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Latest Blogs
- Health Care
by Warren Brookes
- What to say to a food company
by Richard Smith
- A chance to collaborate in a book on complex chron
by Richard Smith
- Reducing chronic disease in Pakistan
by Richard Smith
- Serious Illness Insurance with Health & Wellbeing
by Tony Harrison
Richard Smith's Blog
Country: United Kingdom
Organisation: UnitedHealth Chronic Disease Initiative
Blog link: http://www.3four50.com/blog/richardsmith
What to say to a food company
25th Feb 2010
What should you say to a major food company if asked to speak toits senior manages? A friend of mine, a cardiovascular epidemiologist, receivedsuch an invitation and emailed friends asking for advice on what to say.
The context is that some people consider food companies to be liketobacco companies. They are making money out of selling unhealthy products. Themajor difference is that we can imagine—and hope for—a world without tobaccocompanies, but food companies are highly likely to have a continuing (andprobably increasing) role.
This is what I thought my friend should say to the company.
1. You should engage in debate with everybody, even critics whomay seem ignorant and abusive—and your spokespeople should be sure to staypolite no matter how much they are provoked. (I advise this to everybody: speakto your “enemies.”)
2. You should be as transparent as you can possibly be,remembering that very little is gained by keeping things secret.
3. Don't be defensive, but make sure you have something to beproud of .
4. Steadily reduce the harmful components of your food--salt,sugar, fat, etc. You may be surprised how far and how fast you can go.
5. Move steadily into a healthier product range. It makes businesssense as more and more people want healthier foods.
6. Be science driven but always remember values.
7. Be very serious and responsible about the environment,especially carbon and water consumption.
8. Encourage your employees to be as healthy as possible and helpthem in practical ways.
9. Use your marketing power to encourage healthier and moresustainable living.
10. Never be ashamed about making a profit and work to deepenpeople's understanding of the importance of profit. (Many readers may disagreewith this one. People, especially in Britain, are funny about profit,particularly when you consider that we get almost all of our products andservices from for profit companies. I wrote a blog for the Guardian on the casefor profit
(http://www.guardian.co.uk/commentisfree/2008/apr/16/healthybankbalance),and it evoked some very angry responses.)
11. Think boldly and regularly about the future (important for allorganisations).
12. Stay ahead of public and political opinion: don't have to beforced into doing the right thing. (I bet the drug companies would tell themthis.)
13. Recognise your international responsibility and try as hard asyou can to use the same ethical standards everywhere.
14. Recognise the importance of partnership even with partners whomake you feel uncomfortable.
What would you say to a food company?
Reducing chronic disease in Pakistan
7th Feb 2010
Pakistan, like most developing countries, is experiencingrapidly rising rates of cardiovascular disease, diabetes, obesity, and chronicobstructive pulmonary disease, and it has developed a draft national plan forcountering chronic disease. It’s an impressive and elaborate plan, as Idiscovered when I discussed the plan last week with people from the healthministry in Islamabad.It will, however, be an uphill struggle to implement the plan and make adifference.
One problem is attitude. About half the deaths in Pakistan arestill from infectious disease, and many people are understandably againstshifting any resources away from controlling infectious disease. And resourcesare a problem. Pakistanis a poor country, and, as with most of the world, its finances areparticularly shaky now. Annual spending on health for each person in Pakistan isabout $4, enough perhaps for one packet of statins.
Donorsare not keen on funding programmes to counter chronic disease as, againunderstandably, they want to concentrate on trying to achieve the MillenniumDevelopment Goals, which do not include anything on chronic disease.
It’s sensible to prioritise, and one of the challenges withcountering chronic disease is that it needs a wide range of activities, many ofwhich are in the territory of other government departments like finance,agriculture, and trade.
Before the meeting at the ministry I heard Shah Ebrahimfrom the London School of Hygiene and Tropical Medicine talk in Karachi about the beststrategy for countering chronic disease. He advocated improving socialdeterminants like poverty, concentrating on risk factors rather than diseases,and working to improve health systems, particularly primary care. When pushedon short term strategies he said increase taxes on cigarettes, ban smoking inpublic places, make unsaturated oil cheaper, and concentrate on treatinghypertension.
