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  • A Lancet study suggests moderate alcohol use over time can “significantly shorten your life
  • Experts call for the study’s findings to be widely disseminated and discussed
  • A 2010 Lancet study suggested alcohol is more harmful than heroin or crack cocaine
  • Alcohol related harm is a global epidemic caused by a commercial product
  • There are 3.3m deaths each year caused by alcohol use
  • Policies to reduce the harmful effects of alcohol are palliative rather than preventative
  • A few giant alcohol beverages corporations dominate the global market
  • But 50% of the market is in the hands of informal small-scale producers
  • There is a dearth of reliable information on the alcohol beverages industry
  • Public health research has not kept up with the industry’s ability for innovative marketing
  • British drinkers contribute more in alcohol-related taxes than the direct costs of alcohol-related health and crime issues
  
Moderate alcohol use can kill
 
Just when you thought you knew everything there is to know about the harmful effects of alcohol, a study published in the April 2018 edition of The Lancet, brings new evidence to suggest that even modest alcohol use over time is as dangerous as smoking and can “significantly shorten your life”.  The study reinforces the fact that alcohol-related harm is a ‘global epidemic’ caused by a commercial product, which is aggressively marketed throughout the world. Policies aimed at reducing the harmful effects of alcohol have a limited effect and alcohol use continues to be a significant challenge to medicine and society.  
 
In this Commentary

This Commentary discusses some of the reasons why public policies to limit alcohol use fail to dent the vast and escalating burden caused by alcohol use. We begin by describing the findings of The Lancet 2018 study, which highlights the association between regular modest drinking and early death. The study’s findings motivated healthcare professionals to renew calls for lower limits on alcohol use. A study published in The Lancet in 2010 suggested alcohol is more harmful than heroin or crack cocaine. Public policies to reduce the harmful effects of alcohol use are compromised by the competing interests of the principal industry stakeholders. Such policies tend to be orientated towards the demand side of the market and focus on individual consumers and are less engaged with the supply side and large producers. This results in: (i) public policies that are more palliative than preventative, (ii) alcohol use continuing to be a major healthcare and social challenge, (iii) giant alcohol beverages producers receiving a “free pass”, and (iv) governments enhancing their “political capital” by pointing to the millions spent to correct the drinking habits of vulnerable individuals. This ecosystem is further influenced by: (i) the duty and tax revenues governments collect from alcohol use, (ii) public research failing to keep pace with the sophisticated marketing strategies of large drinks companies, and (iii) well resourced, and smart producers’ marketing strategies out-maneuverering government bureaucracies in endeavours to influence the tastes and preferences of individuals.
 
The Lancet study

The contribution of alcohol use to premature death is less well recognised than the connection between smoking, lung cancer and early death. The Lancet 2018 study helps to redress this by improving on previous meta-analyses to define low-risk drinking thresholds, and to suggest that people who consume more than 7 drinks a week can expect to die sooner than those who drink less. According to a February 2018 World Health Organization (WHO) report, an estimated 3.3m people a year worldwide die as a result of alcohol misuse. The harmful effects of alcohol ranks among the top 5 risk factors for disease, disability and death globally, and alcohol misuse is the 5th leading risk factor for premature death and disability worldwide. Most people who die because of their drinking patterns are not alcoholics, but are people who drink regularly over a number of years.
 
The Lancet 2018 study is significant because of its size and methodological robustness.  There is a high degree of comparability in the datasets used by the authors, which combined data from 83 previous studies undertaken in 19 countries, which yielded a cohort of 600,000 current drinkers for analysis. The previous studies used by the researchers to attain their cohort employed similar methods to quantify alcohol use, cardiovascular risk factors, and cardiovascular disease outcomes and cause-specific deaths. All participants in the cohort were from developed industrial economies, displayed similar patterns of alcohol use and none had a known history of cardiovascular disease.
 
The study’s findings imply that drinking alcohol is as harmful as smoking and suggest that there is a significant increase in all causes of death when more than 100g of alcohol (equivalent to about 4 large glasses of wine) is consumed weekly over a period of time. Every glass of wine or pint of beer over the daily recommended limit - the upper “safe” limit in the UK is 5 standard 175ml glasses of wine or 5 pints of beer a week - will cut 30 minutes from the expected lifespan of a 40-year-old and increase the risk of stroke, fatal aneurysm (a ruptured artery in the chest), heart failure and death. A 40-year-old who drinks up to twice that amount (200g or 8 large glasses of wine per week) will shorten their life expectancy by 6 months. Drinking between 200g and 350g (8 to 20 large glasses of wine) a week will reduce their life expectancy by 1 to 2 years, and 40-year-olds who drink more than 350g (>20 large glasses of wine) a week over a period, shorten their lives by 4 to 5 years.
 
Lowering the recommended limits of alcohol consumption
 
According to Angela Wood, from the University of Cambridge in the UK and lead author of the 2018 study, “The key message of this research for public health is that, if you already drink alcohol, drinking less may help you live longer and lower your risk of several cardiovascular conditions.” Although moderate drinking is commonly associated with reducing your chance of a non-fatal heart attack, “This must be balanced against the higher risk associated with other serious, and potentially fatal cardiovascular diseases,” says Wood. According to the researchers the study’s findings support, “limits for alcohol consumption that are lower than those recommended in most current guidelines [and add] long-term reduction of alcohol consumption from 196g per week (the upper limit recommended in US guidelines) to 100g per week or below was associated with about 1–2 years of longer life expectancy at age 40 years”. Co-author Naveed Sattar, Professor of Metabolic Medicine at the University of Glasgow’s Institute of Cardiovascular and Medical Science in Scotland said: "This study provides clear evidence to support lowering the recommended limits of alcohol consumption in many countries around the world."

