Monday, May 31, 2010

To Pécs, in Hungary, last week for the 3rd Conference on Migrant and Ethnic Minority Health in Europe. I had been invited to give a keynote lecture by my old friend István Szilárd, the conference organiser. István and I first met in 1992 when we were working together to develop a new system of public health training in Hungary. It was therefore especially gratifying to see so many high calibre presentations at the conference by Hungarian public health researchers.

The conference was excellent, both in terms of the practical organisation and the quality of the presentations. I was very impressed by the remarkable growth in research on this topic, from a very low baseline, in the past few years. This research remains concentrated in a few centres, in particular Amsterdam, Copenhagen, and Edinburgh, but there is also a growing number of very good young researchers in other centres. Some of the highlights were a superb plenary by Aldo Morrone, who has done an enormous amount to help the boat people arriving on the Italian island of Lampedusa (you can see a presentation of his work on YouTube), Raj Bhopal’s presentation on the many initiatives to address the needs of minority ethnic populations in Scotland, and a series of individual presentations on topics such as expectations of Poles obtaining health care in Scotland, outcomes of diabetes in Belgium, and patterns of hospital care for minority populations in The Netherlands.

My interest in the topic began some years ago with a book that Judith Healy and I edited on delivering health services to diverse populations, including migrants and indigenous populations. We are now in the process of editing a new book on health and health care for migrants in Europe, due out in 2011.

I have to confess that, a few days before the conference, I had no idea what I was going to say. I was speaking to an audience that, collectively, knew an enormous amount about migrant health, but who also had extremely diverse interests, covering different health disorders and different migrant populations. The word cloud that I created to set the scene illustrates the huge diversity of topics at the conference. What on earth could I say that would be relevant to all of them?

I eventually decided not to talk about health at all but to focus on migration. But who are the migrants? Are they the tens of thousands of elderly northern Europeans retiring to the Mediterranean? Are they the footballers from across Africa being paid millions of pounds/euros to play for premier league clubs in Europe? Or are they the global elite who live in hotel rooms and on planes, exemplified by George Clooney’s character in the recent film Up in the air? (a character that I empathise with!) In fact, much of the conference focuses on other groups, at the other end of the wealth spectrum. They include those risking their lives to get to Europe, often in extremely dangerous conditions, and those who have made it to Europe but are subsisting in low-paid jobs, often being exploited by unscrupulous employers and facing multiple obstacles to basic services.

Those we are talking about, therefore, are only a sub-group of the globally mobile population, defined primarily by their inability to cross borders legally. So why do they try? There are the obvious answers, fleeing persecution and searching for a better life. But if we are to understand migration properly, we need to look at the underlying reasons. These relate to the fundamental inequalities of power and resources in a world that permits free movement of goods, capital, and services but not of people. This creates a situation in which those with power and resources (the ones who can glide through borders) can benefit from cheap, and increasingly, skilled labour in poor countries (for example, in telephone call centres or software companies) and cheap unskilled, and often illegal, labour in rich countries (such as the fruit pickers in California). This is the fundamental issue in understanding migration.
Two weeks ago I went to Madrid for the mid-point evaluation of the Registered Nurse Forecasting (RN4CAST) project. I’ve been involved in research on the contribution of the nursing workforce to hospital performance for some years, working with Linda Aiken at the University of Pennsylvania in the International Hospitals Outcome Study. In the English arm of the study we showed that hospitals with the best patient-to-nurse ratios had consistently better outcomes than those in hospitals with less favourable staffing, with substantially lower mortality, while the nurses in those hospitals were about twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals. RN4CAST is now expanding this work to 11 European countries (Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, Sweden, Switzerland, The Netherlands, and the UK), the USA and three International Cooperating Partner Countries of the European Union (Botswana, China, and South Africa) plus one reference group (Norway). I’ve been asked to be one of the evaluators of the project and I was delighted to see the tremendous progress so far. This study will provide invaluable insights that go beyond its original aims, to shed light on the processes and quality of care in European hospitals.

I was also asked to give a plenary lecture at the conference that was linked to the meeting. The project places a high priority on engagement with policy makers and had brought together a large number of key stakeholders from Spain and the rest of Europe. I focussed my talk on the challenges facing the nursing profession in the future.

