WHO reforms: on course What have economists but core functions still ever done for global require reliable support health? In 2010, WHO’s financial difficulties came to a head, prompting its Director-General Margaret Chan to instigate organisational reforms that are now in their final phase. As part of the process, Member States, donors, and partners have participated fully in setting the priorities that have shaped the WHO’s General Program of Work 2014–19. This week (May 19–24, 2014), Member States meet for the annual World Health Assembly, where they will take stock of the present situation, not least of the financial realities of an agenda that includes welcome new medicine-related resolutions and commitments. Many of these relate to the availability and affordability of essential medicines and other health products. Yet the financing of WHO’s work in support of essential medicines is still a cause for concern. In particular, assurances are still lacking for the norms, standards, policy and pricing guidance, and mechanisms that will support Member States struggling to secure affordable supplies of appropriate medicines. Non-governmental organisations, including Oxfam, have highlighted the impact of underfunding on WHO’s work on medicines, which cuts across almost every component of health services, and upon which health agencies such as UNITAID, the Global Fund, GAVI, and many others depend. Member States now need to ensure that WHO has the necessary resources to effectively build the foundations needed to support universal health coverage and complex and expanded global health needs. We declare no competing interests.
Philippa Saunders, *Mohga Kamal-Yanni [email protected] Oxfam GB, Oxford OX4 2JY, UK
www.thelancet.com Vol 383 May 24, 2014
In response to The Lancet’s persistent attack on economics and economists,1,2 we offer the view that the lack of progress in addressing the global epidemic of chronic diseases is largely failure to recognise it as mainly an economic problem. We would contend that a major reason for little progress in addressing chronic illness is that not enough economics has been involved in the development of interventions and, instead, such tasks have hitherto been taken over by narrow medical and public health perspectives. Solutions proposed for chronic disease, when based on medical treatments or conventional public health programmes such as diet and exercise, are focused on simply mitigating the consequences of a bigger problem. Amid pervasive controversies such as those about the effectiveness of preventative programmes, the role of individual risk factors, and the inability to ensure adherence to programmes that have some promise of efficacy, one of the few solid facts that exist is the gradient between socio-economic status and illness.3 Our view is that the poor progress in addressing the chronic disease epidemic is potentially due to lack of attention given to its economic antecedents. Given the known relationship between illness and socioeconomic status, it would follow that measures to promote social mobility are an effective route to reduce the disease burden. Why then is there little discussion about the role of job creation schemes, income support, economic empowerment, and income redistribution through taxation as measures to combat chronic disease? Where are the trials of such programmes and why is the link between measures to address social mobility almost never evaluated with a health focus?
The likelihood is that such measures cross disciplinary barriers and enter political arenas that public health and medical professionals and researchers see as a step too far. The solution therefore lies in a greater role for economics and economists in the design and evaluation of chronic disease programmes and in doing so, employing measures that incorporate health and economic outcomes. At present, the role of health economics tends to be confined largely to evaluating cost-effectiveness, eliciting consumer preferences, and the secondary analyses of datasets. Contrary to Richard Horton’s recent Offline,2 we believe substantial gains in health and wellbeing can be achieved by putting economics at the front and centre of deliberations about solutions to our major health problems.
AFP/Getty Images
Correspondence
Published Online May 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60840-0
We declare no competing interests.
*Stephen Jan, Virginia Wiseman [email protected] The George Institute for Global Health, Sydney, NSW 2050, Australia (SJ); University of New South Wales, Kensington, NSW, Australia; and the London School of Hygiene & Tropical Medicine, London, UK (VW) 1
2
3
Parkin D, Appleby J, Maynard A. Economics: the biggest fraud ever perpetrated on the world? Lancet 2013; 382: e11–15. Horton R. Offline: What have economists ever done for global health? Lancet 2014; 383: 1024. Wilkinson R, Marmot M. Social determinants of health: the solid facts. WHO, 2003. http:// www.euro.who.int/__data/assets/pdf_ file/0005/98438/e81384.pdf (accessed May 5, 2014).