Almost half of men in Pakistan smoke, and some cigarettescost about 6 rupees for 10—about 3p. It may well have the cheapest cigarettesin the world, and cigarettes are smuggled out of Pakistan. Despite the cheapness ofthe cigarettes the government’s income from tobacco exceeds its totalexpenditure on health. Pakistanalso grows a lot of tobacco and has a national body to promote tobacco sales.So government despite signing the Framework Convention on Tobacco Control isvery cautious on tobacco control. Smoking is banned in public places, but thelaw is flouted everywhere.
Then there is the problem of smokeless tobacco, which comesin some 134 different forms, all of them cheap. Half of men and more than aquarter of women use smokeless tobacco, and doctors regularly see people intheir 30s with advanced oral cancer. There is also now a rage for shishas(bubble pipes from Turkey),which are used by 43% of males and 11% of females. Many parents who object totheir children smoking cigarettes do not object to them using shishas becausethey don’t think that they are dangerous.
Then there are problems of implementing WHO advice on dietand physical activity. Most poor people consume far less fat than the WHO recommendation,but it doesn’t seem wise to encourage an increase. Salt restriction can bedifficult because it’s an important source of iodine, and implementing adviceon physical activity is impossible among the many women in Pakistan who are segregated.
Despite all these difficulties I flew back over thefoothills of the Himalayas (did you know that Pakistanhas five of the seven highest mountains in the world?) feeling confident that Pakistan,a country full of ingenious people, will find its own way to counter chronicdisease.
Competing interest. RS is thedirector of the UnitedHealth Chronic Disease Initiative, which together withthe US National Institute for Heart, Lung and Blood Disease funds centresaround the world, including one at the Aga KhanUniversity in Karachi.
A chance to collaborate in a book on complex chron
7th Feb 2010
Would you like to contributeto a book on complex chronic disease? The book has been written for the Spanishgovernment, which currently has the presidency of the European Union and wantsto draw attention to the importance of complex chronic disease.
You probably don’t recognisethe term “complex chronic disease,” but it’s actually the main concern ofdoctors and health systems. Patients with “complex chronic disease” arepatients who have multiple chronic diseases (cardiovascular disease, diabetes,chronic obstructive pulmonary disorder, cancer, depression, osteoarthritis, andany long term condition) perhaps with complications and certainly withpsychological and social components.
In the classic medical modelpatients present with single diseases, are diagnosed, treated, and cured. Thisis ever less of health care, and yet it continues to be the dominant way ofthinking. A tour around any hospital will show that few patients have single,curable conditions and that most have complex chronic disease. Patients withcomplex chronic disease account for most visits to general practitioners, mosthospital admissions, and a huge proportion of health care costs.
So the first reason you mightlike to contribute to this book is that it will deepen your understanding ofcomplex chronic disease.
The second reason is that youcan probably improve the book. We, the authors of the book, very much believein the “wisdom of the many rather than the few.” James Surowiecki in “The Wisdom of Crowds,”Charles Leadbeater in “We-think,” and Clay Shirky in “Here Comes Everybody” alldescribe cases where the many have been able to do what the few could not.(This is a good reading list for those who want to explore further the power ofthe many unleashed by the internet.)
A third reason for you tocontribute is that you might enjoy being part of an experiment. As far as Iknow, few if any medical books have been written in this way.
A final reason is that if youmake an important contribution to the book we will include you as an author.Perhaps you need to boost your CV. Another selfish but far from ignoble reasonis that you might be invited to the launch of the book in Seville (and possibly the Basque country as well)in June.
If you want to contribute—orjust read the book—you should go to:
http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases/
You should click on thechapter where you would like you to contribute, and I urge you to start eitherwith the introduction or the chapter on prevention, which I have written withcolleagues. You can read the chapters in either English or Spanish and contributein either language. You add your contribution in a comment box that is attachedto each section of the chapters.
