20th September 2008, Liverpool
I had been invited by Michael Marmot to speak at the annual meeting of the Academia Europaea. Michael had organised a session on Health and Wealth so I was presenting our work on the contribution of health to economic growth in Europe. It was my first opportunity to hear Michael speaking since the publication of the Report of the Commission on Social Determinants of Health, which he chaired.
The report begins by documenting, in great detail, the scale of the problem we face. Life expectancy at birth ranges from 54 to 82 years, not in the world as a whole but within a single city, Glasgow. The Commission states very clearly that "social injustice is killing people on a grand scale" and sets out a vision for closing the health gap between rich and poor in a generation.
The Commission made three broad recommendations:

• Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and die Equity from the start; healthy places, healthy people; fair employment and decent work; social protection across the life course; universal health care;
  
• Tackle the inequitable distribution of power, money, and resources—the structural drivers of the above conditions of daily life—globally, nationally, and locally Health equity in all policies, systems, and programmes; fair financing; market responsibility; gender equity; political empowerment—inclusion and voice; good global governance;
  
• Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

This is an ambitious but achievable agenda. The real question is whether the governments of the WHO’s member states will have the courage and determination to take it forward.

18th September 2008, Stockholm
To the European Centre for Disease Prevention and Control. This was my first visit to ECDC, although we do work closely with colleagues there, most recently in our new book on the health system response to complex communicable diseases (primarily, but not only, HIV and TB). Unusually, this time we looked beyond Europe, drawing lessons from both Europe and another region undergoing political and economic transition, Latin America and the Caribbean.
I was there as a member of an expert advisory group on migration. The 2007 Portuguese EU presidency placed the health aspects of migration on the policy agenda and the ECDC is in the process of preparing a report on its consequences for communicable disease.
In some countries, in particular the UK, migration has become a highly politicised issue. Even though the UK has benefited enormously from migration (whether as assessed by the number of foreign born “British” Nobel Prize winners or the army of unrecognised workers who care for the elderly and disabled in our society), there are still shrill voices calling for ever tighter restrictions. These calls have, regrettably, been heard by the current government which has put in place a draconian process to limit the number of highly skilled migrants, as well as quite disgraceful treatment of asylum seekers fleeing persecution in other parts of the world. It has come under particular criticism for its inhumane treatment of children in families seeking asylum. These points are worth recalling as it is easy to overlook the reality that the major threats that migration poses to health are to the health of the migrants themselves.
The report is due out at the end of the year. It will focus on three areas, TB, HIV, and vaccine-preventable disease. However, what became clear from our discussions was the need for an extensive preamble, defining and categorising different types of migration and providing a conceptual framework to understand the health consequences of migration.
A major challenge will be collecting the necessary data. In part reflecting differences in laws on citizenship (at the risk of over-generalisation, there are two approaches – jus solis , where citizenship depends on where you were born, and jus sanguis, where citizenship depends on the nationality of your parents) and constraints arising from data protection legislation.
At the end of our meeting I gave a lecture on migration and health, entitled threats and opportunities. You can see a short video on the ECDC website. It was an opportunity to recall that, even after the breaking down of barriers in Europe in 1989-91, we still live in a divided continent, inhabited by young and old and native-born and migrants. The European social system is, however, based firmly on solidarity. This solidarity owes much to the experiences of the 1940s, where even the most wealthy could be reduced to ruin when they became caught up in the conflict. Two recent books remind us that people of all nationalities suffered. These are Norman Davies’ Europe at War (in which he once again reminds us of the extent of Europe, in this case recalling the carnage on the Eastern Front), and Giles MacDonogh’s After the Reich (where he describes the horrors of the retributions visited on Germans after May 1945). The knowledge that you could go to bed rich but wake up poor ensured that the generation that survived would put in place arrangements to protect their fellow citizens from the consequences of illness and unemployment. This contrasts with the the USA, which has never managed to achieve universal health care coverage. There, those in power, who were overwhelmingly white, could be confident that they would never wake up black. The question we must face up to is whether our belief in solidarity is strong enough to survive the pressures of aging populations, increased migration (by those who are visibly different) and economic downturns. Unfortunately there are some worrying signs in many countries, with growth of extreme xenophobic parties. As Martin Niemoller reminded us over 60 years agoin his famous poem (First they came for...), this challenges everyone who believes in solidarity to speak out before it is too late.