 
Experts call for lower limits on alcohol use

Commenting on the study’s findings, Tim Chico, Professor of Cardiovascular Medicine at the University of Sheffield,UK, said, smokers lose on average 10 years of their life. “However, we think from previous evidence that it is likely that people drinking a lot more than 43 units (about 14 large glasses of wine a week) are likely to lose even more life expectancy, and I would not be surprised if the heaviest drinkers lost as many years of life as a smoker. . . The study makes clear that on balance there are no health benefits from drinking alcohol, which is usually the case when things sound too good to be true.”

In a commentary in the same edition of The LancetJason Connor and Wayne Hall both professors from the University of Queensland Centre for Youth Substance Abuse Research in Australia, anticipated that the suggestion to lower recommended drinking limits would be opposed by giant alcohol beverages corporations. “The drinking levels recommended in this study will no doubt be described as implausible and impracticable by the alcohol industry and other opponents of public health warnings on alcohol. Nonetheless, the findings ought to be widely disseminated and they should provoke informed public and professional debate,” say Connor and Hall.

 
A 2010 study published in The Lancet claims alcohol is more harmful that heroin

In the November 2010 edition of The Lancet David Nutt, Professor of Neuropharmacology at Imperial College London and co-author of the study suggested that alcohol is more harmful than heroin or crack cocaine when the overall dangers to the individual and society are considered. Nutt was the clinical scientific lead on the 2004-5 UK Government Foresight initiative “Brain science, addiction and drugs”. The Lancet 2010 study suggested that if drugs were classified on the basis of the harm they do, alcohol would be a class ‘A’ drug, alongside heroin and crack cocaine. In 2006 Nutt was dismissed for challenging the UK Government’s refusal to take the advice of the official Advisory Council on the Misuse of Drugs,  which he then chaired.

In answer to The Lancet 2010 study a UK government Department of Health spokesperson said: "In England, most people drink once a week or less. If you're a woman and stick to 2 to 3 units a day, or a man and drink up to 3 or 4 units, you are unlikely to damage your health".
No agreed international limits for alcohol use
 
The reality is that there are no internationally agreed limits on alcohol use and current recommended limits vary significantly between nations. In a study published in the June 2012 edition of the Drug and Alcohol Review  researchers from the University of SussexUK, examined government issued guidelines on alcohol limits in 57 countries and found, “a remarkable lack of agreement about what constitutes harmful or excessive alcohol consumption on a daily basis, a weekly basis and when driving”.

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Alcohol use and dementia

In 2016 the UK Government updated its 1995 guidelines  for limits on alcohol use and recommended that neither men nor women should drink more that 14 units of alcohol per week. A unit in the UK is equivalent to 8g of pure alcohol. This means British men are now being told they should drink less than those in Ireland (21.2 British units), Denmark (21), New Zealand (19) and considerably less than the recommended upper limit for men in Spain (35).
 
 
The supply side of the alcohol industry

Current public policies and industry pledges
Although public policies to reduce the harmful effects of alcohol use are aimed at both the individual and population levels, they tend to orientate towards individual problem drinkers. Among the most effective policy options are alcohol taxes, restrictions on alcohol availability and drink-driving countermeasures. The giant alcohol beverages corporations advocate responsible drinking and pledge their commitment to, “supporting balanced initiatives that are linked to their core business functions and those that address wider social and public health issues, relying on initiatives that are evidence based, culturally sensitive, and collaborative.” The drinks producers support the WHO’s Global Strategy to reduce the harmful Effects of Alcohol, and are committed to: (i) reducing under-age drinking, (ii) strengthening and expanding marketing codes of practice, (iii) providing consumer information and responsible product innovation, (iv) reducing drinking and driving, and (v) enlisting the support of retailers to reduce harmful drinking.  

Growth of service economies and the importance of individual preferences
Despite public policies and industry pledges to limit alcohol use, the large and escalating burden of alcohol problems continue to present significant challenges to medicine and public health. In part, this is because population-based public health policies tend to be overlooked in favour of policies oriented towards individual drinkers. This orientation can be explained by globalization.
 
Over the past 40 years globalization has shifted the economic base of developed nations from manufacturing to services, which places greater emphasis on consumer markets and individual preferences. In such a context, efforts to reduce the harmful effects of alcohol use are mainly focused on the demand side of the market, emphasising individual behaviours and preferences; and less focused on the supply side, which is dominated by producers. As a consequence, public policies to limit alcohol use tend to focus on the choices of vulnerable individual drinkers and call for responsible drinking. In effect this provides producers with a “free pass” to pursue and develop their strategies to sustain consumption.
 
50% of alcohol production is in the hands of “informal” small producers
Shifting the policy emphasis to focus equally on the demand and supply side of the alcohol beverages market is not straightforward. Although nearly half of the of the world's alcohol supply is dominated by giant producers, more than 50% is in the hands of ‘informal’ home and local producers. At the national level the industry comprises large and small beer, wine or spirit producers or importers, as well as bars, restaurants and a variety of retail outlets, which markets alcohol to the public. These players have diverging interests as well as interests in common in regard to policy frameworks. There is a dearth of reliable information on the industry and the principal sources of information come from market research firms and business journalism.  
 
Large global fast-growing market
The alcohol beverages market is large, global and fast growing. According to an April 2018 report by Transparency Market Research, in 2017 the market was worth US$1,205bn and is expected to expand at a CAGR of 6.4% and reach US$2,000bn by the end of 2025. Recent consolidation in the industry puts a significant and increasing proportion of alcohol production, distribution and marketing in the hands of a few giant corporations, which dominate national, regional and global markets and wield considerable political influence. Mergers and acquisitions are expected to continue, so the consolidation of the industry is expected to continue.