The first set of challenges arise from the changing nature of health care. These include changing demographics, disease patterns, and professional roles. This has profound implications for the general nurse who faces:

• Loss of much of traditional caring role (to health care assistants)

• Increase in the need for clinical knowledge (of drugs, interactions, side effects)

• Increase in the need for technical skills (new equipment for patient monitoring and treatment, information technology)

• Increase in the treatment co-ordination role (among many more actors, and with a much more mobile group of patients)

• Increase in need for vigilance to identify patients deviating from the expected clinical trajectory

• Increase in working in different settings, often involving greater autonomy

Unfortunately, health systems do not always rise to these challenges, exemplified by a paper in J Health Serv Res & Pol in which a researcher described their stay in a hospital: ““Care was being delivered by a group of professional and semi-professional workers, each of whom occupied their own silo, occasionally picking up information from others to initiate some action, or acting in ways that triggered actions by others, but who were unable to see how they formed part of a whole system”

A second challenge is the recruitment and retention of nurses, with many industrialised countries far too dependent on recruitment of nurses from developing countries that can ill afford to lose them.

The third challenge is how to get the balance right between curing and caring. Too often we focus on the technical aspects of care, encouraged by the focus in some countries on what can be measured, while ignoring the human aspects.

Fourth is the need to strengthen professionalism. In some countries professionalism needs to be developed, where nurses are still viewed as doctors’ handmaidens, but in others professionalism needs to be defended from politicians who endorse George Bernard Shaw’s description of professions as “a conspiracy against the laity”, seeking to micro-manage and infantalise them.
Finally, there is a need to address the challenge of life-long learning, although hopefully not going down the incredibly prescriptive, bureaucratic, and probably unworkable model of revalidation being developed for doctors in the UK.

At the end of April I was in Warsaw, to participate in a meeting of the European Science Advisory Network for Health (EuSANH). This is a network of national science advisory bodies working which in the field of health that promotes independent scientific advice and evidence-based health policy. We have been contributing by preparing reports on bodies fulfilling this role in the UK, including LSHTM’s on-call facility for the Department of Health, the Academy of Medical Sciences, and NICE (with thanks to those involved for providing the necessary information).

The meeting was combined with a conference discussing the role of scientific advice for policy, at which I gave a keynote lecture. I began by reflecting that the world is complex (helpfully illustrated by a diagram published in the New York Times the previous day in which the US Department of Defense sought to represent the challenges it faced using a diagram that had the appearance of an upturned bowl of multi-coloured spaghetti), before looking at the different stages of communicating information. One problem is that researchers too often take pride in the obscurity of their messages, viewing anything comprehensible as lacking intellectual rigour, although an alternative view (which I prefer) is that this is simply an opportunity to defend the status of their discipline. I was therefore delighted, when researching the lecture, to come across a paper from 1968 entitled “Are sociologists incomprehensible? An objective study”. It cited an earlier paper which argued that “A few sociologists write the best English they are capable of writing.... Others, however – and a vast majority – write in a language that has to be learned almost like Esperanto. It has a private vocabulary which, in addition to strictly sociological terms, includes new words for the commonest actions, feelings and circumstances. It has the beginnings of a new grammar and syntax, much inferior to English grammar in force and precisions. So far as it has any effect on standard English, the effect is largely pernicious. “ A more recent paper, reflecting on economics, said “We have all had the experience. You start a new job, be it academic or corporate. You walk into a presentation by a colleague. Before the third slide comes up on the screen, you find yourself totally lost in a morass of method, terminology, and tradition beyond your comprehension. You know the speaker is brilliant and you have full confidence in the conclusions; however, you find it impossible to follow the logic that takes the work from beginning to end.”Enough said!

However, much is being done to redress this situation and I argued that anyone seeking to make a difference should read the excellent series of articles recently published by John Lavis, Andy Oxman, Simon Lewin, and Atle Fretheim in Health Research Policy and Systems, which takes the reader through all the stages, from creating organisational structures that support the use of evidence, through identifying evidence needs and finding and assessing the evidence, to making evidence-based decisions.