Adding the doctor’s voice to the global health agenda There is an increasing desire for UK medical students and doctors to receive more global health training for the benefit of patients at home and overseas.1 The Commission on education of health professionals for the 21st century stated that all “should be educated to mobilise knowledge
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1801
Correspondence
…so that they are competent to participate in patient and populationcentred health systems as members of locally responsive and globally connected teams”. 2 Despite this statement, there has been little attempt to translate improvements in global health education at both undergraduate and postgraduate level into helping such individuals “mobilise knowledge” through advocacy on behalf of the global health agenda. Therefore the Royal College of Physicians and the Alma Mata Global Health Graduates’ Network have organised a series of evening seminars to provide individuals with the skills necessary to lead on a range of global health challenges. Targeted at doctors in training but open to all, these interactive seminars introduce key themes in global health advocacy and demonstrate to attendees how to incorporate these within working life. Across nine sessions so far, approaches have ranged from political lobbying through formal engagement with health policy to grassroots activism. A diverse array of speakers have delivered valuable advocacy perspectives on topics including challenging the rationale of austerity measures, how to pitch policy changes at national and international governance levels, and engaging with minority and disenfranchised communities. We seek to tackle under-represented issues, including community and patient voices, alongside academic and policy experts. To equip tomorrow’s UK global health leaders so that they realise lasting change, it is necessary to provide them not only with knowledge, but also the skills to assess need and subsequently identify, engage with, and influence key policy makers, politicians, and the public. 3 The Royal College of Physicians and the Alma Mata Global Health Graduates’ Network’s seminar series is a key step in a wider call to help clinicians to realise these skills. We declare no competing interests.
1802
*Colin S Brown, Kate Aldridge, Serena Faso, Danni Kirwan, Gareth Lewis, Aeesha Malik, Mairi McConnochie, Gauri Nepali, Clare Shortall, Aliki Traianou, Matthew Foster [email protected] Alma Mata Global Health Graduates’ Network, London N1 6PD, UK (CSB, KA, DK, GL, AM, GN, CS, AT); and Royal College of Physicians, London, UK (SF, MM, MF) 1
2
3
Brown C, Martineau F, Spry E, Yudkin JS. Postgraduate training in global health: ensuring UK doctors can contribute to health in resource-poor countries. Clin Med 2011; 11: 456–60. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: 1923–58. Wilson R, Cokelet E. Advocacy to improve global health: strategies and stories from the field. PATH. http://www.path.org/ publications/files/ER_advo_wrkbk_stories_ field.pdf (accessed April 16, 2014).
Access to controlled medicines for pain relief and anaesthesia in low-income countries Ed Holt’s recent World Report (March 29, p 1114) 1 on the UN Commission on Narcotic Drugs (CND) session in Vienna raised concerns about the effect of the war on drugs on public health, particularly the health of illicit drug users. However, the ramifications of this failed experiment, extend far beyond those for illicit use; the effect of these policies on access to controlled medicines for analgesia and anaesthesia has been devastating for patients in low-income and middle-income countries. 2 During this year’s CND session, UN Member States allowed history to repeat itself, passing a resolution3 calling for ketamine (an essential medicine, and the anaesthetic of necessity in many poor countries) to be placed under national control, against the advice of WHO.4 The medical necessity of this drug received only scant attention, and few medical professionals
were present to argue against this resolution. The three international Conventions that provide consistency in international illicit drug control and scheduling are, paradoxically, the same pieces of law that ensure medical access to many of these same drugs.5 This places international bodies such as the CND and the International Narcotics Control Board (INCB) in the conflicted position of restricting, while also ensuring, access to medicines—a balance that, by the INCB’s own admission, it has failed to achieve.6 We agree that the war on drugs has failed, but we also draw attention to the collateral damage inflicted by this war on access to essential medicines. The medical profession has a responsibility to ensure that access to these medicines is improved, and we have grave concerns that this has been largely neglected by the global health community. We declare no competing interests.
*Jason W Nickerson, Amir Attaran [email protected] Bruyère Research Institute, Ottawa, ON K1R 6M1, Canada (JWN); and University of Ottawa, Ottawa, ON, Canada (AA) 1 2
3
4
5
6
Holt E. Doctors criticise UN’s approach to global drugs control. Lancet 2014; 383: 1114. Nickerson JW, Attaran A. The inadequate treatment of pain: collateral damage from the war on drugs. PLoS Med 2012; 9: e1001153. UN Economic and Social Council Commission on Narcotic Drugs Fifty-seventh session. March 20, 2014. Preventing the diversion of ketamine from legal sources, while ensuring availability for medical use. http://www.unodc. org/documents/commissions/CND-session57/ In_session/Final/ECN72014_L12Rev1_e_ V1401801.pdf (accessed March 29, 2014). WHO. Ketamine Critical Review Report. Expert Committee on Drug Dependence Thirty-Fifth Meeting. http://www.who.int/ medicines/areas/quality_safety/Final_35th_ ECDD.pdf (accessed May 5, 2014). Liberman J, O’Brien M, Hall W, Hill D. Ending inequities in access to effective pain relief? Lancet 2010; 376: 856–57. WHO. Ensuring balance in national policies on controlled substances: guidance for the availability and accessibility of controlled medicines. 2011. http://www.who.int/ medicines/areas/quality_safety/GLs_Ens_ Balance_NOCP_Col_EN_sanend.pdf (accessed March 29, 2014).
