12th March: Ljubljana

Slovenia will have a general election in September. Health care is rising rapidly on the political agenda, largely because of the high share (about a third) of health expenditure now being paid directly. The Slovenian health financing system has a large co-payment element, which many people cover through complementary insurance but others pay out of pocket (See HiT profile).

I was invited to talk about the roles of planning and markets in health care, with particular reference to the UK. My host was the Friedrich Ebert Stiftung, a German foundation that supports dialogue on public policy issues.

The starting point was that markets have clearly delivered many benefits. No-one now would want to go back to the centrally planned system for distributing food in the Soviet Union. The question is whether the conditions for markets to operate apply in health care? Another issue to consider is the differing goals of the various actors. Governments seek to improve the health of their populations, to respond to their legitimate needs, and to do so fairly (or at least they should – this is the WHO definition). Private companies are legally obliged to maximise the returns to their shareholders. These goals may overlap, but it is unlikely that they will overlap completely.

Health care is not a commodity like baked beans, apples, or widgets. It has certain features that make it special. Many people who need care don’t realise it. Even if they know they need something, they may not know what. They are easy prey for unscrupulous providers. This is what we call information asymmetry. It is not only people who are ill who have an interest in being treated. The rest of us also have an interest. This is obvious where they are suffering from infectious diseases, which may infect us, or mental health problems that may lead them to harm us. But simple concern for others also leads us to want to see their suffering relieved – what we call externalities.

Then there is the changing nature of disease. Markets are fine where the transactions are simple, as was once the case in medicine, where an individual patient would go for a single visit to a doctor, who would make a diagnosis (often wrong) and prescribe treatment (often ineffective). The patient either got better or died. The situation now is quite different. A typical older patient may have arthritis, Parkinsons Disease, heart failure, bronchitis, diabetes, and depression. They go to their family doctor. They are then referred to a series of medical specialists, nurses, other health professionals, all working together in a network, collaborating with each other. They receive multiple powerful and effective medicines, all of which are affected by their organ function and by the other drugs they are taking (which will never have been evaluated in combination). They remain under continuing review for the remainder of their now active and fully engaged life. This is seriously complex and someone has to manage it. Unsurprisingly, private providers will run a mile from patients like this. Instead they concentrate on straightforward non-urgent surgery, where the costs are largely predictable, and if they do venture into chronic disease management, they select those people who only have one disease and are otherwise healthy. The public sector picks up the rest – what we call cream-skimming.

But does this matter, as long as everyone can get treatment somewhere? It can do. Think of situation where a family is injured in a high speed car crash. They arrive at an emergency department. There is no paediatric service – it has been moved into the community. Their eye injuries cannot be treated as the ophthalmologists have been relocated to an independent treatment centre to concentrate on waiting lists for cataracts. The complex hip fracture cannot be treated, because the orthopaedic surgeons have been relocated to an independent treatment centre to concentrate on waiting lists for knee replacements. There is no microbiologist to speak to about the wound infection because the service has been privatised and moved 200 km away.
However, perhaps the greatest challenge relates to preparing for the future. As Donald Rumsfeld famously said “there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know. And … it is the latter category that tend to be the difficult ones.” So when we are thinking about the competing strengths of public and private provision, a key issue must be which allows more flexibility to adapt to future challenges. Then there are the things that we can predict, such as the need to train the next generation of health professionals and the need to engage in research and development to generate new knowledge. Again, we need to ask which is better at investing in these future needs.

Taken with the conventional questions such as value for money, this then gives us a framework for looking at two of the developments that have taken place in the UK, the Private Financing Initiative (PFI) (as a means of funding new hospitals) and Independent Sector Treatment Centres.

It is now apparent to all but the most ideologically driven commentators that the UK PFI scheme has been a failure. Allyson Pollock has provided most of the evidence in a series of papers, in the process exposing herself to vicious personal attacks from the supporters of PFI (or in some cases from backbench Members of Parliament who probably never understood the issues but were doing what they thought might be appreciated as they sought to advance their careers). She has shown how the procurement process is expensive, complicated, and prolonged. One result is that several projects have been abandoned at an advanced stage, wasting millions of pounds. Several of the hospitals that have been completed have suffered major quality problems. However, for us the real problem is the inflexibility (see our paper in the Bulletin of the WHO). Because the contracts are negotiated in so much detail, it is virtually impossible to change the specifications, even though we know that the nature of health care is changing rapidly. One example is the ratio of operating theatres to beds. With short acting anaesthetics and minimally invasive surgery we need more of the former and less of the latter. Yet some recently completed hospitals (including one close to where I work) are already obsolete in his respect by the time they open. The accompanying picture illustrates the problem. Given the declining need for beds, a newly built hospital now may have too few (an example is the now notorious Norfolk and Norwich hospital PFI scheme). However, in 30 years time it will have too many. The situation is worse for schools. There are now quite a few examples of schools built under the PFI scheme that are now surplus because of falling birth rates (see article in the Guardian). Yet the local governments still have to pay for them to be maintained for the next 30 years, at a cost of millions of pounds each.

The Independent Sector Treatment Centres raise different issues. Here the evidence is rather less, largely because they have consistently failed to supply the data that were required from them. Consequently, a cartoon accompanying one of Allyson Pollock’s paper in a recent issue of the BMJ compared them to a black hole, with money and patients being swept into them but no idea what happened afterwards. One problem is cream-skimming. They only take the straightforward cases, leaving the NHS to look after the rest. Yet bizarrely, give the lower costs that result, the government pays them 11% more per case! (and this is on top of various other subsidies plus a guarantee to buy back the premises at the end of the contract). It then doesn’t even check whether they have performed all the procedures they have been paid for – a reasonable estimate is that they have performed about 70% of the contracted work but of course they received 100% of the payment.

