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).

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