitor the incidence and prevalence of type 2 diabetes and its known risk factors. A great deal has already been done but much more remains to be done.

29th November – Helsinki. The director of the Finnish Public Health Institute (KTL), Pekka Puska, had invited a group of us (3 Finnish academics and 3 foreigners – myself, Michael Marmot, and Daan Kromhout) to conduct an independent evaluation of the Institute’s work in Chronic Disease Prevention and Health Promotion. KTL is a remarkable institution – a superb example of what a national public health institution should be. KTL’s research output is well known to be world class but, as importantly, it maintains an invaluable research infrastructure in Finland, in the form of cohorts, registers, and biobanks. This, along with its extremely capable workforce, has allowed Finland to punch well above its weight in public health research.

6th December – New York. I was in town for a meeting of the Open Society Institute’s Global Health Advisory Committee. This committee brings together senior people with backgrounds in law and health, but all with a commitment t human rights. The debates are always fascinating, often juxtaposing the individual ethical perspective of the lawyers with the collective perspective of the public health professionals. The task is to balance autonomy with the collective good. Many things to discuss but the most interesting, if depressing, was on the situation in Burma, where the authorities had recently suppressed the protest movement led by the monks, with appalling violence. We were privileged to hear first hand from people with first hand knowledge of the situation and to have a preview of a major report on the situation there.

10th December – Brussels. Steering committee of the European Observatory. In between all the travel I have been editing a series of books, one of which, on cancer in Europe, had just gone to production. This was a time to reflect on what we had achieved and plan for the next cycle – hopefully a little quieter than the last one!

18th December – Rome. The final trip of the year. A EU ministerial meeting on Health in All Policies organised by the Italian government. My task was to participate in a discussion on the relationship between health and economic growth, drawing on our earlier work for the European Commission.

So that brings me to the end of 2007 – a completely crazy year. The next entry will be in 2008, and I’m already behind with that, but it will have to wait for my next flight (tomorrow).