Now I am not saying that markets have no place in health care. Of course they do. All that we have to do is ask whether, in a particular set of circumstances, the prerequisites for a market exist and then whether it will actually deliver what it promises. Fortunately, I don’t have to answer that question for the Slovenian population!

Footnote 1: Credit where credit is due. On Tuesday evening I passed through Terminal 2 at Heathrow. This is normally a deeply unpleasant experience, reminiscent of Douglas Adams’ comment about being drunk, as experienced by a glass of water. Amazingly, I got through security in only a few minutes because there was a security supervisor who was actually managing the process. No-one should underestimate the importance of this development. Could it be that the executives of the British Airports Authority have finally realised that they are meant to be managing an airport, rather than a shopping mall? Somehow I doubt it. Terminal 5 opens in a few weeks and we already know there will only be enough seats for about two jumbo jets’ worth of passengers, presumably with the intention of forcing people wanting a seat to buy food and drink from the many commercial outlets. No. I suspect that this was just an individual who takes pride in his job. I fear he won’t last long.

Footnote 2: I returned through Terminal 2 at Frankfurt. A 20 minute queue to get through security, having been screened only 90 minutes earlier at Ljubljana. It’s close, but in the competition to become the most incompetent airport operator, Frankfurt seems to be drawing ahead.

6th March: Brussels

In June, WHO is organising a ministerial conference on health systems in Tallinn, Estonia. The theme is “Health Systems, Health and Wealth”. The concept underpinning the conference is that all three are mutually linked. Health systems can contribute to better health and to economic growth. Better health reduces the burden on health systems while supporting wealth (economic growth). Wealthier populations are healthier and can afford better health systems. The challenge is to create virtuous circles in which each reinforces the other.


The European Observatory is producing the background material for the conference. This includes a set of policy briefs and two books, one on health system performance, edited by Peter Smith and Elias Mossialos, and one on Health Systems, Health and Wealth, edited by Josep Figueras, Nata Menabde and myself. We were in Brussels for a workshop with the authors of our book.
Many of the elements are already there. Marc Suhrcke, Lorenzo Rocco and I have now published extensively on the contribution that good health makes to economic growth through greater productivity and higher labour force participation. Ellen Nolte and I have shown, in our work on avoidable mortality, how health systems contribute substantially to better health (unless, as in the case of the US system, they are highly dysfunctional – see blog entry of 8th January 2008). The challenge is to bring it all together.



There are, however, some gaps. Although collectively those of us in the room have a great deal of direct experience of health policy in Europe, it is really difficult to find anyone who has made a comparative study of how health policies are made (or not made). One of my favourite quotations is Bismarck’s saying that “two things should never be made in public, laws and sausages”. It may be that the experience of observing policy being made is so awful that few people want to watch it twice! Whatever the reason, there is a desperate need for politician scientists with a comparative perspective who would like to study European health policy (aspiring PhD students please get in touch).



The book will not, however, just be a rehash of what is already there. One of the most interesting areas is the relationship between the health system and the macroeconomic environment. We are often told about the need to ensure a profitable pharmaceutical industry because of its contribution to the economy. But given finite resources, is this really the best use of money? On the available evidence, the jury is still out. On the other hand, there is growing evidence of other ways in which health systems contribute to the economy. Peter Smith cited evidence from China where, especially in rural areas, the health system has largely collapsed. As a consequence, families are hoarding money as a form of insurance against ill health. This is sucking huge sums out of the economy, with serious macro-economic consequences - a warning, for those who seek to shrink the scope of publicly funded systems.

25th February, Sydney
To Sydney for the annual summit of the Oxford Health Alliance. The Alliance brings together participants from industry, academia, NGOs, and governments to tackle the epidemic of chronic disease. They come from many backgrounds, not just public health but the law, the media, the built environment among others. The message is simple – 3four50:

• 3 risk factors – smoking, poor diet, lack of physical activity, lead to


• 4 diseases – heart disease, type 2 diabetes, lung disease, and many cancers, accounting for


• 50% of deaths in the world.

We were allocated to groups, at tables, and asked to discuss the issues raised in a series of plenary presentations (speeches, panel discussions and video clips). OXHA has always had a strong emphasis on understanding (and changing for the better) the environments that people live in and how they impact on their health. This year we focused on cities where more than half of the world’s population now lives. A key theme, developed in particular by

Tony McMichael, was the issue of sustainability. Too often policies create sick people and sick environments. Greater car use leads to obesity, heart disease and diabetes and pollutes the immediate environment while contributing to global warming.

Of course, even in an audience that is committed to tackling chronic diseases, there is scope for disagreement. One area of contention was about how much evidence is enough. Should we delay calling for action until we have all the evidence? Or should we adopt the precautionary principle, even though we may occasionally be wrong? Those favouring the former highlighted the danger of unintended consequences, while the latter reminded us that that it was many years after the original epidemiological studies before we understood, at the biological level, of how tobacco causes lung cancer but it would have been a disaster if we had waited until we had it before acting to reduce smoking.

My role was two-fold. The first was to speak on a panel on getting evidence into policy, something I have spoken about many times. It was an exceptional panel and I was accompanied by Larry Gostin, Fiona Adshead, and Simon Chapman. You can hear commentary on the session by Richard Smith on the conference web-site (click on the Day 2 pm tag). I was arguing that we need to understand where politicians come from, recognising their personal agendas and trying to find win-win solutions. Yet that does not mean that we should not challenge how the political process works. In recent years there has been an enormous amount of soul searching by researchers about issues such as interpretation of evidence and research fraud. This is entirely justified. Yet the sins of a few researchers pale into insignificance in comparison with much everyday politics.