17th September, 2008 Rotterdam
In Rotterdam for the initial meeting of our new EU-funded project Avoidable mortality in the European Union: towards better Indicators for the effectiveness of Health Systems (AMIEHS). Jointly led by Johan Mackenbach at Erasmus Medical Academy and us at LSHTM, with partners from France, Germany, Spain, and Estonia, it seeks to understand how the concept termed “amenable mortality” can be used as an indicator of health system performance.
The concept of amenable mortality was developed by Rutstein and colleagues in the 1970s. It was based on the premise that deaths from certain causes, and certain ages, that should not occur in the presence of timely and effective care. Subsequent work has expanded the list of causes of death considered amenable, reflecting advances in health care, and increased the upper age limit for these deaths, reflecting improvements in life expectancy. The concept has also been refined to include differentiation of causes amenable to the health care system and those to public health policy, while specific causes have been partitioned into the proportion to which reductions are attributable to primary, secondary, and tertiary actions.
In recent years, amenable mortality has undergone something of a renaissance. In part this reflects the much greater interest in performance of health systems, stimulated by the 2000 World Health Report, with improved tools being sought avidly by policy-makers seeking to determine whether they are getting value for money. An example was our study showing that deaths from amenable mortality in the USA around the year 2000 had hardly changed at a time when other industrialised countries were experiencing substantial declines.
In its original conceptualisation, amenable mortality included some conditions where medical care could do little to prevent death once the disease process had occurred but where the onset of the disease could be prevented by health promotion activities. This is exemplified by lung cancer, where, it was argued, health professionals could be effective in preventing people smoking or encouraging them to quit. However, assuming they were successful, the deaths that would then be avoided would occur several decades later. Clearly, this is incompatible with the idea that contemporary rates of amenable mortality reflect the current performance of health systems. Hence, only those deaths than can be prevented by contemporary interventions should be included. The definition of contemporary is inevitably somewhat arbitrary but a period of five years has the attraction of consistency with the period used to assess what is popularly considered as “cure” in analyses of cancer survival.
The original list of amenable causes included causes of death that could be prevented entirely by health care and those from which some deaths would be inevitable but the number could be minimised. The former is exemplified by vaccine preventable diseases such as measles; the latter by ischaemic heart disease, where even in the best performing health care system, some deaths will be sudden and unobserved. However, there are also many causes of death not considered to be amenable where, in some circumstances, health care can be life-saving. This is true of many cancers for which a small proportion may be identified early, making possible curative treatment. An example is cancer of the pancreas. This begs the question of what proportion of deaths from a specific cause should be preventable for the cause to be considered amenable. This issue has previously been addressed only implicitly but it is now time to make it explicit. The figure is, again, somewhat arbitrary but we propose that a 50% reduction has the benefit of simplicity.
There are, however, a number of considerations to be taken into account. In some cases, reductions in mortality in this scale will be achievable with a single intervention. The term “magic bullet” recalls the dramatic benefits of penicillin when it was first given to patients with severe staphylococcal infections in the 1940s. More often, health care will prevent deaths through a combination of interventions that were introduced incrementally, perhaps over decades. In these cases it will be necessary to look at changes in death rates over considerable time, introducing the problem of attribution as it is necessary to exclude other explanations for observed changes.
It will be necessary to draw on a variety of sources of evidence. In some cases, there will be randomised controlled trials. However, these are most likely to exist for single interventions; they are much less likely where a combination of interventions is involved. Randomised controlled trials also face the problem of external validity, as they often exclude both children and older people, those with co-morbidities, and historically, women. Hence, it will also be necessary to draw on natural experiments, where it is possible to determine when new treatments were introduced. An example is the introduction of HAART for patients with AIDS, where death rates fell very rapidly. In other cases, even where detailed data are unavailable, it may be possible to infer the impact of health care where there has been wider system change. An example is the political transition in eastern Europe around 1990. The opening of borders to modern pharmaceuticals and ideas of evidence-based medicine made it possible to provide treatment that was previously denied to sufferers from many chronic diseases. Thus, in countries such as Estonia, there was a rapid decline in mortality from stroke, almost certainly as a result of better treatment of hypertension, at a time when such deaths were increasing in neighbouring Russia. It may also be necessary to look at historical evidence. Thus, conditions such as acute appendicitis became amenable to health care once the introduction of asepsis and anaesthesia made intra-peritoneal surgery possible in the late 19th century. Treatment of hypertension has a shorter history but has still been possible since the late 1950s.
In all previous studies, the definition of amenable deaths has had an upper age limit, reflecting the view that “everyone must die of something”. The age limit has increased over time, from 65 to 75, but this creates certain problems. The first is that it is explicitly ageist, as it devalues curative care for those aged over 75. The second is empirical, first because life expectancy in some countries now exceeds this figure but, second, as there is growing evidence that many types of health care are very effective in older people. If, however, the definition of an amenable cause is one where health care can reduce the death rate by 50% or more, then there is no intrinsic reason to have an upper age limit. Yet, while conceptually attractive, this also poses problems of obtaining evidence, first because older patients are often excluded from trials but, second, because the absence of an observed decline in mortality at older ages at a time when an intervention was being introduced may simply mean that this population was not offered treatment.
So far we have not addressed one of the most difficult definitional issues in assessing health system performance, how to define the borders of the health system. The 2000 World Health Report adopted an essentially pragmatic definition as it was necessary to include all of the WHO’s 193 member states, the majority of which had no functioning system f vital registration and certainly no possibility of ascertaining causes of death. As a consequence, it defined the health system extremely broadly. This included a range of inter-sectoral actions. It is, however, difficult t justify holding the health system to account for actions that others must take. For this reason, we propose that the boundaries must be drawn more tightly, to include interventions delivered by those working what is unambiguously the health care system but also those developed by public health agencies, such as immunisations and screening for cancer.
This is a three year project. What I have described above is only the first step, as we then need to show whether changes in amenable mortality actually do correlate with innovations in health care. If we are successful, this should be a valuable contribution to the debate on health system performance.