www.thelancet.com Vol 383 May 24, 2014
Philippa Saunders, *Mohga Kamal-Yanni [email protected] Oxfam GB, Oxford OX4 2JY, UK
www.thelancet.com Vol 383 May 24, 2014
In response to The Lancet’s persistent attack on economics and economists,1,2 we offer the view that the lack of progress in addressing the global epidemic of chronic diseases is largely failure to recognise it as mainly an economic problem. We would contend that a major reason for little progress in addressing chronic illness is that not enough economics has been involved in the development of interventions and, instead, such tasks have hitherto been taken over by narrow medical and public health perspectives. Solutions proposed for chronic disease, when based on medical treatments or conventional public health programmes such as diet and exercise, are focused on simply mitigating the consequences of a bigger problem. Amid pervasive controversies such as those about the effectiveness of preventative programmes, the role of individual risk factors, and the inability to ensure adherence to programmes that have some promise of efficacy, one of the few solid facts that exist is the gradient between socio-economic status and illness.3 Our view is that the poor progress in addressing the chronic disease epidemic is potentially due to lack of attention given to its economic antecedents. Given the known relationship between illness and socioeconomic status, it would follow that measures to promote social mobility are an effective route to reduce the disease burden. Why then is there little discussion about the role of job creation schemes, income support, economic empowerment, and income redistribution through taxation as measures to combat chronic disease? Where are the trials of such programmes and why is the link between measures to address social mobility almost never evaluated with a health focus?
The likelihood is that such measures cross disciplinary barriers and enter political arenas that public health and medical professionals and researchers see as a step too far. The solution therefore lies in a greater role for economics and economists in the design and evaluation of chronic disease programmes and in doing so, employing measures that incorporate health and economic outcomes. At present, the role of health economics tends to be confined largely to evaluating cost-effectiveness, eliciting consumer preferences, and the secondary analyses of datasets. Contrary to Richard Horton’s recent Offline,2 we believe substantial gains in health and wellbeing can be achieved by putting economics at the front and centre of deliberations about solutions to our major health problems.
AFP/Getty Images
Correspondence
Published Online May 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60840-0
We declare no competing interests.
*Stephen Jan, Virginia Wiseman [email protected] The George Institute for Global Health, Sydney, NSW 2050, Australia (SJ); University of New South Wales, Kensington, NSW, Australia; and the London School of Hygiene & Tropical Medicine, London, UK (VW) 1
2
3
Parkin D, Appleby J, Maynard A. Economics: the biggest fraud ever perpetrated on the world? Lancet 2013; 382: e11–15. Horton R. Offline: What have economists ever done for global health? Lancet 2014; 383: 1024. Wilkinson R, Marmot M. Social determinants of health: the solid facts. WHO, 2003. http:// www.euro.who.int/__data/assets/pdf_ file/0005/98438/e81384.pdf (accessed May 5, 2014).
Adding the doctor’s voice to the global health agenda There is an increasing desire for UK medical students and doctors to receive more global health training for the benefit of patients at home and overseas.1 The Commission on education of health professionals for the 21st century stated that all “should be educated to mobilise knowledge
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1801
Correspondence
…so that they are competent to participate in patient and populationcentred health systems as members of locally responsive and globally connected teams”. 2 Despite this statement, there has been little attempt to translate improvements in global health education at both undergraduate and postgraduate level into helping such individuals “mobilise knowledge” through advocacy on behalf of the global health agenda. Therefore the Royal College of Physicians and the Alma Mata Global Health Graduates’ Network have organised a series of evening seminars to provide individuals with the skills necessary to lead on a range of global health challenges. Targeted at doctors in training but open to all, these interactive seminars introduce key themes in global health advocacy and demonstrate to attendees how to incorporate these within working life. Across nine sessions so far, approaches have ranged from political lobbying through formal engagement with health policy to grassroots activism. A diverse array of speakers have delivered valuable advocacy perspectives on topics including challenging the rationale of austerity measures, how to pitch policy changes at national and international governance levels, and engaging with minority and disenfranchised communities. We seek to tackle under-represented issues, including community and patient voices, alongside academic and policy experts. To equip tomorrow’s UK global health leaders so that they realise lasting change, it is necessary to provide them not only with knowledge, but also the skills to assess need and subsequently identify, engage with, and influence key policy makers, politicians, and the public. 3 The Royal College of Physicians and the Alma Mata Global Health Graduates’ Network’s seminar series is a key step in a wider call to help clinicians to realise these skills. We declare no competing interests.