Unfortunately, few health-related decisions are subject to the scrutiny that we need to understand how they came about. Instead, we need to look for insights from other areas of policy. Our sources are some recent books, such as Anthony Seldon’s biography of Tony Blair. Bob Woodward’s State of Denial, and Carl Unger’s The fall of the house of Bush. These well-referenced books remind us of the importance of personal relationships. Unger shows how many of George W Bush’s policies were driven by his determination to go down in history as a greater president than his father. Woodward describes how the decision to go to war in Iraq took place in a US cabinet where, when Donald Rumsfeld was speaking, Colin Powell ignored him and vice versa, while George W Bush seemed incapable of understanding what either was saying. In the UK, Seldon describes graphically how policy making was dominated by the visceral and mutual hatred of each other by supporters of Tony Blair and Gordon Brown, to the extent that some of their senior advisors would not even sit in the same room. The relation was summed up best by Gordon Brown’s now famous remark to Tony Blair that "There is nothing you could ever say to me that I could ever believe."

It is, however, when we get into the detail of the decision-making process that we can really understand how some politicians understand the concept of evidence. The best described example is, of course, the case for invading Iraq. Here our sources are Woodward and Unger. It is now apparent that the “uranium from Niger” story was manufactured by the Italian security services to ingratiate them with the Americans. The flaws in the story, such as the fact that the French authorities were in complete control of the Niger mining operation and the story required that 500 tons of uranium ore be transferred between ships on the high sea (if not impossible certainly extremely difficult) was conveniently overlooked by the US and UK security services. The mobile chemical weapon factories, later found to be trucks for filling weather balloons with helium, were known to be harmless from the beginning. Interestingly, we now know, from an analysis by Ronan Bennett, that it was not French obstruction that prevented a UN resolution in favour of an invasion of Iraq but rather the role of the Mexican Ambassador to the UN, Adolfo Aguilar Zínser, then on the Security Council, who was the only one not to be taken in by the “intelligence” and to ask serious questions. One was whether there was any correlation between how well hidden weapons were and the speed with which they could be deployed. The admission that this was true suggested some contradiction between the two arguments being made that a) the weapons were so well hidden that they could not be found yet b) they could be made ready within 45 minutes! He was not persuaded, and as a result, neither were the ambassadors of the other undecided countries. At this stage, French support would have been irrelevant. So how was this peer-reviewer rewarded for his diligence in exposing this appalling example of research fraud? The US authorities put pressure on the Mexican government and he was recalled. While of course we need to continue the struggle against fraudulent researchers, we should not let politicians get away with the same crimes.

I did, however, have a second role. OXHA has been at the forefront of exploiting the opportunities offered by the media, thanks to the expertise of an extremely innovative production company, Joose TV. The summits are web cast live and, if you have followed the links above, accompanied by webcast commentaries. In an innovation this year I did a series of interviews with some of the participants: Larry Gostin, Srinath Reddy, Judith Mackay (Bloomberrg Tobacco Initiative), Abdullah Daar (leader of the Grand Challenges project), Claire Lyons (Pepsico Foundation), Viliani Tangi (Health Minister of Tonga), and Christine Hancock (OXHA). You can view them on the 3four50 site.

18th February: Izhevsk, Russia
Not an auspicious start. Shortly after we arrived at Moscow airport it was announced that our Izhavia flight was delayed two hours, then another two hours, and then a few more. Izhavia only has a few planes and several of them were out of order. Our Yak 42 that should have left at 7pm finally took off, in heavy snow, at 3 am. The joys of travel…
We have been working with colleagues in Izhevsk, an industrial city near the Urals, for about 5 years. It was there that we undertook the research showing the major role played by surrogate alcohols (aftershaves, fire lighting liquid and the like) in the Russian mortality crisis. In our earlier work we reported that these substances were drunk regularly by about 8% of working age men and their consumption was very strongly associated with premature death, even after taking account of consumption of other forms of alcohol. There are, of course, a few sceptics who are unconvinced of their importance but the evidence is now overwhelming.
The obvious next step is to do something about this problem. In fact, the Russian government did introduce a package of measures in 2006 that reduced supply of these substances, mainly by making it more difficult to get licences to sell them and the monitoring equipment needed to assess tax on them. Since then, life expectancy has increased markedly although it is still too early to say if it is a direct result of the new legislation or not.
Our current research involves following up those men who were the controls in our earlier study, to see how they have fared since we last spoke to them. We are also inviting them to come for health checks, where we can advise them about problems such as high blood pressure – a major problem in Russia. Those who are drinking heavily are being invited to participate in a randomised controlled trial of motivational interviewing, a brief intervention that has been effective in changing behaviour elsewhere.
By coming back to the same place for several years it is possible to see how things are changing. When we first came to Izhevsk we stayed in a trade union hotel for health workers that had changed little since Soviet days. Like other buildings of the period, no two steps on the stairs were the same height, something that we tend to take for granted in the west. Now we stay in a lovely little hotel that could easily have been transported from Vermont, with its beautiful wood panelling, comfortable bedrooms, incredibly helpful staff, and even WiFi. But it is not the only thing that is changing in the city. This time we got stuck in a traffic jam, something that was previously unimaginable. We heard that there are now quite a few Porsche cars in Izhevsk and there are now some very up-market cafes serving food from around the world. Yet many people still live in the wooden barracks built before WW2. This is definitely a society in transition.
On the way back, I took a brief trip into Moscow to catch up with colleagues at the Open Health Institute. With funding from the Bloomberg tobacco initiative, they have created the Russian Antitobacco Advocacy Coalition (Ataca), something I described a few weeks ago on this blog, following my last trip here. Ataca has already made enormous progress. The Russian government is well on the way to ratifying the Framework Convention on Tobacco Control and a much strengthened law on tobacco advertising has just been passed. There is a long way to go but it is great to see so much happening so quickly.

