Sunday, April 27, 2008

My second trip to Brussels this week. I was with my colleagues Christian Haerpfer and Alexander Chorostov to begin negotiations with the European commission on our new FP7 project, Health in Times of Transition: Trends in Population Health and Health Policies in CIS Countries. This is a follow-up to our earlier project entitled Lifestyles Living Standards and Health. In it, we conducted household surveys in eight former Soviet countries, providing important new information on topics such as tobacco and alcohol consumption, access to safe water, and use of health services. In the new study, we will be expanding the household surveys to 11 countries, covering the entire Commonwealth of Independent States with the exception of Turkmenistan. We will also be undertaking a number of community profiles to understand better the circumstances in which people live, in particular their access to different forms of food, the extent and nature of tobacco marketing, and their access to healthcare. We are hoping that the project will begin in November 2008 with the first survey data being collected in early 2010.

Footnote: I read that the UK government is planning to introduce a new
facial recognition system “to reduce delays at immigration in British airports”. This news simply confirms to me that the Home Office is viewed as an incredibly soft target by anyone with a computerised gizmo that no-one else is stupid enough to buy. When it was introduced, I enrolled in the IRIS system, which was a complete waste of time. The system is frequently out of order and, even when it is working, it is so slow that it is quicker to use the ordinary queue. I was reading about the new system as I was getting on the Eurostar at Brussels, where one must show one’s passport to Belgian officials and then again, about 10m further on, repeat the entire process with the British (only more slowly as it is clear that their computers are creaking under the weight of data from the new biometric passports. If the government really is interested in reducing queues at immigration, there is an obvious solution. Join the Schengen Agreement like the rest of Europe!
To Brussels, for a meeting of the steering committee of the European Observatory. It has been an incredibly busy year, beginning with the publication of our book on cancer in Europe and continuing with intensive preparations for the Ministerial Conference on Health Systems in Tallinn in June.

It is always nice to know that one is appreciated, so it was a great pleasure for us all when the Observatory was recognized in an award schema that had been launched by the World Bank for initiatives that improve the lives of people living in Europe and Central Asia. A total of 19 awards were made, most for projects within countries, such as the restoration of the famous bridge in Mostar, in Bosnia, that was destroyed during the war, or an AIDS control project in Moldova. The Observatory was recognised by a multi-country award. The picture shows Armin Fidler, who had previously accepted the certificate from the president of the Bank, in Washington, handing it on to Charles Normand, the chair of our steering committee, and accompanied by Josep Figueras, Director of the Observatory.

