166
NEWS & COMMENT
London
Perspective
Health, but
not for all
Not everyone was critical of the Government’s new preventive health policy that was finally released in last week’s white paper, The Health of the Nation. The Health Education Authority did not issue a word of criticism on the day, but then it did not issue any comment at all: it was under orders to keep quiet. Why? Well, of the 2000-plus responses that the Government received from its first draft, 1800 pointed to tobacco as the beast that had to be tamed. The Government too recognised this fact. It aims to reduce smoking by a third-to no more than 20% of the population-by the year 2000 with particular emphasis on discouraging children and pregnant women from smoking. But in setting out what was to be achieved ministers ignored the most obvious route. Despite the success of the 20 states that have introduced advertising bans on tobacco, the Government decided to continue with its voluntary code-a code so unsuccessful that the industry is recruiting 450 new young smokers a day to replace the 100 000-plus it kills every year at the other end of the life cycle. The unhealthiest tobacco link of all, of course, is the industry’s links with the Conservative party. In the last election the tobacco industry gave the Conservatives 2000 prime advertising sites to promote their campaign. Now it has been well rewarded. There were other large and embarrassing holes in the new strategy. No mention of poverty, homelessness, or unemployment. No links drawn between poverty and poor diets, homelessness and respiratory diseases, or unemployment and suicide. Just a begrudging recognition that people in "manual occupations" have much higher morbidity and mortality rates, but "the reasons for these variations are by no means fully understood". So that’s all right then? As it’s so complex ("an interplay of genetic, biological, social, environmental, cultural and behavioural factors"), we do not need to do anything? That, in six brief paragraphs, is the Government’s response to the World Health Organisation’s call to make the reduction of health inequalities between social groups the central plank of preventive health. Instead the Government selected five other key areas. In each of these areas, some targets have been clarified since the first draft. They are: W Coronary heart disease and stroke-a 40% reduction in deaths in people under 65, plus a 30% reduction in CHD and a 40% reduction in stroke for people aged between 65 and 74 by the year 2000. .Cancers-a 20% reduction in cervical cancer and a 25% reduction in breast cancer (of those invited for screening) by 2000, plus a 15% (women) and 30% (men) reduction in lung cancer for people under 75 by 2010. .Mental illness--a 15% reduction in suicides, and a 33% reduction in suicides for severely mentally ill patients, by 2000. A commitment to "improve significantly"the health and social functions of the mentally ill.
8HIV/AIDS and sexual health-a 20% reduction in
gonorrhoea by 1995 (as an indicator of HIV/AIDS trends), and a 50% reduction in conceptions by under-16s. 8Accidents---a 33% reduction in fatalities among children under 15, a 25% reduction in the 15-24 age group, and a 33% reduction in the over-65s, all by 2005.