1802
*Colin S Brown, Kate Aldridge, Serena Faso, Danni Kirwan, Gareth Lewis, Aeesha Malik, Mairi McConnochie, Gauri Nepali, Clare Shortall, Aliki Traianou, Matthew Foster [email protected] Alma Mata Global Health Graduates’ Network, London N1 6PD, UK (CSB, KA, DK, GL, AM, GN, CS, AT); and Royal College of Physicians, London, UK (SF, MM, MF) 1
2
3
Brown C, Martineau F, Spry E, Yudkin JS. Postgraduate training in global health: ensuring UK doctors can contribute to health in resource-poor countries. Clin Med 2011; 11: 456–60. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: 1923–58. Wilson R, Cokelet E. Advocacy to improve global health: strategies and stories from the field. PATH. http://www.path.org/ publications/files/ER_advo_wrkbk_stories_ field.pdf (accessed April 16, 2014).
Access to controlled medicines for pain relief and anaesthesia in low-income countries Ed Holt’s recent World Report (March 29, p 1114) 1 on the UN Commission on Narcotic Drugs (CND) session in Vienna raised concerns about the effect of the war on drugs on public health, particularly the health of illicit drug users. However, the ramifications of this failed experiment, extend far beyond those for illicit use; the effect of these policies on access to controlled medicines for analgesia and anaesthesia has been devastating for patients in low-income and middle-income countries. 2 During this year’s CND session, UN Member States allowed history to repeat itself, passing a resolution3 calling for ketamine (an essential medicine, and the anaesthetic of necessity in many poor countries) to be placed under national control, against the advice of WHO.4 The medical necessity of this drug received only scant attention, and few medical professionals
were present to argue against this resolution. The three international Conventions that provide consistency in international illicit drug control and scheduling are, paradoxically, the same pieces of law that ensure medical access to many of these same drugs.5 This places international bodies such as the CND and the International Narcotics Control Board (INCB) in the conflicted position of restricting, while also ensuring, access to medicines—a balance that, by the INCB’s own admission, it has failed to achieve.6 We agree that the war on drugs has failed, but we also draw attention to the collateral damage inflicted by this war on access to essential medicines. The medical profession has a responsibility to ensure that access to these medicines is improved, and we have grave concerns that this has been largely neglected by the global health community. We declare no competing interests.
*Jason W Nickerson, Amir Attaran [email protected] Bruyère Research Institute, Ottawa, ON K1R 6M1, Canada (JWN); and University of Ottawa, Ottawa, ON, Canada (AA) 1 2
3
4
5
6
Holt E. Doctors criticise UN’s approach to global drugs control. Lancet 2014; 383: 1114. Nickerson JW, Attaran A. The inadequate treatment of pain: collateral damage from the war on drugs. PLoS Med 2012; 9: e1001153. UN Economic and Social Council Commission on Narcotic Drugs Fifty-seventh session. March 20, 2014. Preventing the diversion of ketamine from legal sources, while ensuring availability for medical use. http://www.unodc. org/documents/commissions/CND-session57/ In_session/Final/ECN72014_L12Rev1_e_ V1401801.pdf (accessed March 29, 2014). WHO. Ketamine Critical Review Report. Expert Committee on Drug Dependence Thirty-Fifth Meeting. http://www.who.int/ medicines/areas/quality_safety/Final_35th_ ECDD.pdf (accessed May 5, 2014). Liberman J, O’Brien M, Hall W, Hill D. Ending inequities in access to effective pain relief? Lancet 2010; 376: 856–57. WHO. Ensuring balance in national policies on controlled substances: guidance for the availability and accessibility of controlled medicines. 2011. http://www.who.int/ medicines/areas/quality_safety/GLs_Ens_ Balance_NOCP_Col_EN_sanend.pdf (accessed March 29, 2014).
www.thelancet.com Vol 383 May 24, 2014