We, the authors and editors,will read all the comments and revise the chapters and allocate authorshipaccordingly. I hope that you will contribute, and I hope that I may bump intoyou in Seville,where I’ll be happy to buy you a glass of Rioja (even if it turns out thatthere are thousands of you.)
Competing interest: I’m anauthor of one of the chapters in the book but was not paid, and I’ll have topay my own way to Sevilleand for your glass of Rioja.
Scaling up to defeat childhood obesity
4th Dec 2009
Some three million children in Britain are obese, and treatingchildhood obesity is far from easy. To have any chance of responding adequatelyto the epidemic of obesity we need to find, firstly, a treatment that worksand, secondly, a way to scale it up so that it can be delivered efficiently.Both problems are hard, but the scaling up is, I suggest, the harder problem. Iwas therefore impressed to encounter an organisation in the backstreets ofSouthwark that is making real progress with both problems—and already beginningto work not only in Britainbut also across the globe.
MEND (Mind, Exercise,Nutrition, Do it!) is a social enterprise that is research driven and hasdeveloped a family and community based treatment for childhood obesity. Thetreatment has been shown in a randomised trail to be published in Obesity next year to reduce waistcircumference and body mass index and to increase cardiovascular fitness,physical activity, and self esteem.
The treatment comprisesadvice on behaviour change, nutrition, and physical activity. There are 18 twohour sessions delivered over ten weeks by two trained leaders and an assistantto groups of 8-15 children with their parents, carers, and siblings. Thesessions happen in leisure centres, schools and other community venues; andthere are eight on behavioural change, eight on nutritional advice, and 16 withphysical activity. The treatment is highly standardised with training for theleaders, theory and exercise manuals, children’s handouts, programme resources,and teaching aids. There is detailed guidance on how to run each session.
Childhood obesity isconcentrated in poorer neighbourhoods, and MEND is committed to promotinghealth equity. Of the children in the trial half were from ethnic minoritiesand two thirds came from families where the parent or parents were unemployedor doing manual jobs.
Having designed an effectiveintervention, MEND has developed a technology platform to scale it up. Theinternet based Operations Management Monitoring System (OMMS) makes it easy forthe programme manager to organise and monitor the programme and for the MENDteam to quality assure the programmes and to gather data on all theparticipants in the programmes. Some 17 people, mostly in India, have been involved inwriting the software and running the system.
It’s this scaling up thatmost public health programmes don’t manage and makes MEND so important. Programmesare now running at some 350 centres across the country—some paid for by primarycare trusts and some sponsored. Each extra programme means that the unit cost ofservice delivery (total costs divided bynumber of programmes) goes down, making scaling ever easier. MEND has data onsome 12 000 children and have found results similar to those in the randomisedtrial—and importantly many of the children are still from deprived backgrounds.
Childhood obesity is aglobal problem, even coexisting in poor countries with undernutrition, and MENDhas work underway in Denmark,Australia,and US. The latter two are the “fattest” countries in the world, and the US has25 million obese children.
Another importantchallenge for scaling up is selecting the right business model. That can’t beresearch grants as research funders are not in the business of implementing theresults of the research they fund on a large scale, although perhaps theyshould be. Depending on sponsorship is fickle, and sponsorship rarely goes onfor long. The best model is to serve organisations and people who value whatyou have to offer and will pay for it. This approach motivates both the quality andrange of public health services made available. A virtuous circle can begenerated as increased revenue from delighted customers is reinvested inservice improvements.
MEND has successfully demonstrateda sustainable, scalable model but a significant task still lies ahead.. If 15000 children in Britainhave been treated that leaves 2 985 000 who haven’t—and there are hundreds ofmillions in the rest of the world. As Lord Darzi suggests, preventive healthservices, like those offered by MEND, need to be commissioned on an industrialscale if we are to respond effectively to the chronic disease burden.