The market is driven by increasing urbanization, the global young-adult demographic, high and growing disposable incomes and increasing consumer demand for premium and super premium beverages. The latest figures suggest that the average alcohol use in the UK is about 9.7 litres per adult, which compares with 8.8 litres for adults in 34-member countries of the Organisation for Economic Co-operation and Development  (OEDC), and ranks the UK 16th out of the OEDC countries. Since 1970, alcohol consumption has decreased by an average of 15% across OEDC countries, while in the UK it has risen 14% over the same period. Alcohol use has declined 69% in Italy, 48% in France, 36% in Spain and 30% in Germany, but has increased 51% in Ireland. Consumption of alcohol per head in the UK has fallen by about 17% since its recent peak in 2004. But that followed a steep rise.

A study reported in 2015 in the International Journal of Advertising suggests that advertising has little impact on how much we drink, but it is effective at influencing what we drink. ‘Premiumization’ is a term used in the industry to describe how spirit brands have had success convincing consumers that they should drink “higher quality” and more expensive beverages. An example of this is the recent boom in the sale of gin, which corresponded with the industries premiumization strategies that linked gin with “fashionable” early 20th century style.
 
UK alcohol taxes far exceed the costs to public services
 
The “free-pass” enjoyed by alcohol beverages corporations is strengthened by the relative lack of public scrutiny they receive. This might be partly explained by the fact that governments benefit significantly from alcohol related taxes and duty. Consider Britain. In 2016 the UK government made nearly £3.4bn in tax revenue from spirits; beer sales made the UK government £3.3bn in 2017. Some 60% of the price of a pint of beer is taken in VAT and alcohol duty, while VAT on the price of a bottle of gin is 76%. Wine is the biggest earner for the UK exchequer yielding over £4bn in taxes from sales in 2016. These sums accord with a September 2015 Institute of Economic Affairs (IEA) study on alcohol taxes, which suggests that the annual revenue generated from alcohol taxes in the UK is  “illogical and excessive.”  Rather than tax alcohol the UK government taxes drinks. For instance, a unit of alcohol is taxed at 28p if it happens to be in a glass of whisky but only 8p if it is in a pint of cider. Further, if the cider is strong, the tax is 7p but if it is fizzy the tax is 34p. The tax on a unit of alcohol in a glass of wine is 20p, but if wine is sparkling, the tax is 25p. Confused? The structure of alcohol excise taxes is partly restricted by an EU Directive, which sets out different tax rates for different alcoholic beverages.

Revenues from UK alcohol taxes and duty far exceed the actual direct costs of alcohol-related health and crime issues. According to the IEA study, the UK exchequer collects about £10bn a year in alcohol taxes while the direct costs of alcohol related problems to the health, police, prison services, welfare system and judiciary, amount to some £4.6bn per year. Although studies that report cost-of-alcohol data are notoriously unreliable, the IEA suggests that British drinkers contribute about £6.5bn each year to the UK exchequer and believes that, even within the current constraints, the UK tax system could more effectively target problem drinking. In a February 2017 paper the IEA describes a suggested reform of the UK’s alcohol tax policy.

 
Takeaways
 
Findings of the 2018 study published in The Lancet suggest that risks from alcohol start from any level of regular drinking and rise with the amount being consumed and any amount of regular alcohol use can significantly shorten your life. This echoes a 2010 study also published in The Lancet, which suggested that because alcohol is so widely available it is more harmful than heroin and crack cocaine.

This commentary reaffirms the global epidemic of disease, injury, social problems and death caused by alcohol and suggests an explanation why for decades governments have failed to effectively limit alcohol use.
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NHS maternity units are in crisis because of the shortage of midwives and the increase in births. According to a UK National Audit Office 2013 Report, there's a shortage of 2,300 midwives and births are at their highest level for 40 years. This is straining overstretched maternity units and resulting in closures and blunders.

Closures of maternity units

"Where the demand for maternity services might outstrip capacity, some trusts are restricting access through pre-emptive caps on numbers or reactive short-term closures in order to safeguard the quality of care," the Report says.

Between April and September 2012, 28% of NHS maternity units closed for 12 hours or more, including eight that shut for a total of at least two weeks, either because they lacked physical capacity or midwives.

Health Minister's response

In response to the Report, Dr Dan Poulter, the UK government's health minister, said there were 1,300 more midwives than in 2010 and 5,000 more had been in training since then. The number of midwives in the NHS, he said, was increasing twice as quickly as the birth-rate. Also, the presence of consultant doctors on maternity wards had increased significantly.

Notwithstanding, the National Audit Office report drew attention to the high dropout rate and impending retirements of midwives. This could mean that shortages will continue.

The impact of the rise in fertility

During the 1990s the total fertility rate (TFR) in England and Wales saw a steady decline. Between 2001 and 2008 it gradually increased. Since 2008 the TFR has remained relatively stable, fluctuating between 1.90 and 1.94 children per woman and peaking in 2010.

There is no single explanation for this rise in fertility. Possible causes may include: more women currently in their twenties having children, more older women giving birth, increases in the numbers of foreign born-women who tend to have higher fertility than UK-born women and government policy and the economic climate indirectly influencing individuals' decisions around childbearing.

The impact of migration on maternity units

Between 2000 and 2010 births in England increased by over 114,000: from 572,826 to 687,007. Immigration has played a role in this. Three quarters of the increase in births was to women born outside the UK. Overall, in 2010, over a quarter of all live births in England were to mothers born abroad. The proportion of such births has grown consistently every year since 1990, doubling over the past decade: from approximately 92,000 in 2000 to almost 180,000 in 2010. This represents nearly 500 births on average every day

Although the Minister is right and an increasing number of midwives are in training, their numbers have not kept pace with the overall growth in numbers of births. Before 2010 UK governments permitted high levels of net migration without ensuring that maternity services received adequate staffing.