Friday, April 18, 2008

17-18th April 2008, Riga, Latvia
We are here for a meeting of the
EURO-PREVOB project. This is seeking to develop a methodology to map policies, both “on the books” and “on the streets”, that can address the increasing problem of obesity in Europe. We are interested in policies that influence both energy intake and expenditure, in other words, nutrition and physical activity. With support from the WHO, we were joined by many of the leading experts on food and physical activity from across Europe, who provided extremely valuable inputs into our thinking.
We began with a series of presentations that brought us up to date with developments in this field.
Liz Dowler reminded us that, as we think about access to healthy food, we need to think about whether it is culturally appropriate food in an increasingly multi-cultural Europe. Mike Rayner reminded us that marketing involves 4 Ps: product, promotion, place, price. Effective action must address all of these. A key issue we need to address is food labelling. Although almost everyone has signed up to the need for labelling to inform the public, some companies are working hard to avoid the use of traffic light systems – red for danger, green for healthy – for the obvious reason that their products would have a line of red splodges. Instead they are pushing for more complex labels, often on the back rather than front of packs, that the public finds confusing (see link for UK Food Standards Agency evaluation). Mike also reported some very interesting evidence on the effects of so-called “fat-taxes”, or more generally increased taxes on unhealthy foods. In fact, in the EU, many foods are already taxed – in the UK there has been a very interesting legal action recently to decide whether a marshmallow is a cake or a biscuit, with very considerable financial implications for the Treasury. The question is whether the existing somewhat confused and contradictory regime can be refined to incorporate a health dimension. What the research showed was that simply taxing unhealthy foods would actually increase deaths. What is needed is an integrated policy that is linked to subsidies for healthy foods.
Tim Lobstein then took us through the tactics that are being used increasingly to market food to children. He reminded us of a study that looked at the range of foods marketed to children. Some products were low in fat (but high in sugar), some were low in sugar (but high in salt), so that only 1% of products were actually low in salt, saturates, fat and sugar. In other words, virtually all food aimed at children is junk.
Any parent will be familiar with some of the more obvious methods used to persuade children to consume energy dense foods, such as McDonalds’ Happy Meals, otherwise known as “edible entertainment”. Many of these products give away sets of toys, with the sets changing regularly to encourage children to eat enough to get the whole set. Then there are the links to “good causes” where companies distribute tokens that can be exchanged for school sports equipment and the like. We were reminded of Cadbury’s tokens, whereby, if one managed to consume 20,000 kcal of chocolate, one could get a netball. Then there are the companies offering free logos and ringtones for mobile phones, and of course once the numbers are logged, the children can be bombarded with advertising text messages. Or the books where children learn to count by placing M&Ms on pictures, no doubt eating a few as they do. It is clear that the regulators are many steps behind the industry.
So what is to be done? We were meeting in Latvia, a country where, unusually, the government has taken a strong stance against additives and colouring in food aimed at children. Leaving aside the emerging evidence that some additives may have harmful effects on children’s behaviour, we are faced with a situation in which colourings are used very extensively simply to make otherwise unattractive (and unhealthy) food attractive to children. There seems a strong argument for banning their use in food aimed at children.
So back to the project. Essentially, if we want to understand existing policies in a country, how they relate to needs, and the scope for further development, we need quite a lot of information. We will be focusing, first, on the “law on the books”. The idea is to identify a national focal point in each country who can convene a group of knowledgeable informants who can tell us about what policies are in place. Of course, that is just the first step, so we need them to tell us not only whether a policy exists but also whether it is written down , whether there are financial and human resources identified to implement it, and whether there are systems for monitoring, evaluation and accountability. The second focus is on “law on the streets”. Here we have to develop a means to capture what is happening in reality. Do the foods on sale in shops have nutritional labels? Can people afford to eat a healthy diet (and can they get to the shops that sell it)? Does the layout of the streets force people to use their cars or to walk of cycle? Finally, drawing on Marx’s comment that “the philosophers have only interpreted the world, in various ways; the point is, however, to change it”, we need to identify who the key stakeholders in a potential new policy might be, what their positions are, their interests, and their influence. We have a lot of work ahead of us!
17th April 2008, Flying from Tallinn to Riga
A short flight down to Riga. The Baltic States are now in the Schengen zone so no need to go through immigration, unlike the ridiculous situation when entering the UK, whose government continues to emphasise its semi-detached relationship with the rest of Europe.
I read in the in-flight magazine an article by Bertolt Flick, the CEO of
Air Baltic, that there is some prospect that the EU might get rid of the ban on liquids in hand baggage. He writes that he has serious doubts that they ever contributed to safety. So he should. As anyone with a moderate knowledge of chemistry will know, this policy is devoid of any basis in evidence (surely if it was so easy to make explosives from household liquids we would be seeing bombs going off in European capitals every week?). We must thank the European Parliament, whose members have been asking some quite penetrating questions (even if the European Commission has failed to answer them, citing secrecy – the argument of the truly desperate). The Parliament is pushing through long-awaited legislative measures to bring some basic common sense to the often bizarre array of security measures that simply serve to make air travel in Europe even more awful than it would otherwise be. However, I am not holding my breath. This will involve some governments admitting that they got it seriously wrong and, given that some still believe there are WMD in Iraq (and also presumably fairies at the bottom of their gardens), this may take some time.
15-16th April 2008 – Tartu, Estonia
Estonia has, in many ways, had a very successful transition from communism. Its economy is growing rapidly (somewhat faster than its neighbours Latvia and Lithuania), it has maintained a high level of fiscal stability, and its markets are now closely integrated with the rest of the EU. It has made remarkable progress in reforming its
health care system, introducing a very effective system of primary care, it has managed to restructure its hospital system very successfully, and has a health insurance system whose income and expenditure are in balance. These largely reflect the efforts of a number of extremely talented young Estonians (hope you are reading this, Maris and colleagues). Their achievements stand out in a region that has struggled, often unsuccessfully, to bring about much needed changes to health care systems.
Yet there is still some way to go, both in terms of economic progress but more importantly in terms of health. Life expectancy at birth for Estonian women lags behind that in Sweden by over 4 years; for men the corresponding figure is a massive 11 years!
Things are improving. Indeed, Estonia has managed to achieve sustained increases after 2005 at a time when Latvia and Lithuania have experienced what are hopefully only temporary setbacks. One area where there has been a marked improvement is in deaths from stroke, almost certainly reflecting the reform of Estonian primary care and resulting improvements in the treatment of high blood pressure. This is at a time when Lithuania has actually seen a slight worsening in death rates. There have been other achievements, most notably the successful implementation of a ban on smoking in public places (something I argued for in the Estonian paper Eesti Päevaleht in December 2004 (
Tubakasuits tuleb laiali ajada. Eesti Päevaleht). Yet there is one area that stands out because of the complete absence of a policy – alcohol. Like all countries that emerged from the USSR in the early 1990s Estonia has long had a problem with alcohol. Spirits are cheap and easily available (despite some local efforts to reduce the possibility of buying them late in the evening). As we showed in a recent study, aftershaves and medicines containing high concentrations of alcohol are sold widely, in the knowledge that they are being drunk. In a second study we showed that the main outlet is street kiosks, which sell an eclectic mix of aftershaves, pet food, washing powder, and condoms. One result is that, at a time when mortality overall has been falling, deaths from liver cirrhosis have been rising, to a level that is now three times higher than in 1990!
This provides the rationale for one of our research projects in Estonia. Working with Katrin Lang, Marika Väli, and Kersti Pärna and other colleagues at the University of Tartu, we are trying to understand better the role played by alcohol in premature deaths in Estonia and, in particular, the role of alcohol in sudden cardiac death, something that is still imperfectly understood. We should begin to have enough data to draw some conclusions in about 18 months.