16th September 2008, Velden, Austria
Carinthia is a stunningly beautiful part of Europe. Its lakes, mountains, and traditional towns and villages make it an ideal holiday destination. Unfortunately my stay was for just over 12 hours but long enough to put it on the list for future visits. Situated in the south of Austria, it borders Italy and Slovenia and, since the 2004 enlargement of the European Union enlargement, links across these borders have strengthened greatly. This is especially true in the health sector, with the Carinthian authorities establishing a formal system of collaboration with colleagues in Slovenia and in the Friuli and Veneto regions of Italy. I was speaking at the Austrian Health Economics Forum, sharing a session with my colleague Luigi Bertinato from the Veneto region. I was talking about the three way relationship between health systems, health and wealth (see Tallinn Conference) while he was discussing the changing nature of international health tourism. Veneto Region has been developing links with Dubai, where an international “medical city” is being built with the intention of attracting patients from across the world to what will be a first class medical facility.
Two weeks before I had been speaking about the Dubai venture on BBC World Service TV. I confess that I was not entirely optimistic. There is no doubt that there is a growing market for medical tourism but I’m not sure that Dubai can compete with the much lower costs in countries such as South Africa, India and Thailand. There is, of course, a potentially large American market, given the increasing unaffordability of care even for those Americans who have coverage. However, I’m not sure how many will be prepared to fly to he Arabian peninsula in the current political climate, especially when they can get care for rather less in Mexico.
Both in the presentations and discussions over coffee a key issue to emerge was that of quality of care. In Austria, as in many other countries with social insurance systems, it has proven extremely difficult t get the medical profession to engage in effective mechanisms to assess and improve the quality of the care they provide. There are, of course, lots of small scale individual efforts but there is still a lot of opposition to anything more systematic. As we have shown in our new book reviewing the mechanisms to promote quality in all 27 EU Member States, Austria is not alone.
This is becoming an important issue at a European level. The proposed framework directive on patients’ rights in relation to cross-border care will require that each country establish systems to ensure quality of care, and while they will be free to decide how to do this, future work is planned to monitor whether they are doing it (See our recent BMJ editioral). A further issue is the introduction, in a few countries of revalidation of the right to practice medicine. Again, this is something we have looked at in a recent paper and, in some more a detail, in a policy brief. Clearly this is an area where some discussion at a European level is needed, not least to ensure that the arrangements are workable (but also to ensure that they are not hijacked by bureaucrats who believe that the larger the pile of paperwork, the better the system (as seems to be happening in the UK)). Unfortunately, and as usual, the Commission’s DG Internal Market doesn’t agree. It invariably sees any attempt at regulation that would protect the public as a constraint on free movement. It is essential that its views are not allowed to prevail.