The majority of mums are satisfied

Although the Report suggests that many NHS maternity units need to improve, most of the 700,000 women who give birth in England each year are happy with the NHS service they receive.

Notwithstanding, over 25% of maternity units were forced to close. The National Audit Office report drew attention to maternity units having to shut temporarily or turn away expectant mothers because of the dearth of midwives and struggle to cope with the current baby boom.

Quality of care compromised

The paucity of trained staff affects the quality of care. In 2011, one in every 133 babies in England was stillborn or died within a week of birth. As the Report suggests, births are also becoming increasingly complex, putting even more demands on midwives and maternity services. Cathy Warwick, CEO of the Royal College of Midwives, said: "We are many thousands of midwives short of the number needed to deliver safe, high quality care. Births are at a 40-year high and . . . show that this is set to continue".

Increase insurance cover

According to the National Audit Office's Report, maternity units fail mothers and babies so often that one fifth of their budgets is now being spent on negligence cases.

Over the past five years, lawsuits involving alleged failings in maternity care increased by 80%. Increased litigation has meant that in 2012-13 almost £0.5bn was spent on malpractice claims because of blunders during labour. This amounts to about 20% of the NHS's total budget for negligence claims, which translates into about £700 per birth being spent on clinical negligence cover.

Absence of consultants

One concern is the lack of senior staff available on maternity units. More than half of maternity units were not meeting the levels of consultant presence recommended by the Royal College of Obstetricians and Gynaecologists. The Report says that while 73% of obstetric units in hospitals had a consultant on duty for at least 60 hours a week, 53% did not provide as much consultant cover as recommended.

Takeaways

Over the coming years, maternity services in England face significant challenges driven by changing demographics, rising birth rates, increasing fiscal constraints and the continuing rise in maternal morbidity rates. In order to maintain high levels of safety, the service will need to change.

Dr David Richmond, president of the Royal College of Obstetricians and Gynaecologists, suggests that: "Although the UK is generally a safe place for women to give birth, we have known for some time that pressure on maternity services is growing . . . More consultants are needed to deal with not only the rapidly increasing birth rate, but the rise in complex pregnancies, with older mothers, maternal obesity and multiple pregnancies at the fore".

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Here's the paradox: cancer is the most preventable of all the chronic illnesses and yet the incidence of cancer growth in Africa and other developing regions of the world is of pandemic proportions, which is exacting a significant economic and social toll.

Reason 1: There is a massive difference between global spend on cancer and on infectious diseases. Although cancer claims more lives globally than HIV/AIDS, malaria and tuberculosis combined, it receives less than three percent of public and private funding from global health. The overwhelming amount goes to infectious diseases.

Reason 2: African countries lack financial clout to attack cancer. They lack epidemiological information to guide resource planning. They lack health workers. They lack the political will and they have competing healthcare demands.

Reason 3: Bad advice. For example, recently a well resourced UK global health advisory group travelled to a poorly resourced African country, which had one of the world's highest rates of cervical cancer mortality and recommended that it should improve its road transport infrastructure to enable health workers easier access to rural areas.

Narrowing the global medical knowledge gap
Sixty years ago, cervical cancer was one of the most common causes of death for western women. However, between 1955 and 1992, the cervical cancer mortality rate in affluent western countries declined by almost 70% as medical knowledge to detect and manage the disease improved. Similar outcomes are true of other forms of cancer to the point where cancer is now preventable and manageable in most developed economies.

According to Margaret Chan, Director General, World Health Organization, the exponential growth of cancer in Africa can be significantly reduced and managed by narrowing the medical knowledge gap between the develop world and African countries.

Notwithstanding, well resourced dedicated centres of global health in affluent developed countries are failing to narrow this gap and thereby failing to reduce and control the 12 million cancer cases that occur annually. If this gap continues over the next 20 years, cancer is expected to exact a significant toll in morbidity, mortality and economic cost particularly in Africa. By 2030, the number of new cancer cases each year is projected to increase to 27 million, cancer deaths to 17 million and much of the cancer burden will fall on poorly resourced African countries.

Mobile phones rather than tarmac
Narrowing the medical knowledge gap between rich and poor countries will neither be achieved by building more roads nor continuing traditional ways of communicating medical knowledge. Such means are slow, costly and ineffective. Narrowing the medical knowledge gap will only be achieved by widespread use of the most ubiquitous healthcare innovation: the mobile telephone.

Although operationally relevant, the mobile telephone is an underdeveloped healthcare application. However, in Africa, the implementation of any healthcare strategy to reduce the burden of cancer and other debilitating health conditions should not be contemplated without leveraging mobile telephony. Why? Because Africa has one of the fastest growing telecommunication infrastructures in the world.

According to a recent joint World Bank and African Development Bank Report there are 650 million mobile users in Africa, surpassing the number in the US and Europe. "In some African countries more people have access to a mobile phone than to clean water, a bank account or electricity," the Report says.

A recent Deloitte's Report suggested that between 2000 and 2012, mobile phone penetration in Africa increased rapidly from one percent to 54%. Today it is over 60%. The main catalyst for this explosive growth is youth. "The cell phone is their landline, ATM and email in one device. Cell phones are central to their life," says Teresa Clarke, CEO, Africa.com.

According to Maurice Nkusi from Namibia Polytechnic who designed a mobile phone-based curriculum, most African youths, "have never even used a computer, but the rapidity with which they master mobile telephony reflects the era in which they live".