Countering chronic disease in rural China
27th Nov 2009
The differences between ruraland urban Chinaare stark. Beijing, Shanghai,and other major cities are filled with newbuildings, best illustrated by those built for the Olympics, whereas rural Chinahas as many as 300 million people living on under a dollar a day, more than anyother country. Indeed, Chinacan be described as three countries: a low income country in the West, a middleincome country in the middle, and a developed country in the East.
Peopleliving in the big cities have access to the latest medical technology, whereasthose living in the countryside are served by a “village doctor” (many of themonce the famous barefoot doctors) with limited training. So far most healthresearch has been conducted in large hospitals in the cities, but a newprogramme—the China Rural Health Initiative—plans to build a platform forresearch in rural areas Last week in Beijing I heard the plansfor the initiative.
The China Rural Health Initiative is the flagship programmeof the China InternationalCenter for Chronic Disease Prevention,which is basedat the George Institute China, with PekingUniversity HealthScience Centerits lead domestic partner. There are alsofive partners from five of the provinces closest to Beijing,which together have about 190 million inhabitants, and six internationalpartners, including the George Institute in Sydney,Duke University,and Imperial College.
One of the first studies to be conducted will be a cluster randomisedtrial of training the village doctors and providing community health educationto prevent heart disease and stroke. People in NorthernChina use huge amounts of salt and consequently have high levelsof hypertension and stroke. Many people have a daily consumption of 12 g or evenmore (when WHO recommends no more than 5 g and many think it should be 2.5 g),and poorer people use more salt.
Thevillage doctors will receive training in a simple, low cost, evidence basedpackage for high risk patients that includes regular blood pressure tests, freemedication, and salt reduction and potentially substitution.The doctors will also be given a health education kit and incentivised topractice prevention. The primary outcome measure of the trial will be theproportion of high risk people treated with at least one drug, and secondaryoutcomes will be blood pressure and the control rate of hypertension.
There is also a provisional plan to at the same time conducta trial of community based education on reducing salt consumption. Twenty fivetownships with between 18 000 and 26 000 inhabitants would receive bothinterventions (training of village doctors and community education), 25neither, and 25 each one or the other. The hope is that this will lead to apackage that could introduced across rural China.
A third possible study if funding can be found will be a randomisedtrial of salt substitution with high risk individuals. Families with high riskindividuals would be randomised to receive free salt substitute (containing 65%salt, 25% potassium chloride, which lowers blood pressure, and 10% magnesiumsulphate) or to the control group. A pilot study has already shown that saltsubstitution can lower blood pressure by 5 mg Hg (about the same as one drug),but the proposed trial would look for a reduction in stroke, heart attack, anddeath. Because of the known reduction in blood pressure there is every reasonto expect a reduction in events anddeaths, but the investigators judge that such a trial would lead to a change inpolicy in Chinaand beyond.
It’s possible to do a trial like this in rural China becausemost salt is added by people when cooking, whereas people in Chinese cities andthe developed world receive most of their salt through processed foods.
A fourth possible study, again dependent on funding, wouldtry to validate a method of verbal autopsy. Physical autopsy is not possible inmost developing countries, and the data for the global burden of disease arebased on doubtful evidence. The study would compare the diagnosis reached inthose who die in hospital (the best “gold standard” available) with a verbalautopsy, a series of questions, used with carers one to three months afterdeath. This would be done for the top 20 to 40 causes of death, and if theverbal autopsy proves reliable then a later study would quantify the cause ofdeath across communities.
The great attraction of establishing a reliable platformfor research is that other studies can be conducted without the difficultiesand cost of developing a platform, and already there is interest in studyingbiomarkers, interventions to prevent progression of chronic kidney disease(which is known to be common in rural China), and telemonitoring to speedtreatment of patients with heart attacks. Remarkably, another possible study isa randomised trial of conservative versus surgical treatment of hip fracture;this might be possible in rural Chinabecause it seems that many patients are treated conservatively.