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

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”.

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.

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).

Helsinki, 11-13th October
… for the Annual Conference of the European Public Health Association. An especially busy few days, with a plenary speech to give, as well as three shorter presentations and a workshop to organise.
The presentations were on topics I have spoken about many times before – the mortality crisis in the former Soviet Union, the health of the Roma people, and the relationship between health and economic development.
The workshop was something I had agreed to organise in my role as a member of WHO’s European Advisory Committee on Health Research. In November 2008 health ministers from around the world will converge on Bamako, in Mali, to discuss the state of health research world wide. The 2008 Global Ministerial Forum on Research for Health is a follow up to the 2004 conference held in Mexico. We wanted to make sure that, in this global discussion, Europe was not overlooked, both in terms of its interests and its potential contribution to the global health research agenda.
To my surprise, even though it meant missing out on lunch, about 50 people turned up and engaged in a lively and highly productive discussion. The key messages, which will appear later in a paper, were as follows.
First, we need to make sure that governments live up to the commitments they made in Mexico. There, they agreed:
* to commit to fund the necessary health research to ensure vibrant health systems and reduce inequity and social injustice,
* to establish and implement national health research policies,
* to promote activities to strengthen national health research systems, including the creation of informed decision makers, priority setting, research management, monitoring performance, adopting standards and regulations for high quality research and its ethical oversight, and ensuring community, nongovernmental organization, and patient participation in research governance, and
* to establish sustainable programmes to support evidence-based public health and health care delivery systems, and evidence-based health related policies.
It will be important to document what Europe’s governments have actually done in the intervening four years. The overwhelming consensus of those present was “not much”. Indeed, there was a widespread feeling that no new developments could be attributed directly to the Mexico meeting.
Second, while accepting the importance of issues such as HIV, tuberculosis, malaria, and tobacco control, it was felt that these will be identified by every region in the world. Were there any specific issues that Europe would like to see in a global health research agenda? Three issues emerged: aging, migration, and alcohol.
Third, what can Europe contribute to the rest of the world? Here we identified expertise on the epidemiology and health system response to complex non-communicable diseases. These are rapidly growing in importance everywhere but often receive far too little attention.
The title I was given for my plenary was “The future of public health in a unified Europe”. I took the liberty of adding a question mark. Europe (or at least some parts of it) is now clearly united. Ten former communist countries, divided from the rest of Europe for 45 years by the Iron Curtain, are now part of the European Union. Yet it takes more to unite a continent than to pull down a wall.
Europe’s population is changing. Most obviously, it is aging and, as a consequence, needs more young people to maintain its workforce. With birth rates at a record low, this can only occur through migration. For the past half century, western Europe has been based on a particular social model, with consensus on the need for the rich to support the poor, the young to support the old, and the well to support the ill. This is very different in the USA. One obvious reason is that rich white people have often been reluctant to pay for poor black people, something that was all too apparent in the images of the aftermath of Hurricane Katrina in New Orleans. As Europe becomes more ethnically diverse, will it place strains on our commitment to solidarity? The newspapers I read on the flight to Helsinki certainly did nothing to allay my concers (see picture).
Then, how will our children respond to the much greater numbers of older people, especially when they realise that we have been borrowing from them for decades, through unfunded pension schemes and ill-thought out public private partnerships, such as the build today, pay (many times over) tomorrow UK Private Finance Initiative. In my talk, which will also be published in due course, I argued that we need to think about these issues now, because the alternative of a fractured, unforgiving society, where everyone must fend for themselves, is not a world that any of us want to live in.

Washington, 7-8 October
I was in Washington for the annual meeting of the Institute of Medicine, to which I was (somewhat surprisingly to say the least) elected last year, along with my colleague Anne Mills (as there are only 84 foreign (non-US) members, we felt it was quite a nice surprise – and possibly a unique one- to have two elected from the same institution in a single year).
It was a rather imposing occasion, held at the National Academy of Sciences building just beside the State Department. The theme of the day was “Evidence-based medicine and the changing nature of health care.” It was at the same time interesting and depressing. Interesting, in that there were, as one would expect, some superb presentations. Depressing, in that so little seems to have changed in the US health system – at least in tackling some of the fundamental issues around quality of care - in the past two decades.
For me, the highlight was a paper by Elliott Fisher, from Dartmouth Medical School. You can listen to it online and download the presentation on the IoM site. The key message was that there are still enormous geographical differences in per capita Medicare expenditure. What was most interesting was the comparison between high and low cost areas. Rates of clearly effective interventions (e.g. reperfusion within 12 hours and aspirin on admission with a myocardial infarct or pneumococcal immunisation) and of interventions where patients can decide whether they want treatment, after balancing risks and benefits (e.g. hip replacement and CABG) were essentially the same in both areas. What differed was the process of care, with those in the high cost areas having more inpatient days, more visits to specialists, and more investigations. Importantly, there were few differences in outcome and, in all cases, where they existed, outcomes were better in the low cost areas. What explained the difference? One major factor was the ratio of specialists to primary care providers, a finding that was unsurprising in the light of Barbara Starfield’s excellent work over many years. Over-specialisation has profound implications for the US health system. Any solution will be difficult, but I was taken by Elliott’s observation that if 30% of the medical workforce in the US was to move to Africa it would improve the health of the populations in both continents!
While I was there I was greatly privileged to meet this year’s recipient of the Gates Award for Global Health, Mechai Viravaidya, the founder of the Thai Population and Community Development Association. The PCDA started out as an organisation providing family planning services to rural communities throughout Thailand that were not covered by government programmes. It worked through a network of village-based volunteers, with a strong emphasis on enabling women to take control of their own lives. When Thailand was confronted with the AIDS epidemic, it shifted gear. Mechai and his colleagues were the driving force behind a remarkable HIV prevention programme that is credited with much of the responsibility for an over seven-fold reduction in new infections between 1991 and 2003. Subsequently, it has expanded even further, into primary health care, water supply and sanitation, income-generation, environmental conservation, support for small-scale rural enterprises, and gender equality.
Listening to Mechai’s acceptance speech was one of those amazing occasions that will stay with me for ever. He took us on a remarkable journey, describing how the organisation had responded to emerging challenges. This is someone for whom there are no problems, only solutions. You felt that if anyone could sell snow to Eskimos, he could! He described how he had used humour to break down prejudices about sex, and in particular how he had tackled an unwillingness to use condoms. Indeed, in Thailand he is now often referred to as Mr Condom! He handed out T-shirts showing multiple sexual activities, each stating whether a condom was needed or not. He told us how his team worked to support young girls in rural areas who were being lured into the sex industry. And he told us how they had supported small scale enterprises so that villages could become economically self-sufficient, with benefits for health and education.
This was a truly humbling occasion – a quite remarkable man and a very well deserved recipient of this prestigious award.