10-11th September, 2008 Tiberias, Israel
I was in Israel for a meeting of the International Advisory Board of the Israel National Institute for Health Policy and Health Services Research and for the international conference that followed it. The conference was on the Public-Private mix in health care. The discussions were fascinating, reminding us of the many semantic difficulties in health policy. Specifically, could we agree on what we meant by public and private? This is of particular relevance in Israel, where the sickness funds are private bodies but operating within a statutory framework. Most of those representing them do not claim to be private organisations, rather seeing themselves as fulfilling a public role. Perhaps the only way to resolve the issue is to accept that some organisations have public and private dimensions and which predominates depends on the specific circumstances!
All health care systems are a product of history and, if one was starting from scratch it is unlikely that anyone would design them as they are now. Much of the discussion inevitably focused on issues facing the Israeli health system. Revital Gross provided a remarkably clear explanation of a highly complex financing scheme, where everyone is covered through the social insurance scheme yet where 80% purchase supplemental insurance from the sickness funds while 38% also pay for complementary private insurance. However, this was simplicity itself compared with the new Dutch insurance system, presented by Wynand van de Ven, which left many of us relieved that we didn’t have the choice that it offered, as the complexity of the many packages on offer seemed to test the comprehension of most of those present, that vast majority of whom had the benefit of tertiary education!
The conference was held in Tiberias, on the Sea of Galilee Its banks are steeped in history, from biblical times to the 20th century (it is overlooked by the Golan Heights). Over 200 m below sea level, the surroundings are beautiful and the warm water is fresh and clear (and I did manage to find some time to swim in it). Yet it also provides a warning. It is surrounded by jetties and harbours whose walls now tower over the stones that line its shores. Although it is difficult to tell, it seems to be about 8m lower than it once was, serving as a reminder that, ultimately, the survival of this region is dependent on one scarce commodity, water.