Yet, no matter how hard researchers try, they need to confront the biases that exist in the minds of recipients of evidence. David Stuckler and I were thinking about this in the run up to the recent UK general election. At one stage, when it became clear that he was trailing in the public response to the televised debates between the party leaders (among those watching on TV, not those listening on radio, echoing an earlier debate between Nixon and Kennedy), Gordon Brown called for a focus on substance, not style. This was a complete waste of time. As we showed in a paper in the BMJ reviewing new research from neurosciences, once the electorate have come to a judgment on an individual, it doesn’t matter what they say. Research using fast magnetic resonance imaging shows that they automatically discount your messages, while ignoring obvious contradictions from politicians they admire. These biases influence how objective evidence on health policy is interpreted. An elegant American study published in late 2009 looked at how political allegiance shaped interpretation of evidence on the causes of diabetes, presenting news stories that were identical except for what they said was its main cause (not mentioned, genes, individual lifestyles, or social determinants, such as the obesogenic environments in which many of us live). Democrats and Independents reading the last of these were more likely than those whose news item mentioned no cause (controls) to agree that social determinants were important, while there was no effect among Republicans. However, while reading the explanation invoking social determinants made Democrats and Independents more likely than controls to support collective social responses, Republicans were less likely to.

Then there is the effect of the media. Ben Goldacre has drawn attention to some of the more bizarre stories in the British tabloid paper the Daily Mail, including its apparent campaign to place every object in the world in the categories of causes or cures for cancer, and in some cases both simultaneously (indeed, so numerous are its claims that there is a website specially for those who wish to keep up with them, helpfully listing them in alphabetical order). However, it has an equally vociferous campaign against what it calls the “nanny state”, in which most of us would include the spectrum of public health policies that have rendered death in childhood a rarity in Britain and have contributed to a steady gain in life expectancy. But does the media matter. Sadly, yes, as was shown in a study that tracked the roll-out of Fox News to cities on cable channels in the USA between 1996 and 2000. Its appearance in a city was associated with a significant electoral shift to the right.

Finally, there is the role of vested corporate interests. Marshalling vast financial resources, and using remarkably sophisticated marketing techniques, they have developed tremendous experience in influencing how we think. A now notorious example is the use of product placement in movies by tobacco companies.

So, in summary, if we as researchers are to have an impact on policy, then we need to get our own house in order, finding out what it is that policy makers want and giving it to them. But as citizens, we should also demand that our policy makers recognise their responsibilities to be aware of the biases they bring (and the forces that influence them) and at least try to be objective.

Saturday, May 29, 2010

It’s back. At last. It’s been a year and a half since I last posted an entry on this blog and I reckon it’s time to restart it. The problem was that I didn’t know how to restart. Most of my postings were written on the plane back from somewhere, but I was finding that that time was being used up by writing meeting reports, preparing the next talk to give somewhere else, editing papers, or simply catching up with the journals. There was just no time at all. I felt I needed to offer some explanation for why I hadn’t been writing on the blog, but couldn’t find the words.
So what has changed? Well, nothing really. The volume of work remains at a completely unsustainable level, but then it’s been like that for years and I’ve managed to sustain it .... just. But just for once I’m on a plane and have no immediate deadlines – well, not quite true – I still have to prepare two lectures that I’m giving next week and the week after. But I’m not going to manage to finish them up here so I just thought – let’s do it.

I’m sorry I haven’t kept an on-line record of the last 18 months, as there was plenty to write about. Some of the highlights included:

• Speaking at the Global Ministerial Forum of Research for Health, in Bamako, Mali in November 2008. Health ministers from almost 60 countries committed to developing and funding health research strategies, including research infrastructure (ethical review procedures, clinical trials registries, and open access to data) and knowledge translation. As I argued in a BMJ editorial, this is an ambitious agenda and it will be important to hold governments to their commitments.

• Participating in the WHO global Advisory Committee on Health Research, in which I’m privileged to work with some outstanding colleagues from across the world as we develop an ambitious and exciting agenda to support research for health. In November 2009 we had a joint meeting in Panama with the PAHO regional committee, chaired by John Lavis from McMaster University, which really sets the benchmark for the other regions.

• Setting out an agenda for health research at the WHO’s European Regional Committee in September 2009, which will pave the way for action to begin to address the severe under-representation of some European countries in projects undertaking research for health.