Six years ago, Elias Mossialos, Rita Baeten and I were asked by the Belgian government to prepare a book on the consequences of European law for health services, as part of their preparations for their EU presidency. At that time many governments remained in a state of denial on this issue. They had signed the Maastricht Treaty, which made clear that health services were a matter for member states and not the EU. Yet they forgot that all those things that a health care system needs to function, from drugs to medical technology to health professionals, were subject to EU law. For example, for over 30 years, health professionals had enjoyed the right to move freely within the EU. Patients could also receive treatment abroad, should they become unexpectedly ill, safe in the knowledge that their health care payer at home would cover the bill. It was also possible for patients to go abroad to get treatment for an existing disease but their insurer had to give permission in advance, or so it was thought. Anyway, these things were at the margin. Very few health professionals did move from one country to another, save for a few traditional flows, many of which long predated the EU, such as Irish doctors moving to England. The number of people falling ill abroad was small and anyway most claimed on their travel insurance. It was hardly surprising that no-one seemed too fussed.
Of course, in 1998 it all changed. Two citizens of Luxembourg travelled abroad, in one case to obtain spectacles from Belgium, in the other to get orthodontic treatment for his daughter in Germany. When they returned, they presented their bills to their insurer, who refused to pay. A long time later, it was forced to by the European Court of Justice.
These rulings sent shockwaves through the corridors of health ministries. Spectacles and dental treatment were not a problem, but where was this leading to? Yet in many capitals, the shockwaves rapidly subsided. Ministries reassured themselves that the Court’s rulings did not apply to national health services, or to hospitals, or indeed beyond the precise circumstances of the cases. In contrast, a growing number of people, often with remarkably unusual conditions, spread out across Europe seeking to test the limits of the new legal situation. Progressively, the right to obtain care abroad was expanded, and it became clear that many of the safeguards that governments thought they had in place were not as safe as they thought.
At the same time, a few governments were waking up to the implications of what had, until then, been a rather obscure legal instrument, the Working Time Directive. This limited the hours that people could work each week, but it was widely believed that it did not apply to medical staff who were on call but not actually working. Once again, they were wrong. The consequences are profound and even now poorly understood by many people responsible for the delivery of health care. Small hospitals, with a few medical staff on a rotation, became unviable. The established system of medical training needed radical revision.
Back then, we actually exceeded our brief for the Belgian government, producing one authored and one edited book. We now realise just how important the two books were. While I am still not convinced that many people, except for the small group of Euro-policy wonks, actually read them from cover to cover, the fact that it was possible to write two entire books on a subject that many people had previously regarded as a non-issue did seem to make an impression.
Yet six years is a long time (in fact the books appeared in 2002) and a trickle of health-related cases before the European Court has turned into, if not a torrent, at least a respectable stream. Consequently, again with support from the Belgian government, a new book is on the way. This time it is edited by Elias and Rita, along with Tamara Hervey and Govin Permanend. My role is limited to co-authoring two chapters (although today I seem to have acquired a third!).
Today we (the editors, authors, and a few policy experts whose job is to make sure we are grounded in reality) were in Brussels to discuss our draft chapters. Readers will be familiar with the concept of authors’ workshops, which we use with all the Euroepan Observatory books.
So what has changed in six years? The law of course. The European Court has ruled on a substantial number of cases hat have variously clarified or obscured the situation. However, it is beyond doubt that the legal situation is now very different.
Awareness of its importance has also changed. Now, no-one who is at all informed maintains that EU law is irrelevant to health care (but see later). In the intervening years, governments have established a high level reflection group to explore the nature of its implications. An attempt to treat health care like any other service, in a general directive on services, was roundly defeated. Yet while there is now an acceptance that health care is special, it has been extremely difficult to square the circle of delivering socially inclusive, evidence-based care, in an internal market.
Another change is the number of academics working in this field. Six years ago, there were only a handful. Now there are well-established teams of legal researchers specialising in EU health law in a number of universities, mostly in Belgium and The Netherlands, but also in, for example, Sheffield, directed by Tamara Hervey.
Yet some thinks have not changed. Surprisingly frequently, questions were raised about the conformity with EU law of developments in one country, England. There, a bewildering array of quasi-market mechanisms have been established, often shrouded in substantial legal uncertainty. From the time they were introduced, ministers have maintained that contracts between NHS purchasers and providers are contracts, but not ones that are legally enforceable. Outside the parallel universe in which many of their advisors inhabit, this is not a concept that is widely recognised. Furthermore, as new structures, such as Foundation Trusts, are created, the legal situation becomes ever less clear. Now this situation offers endless scope for debate on issues such as what is an undertaking or what is a service of general interest. And of course, nothing is more engaging for lawyers than endless debate (academic lawyers excepted of course!). Consequently, one question that came up several times was why none of the private health care providers active in England had challenged decisions under EU law. The only plausible solution was that, despite all its flaws, the pickings were so rich that no-one wanted to rock the boat. Whether this will continue if the flow of money slows remains to be seen.