So, belatedly, England has a health strategy. There will be committee of ministers to coordinate the 11separate government departments involved. There will be much more monitoring than Britain is accustomed to: annual health and nutrition surveys, biennial detailed dietary and a new
nutrition surveys,
a mental health morbidity survey, epidemiological overviews, a health outcomes unit, plus the annual reports of local directors of public health. The national targets will be translated into regional and local
targets. There will be national focus groups for each of the five key areas to monitor and promote progress. There will be three working groups-a priorities group chaired by the Chief Medical Officer, an NHS implementation group chaired by the NHS chief executive, and a wider strategy review group chaired by the Health Minister. The aim is for action to be taken in six "settings"-schools, hospitals, workplaces, cities, home, and environment. There is, however, much to remain sceptical about. First is how seriously these issues will be tackled. As a signatory to WHO’s Health for All charter, England should have drawn up its strategy by 1990. Wales began setting targets 7 years ago. Then there are the contradictions. The goal to cut teenage pregnancies in the under-16s (5000 last year) is welcome, but under this government 1 in 4 of all health authority family planning clinics have been shut and the Education Secretary is refusing to insist on sex education being included in the school curriculum. There are new targets for reducing saturated fats but no moves on food labelling, let alone a Ministry of Food to insist on cleaning up the food chain. The Government wants to reduce accidents and heavy drinking, but still refuses to adopt the one policy that would achieve both-random breath tests. It wants to reduce respiratory diseases, but has cut the housing programme in half. In the past decade over 1 million families (3 million people) have been registered homeless, and another million have been refused registration because they are single. One early unpublished draft last year did include a table showing the link between poor housing and health, but it was removed. The biggest contradiction, of course, is the desire to improve health set against the deliberate moves by this Government through the tax and benefits system to reverse a 50-year trend in which the differences in income were gradually narrowing. Not since records began has there been such a massive increase in inequality in Britain, or a harsher widening of divisions-between classes, regions, and age groups-than in the past 13 years. The proportion living in poverty (defined as below 60% of average earnings) is now twice as high as 30 years ago. In Mrs Thatcher’s first decade tax savings reached £ 27 billion-over 20% going to the top
’
i
167
1BJ 000 (0’2%), and a mere 2% to the 3 million lowest paid. The bottom 50% have lost ,C8.50 a week and the top 10% have gained 40. No wonder the Government was reluctant m look at the effects of poverty on the health of the nation.
Malcolm Dean
Round the World France: Stricter rules for drug exports June 30 the National Assembly passed a bill that tightens controls on drug exports. Initially the bill was intended to translate the EC directive on export of drugs (89,41) into French legislation, but this directive imposes On
very few constraints
on
exporters. As in the World Health
Organisation’s Certification Scheme, it required a document attesting whether or not a specified product is licensed for use in the exporting country to be issued only at the request of the manufacturer or the importing country. Moreover, the bill omitted the French law’s requirement for previous authorisation of exports. The French medical action group PIMED,1 together with the Agir Ici group2which campaigns for the rights of developing countries, called for amendments to the bill so that all French drugs exported to non-EC countries would require full French marketing approval. Members of the public sent about 7000 postcards to their local MPs and to the Health Minister Bernard Kouchner. Several articles appeared in the press, especially in the Canard Enchaine, a satirical journal. After the Social Commission of the National Assembly adopted PIMED’s amendment, the Minister proposed an amendment of his own, which the Assembly then accepted. The exporter must obtain from the Health Ministry a certificate stating that the exported drugs have been produced in accordance with Good Manufacturing Practices. When the drug is not licensed in France the manufacturer must explain why it is not registered. The Health Minister transmits this explanation to the Health Minister of the importing country. Drugs that have been withdrawn or suspended in France cannot be exported. The Minister may ban the export of unlicensed drugs or drugs with an unfavourable risk/benefit ratio. The Senate is likely to approve all these measures in October. Only 16% of the 3000 drugs sold by European pharmaceutical companies meet the WHO definition of essential drugs.3 These exports include products that have been withdrawn from the European market or that have not been considered for domestic registration because they are ineffective or are irrational combinations. The basic premise of export control is that the same standards should be applied for the domestic market and for the export of pharmaceuticals. The adoption of this law in France should make it easier to impose higher export standards in the other countries of the European Community.
Agnès Vitry Jean-Marie Fardeau Pour une Information Médicale Éthique etle Développement,24quaidelaLoire,75019 Pans. 2Agir Ici,
17 placedel’Argonne,75019Paris.
3. van der Heide B. Exposed: deadly exports. Amsterdam: WEMOS, 1991. (Obtainable from HAIEurope,JvLennepkade334T, 1053NJAmsterdam,Netherlands;DF125.)