Mobile telephony in Africa has narrowed divides between urban and rural, rich and poor and African youth today is the first generation to have direct access to mobile phones, which are used for communicating, transferring money, shopping, listening to the radio and mingling on social media. It is a relatively small step to integrate healthcare content on mobiles that would help prevent and manage cancer.

Africa internet use increases as costs fall
Internet prices in Africa are falling and speed is increasing thanks to fibre-optic submarine cables running along the east and west coasts of Africa and connecting many countries and millions of people.

The Eastern Africa Submarine Cable System (EASSy) is a 10,000km fibre-optic cable deployed along the east and south coast of Africa to service voice, data, video and internet needs of the region. It links South Africa with Sudan via landing points in Mozambique, Madagascar, the Comoros, Tanzania, Kenya, Somalia and Djibouti. The system also interconnects with multiple international submarine cable networks for onward connectivity to Europe, the Americas, the Middle East and Asia.

At a 2013 BRIC summit in South Africa, Andrew Mthembu, chairman, i3 Africa announced that EASSy is to be complimented by a new marine cable connecting 21 African countries with Brazil, Russia and China.

Along the West African coastline is a similar submarine fibre-optic cable, which links West African countries with Europe and brings ultra-fast broadband to a region from Seixal in Portugal through Accra in Ghana to Lagos in Nigeria and branches out in Morocco, Canary Islands, Senegal and Ivory Coast.

This existing 7,000km cable has been recently complemented by a France Telecom-led system, which uses high-speed fibre optic technology to link Europe with 18 countries along the west coast of Africa and provides the capacity to allow approximately 20 million ordinary videos and up to five million high definition videos to be streamed simultaneously, without any buffering.

Today, there are 84 million Internet-enabled mobiles in Africa, all of which can access data and rich media from the internet. By 2014, 69% of mobiles will have Internet access in Africa. In response to the burgeoning demand, African markets are rapidly transitioning from mobiles with limited data access to low-cost smartphones with access to the Internet. Chinese handsets are readily available in Africa for as little as US$20.

Takeaways
Previous HealthPad commentaries have described mHealth initiatives in Africa, but few western centres for global health have fully appreciated that medical knowledge has become mobile, digital and global. Further, they have not fully appreciated the telecommunications revolution that has taken place in Africa over the past decade. Such failures help to explain why the medical knowledge gap between the developed world and African countries has not been narrowed.

This failure is also an opportunity for centres of global health to take a lead in capturing and organising medical knowledge to assist in the management of cancer and other chronic diseases and then to leverage established telecommunications infrastructures to distribute that knowledge to where it is needed the most. What a pity that narrowing the medical knowledge gap was not a Millennium Development Goal.

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joined 7 years, 10 months ago

Mike Farrar

Independent management consultant

Mike Farrar is an independent management consultant and former Chief Executive of the NHS Confederation. He joined the organisation in May 2011.

Mike was chief executive of the North West England SHA from May 2006 to April 2011. He was previously chief executive of West Yorkshire and South Yorkshire Strategic Health Authorities, chief executive of Tees Valley Health Authority and head of primary care at the Department of Health.

Mike was also a board member of Sport England, and in August 2009 was appointed as National Tsar for Sport and Health. Mike was also awarded the CBE in 2005 for services to the NHS and is an honorary fellow of the University of Central Lancashire.


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7 years, 10 months ago

A&E is the barometer of the NHS. In 2012 some 22 million people attended A&E in the UK. A 50% increase in the last 10 years, while the UK population only increased 7% over the same period.

The Royal College of Surgeons has warned that the knock-on effect of this is last minute cancellations of planned surgeries. Official figures show that for the first three months of 2013 some 20,000 planned operations were cancelled.

Read more

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Can patient aides, comprised of online video content libraries of trusted health information, enhance shared decision making between patients and their doctors, lower costs and increase the quality of healthcare? American payors think they can.


Both ends of the stethoscope

We know very little about the hidden dynamics of doctor-patient relationships. We do know however, that doctors have a moral and legal obligation to inform patients about their medical conditions and explain treatment options, but only patients have the right to decide on their treatment. So, how do patients decide about competing treatment options?

For example, how do women, diagnosed with breast cancer, choose between a mastectomy and a lumpectomy? How do mothers choose between Gardasil and Cervarix for their daughters?

Peter Ubel, a professor at Duke University and author of Critical Decisions, provides some insights into the elusive world of private medical consultations between doctors and their patients. According to Ubel medical consultations are fraught with a multitude of unresolved communication issues because doctors', "moral obligations to inform patients, outstrip their abilities to communicate".

In the US there is mounting concern that doctors are aggressively pushing for more costly invasive procedures, even though they may not be any better or safer than slower and simpler ones. Ubel describes how hidden dynamics in doctor-patient relationships and the dearth of premium, trusted and independent patient aides, prevent patients from making optimal medical decisions. This, he says, increases costs and lowers the quality of care.


Spurious online health information

Doctor-patient relationships are further complicated by the ease that patients can access spurious and misleading online health information. It’s true that they also have access to accredited online medical information such as that provided by WebMD. The difficulty however, is for patients and their carers to judge between legitimate and spurious online medical information.

This is confirmed by research published in 2010 by the US National Institute of Health, which reported that over 75% of all people who search online for health information encounter difficulties in understanding what they find and as a consequence become frustrated and confused.

In December 2012, such difficulties resulted in a UK mother, Sally Roberts, denying her seven year old son Neon radiotherapy to treat his brain tumour. Information she found on the internet convinced her that radiotherapy would do more harm to her son than good. The UK hospital treating Neon disagreed, took legal action and a High Court Judge ruled that Neon should receive radiotherapy.