In the nineteenth century the world was transformed by the industrial revolution. In the twentieth century it was the turn of the information revolution. The scale and pace of change is truly amazing. In the 1940s, Thomas Watson, the head of IBM, is reported to have forecast that the total world demand for computers would be at most five machines! Today, the vast majority of families in high income countries are connected to the internet.
These technological advances are being used for many purposes. Some are clearly beneficial. It is a great advantage to be able to check one’s bank balance or book an airline ticket whenever you want to. Yet some are more problematic. This week it was revealed that the US Department of Homeland Security has been accumulating comprehensive details of all travel undertaken by American citizens (and presumably others as well). The European Commission is planning a similar system. The United Kingdom, a country where urban areas are already almost entirely covered by surveillance cameras, is proposing to introduce a biometric identity card that will track every encounter that an individual has with an official agency, in the same way that loyalty cards allow supermarkets to monitor individual’s shopping habits. Data protection laws seem simply to be ignored.
Yet, while every move that we make in high income countries is being recorded by someone, in poor countries people are still born, live their often short lives, and die without anyone ever recording anything about them. Worldwide, only about 70 countries have any reasonable data on deaths of its adult citizens.

This will probably come as a surprise to many people, familiar with graphs and tables that purport to show life expectancy in countries such as Liberia or Sierra Leone. In fact, these data are simply guesses, albeit guesses that are informed by some scraps of evidence (or what some people would call “estimates”).
What has happened is that standard life tables have been created, showing what is thought to be the probability of death at different ages in countries exhibiting certain characteristics. Then, data on deaths in infancy and childhood are identified, typically from surveys, and are fed into the life tables to give an overall life expectancy. Obviously, this is critically dependent on us having a good understanding of the relationship between deaths in childhood and deaths in adulthood, which we now realise we don’t have. In other words, we really have no idea about what is happening to adult mortality in much of the world.
This week I was invited to Seattle to join a small group of people to discuss what might be done. The meeting was organised by Chris Murray, who has recently moved from Harvard to the University of Washington, where he has established the Institute for Health Metrics and Evaluation. We had convened within the framework of Grand Challenge 13, funded by the Bill and Melinda Gates Foundation. The challenge is to devise new ways of accurately measuring population health.
We spent the first day looking at the problem of simply capturing data on how many people have died. As Alan Lopez reminded us at the end of our discussions, the gaps in our knowledge are a “scandal of ignorance”. There is little doubt about where we need to be. All countries should have effective systems of vital registration. Yet for many this is still at best a distant prospect, especially those where establishing even the most basic governance functions seems as far away as ever. There are, however, possible intermediate steps, such as sample surveillance, where data are collected from a sample of locations, in the hope that they will be reasonably representative of the overall population. This is what is done in India and China. Then there are the indirect methods, based on data from surveys. Yet none of these are perfect and we still face many unanswered questions about the validity of the methods we are using. A problem in many parts of the world is that many people do not know what age they are. This can lead to what is called heaping, where reported ages are concentrated in numbers ending in 5 or 10. However I was fascinated to learn, although I suppose I should have realised, that in societies where astrological correlates of birth dates are important, people are much better informed. Ken Hill told me that the distribution of ages in the 1953 Chinese census is perfect.
Day two looked at the even more difficult problem of collecting data on cause of death. Here, a degree of realism is needed in what can be achieved. Even in countries with the best possible systems, there will always be considerable uncertainty about the main cause of death in older people who have multiple disorders. Yet it is clear that even here we can do better, in particular by understanding the principles that are used in different countries in assigning a single cause of death where several co-exist.
Where vital registration systems don’t exist, an alternative is to use a “verbal autopsy”, where surviving relatives are asked a series of structured questions about the deceased. Yet here too there are many methodological issues unresolved about how best to allocate a cause of death. Computerised systems are consistent but not always correct. Physicians inspecting the data are less consistent, but may be more often correct. One interesting possibility proposed by Chris Murray was the use of a computerised model that would take the reported signs and symptoms and, based on a validated data set from the same (or a similar) location, allocate a probability to different causes of death. If combined with clinical judgement (i.e. the physician is presented with the probabilities of different causes and, using any additional information available, decides on the most likely cause) this could be a valuable way forward. Clearly the increasing availability of hand held computers offers considerable potential. This would also overcome the problem seen in many existing sentinel surveillance sites of piles of paper forms lying uncoded long after the events they describe took place.
There are other opportunities too. It was pointed out that we are coming up to the next round of censuses in many countries, typically conducted every ten years. It would be possible to include a question asking whether anyone had died in a household in the past year or so and, where this had happened, to follow it up with survey teams applying a shortened verbal autopsy instrument.
Of course, none of this will happen unless the world community begins to take adult mortality seriously, something that it has so far singularly failed to do. What efforts exist have focused on child and maternal mortality. It was even suggested that these efforts have diverted attention away from adult mortality. The problem, as is so often the case, is that we are in a vicious cycle. The priority for international development is the need to reduce child and maternal mortality rates, because these are often the only figures we have on population health in many parts of the world. Yet because these are the priority, no-one (except the Gates Foundation) is willing to invest in the collection of data on anything else.
But maybe there are solutions to the problem of resources. As I came back through Heathrow the iris scanning machine, designed to let frequent travellers pass through immigration a little quicker, was yet again out of order (as it had been last week too). As I noted above, the British government is about to spend billions of pounds (the exact amounts are shrouded in spin and obfuscation, as usual) on a system of biometric identity cards that is doomed to failure (the full account of the failings are in an excellent account by a team at the London School of Economics). If only a fraction of the resources being devoted by the British and American governments could be diverted from the almost entirely pointless and futile attempts to track every move made by their citizens, then maybe we might at least be able to move away from a position where our fellow human beings can live and die without anyone ever recording it. What is more, the much simpler technology required is at least likely to work.