Wednesday, April 09, 2008

Five years ago the University of Crete established a postgraduate training course in public health. I’m here at the invitation of the course director, Professor Anastas (Tassos) Philalithis, to join in a review of the course, accompanied by colleagues from the UK, Sweden, and Canada.
Public health has not, traditionally, been strong in Greek universities (the Athens School of Public Health is part of the Ministry of Health, not Education). The creation of the course was therefore a very welcome development. In the short time that it has been going, it has attracted large numbers of students (and also attracted some very talented staff who had been working abroad). The Medical School here at the University of Crete has a spectacular modern campus, with a view of the mountains and sea that must inspire great thoughts! Although we are only half way through the process, we have had a chance to talk to the extremely motivated students and to look at their dissertations , all of which are very impressive.

Crete has a special place n the geography of public health. Cretan researchers participated in the landmark
Seven Countries Study. The study recruited men aged between 48 and 59 and followed them up from 1958 to 1970. At that time, remarkably little was known about the causes of cardiovascular diseases. The Seven Countries Study was far ahead of its time, using standardised data instruments and analyses. It included countries with some of the highest and lowest mortality rates known anywhere at that time. By comparing risk factors in Karelia with those in Crete, the research team discovered the key role played by diet, in particular lipids, in the genesis of this disease. In due course this study, along with others, would confirm the status of the traditional Cretan diet, with its olive oil and high levels of fresh fruit and vegetables, now considered the healthiest anywhere in the world.