Switzerland: Attempts to curb health costs in Geneva Geneva is the focus of attention in moves to curb soaring health costs (see Lancet June 6, p 1406). Six of the main sickness insurance funds-which provide coverage for about 200 000 people-are to open negotiations with doctors working in private hospitals and private wards of the cantonal (public) hospital. The funds are seeking an agreement similar to that already concluded with doctors in the neighbouring canton of Vaud who agreed in June to apply a uniform scale of charges that are 15 to 20% lower than the current fees. Fund managers regard Geneva as the worst canton in Switzerland with respect to costs; also, the local authorities there accept some prescribed pharmaceuticals not recognised as reimburseable elsewhere in the country. According to a survey in Geneva by the funds, average hospital stay for normal maternity cases (without complications) ranges from 8-43 to 11.5 days at private clinics, compared with 6-6 days for public wards at the Geneva cantonal hospital (8 days for caesareans). This variation is regarded as "inadmissible" by Jean-Paul Diserens, chief negotiator for the funds, which are also additional abolition of Geneva’s demanding pharmaceuticals list. The Geneva Medical Association has said that it is prepared to recognise in principle the notion of operations "by contract", provided that additional hospital stay necessitated by complications is taken into account. It points out, however, that this issue would no longer be relevant with the introduction of legislation, now being prepared, whereby the funds would charge a uniform premium and share the risks equitably between them. Insurance along those lines will come into force in Vaud as from January 1. The Geneva association is also prepared to accept the notion of transparency in costing by individual doctors, "provided this information is not used to bring doctors under
pressure". Negotiators
are conscious that the eyes of all Swiss doctors are upon them, not least the junior staff in Lausanne hospitals whose working conditions have just been appreciably improved. So badly done by did they feel on being referred to as "apprentices" by a municipal councillor at the turn of the year that they resorted to parading through the streets and gave the media detailed accounts of their responsibilities as well as of their excessive, inadequately remunerated, working hours.
Alan
McGregor
Europe: Homoeopathic medicine In its attempts to reconcile national rules on health products in the twelve member states of the European Community, the EC Commission has faced particular difficulties with homoeopathic treatment. In some states homoeopathy is merely tolerated; in others-notably France and Germany-it is recognised for reimbursement from health insurance systems. Yet in the European Single Market, it should in principle be possible to market products legally produced in any one member state in the other eleven. In its draft legislative proposals, the EC Commission has sought so desperately to maintain a neutral stance that the wording of two parallel directives on human and veterinary
NEWS & COMMENT
London
Perspective
Health, but
not for all
Not everyone was critical of the Government’s new preventive health policy that was finally released in last week’s white paper, The Health of the Nation. The Health Education Authority did not issue a word of criticism on the day, but then it did not issue any comment at all: it was under orders to keep quiet. Why? Well, of the 2000-plus responses that the Government received from its first draft, 1800 pointed to tobacco as the beast that had to be tamed. The Government too recognised this fact. It aims to reduce smoking by a third-to no more than 20% of the population-by the year 2000 with particular emphasis on discouraging children and pregnant women from smoking. But in setting out what was to be achieved ministers ignored the most obvious route. Despite the success of the 20 states that have introduced advertising bans on tobacco, the Government decided to continue with its voluntary code-a code so unsuccessful that the industry is recruiting 450 new young smokers a day to replace the 100 000-plus it kills every year at the other end of the life cycle. The unhealthiest tobacco link of all, of course, is the industry’s links with the Conservative party. In the last election the tobacco industry gave the Conservatives 2000 prime advertising sites to promote their campaign. Now it has been well rewarded. There were other large and embarrassing holes in the new strategy. No mention of poverty, homelessness, or unemployment. No links drawn between poverty and poor diets, homelessness and respiratory diseases, or unemployment and suicide. Just a begrudging recognition that people in "manual occupations" have much higher morbidity and mortality rates, but "the reasons for these variations are by no means fully understood". So that’s all right then? As it’s so complex ("an interplay of genetic, biological, social, environmental, cultural and behavioural factors"), we do not need to do anything? That, in six brief paragraphs, is the Government’s response to the World Health Organisation’s call to make the reduction of health inequalities between social groups the central plank of preventive health. Instead the Government selected five other key areas. In each of these areas, some targets have been clarified since the first draft. They are: W Coronary heart disease and stroke-a 40% reduction in deaths in people under 65, plus a 30% reduction in CHD and a 40% reduction in stroke for people aged between 65 and 74 by the year 2000. .Cancers-a 20% reduction in cervical cancer and a 25% reduction in breast cancer (of those invited for screening) by 2000, plus a 15% (women) and 30% (men) reduction in lung cancer for people under 75 by 2010. .Mental illness--a 15% reduction in suicides, and a 33% reduction in suicides for severely mentally ill patients, by 2000. A commitment to "improve significantly"the health and social functions of the mentally ill.