Over the past few years I’ve been working with Marc Suhrcke, from the WHO office in Venice and Lorenzo Rocco from the University of Padua to understand better the relationship between health and wealth. The Commission on Macroeconomics and Health showed how important health was for economic development in poor countries. We have subsequently shown conclusively how this is also true elsewhere. Specifically, in the European Union, South East Europe, and Eastern Europe and Central Asia, those in poor health are less likely to be working, and when they do they work shorter hours and they are less productive.
There are, however, many middle income countries where, although we may reasonably assume that this is so, we have no direct evidence. And we also know that policy-makers like to see local evidence before acting.
For this reason we were asked by colleagues at the World Bank whether we could apply our work to the countries of the Middle East and North Africa. This is a region where, so far, there has been remarkably little health research. The opportunity for us to present some preliminary work was at a meeting of the newly created Middle East and North Africa Health Policy Forum, a grouping of academics and policy makers from across the region. I was joined by my colleague Josep Figueras, who was talking about our experience in the European Observatory in translating evidence into policy.
The meeting was held in Cairo on 8-10th September so it was logical that we should start by looking at some Egyptian data. In fact, there are quite a few household surveys from countries in this region that are suitable for the sorts of analyses we have been doing. There is clearly enormous scope to make use of them.
The first task was to get some basic understanding of the health situation in the region, and in Egypt in particular, given that this is not somewhere I am especially familiar with. The available evidence reveals that Egypt has actually been very successful in improving health. Under-five-mortality has fallen by more than half in two decades and data from the most recent Demographic and Health Survey suggest it has fallen to 46 per 1,000. Male life expectancy has increased from 52.7 years in 1976 to 67.9 in 2003, while the corresponding figures for females are from 57.7 to 72.3. Looking to the future, Egypt has much in its favour. A falling birth rate means that there will be a substantially greater share of the population in the workforce. Fewer children also means that there will be more resources available for their education, a clear priority for future investment. Yet there are challenges. Using a model we have applied elsewhere we were able to show that if adult mortality could be reduced by 3% per year then, by 2030, Egypt’s GDP would be about $8,500 per capita, compared to $6,900 if it stayed as it is now, all else being equal. Unfortunately, even keeping it as it is now may be difficult. We looked at data on body mass among young children. Although there is still some evidence of malnutrition, what is really striking is the very high level of obesity, with almost 14% of under threes overweight in 2000, compared to less than 3% in many otherwise comparable countries.
The health situation in this region is clearly very different from that in eastern Europe, where I do most of my work. However the problems are equally challenging.

This blog has been rather neglected over the summer. Colleagues sometimes ask me how I find the time to write it. Sometimes I wonder myself! Usually it is on planes back from wherever I’ve been but the past six weeks have been so hectic trying to clear the backlog of unfinished papers and books. I even discovered a new condition – shoulder injury from over use of the mouse pad on a laptop!
I did, however, take one short break from writing in August to teach on our new summer school. For many years the Observatory ran a very successful summer school in Dubrovnik, Croatia. It was, however, a huge amount of work to organise it and as the tourists returned to Croatia after stability returned to the region, it became impossibly difficult to sort out the flights and accommodation.
There was, however, an enormous demand to recommence the summer school and this year we decided to do so, moving across the Adriatic to Venice. Our colleagues in the Veneto region had identified a superb study centre, San Servolo, a short journey on the water bus from Saint Marc’s Square.
About 40 participants from across Europe, and even a few from beyond, came together to examine one of the most pressing issues facing health systems today - the people who work in them. The problem is simple. We never seem to have the right people in the right place at the right time. The solutions are much more elusive.
The first difficulty is knowing who is in the health workforce. Statistics are plagued by problems of comparability, especially where health systems are fragmented. There are always interface problems, especially where health and social care intersect. And the words don’t even mean the same things. Unfortunately, a nurse trained in one country may have a very different set of skills from one trained in another.
A second is how to keep pace with the changing nature of health care. Patterns of disease are changing. Complex chronic diseases are now by far the leading contributors to the overall burden of disease in industrialised countries. We need people with new skills and perspectives, who can work in multi-disciplinary teams and who can work in partnership with patients. In some countries we need to accept that doctors are not always the best people to manage chronic diseases. There is now compelling evidence that nurse-run clinics for conditions such as diabetes and asthma get better results.
A third is the increased movement of people across the globe. This is an especially acute problem in the European Union’s new member states, where wages are much lower than in the west.
There are no easy solutions. However, it is good to be able to take some time out, in a place that is so conducive to thought and contemplation, to learn from each other.
The next task is to decide what the subject will be next year!