No doubt many other studies will be proposed, and the hopemust be that the result is not simply lots of publications but realimprovements for the vulnerable, poor people in rural China.
Competing interest: RichardSmith is director of the UnitedHealth Chronic Disease Initiative, whichtogether with the National Heart, Lung and Blood Institute is funding the China InternationalCenter for ChronicDisease Prevention.
Chronic disease: “a wicked problem”
18th Apr 2009
Trying to slow the progress of the pandemic of chronic disease sweeping through the developing world is, a “wicked problem” said David Mathews of the Oxford Health Alliance at the summit.
A wicked problem is highly complex, perhaps ultimately insoluble, has no obvious solution and is full of contradictory data; every step forward is possibly a step backwards. Such problems can be tackled only by partnerships devising multiple options for responding and being content with “constructive ambiguity,” whereby partners who may feel uncomfortable with each—like public health practitioners and food companies—concentrate on where they agree and park their disagreements.
It’s easy to be overwhelmed by wicked problems, but I left the Oxford Health Alliance Summit feeling positive not overwhelmed. One good way to approach wicked problems is to “think big, act small, move fast, and leverage like hell.”
The big thinking is to maintain faith that we can make a difference. We know what to do to prevent much chronic disease, and we have seen rates of heart disease and stroke come down in developed countries. There have also been spectacular achievements in some countries with reducing smoking rates, although WHO estimates that only 5% of the world’s population is covered by effective interventions to combat tobacco use.
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Community interventions for health: real progress
18th Apr 2009
I’m trying to break my blogs up into readable chunks, and I want to develop my theme of “think big, act small, move fast, and leverage like hell” by summarising what was said about the community interventions for health, where an attempt is made to redesign neighbourhoods so that “healthy choices are the easy choices.”
The interventions are made in schools, workplaces, health centres, and the whole environment, and ideally the interventions operate not by persuading individuals but by making structural changes like banning smoking in public places, making stairs more accessible, improving public transport, reducing the amount of sugar in drinks, or a hundred other possible changes. Some are large and might require legislative actions, while others are small and easily implemented—like putting notes beside lifts encouraging people to use the stairs.
These interventions require political support and agreement from all the different stakeholders in a community. Indeed, the very act of bringing people together to think how they can redesign their environment is in itself an important intervention. Ideas for change will begin to flow.
These programmes are underway in Kerala, Hangzhou, and Mexico City and are being planned for Leicester, New Haven, Andover, Delhi, and Sousse in Tunisia. Most of the programmes will be rigorously evaluated, although evaluating such programmes is itself close to being a wicked problem.
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Polypill: an historic meeting of leaders
18th Apr 2009
Another way to prevent heart disease and stroke—but not other chronic diseases--is through the polypill, a pill that combines a statin (reducing blood fats), drugs to reduce blood pressure, and aspirin (which makes platelets less likely to stick and so form clots). These drugs work in different ways and so their benefits can be added together. Nick Wald, who spoke at the summit, proposed in 2003 together with Malcolm Law that such a pill could reduce heart attacks and strokes by about three quarters.
Now Denis Xavier, who was also at the summit, and colleagues have begun to test the idea, conducting a trial in over 2000 people in India. They have shown that people will take the pill, it is safe, and it does have the expected effects on reducing blood fats, blood pressure, and platelet stickiness—although the effects were not quite as dramatic as Wald and Law hypothesised. Still, however, one pill that might be available for as little as a dollar a month could prevent more than half heart attacks and strokes.
Tom Marshall, also at the summit, is conducting a trial in Iran and has results similar to those from India.
There seem to five polypills in the world (three from India, on from Iran, and one from Spain), and all but the Spanish one were represented at the summit—making this an historic occasion.
Anthony Rodgers from Australia has helped Dr Reddy’s Laboratories from India make one of the first pills, but in his talk he regretted the slowness of progress. He attributes the slowness to professional conservatism, regulatory hurdles, and lack of market pull. Nevertheless, I was left with a feeling that we are at last gathering momentum, and polypills may be on the market in Europe and the US within a couple of years.