 

The increasing importance of video in healthcare

US payors are becoming increasingly confident that online video libraries of premium trusted medical information that assist patients to reach more informed decisions about their health are important in shifting emphasis away from clinicians towards patients and their needs, wishes and preferences.

Large US hospital groups are producing trusted and reliable consumer aids that they are using to create, develop and manage specific online patient communities. One example is the Cleveland Clinic, which employs online videos to share health tips and clinical research with patients.
Why video?
One reason video has become so popular among patients is because it delivers a human-touch to health information that digitalized written words don’t. So it’s not surprising that video is the preferred format for patients to receive health information, which increasingly they access on smartphones.


American initiatives
The main push for patient aides to inform shared decision making is from the US Government and health payors and is driven by their efforts to control escalating healthcare costs while improving the quality of care.

For the past six years the state of Massachusetts has produced videos to help terminally ill patients and their carers better understand end-of-life decisions. Washington State, among others, provides patients with video aides to support shared decision making. And three patient aide projects sponsored by the Center for Medicare & Medicaid Innovation are expected to yield savings of more than US$130 million within three years, while enhancing the quality of healthcare.

According to James Weinstein, CEO and President of the Dartmouth-Hitchcock Health System, comprised of 16 medical centres that treat millions, “Patients want to have good information about their health care decisions, which is independent of any bias.”

Jack Daniel, Executive Vice-President of Med-Expert International, a Californian based company, which produces patient aides for people on Medicare and Medicaid said, “When a person calls us we can say here’s what the world’s best medical minds are saying about your condition.”


Takeaways
In 2010 business leaders participating in the prestigious Salzburg Global Seminar concluded that, “Informing and involving patients in decisions about their medical care is the greatest untapped resource in healthcare." Shared decision making they said, “is ethically right and practical, since it lowers costs and reduces unwarranted practice variations”.

Over the past 30 years patients have become better educated and better informed about their healthcare options. Everything suggests that this is just the beginning. Over the next decade, healthcare systems will be increasingly challenged by aging populations, escalating incidences of chronic diseases and fiscal constraints and consumers and communications will assume a more pivotal role. This will accelerate the need for premium, trusted, online health information that patients can access at speed, anytime, anywhere and anyhow.

Until patient aides become commonplace we will not change the way we communicate inside hospitals and doctors’ surgeries. Health costs will continue to rise, the provision of healthcare will continue to be stretched and the quality of care will continue to be challenged.

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“If I’d known I was going to live this long I would have taken better care of myself.” Memorable words from Eubie Blake, the American jazz composer, lyricist and pianist who died in 1983 at the age of 96. Today, people do take better care of themselves. Examples of people who do, include rock legends Mick Jagger and Paul McCartney, the badboys of the 1960s who became the goodboys of the 1990s. Now, at 70 and 69 respectively, they continue to work, support worthy causes and enjoy a good quality of life.

Over the past 50 years, the number of people over 65 in the developed world has tripled and is projected to triple again by 2050. The UK’s Office of National Statistics forecasts that a third of babies born in 2012 will live to 100. “Age is uninteresting,” said Groucho Marx, “All you have to do is to live long enough.” Age, however has become interesting as it is an unavoidable part of the human condition and a significant challenge for nations where millions will be retiring with a third of their lives still ahead of them. They will no longer be productive, but will be in need of healthcare. Healthcare systems have been slow to adjust to the new realities of aging populations and the financial costs of treating the elderly.

One way for nations to manage retirement and aging was suggested by Euripides in 500BC. “I hate men,” he said, “who would prolong their lives by foods and charms of magic art, preventing nature’s course to keep off death. They ought, when they no longer serve the land, to quit this life and clear the way for youth.” Euripides’ sentiment resonates today. In advanced industrial economies there is a relatively low tolerance of elderly people. This is manifest in the number of offences against elderly vulnerable patients, which involves neglect and physical violence. In his 2013 Report into the UK's Mid-Staffordshire NHS Foundation Trust, where hundreds of patients had died as a result of inadequate care, Robert Francis said that between 2005 and 2009 patients were subject to, “appalling and unnecessary suffering”. In June 2012, at a conference in London’s Royal Society of Medicine, Professor Patrick Pullicino claimed that each year UK National Health doctors prematurely end the lives of about 130,000 elderly hospital patients because they are difficult to manage and to free up beds for younger patients.

According to a UN Report presented at the World Assembly on Aging in 2002, population aging is an unprecedented global phenomenon. The 21st century will witness more rapid aging than did the 20th century and countries that started the process later will have less time to adjust. There will be no return to the young populations of previous generations and aging populations will have profound implications for healthcare.

Moralists argue that healthcare is a human right and all people should be treated similarly unless there are sound moral reasons not to do so. But, who pays? Daniel Callahan, a contemporary philosopher widely recognized for his innovative studies in biomedical ethics has an answer. Invoking Euripides he argues that age should be a limiting factor in decisions to allocate certain kinds of health services to the elderly. The demographic shift, says Callahan, increases competition for scarce healthcare resources and therefore healthcare should be rationed. Life extending care for the over 70s should be replaced with less expensive pain relieving treatment. Opponents of rationing suggest that wealthy governments should reduce their defense spending and increase their commitment to healthcare and enact reforms to cut costs and improve the efficiency of healthcare systems.

Callahan, however, has little faith in political leaders to deliver cost cutting strategies and argues that calls to cut healthcare waste and inefficiency have been made for decades with no effect. This is definitely the case in the UK where subsequent governments have failed to reconcile escalating costs of healthcare with maintaining and improving the quality of care for the elderly. According to Callahan, “Our whole health care system is based on a witch’s brew of sacrosanct doctor-patient autonomy, a fear of threats to innovation, corporate and (sometimes) physician profit-making, and a belief that, because life is of infinite value, it is morally obnoxious to put a price tag on it.”