18-22nd August, 2008. Auckland and Wellington, New Zealand
New Zealand holds a great deal of interest to anyone interested in health policy and living in the UK. In both countries the executive has almost unchallenged power to introduce laws, with no need to build supportive coalitions at other tiers of government or with civil society organisations. This has many attractions for politicians – after all, why explain your decisions if you don’t have to. However, the absence of detailed scrutiny also makes it easy to enact unworkable laws, and then to revise them with ever increasing rapidity.
New Zealand acted as a health policy laboratory in the 1980s and 1990s, introducing market reforms that went well beyond those then being contemplated in the UK. The word “hospital” was no longer acceptable, being replaced by Crown Health Enterprises. They were intended to work like businesses but to continue to be socially responsible. Inevitably, those running them failed to resolve the contradictions. Many chief executives left. Costs increased rapidly, as did waiting lists. By 1996 the Treasury concluded that ““The health reforms have yet to yield the original expectations. By a range of measures … the pace of performance seems, if anything, to have been weakened since the reforms.” However, lessons were learnt. Those bits of the system that had worked were retained, especially Pharmac, the pharmaceutical purchasing scheme that ensures that New Zealanders get low cost drugs. However the purchaser-provider split was abolished and a new system was put in place in which health care was delivered by 21 district health boards. The most important lesson was the destructive effects of what can seem like endless attempts at reform. Reform fatigue set it and even though there is widespread agreement that the current system is not perfect, there is little appetite for structural change.
I was in New Zealand for a series of meetings, concluding with a conference entitled “Building tomorrow’s health services”, held in a spectacular community and conference centre built in the form of an upturned Maori boat.
My trip included several meetings at the Minstry of Health in Wellington and a masterclass in Auckland. New Zealand’s health system faces many familiar challenges, including an aging population and the rise of complex non-communicable diseases, as well as some that are less familiar, such as a long-term redistribution of population, away from the South Island and into the greater Auckland area. It also experiences a high level of emigration of health professionals although, as we learnt, the emigration rate is not significantly different to other graduates. There is, however, a remarkably clear vision of what needs to be done, embracing prevention (and especially action to reduce the persisting inequalities between Maori and European populations) to integrated delivery systems.
In 1948 Aneurin Bevan, when asked to speculate about the forthcoming introduction of the National Health Service replied “do I need a crystal ball when I can read the book”. He was referring to the successful introduction of a health service in New Zealand a decade earlier. Could it be that English politicians will once again learn a lesson from New Zealand and place major structural chage on hold for a while to allow people to just get on with the job of delivering better care. Somehow I doubt it, but we can but hope.

3-8th August 2008, Venice
This year’s European Observatory summer school is on the “Hospital re-engineering: New roles, tasks and structures”. It draws extensively on our forthcoming book and we have, once again, been able to assemble a first class team to teach on the course, which is held in the idyllic setting of the island of San Servolo, close enough to Venice to be inspired by the view but far enough away from crowds of San Marco to allow for the reflection and contemplation necessary to exchange and absorb new ideas. As always, one of the greatest assets is the range of participants, collectively bringing a vast range of experiences that they are willing to share.

3rd July, 2008, London
Among the hundreds of thousands of words written about different health systems (and I confess that I can account for quite a few thousand alone) there is remarkably little describing what health professionals in different countries actually do. Although we have statistics on how long patients stay in hospital (themselves increasingly meaningless in a world dominated by ambulatory care), we know very little about what happens when a patient with a common medical or surgical problem comes into a hospital. Well, we know what happens in our own country but unless we engage in participant observation, either as health professionals or as patients, in a hospital in another country, we know almost nothing about how things are done elsewhere. Yet without this crucial information, it is difficult to see how we can say anything meaningful about how different health systems perform.
This was what prompted the organisation of a meeting by the NHS Confederation and the European Observatory that brought together health professionals from countries such as Sweden, Finland, France, Germany and Italy to talk through a series of scenarios such as acute myocardial infarction and deep venous thrombosis. As expected, there were many similarities in how patients are managed but also quite a few differences, reflecting the organisation of care in each country. In particular there were differences in the extent to which care was centralised in specialised hospitals or dispersed, in the roles of different health professionals, and the extent to which quality of care was monitored. This is only the beginning of what will be a long process. We will next be using this approach to understand the delivery of child health services at a workshop at the EUPHA conference in Lisbon in November. I hope anyone that is interested in these issues will join us there.