Business innovation in countering chronic disease
18th Apr 2009
Innovation will be essential for tackling chronic disease, but it’s probably less scientific innovation and more innovation in making change happen, getting things done. An example came from Tal Gilbert, head of research and development at PruHealth, a joint venture between the venerable Prudential and the South African company Discovery.
The company offers heavy incentives to people to adopt healthy life styles. Those covered by its policies are given detailed information on what they could do to live healthier lives, guided to companies who can help them by providing healthy foods or access to gyms, and then given “vitality points” for eating healthy foods and exercising. The points become cash benefits. Academic analysis soon to be published suggests that those who collect many points have much lower claims; interestingly and surprisingly the big reductions are in cancer and mental health. (There is the obvious problem of causation, but Gilbert said that those conducting the analysis were well aware of all the methodological problems.)
The importance and difficulties of partnership
18th Apr 2009
“Leveraging like hell” was in many ways the major theme of the conference. Building a jumbo jet was a complex problem but not a wicked one in that there was a clear blueprint. Yet no individual knows how to build a jumbo jet. It depends on many different groups of people with different knowledge and skills, and we are likely to make progress with chronic disease only by bringing together many different stakeholders—politicians, academics, patients, health workers, social scientists, private companies, non-governmental organizations, and many others.
Jonathan Horrell from Kraft Foods UK described the experience in Britain of bringing together government, business, charities, and community organisations in the Department of Health’s Change for Life programme. He is part of Business for Life, and the government’s hope is that industry will contribute some £200m in kind through marketing and creativity. The media and some of the other partners are understandably suspicious that food companies are part of the problem rather than the solution, and building trust among the different groups is proving difficult. “Bilateral trust” among just two groups is not so hard but it’s trust among all that is hard to achieve.
Resources: more on the way
18th Apr 2009
Partnership, ideas, and innovation can achieve little without resources, and lack of resources has always so far been a problem for those trying to counter chronic disease in the developing world. Rajaie Batniji from Oxford University pointed out that about $3 in aid is spent for every death from chronic disease compared with £1030 for every death from AIDS.
Rachel Nugent, an economist from the Centre for Global Development in Washington, described how data from the OECD showed that only around $2m of aid was spent on chronic disease in 1996, but the figure was $56m in 2007, although $31m of that was on “mental health”—in fact conflict resolution. In the same year $1346m was spent on infectious disease. Nugent’s survey of donors did, however, suggest that total funding has increased to over $600m by 2008 with about half of it coming from private donors.
Stig Pramming of the Oxford Health Alliance led the summit towards an upbeat conclusion by announcing that June will see the launching of a Global Alliance for Chronic Disease that will include the government research bodies from the US, Canada, UK, India, China, and Australia. It will initially have some $45m to invest in research.
Let the vegetarian course be the main course
17th Apr 2009
One little thing at the Oxford Health Alliance Summit that appealed to me greatly was the idea that at all formal dinners (and my how I’ve suffered from formal dinners over the years) the main choice would be vegetarian. You’d have to request meat. The idea came from Susan Jebb, the Medical Research Council head of nutrition, in one of the best talks at the summit.
How many people would request meat? Not many is my bet. Many would just never get round to it, and others would feel slightly awkward asking for meat. Meat eating is, after all, one of the main factors destroying the planet as well as giving us chronic disease. I’d never have the nerve to ask for meat even if I was hungering for a rare steak dripping with blood, something I love.
Such a change would be a perfect example of “nudge economics,” whereby the healthy option is presented as the main option and you must opt out to get the unhealthy option. Richard H Thaler and Cass R Sunstein describe “nudge economics” in their book “Nudge: Improving Decisions About Health, Wealth, and Happiness.”
You could, of course, do the same with all courses. Vegetable soup for the first course or maybe no first course at all unless people asked for it. Fruit salad for desert, and perhaps an expected 500m walk between courses unless people opted out.
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