Some age related incurable diseases that affect mostly older people in wealthy countries have contributed to the ghettoizing of age. One such disease is Parkinson’s, a progressive degenerative neurological movement disorder, which affects between six and 10 million people worldwide. In the US, the combined direct and indirect costs of Parkinson’s disease is estimated to be nearly US$25 billion per year. Medication costs for an individual person with Parkinson’s is on average US$2,500 a year and therapeutic surgery, such as deep brain stimulation, can cost up to US$100,000 dollars per patient.

However, not all age related diseases are like Parkinson’s. Indeed, it is not altogether true that old age corresponds to debilitating diseases and hikes in healthcare costs. Indeed, healthy years among the elderly are increasing and the spike in health costs tend to be in the last two years of life, regardless whether a person is 99 or nine. Rather than viewing the elderly as a burden and assessing them by their chronological age, it might be more appropriate to view them as assets and assess them by their number of healthy years. Healthy years are not necessarily years without illness, but years in which people manage whatever medical conditions they might have. A good example of this is Dame Maggie Smith, the English film, stage and television actress, who at the age of 78 has recently won a Golden Globe Award for her role as the Dowager Countess of Grantham in the television series Downton Abbey.


Longevity is one of the greatest successes of 20th century medical science and nutrition, but its challenges include the dearth of health workers with geriatric skills, the prevention of physical disabilities and the extension of healthy years. Recent studies suggest that healthy aging is possible and chronic non communicable illnesses such as heart disease, diabetes and dementia, may be delayed or prevented by certain lifestyle choices. Notwithstanding, currently there are millions of elderly people who have not taken good care of themselves and require specialist geriatric care.

In the US there is a monetary disincentive for doctors to specialise in geriatrics since geriatricians earn significantly less per year than more mainstream specialists. Further, only 11 of the 145 US medical schools have fully fledged geriatric departments. In 2010 the US federal budget allocated $11 million to fund geriatric education. Interestingly, today a substantial amount of geriatric care in wealthy countries is undertaken by health professionals trained in poorer countries. This raises ethical questions about rich countries encouraging the immigration of health workers from countries that lack them and the responsibilities of migrant health professionals to countries of their origin. Although geriatricians in the UK are well compensated, the British Geriatric Society reports that the number of geriatricians is not keeping pace with the needs of geriatric care.

According to the OECD between 10% and 20% of populations in developed economies require long term care and costs between 1% and 2% of GDP and these costs are projected to increase. The costs of long term care are skewed because a significant proportion of elderly care is carried out by informal, unpaid carers who are often family members. For example, in the UK there are 1.5 million official carers and about 5 million unpaid carers. In the developing world the situation is more extreme and some 60% of people over the age of 60 live with their children or grandchildren. While familial care may yield significant benefits, it is not a long term solution because as developing economies become more westernized, their family structures become more nuclear and less able to provide the support and care that they do now.

According to the first noble truth of Buddhism, life is painful and involves suffering. For a significant proportion of elderly people this is certainly the case, but it need not be. On an individual level, living longer must be welcome, but more generally, the greying of populations is perceived in terms of increased costs and pressure on overstretched healthcare systems, rather than freeing-up valuable resources that may contribute to society. Although elderly people tend to have long term medical conditions, increasingly they are successfully managed to allow a good quality of life. Old age is not a disease. Elderly people are a valuable resource of intellectual capital and knowhow, which nations cannot afford to waste. Unlocking this reservoir of grey-knowledge is important for the future wealth of nations. Let us hope nations have something better to offer their elderly than to call on them to do as Captain Oates did on the 16th March 1912. On his return from the South Pole, Oates, convinced that his ill health compromised his comrades, walked from his tent into a blizzard saying, "I am just going outside and may be some time.” He was never seen again.

Whose age is it anyway?

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You can’t see “it”. You can’t touch “it”. “It” tends to creep up on you unnoticed. Every year “it” kills tens of millions and costs billions. “It” destroys households, communities and even nations. "It" has been described as "the biggest threat to the 21st century.”

“It” is chronic non communicable diseases (NCDs): cancers, cardiovascular diseases, respiratory conditions and type2 diabetes, four of the biggest killers that have emerged as one of the greatest social and economic development challenges of this century.

In December 2012, the Lord Crisp, representing the All Party Parliamentary Group on Global Health, introduced a debate in the Atlee Suite of the London Houses of Parliament on NCDs. Drawing on his experience as a former CEO of the UK’s National Health Service he suggested that the global NCD burden may only be successfully addressed by changing the way healthcare is delivered. Other speakers emphasised the complexity of global health issues.

From a global health perspective, NCDs now account for more deaths every year than AIDS, tuberculosis, malaria and all other causes combined and result in roughly two out of three deaths worldwide. Mental illness, which has significant health, social and economic implications, is also considered by some as a NCD, but rarely leads to mortality.

A 2011 report produced by the World Economic Forum and the Harvard School of Public Health, argues that, “Over the next 20 years, non communicable diseases will cost more than US$30 trillion, representing 48% of global GDP in 2010 and pushing millions of people below the poverty line. Mental health conditions alone will account for the loss of an additional US$16.1 trillion over this time span, with dramatic impact on productivity and quality of life.”

NCDs are often viewed as diseases of affluence as their prevalence is highest in wealthier countries and are caused by bad diets and sedentary lifestyles. The economic impact of NCDs in rich nations is compounded by the ageing and shrinking of their populations and extends beyond the costs to health services since they affect economies, households and individuals by reducing labour productivity, increasing medical treatment costs and lost savings. Over time developed economies have accumulated knowledge and expertise to treat and manage NCDs. In developing nations, however, NCD's are a relatively recent phenomenon, but currently, they are growing exponentially and each year kills millions at dramatically young ages. This is because developing economies lack the knowledge and expertise to treat and manage the diseases and their policy makers show little interest in the prevention and control on NCDs.