25-27th June, 2008, Tallinn
At last, the culmination of over two years’ work. Health ministers and their representatives from the 53 Member States of the European Region of WHO have come together in a major conference to discuss the links between health systems, health, and wealth. I’ve been involved in many aspects of this process, including writing some of the background reports, but here my task is to give one of the opening speeches, along with Mary Robinson, former UN High Commissioner for Human Rights and President of Ireland, and Uwe Reinhardt, from Princeton University. Both extremely hard acts to follow. If you want to see whether I succeeded you can watch a webcast of the speech on the conference website.
The framework underpinning the conference is a series of reciprocal relationships between health systems, health, and wealth. The first set of relationships are between health and wealth. It is obvious the greater wealth, whether at the level of the individual or a country, provides greater opportunities for health. People with more economic resources can make healthier choices in terms of what they eat, where they live, and how they spend their leisure. Countries with more economic resources can provide healthier environments. However, there is now a large body of evidence that healthier individuals and healthier populations contribute to greater economic growth. Healthy individuals are more productive and more likely to remain in the labour force. Historical studies show that much of the wealth of countries today is due to improvements in health over the last 200 years.
Health systems contribute to health, by preventing death and alleviating suffering. We can I quantify this through research using the concept of avoidable mortality, which measures the number of deaths that should not occur in the presence of timely and effective care. However better health also contributes to health systems, as healthier people have less requirement to use health care. This was the basis for at the analysis conducted by Sir Derek Wanless in his report to the UK Treasury, when he was asked to look at future expenditure on the National Health Service.
Wealth can contribute to health care as wealthier countries clearly have more resources to spend on modern medicine. On the other hand, health care systems can contribute to economic growth, especially at a regional level, where the provision of high-quality health care and support inward investment. Investment in health facilities can benefit the local economy, reducing unemployment, and thereby improving the health of the population, but only if it is structured in a way that enables local companies to bid for tenders on a level playing field with multinational corporations.
What we were trying to convey at the conference was not the detailed prescription for action, but rather a vision of where policy should be heading. We believe that it is possible to create a virtuous circle, with benefits for everyone.
Although there was a large attendance at the conference, and the background material is available on the Internet, we had recognized that there was a need to reach out to a much wider audience. Fortunately, as at the Oxford Health Alliance meeting in Sydney in February, we were able to enlist the invaluable support of Eddie McCaffrey and his team at JooseTV, who not only webcast the entire conference, but also produced a series of news bulletins at the end of each session and in-depth interviews with some of the key individuals who were at the conference. If you watch nothing else, check out the film shown at the end of the conference that really captures the atmosphere of excitement and enthusiasm there. Once again, I conducted many of the interviews and you can watch them on the conference website. The opportunities provided by webcasting also allowed us to connect with the European Health Management Association conference, taking place at the same time in Athens, with a specially tailored interview. If we really want to communicate messages to a wider world, this is definitely the way to go forward.

20th June, 2008 Leiden, The Netherlands
I was privileged to be asked to speak at a conference of the EUPHIX consortium. This team, led by colleagues at RIVM in The Netherlands, has done a remarkable job in creating a portal for information on health in Europe. In my speech I asked, somewhat tongue in cheek, whether with EUPHIX we needed Interail to see Europe’s rich diversity. The portal is much more than a directory of information. It includes software for mapping data (down to regional level) and manipulating it graphically. However, crucially, it is supported by extensive guides, helping users to understand the strengths and limitations of the data they are using.

18th June, 2008 Belfast
In Belfast for the launch of the new Centre of Excellence in Public Health, led by Frank Kee at Queen’s University, Belfast. As a graduate of Queen's University, have been delighted to see the remarkable progress in academic public health under Frank’s inspired leadership. I was particularly delighted to see that the launch conference was opened by Northern Ireland’s Deputy First Minister and Health Minister, two individuals from different political parties who, not so many years, would not have spoken to one another. The Centre’s research programme recognises the importance of interlinkages between different disciplines and the need to translate research into policy. This is just what Northern Ireland has needed for a long time and it is certainly something to watch.