• Starting a new EU funded (Framework 7) project, Health in Times of Transition) to study health and lifestyles in nine former Soviet countries. This builds on our earlier Lifestyles, Living Standards and Health study that provided a wealth of comparative analyses of eight countries in this region. The new project adds Azerbaijan. Field work is well under way and we should have the first results this autumn. An added strength is that, this time, we are adding community profiles, so we can understand the environments that shape the decisions that people live in. This will be the first time this has been done in this region and, at a recent meeting in Minsk there was real excitement as the different research teams worked together to address the not inconsiderable challenges.

• Making progress on the Prospective Urban and Rural Epidemiology (PURE) study. This remarkable project is led by Salim Yusuf at at McMaster and has now recruited almost 150,000 people in 17 countries worldwide. Again, we are collecting data on the circumstances in which people live and the early results presented when we met in Beijing in November 2009 indicate that it will yield some very important new findings.

• Making progress on our Rockefeller Foundation funded project updating the study on Good Health at Low Cost published 25 years ago. Their report then identified several countries and regions that were achieving much better health outcomes than would be expected given their level of economic development. They included Sri Lanka, Costa Rica, and Kerala, in India. This time, as well as seeing how the original countries have fared since that report was published, we are looking at another five that are now viewed as doing better than expected: Thailand, Bangladesh, Ethiopia, Kyrgyzstan, and Tamil Nadu. At our last team meeting in Bangkok, in April this year, provided an invaluable opportunity for the research teams from these somewhat different countries to exchange experiences.

• Preparing a report on the implications of ageing for health systems for the Czech EU Presidency, with mu colleagues Bernd Rechel, Yvonne Doyle, and Emily Grundy, subsequently published in summary form in the BMJ. This is one of the most important issues facing European governments and I hope we have been able to dispel some of the many myths.

Several projects have come to an end. The EURO-PREVOB project has provided new instruments for assessing the extent to which the environments in which people live influences their diets and levels of physical activity and the IMAGE project has succeeded in developing and publishing European evidence-based guidelines for the prevention of diabetes in those at risk.

Then there have been the papers. Early in 2009 David Stuckler, Larry King and I published a paper in the Lancet showing how the scale and speed of mass privatisation in the former communist countries correlated with the increase in mortality that occurred at the same time. We thought that this was fairly uncontroversial and saw our most important contribution (besides quantifying the relationship) as identifying the role on community support (measured as membership of organisations) in protecting people. That fitted with another study we published last year showing how measures of social capital were associated with better health in the region. We never expected the response from those who had been advocating rapid privatisation. The Economist used a leader article to dismiss our results (doesn’t everyone know that privatisation is the only thing to do....), using a graph purporting to show trends in Russian life expectancy but looking nothing like anything we’ve ever seen before. Eventually we discovered what they had done. Despite life expectancy fluctuating rapidly from year to year, they took five year averages! This had the effect of making the Russian mortality crisis disappear! Just as Stalin caused millions of deaths at the stroke of a pen, The Economist brought similar numbers back to life. And they never apologised .... Over the course of the next year, we engaged in seemingly interminable (and often frankly bizarre) exchanges, via Richard Horton, with some of the supporters of mass privatisation. The final words can be read in two letters from our critics in the Lancet, which work very hard to show that our results were wrong, along with our letter in response, in which we invoke the criteria of data torture to try to understand how they managed to get our findings to disappear. I would encourage everyone to read all three letters and make up their own minds. Unfortunately, as we have since discovered, no matter how well we rebut our critics, it has become clear that some people will never be convinced.

To coincide with renewed attention to progress in achieving the health-related Millennium Development Goals (MDGs), which focus very largely on deaths in childhood, we looked at whether adult mortality was important. Chronic diseases in adulthood have attracted much less attention than childhood illness (as we showed in an analysis of WHO expenditure prepared for the Bamako forum and published in the Lancet) yet we reckoned that the death or serious illness of a parent must be bad for their children. Our study confirmed this, showing that high rates of disease burden from non-communicable disease, such as cardiovascular disease, stroke and diabetes, were indeed associated with slower progress towards the MDGs and we were delighted when it was cited at the UN General Assembly.

And then the books… The main ones in the past year have been our two on the hospital of the future, one bringing together a series of case studies from some of the most innovative developments in Europe and the other drawing together the many issues facing hospital design in the future. These have, to our slight surprise, attracted enormous attention and have spun of a considerable number of papers as well as numerous presentations and policy dialogues.

So there we are. The blog is back. The challenge will be for me to keep it up!