This knowledge gap between developed and developing economies exacerbates the global NCD burden. Narrowing it entails capturing and organising relevant healthcare knowledge from wealthy nations, transferring it to developing countries and distributing it to where it is needed the most. Such narrowing of the global NCD knowledge gap will help significantly to reduce and manage the global NCD burden, but this will only be achieved by widespread use of cost effective healthcare technology.

What is the most ubiquitous healthcare innovation? . . . . . . . . . . . . . . . . . . . . . . . the mobile telephone and the smartphone, which combines telephony and computing. Although operationally relevant, such devices are underdeveloped healthcare applications. In today’s world, the implementation of any global healthcare strategy should not be contemplated without leveraging telephony and computing technologies. As the reduction and management of NDCs is increasingly about scarce information and connectivity, these technologies and mHealth should become increasingly important.

Despite its underdeveloped status, over the past decade, mHealth programmes, which use mobile telephones to distribute health information, have increased significantly in developing economies, especially in Africa. They are suggestive of scalable, cost effective strategies to help reduce the NCD knowledge gap and address the growing global burden of NCDs.

Recently, the FDA has approved a number of mobile phone-based medical imaging and data monitoring devices. One is a $99 electrocardiogram, which allows remote patients to monitor their heart rhythms at anytime from anywhere. The mobile app gives immediate feedback and data can be simultaneously relayed to a cardiologist anywhere in the world for a specialist opinion.

Microsoft is taking advantage of mobile telephony’s broad reach in Africa to develop an integrated healthcare information service, which serves both health workers and the general public. The system uses mobile phones to allow health workers to capture, store and process, transmit and access health information. Importantly, Microsoft has demonstrated that this lowers costs and enhances efficiency by eliminating redundancy and reducing the amount of time devoted to health information input. The public can also turn to the system for information: individuals pose frequently asked questions about health issues via SMS messages and receive replies straight to their mobile phones. Despite a high proportion of the users being poor, migrant, illiterate rural workers, Microsoft is convinced that its African mHealth service has the potential to become a valuable tool and is increasing its scope.

A study, published in the American Journal of Managed Care, concluded that mHealth can improve the management of diabetes and other NCDs while reducing visits to clinics. It argues that personalised healthcare is an under-represented feature in the management of NCDs and suggests that social media concepts developed by Facebook might be used in the self-management of NCDs and merit more consideration.


The International Telecommunications Union estimates that mobile subscribers worldwide reached 6.5 billion by the end of 2012 and is projected to reach eight billion by the end of 2016. Cheaper handsets, ever-decreasing data charges, the improvements in phone web browsers and increased 3G coverage have fundamentally changed the way we use our phones, resulting in smartphones increasingly becoming used as healthcare devices.

According to Strategy Analytics, in Q3 2012 the number of smartphone users globally rose to above a billion and the current paths of mobile technology and social networking are inextricably linked. Currently, some 650 million people globally use their mobile for emails and social networking. Although smartphone users make up only 13% of the world’s mobile users, they generate two-thirds of the world’s mobile traffic. Over the next five years this data traffic is expected to increase by 700% on average per user. By 2015 the number of smartphone users is expected to reach 1.4 billion, which will represent about 30% of total mobile subscribers worldwide.

Today, Australia, UK, Sweden, Norway, Saudi Arabia and UAE each have more than 50% of their population on smartphones. The US, New Zealand, Denmark, Ireland, Netherlands, Spain and Switzerland have greater than 40% smartphone penetration. All these countries have an escalating burden of NCDs. Mobile phone penetration across Africa is around 70%, but smartphone penetration in Africa is only 10% to 15%. Nigeria is the leading African country in smartphones with a penetration 41%, followed by South Africa with 31% and Kenya with 7%. However, the costs of smartphones are falling and telecom companies, such as Huawei and ZTE, are aggressively driving smartphone sales in the developing world’s rapidly modernizing consumers and looking to lift smartphone penetration in Africa closer to the 70% level. In February 2011 Huawei partnered with Safaricom, to offer the Android-based Ideos smartphone to the Kenyan market for US $80. Huawei is now attempting to build on the Ideos’ momentum in Nigeria.

These trends suggest that there are significant opportunities to reduce and manage NCDs by healthcare programmes piggybacking on existing global and local mobile networks. Narrowing the global NCD knowledge gap requires targeting risk factors and promoting healthier lifestyles. This means focused prevention efforts while mitigating the impact of NCDs on economies, health systems, households and individuals. Such a strategy must involve individuals, households and communities because the causal risk factors are deeply embedded in the social and cultural framework of communities. This will require a significant change in the way healthcare is implemented: a move away from diagnosis and treatment towards prevention and the promotion of wellbeing.

To reduce premature morbidity and mortality caused by NCDs, governments will need to invest in mHealth strategies to improve patient awareness of their own health and encourage them to manage their own wellbeing. Over time, this should free up resources that can then be focused on the patients most in need, while relieving the economic burden of NCDs on society as a whole and eventually leading to increased productivity.

The Lord Crisp is right to suggest that the global NCD burden will only be successfully addressed by changing the way healthcare is delivered.
The “complexity” of global health issues, suggested by speakers at the London NCD debate, is more a function of the forces protecting the status quo rather than the issues themselves. Mobile networks are ubiquitous. mHealth is operationally relevant. Governments are slow to address effectively the NCD burden. Is the missing part recruiting the help of Mark Zuckerberg?

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