8-10th June, 2008 Washington DC
This year’s AcademyHealth conference was held in the sweltering heat of Washington in June, a city where summer is always hot and sticky but which this year was experiencing what was, for it, a heatwave. A strong disincentive to leave the conference venue! With my colleague Bernd Rechel, we had organised a session based on our forthcoming book on hospital. This is the product of a collaboration between the European Observatory and the European Health Property Network.. After introducing the scope of the study, which draws on the most innovative ideas in hospital configuration and design from across Europe, we looked in detail at some of the most interesting examples. One was Northern Ireland’s regional hospital plan, which will create a network of hospitals offering different levels of care, primary care and rehabilitation facilities, and care in patients’ homes. Another was the Orbis Medical Park, near to Maastricht, in The Netherlands, where a new hospital is being designed to support clinical pathways and processes rather than, as is more usual, ignoring them. The third was the Alzira Hospital in Valencia, Spain, which has implemented a new financing model that was initially quite problematic but is now working well, in contrast to the UK’s Private Finance Initiative, which is now suffering what seem to be terminal death throes.
As always, many of the presentations at the conference focused on the problems that arise when you fail to provide universal health coverage. A growing number of states are now taking initiatives themselves, typically by requiring people (and their employers) to purchase insurance schemes. However, for a European the overwhelming impression is of just how complex these schemes are, and also how many holes there seem to be in them. It is difficult to see how any of them will ever really work without addressing some of the reasons why health care is so expensive in the USA, in particular the high cost of pharmaceuticals and the huge administrative costs of maintaining a multi-payer system.
There is, of course, an election coming up but it is not obvious that either candidate has a solution. What’s more, we heard that health reform is not high on the concerns of ordinary Americans, and is training far below where it was when Hilary Clinton attempted to do something in the early 1990s. Instead they are concerned about the economy and the wars in Iraq and Afghanistan. Yet this may change, as manifest by the growing evidence that people are having to cut back on expenditure to meet health care costs. Something must be done sometime, but I suspect things will have to get a lot worse before they get better.

4-5th June, Izhevsk, Russian Federation
Izhevsk, a city on the European side of the Urals, is the setting for a major Wellcome-funded study we are undertaking to understand the high level of adult mortality in Russia. Readers of this blog will be familiar with our earlier work highlighting the role of alcohol. In our current work, and in previous work in other parts of Russia, it has become clear that we are facing an enormous problem of untreated hypertension. The Soviet Union never managed to deal effectively with chronic diseases. It never developed a modern pharmaceutical industry and, even if it had, it would never have been able to distribute the drugs that those in the west take for granted and which, when taken regularly, can be life-saving. Now the drugs are available and the distribution system is in place, but we still face two problems. First, those taking drugs as outpatients have to pay for them. As they are often much more expensive than in the west because of mark-ups along the supply chain they are often effectively unaffordable. Second, there are very low expectations as to what can be achieved, so that physicians seem content to leave patients untreated even with what we would consider dangerously high pressures. This should be an entirely soluble problem but I suspect it will take some time to resolve it.

27th May 2008, Lausanne
This was my second year teaching on the course run by Alberto Holly in Lausanne. The title of this year’s course was “Mastering the new challenges of health care”. There is a wonderfully diverse mix of students, making the discussions especially rich. My sessions were on health system performance and the future of health care. These are both topics I have spoken about many times before. Predicting the future is never easy. A few have managed it successfully, such as Jules Verne and HG Wells, but even they recognised their limitations and, as far as I know, never staked their fortunes on the outcome of a horse race! Yet there is one thing that we can be fairly certain about, and that is that health care in the future will be much more complex than it is now, with aging populations suffering from multiple disorders, each interacting with one another, with their ability to function secured by a complex mix of medicines that have never been tested in combination, and especially in people with impaired liver and kidney function. This poses real challenges for modern health systems, something Ellen Nolte and I will be looking at in our new book on the health system response to chronic disease, due out in September.