Of course, Crete is a Mediterranean island, benefiting from the Mediterranean climate and culture. The main square in Heraklion has a reminder of this shared culture, with a bust of one of it’s most famous sons, Doménicos Theotokópoulos, better known as El Greco. Although born here, he spent time in Venice and Rome before finally settling in the Spanish city of Toledo, where many of his greatest works were painted.

Unfortunately, as in other parts of the Mediterranean, the traditional Cretan lifestyle is under threat from the forces of globalisation. The diet is giving way to fast food, the growth of motor vehicles is reducing the amount of physical activity that people take (and leading to an enormous number of premature deaths from traffic injuries, in part because of a widespread rejection of the concepts of seatbelts and motorcycle crash helmets), and obesity rates are increasing rapidly. However, perhaps the greatest problem, and the one that can be addressed most easily, is the high rate of smoking.
I watched someone smoke three cigarettes, one after the other, at breakfast in the hotel yesterday morning. Every bus shelter has large advertisements for cigarettes, clearly designed to attract new smokers among Cretan adolescents. As the pictures here show, there are health warnings but they are very difficult to see. The result – death rates from cardiovascular disease and cancer are now rising in Crete and, as we showed in a recent paper looking at regional patterns of mortality in the Mediterranean countries, in many other places that traditionally had a health advantage.
The tragedy is that many Greek politicians do not seem to have understood what is happening to the health of their population. The public health service remains focussed on traditional hygiene. There is still no proper career structure for public health professionals. Although there are some world class public health researchers, they have so far had to go abroad for their postgraduate training and many have not returned. There are few funds for research training, except those available from the European Union. The health insurance funds, that might be expected to show some interest in preventing illness and ensuring that the care they pay for is effective, take little interest as, when faced with rising costs, they simply increase their deficits and from time to time ask the government to bail them out. Until now the gods have been kind to the Greeks, blessing them with a long life expectancy. It was easy to believe that a modern public health workforce was a luxury. Hopefully, before it is too late, Greece’s political leaders will realise that it is not. When they do, the University of Crete is well-placed to rise to the challenge.

One of the things I enjoy about Greece, as a non-Greek speaker, is spotting the many words of Greek origin that have made it into English. The emergency exits in the university bear signs labelled “exodus”. The labels on the fire extinguishers begin with “pyros”. The wings of the university building are Pteriga (as in Hymenoptera – bees and wasps – or Pterodactyl (wing/ fingers)). I was therefore fascinated to learn from Tassos that, back in the 1950s, Xenophon Zolotas, an eminent Greek economist, had developed the art of making speeches to the international financial bodies, ostensibly in English but using virtually entirely words of Greek origin. One of his speeches, to the IBRD, is reproduced here. Another can be found by clicking on his name above.
I always wished to address this Assembly in Greek, but realized that it would have been indeed "Greek" to all present in this room. I found out, however, that I could make my address in Greek which would still be English to everybody. With your permission, Mr. Chairman, l shall do it now, using with the exception of articles and prepositions, only Greek words.
Kyrie, I eulogize the archons of the Panethnic Numismatic Thesaurus and the Ecumenical Trapeza for the orthodoxy of their axioms, methods and policies, although there is an episode of cacophony of the Trapeza with Hellas. With enthusiasm we dialogue and synagonize at the synods of our didymous organizations in which polymorphous economic ideas and dogmas are analyzed and synthesized. Our critical problems such as the numismatic plethora generate some agony and melancholy. This phenomenon is characteristic of our epoch. But, to my thesis, we have the dynamism to program therapeutic practices as a prophylaxis from chaos and catastrophe. In parallel, a Panethnic unhypocritical economic synergy and harmonization in a democratic climate is basic. I apologize for my eccentric monologue. I emphasize my euharistia to you, Kyrie to the eugenic and generous American Ethnos and to the organizes and protagonists of his Amphictyony and the gastronomic symposia.