It is estimated that 230 million people worldwide have diabetes. Some cope well with this disease, managing to live a relatively normal life. Many don’t. In large parts of the world the onset of insulin dependent diabetes is a death sentence. John Yudkin and David Beran, at the International Insulin Foundation, have done a tremendous job in raising awareness of the many people in developing countries for whom a diagnosis of insulin-dependent is a sentence of death. For these people, mostly young children, the situation is unchanged from what it was before Banting, Best and their colleagues discovered insulin in 1921. Steadily, over a period of about 18 months, they waste away and eventually die. Yet even in wealthy countries many people with diabetes face almost insurmountable problems. Death rates from diabetes among young people in the USA, with its fragmented health system and its failure to provide more than the most basic care to 40 million people, are many times higher than in the much better integrated European countries. And things do not always get better. We have previously shown how death rates from diabetes have increased in most former Soviet countries (with detailed studies in Ukraine and Kyrgyzstan) as once functioning (albeit at a basic level) systems fell apart.
For these reasons we have increasingly seen diabetes as a lens through which we can observe the functioning of health systems. In essence, if health systems are working well, then people with diabetes survive; if the systems fail, then they die.
This was the subject of a talk I gave in Oxford on the 28th June. I was speaking at one of the now famous seminars organised annually at Exeter College by David Matthews. I began by looking at the enormous variations in outcomes of diabetes among industrialised countries, drawing on our earlier work relating mortality to the incidence of diabetes, before describing the reality for people with diabetes a variety of dysfunctional health systems in the former Soviet Union. The problem we face is that you need to get a lot of things right if people with diabetes are to receive effective care. You need trained staff who actually understand diabetes, reliable supplies of drugs (and not only insulin) as well as all the equipment to administer insulin and to monitor control, systems of referral when complications arise, and social support so that people with diabetes are not thrown on the scrap heap. All of this is discussed in detail in a new analysis of the management of chronic diseases led by Soji Adeyi at the World Bank, to which we were privileged to contribute.
However, as I mentioned above, things are not so good even where resources are plentiful. As the picture shows, death rates vary enormously within the United States. Unsurprisingly, the situation is much worse for African Americans, although the racial gap in outcomes varies considerably among states, with some surprising results. It is relatively narrow in states such as Maryland and Mississippi but wide in Tennessee and Louisiana.
Of course, I was talking to an audience of experts in diabetes. Do these findings have a wider relevance? Yes, they do. I also showed the close correlation, among US states, between deaths from diabetes and those from overall deaths that could be avoided if there was timely and effective care, a concept that my colleague Ellen Nolte and I have been revisiting over recent years (see our book for more details). However, looking beyond this, it must surely now be apparent to those trying to scale up treatment of HIV/AIDS that they face exactly the same challenges as those trying to put in place effective care for diabetes. The two disorders are both complex chronic disorders. They both need certain basic drugs – insulin/ anti-retrovirals. But they both need a lot more, in terms of an integrated system to deliver care. Furthermore, both diseases exemplify the way in which the traditional divide between communicable and non-communicable diseases is breaking down. People with diabetes develop long term infectious complications, such as a higher risk of tuberculosis or infected foot ulcers. People with AIDS are increasingly developing vascular diseases because of the atherogenic effects of anti-retrovirals. So yes, diabetes is a lens through which we can view, and understand, the health system.
The good thing about speaking at seminars such as this is the opportunity it gives to hear other people. The other speakers were, without exception, superb and I now know a lot more about the mode of action, and thus the effects, both positive and negative, of the new oral hypoglycaemic drugs. I also know probably more than I need to about erectile dysfunction, thanks to some graphic slides by Jonathan Levy! However two rather different presentations stood out from the rest. The first was by Helen Lloyd, a former BBC producer and now oral historian. In a Wellcome Trust funded project with David Matthews, she had interviewed 50 people diagnosed with diabetes between 1927 and 1997. Their stories can be read, and heard in their own words, on a superb project web site. Those diagnosed before the creation of the NHS faced incredible obstacles, with their families scraping together the money for insulin. So many of the stories from the 1920s-1940s echoed those I had heard in the former Soviet Union. Several people described how, as children, they had been excluded from education. Even in the 1980s, people in the UK with diabetes were being discriminated against, excluded from many jobs that they could perfectly easily have done, recalling contemporary practice in the former Soviet Union where children with diabetes are educated separately and, as soon as they reach adulthood, are labelled as disabled and excluded from the workforce. Anyone interested in the human aspects of health systems really should visit this web site. The project is now in a second phase, interviewing those who cared for people with diabetes. We had a preview; the interview that struck me most was with Harry Keen, who described the realisation that insulin was not a panacea and long term treatment was associated with increased risks of cardiovascular and other diseases, an observation with much contemporary relevance given my earlier comments about the cardiovascular consequences of AIDS.
The other noteworthy presentation was by Sir Michael Hirst, former Chair of Diabetes UK and now vice-president of the International Diabetes Foundation. He described the struggle to get a United Nations Declaration on diabetes. Now of course a declaration about a disease is just that, no more and no less. Yet for those struggling to tackle this disease, these things are important and highly symbolic, not least because of the way in which diabetes and many other chronic diseases are often effectively ignored.
It is a story that I hope he will publish sometime. The heroes are the governments of Portugal and Ukraine. The villain was the British government. It is a story of intrigue, duplicity, and deceit. Fortunately, following the recent cabinet reshuffle, some of those involved are now on the back benches. However, it did have a happy ending as the other EU governments, mystified by the hostile position of the British, one by one moved from not understanding what it was all about to active support for the Declaration. This is a story that should be heard by anyone trying to get health on the international agenda in the face of apathy or worse (especially when it is from one’s own government) outright hostility.