8HIV/AIDS and sexual health-a 20% reduction in
gonorrhoea by 1995 (as an indicator of HIV/AIDS trends), and a 50% reduction in conceptions by under-16s. 8Accidents---a 33% reduction in fatalities among children under 15, a 25% reduction in the 15-24 age group, and a 33% reduction in the over-65s, all by 2005.
So, belatedly, England has a health strategy. There will be committee of ministers to coordinate the 11separate government departments involved. There will be much more monitoring than Britain is accustomed to: annual health and nutrition surveys, biennial detailed dietary and a new
nutrition surveys,
a mental health morbidity survey, epidemiological overviews, a health outcomes unit, plus the annual reports of local directors of public health. The national targets will be translated into regional and local
targets. There will be national focus groups for each of the five key areas to monitor and promote progress. There will be three working groups-a priorities group chaired by the Chief Medical Officer, an NHS implementation group chaired by the NHS chief executive, and a wider strategy review group chaired by the Health Minister. The aim is for action to be taken in six "settings"-schools, hospitals, workplaces, cities, home, and environment. There is, however, much to remain sceptical about. First is how seriously these issues will be tackled. As a signatory to WHO’s Health for All charter, England should have drawn up its strategy by 1990. Wales began setting targets 7 years ago. Then there are the contradictions. The goal to cut teenage pregnancies in the under-16s (5000 last year) is welcome, but under this government 1 in 4 of all health authority family planning clinics have been shut and the Education Secretary is refusing to insist on sex education being included in the school curriculum. There are new targets for reducing saturated fats but no moves on food labelling, let alone a Ministry of Food to insist on cleaning up the food chain. The Government wants to reduce accidents and heavy drinking, but still refuses to adopt the one policy that would achieve both-random breath tests. It wants to reduce respiratory diseases, but has cut the housing programme in half. In the past decade over 1 million families (3 million people) have been registered homeless, and another million have been refused registration because they are single. One early unpublished draft last year did include a table showing the link between poor housing and health, but it was removed. The biggest contradiction, of course, is the desire to improve health set against the deliberate moves by this Government through the tax and benefits system to reverse a 50-year trend in which the differences in income were gradually narrowing. Not since records began has there been such a massive increase in inequality in Britain, or a harsher widening of divisions-between classes, regions, and age groups-than in the past 13 years. The proportion living in poverty (defined as below 60% of average earnings) is now twice as high as 30 years ago. In Mrs Thatcher’s first decade tax savings reached £ 27 billion-over 20% going to the top
’
i
167
1BJ 000 (0’2%), and a mere 2% to the 3 million lowest paid. The bottom 50% have lost ,C8.50 a week and the top 10% have gained 40. No wonder the Government was reluctant m look at the effects of poverty on the health of the nation.
Malcolm Dean
Round the World France: Stricter rules for drug exports June 30 the National Assembly passed a bill that tightens controls on drug exports. Initially the bill was intended to translate the EC directive on export of drugs (89,41) into French legislation, but this directive imposes On
very few constraints
on
exporters. As in the World Health
Organisation’s Certification Scheme, it required a document attesting whether or not a specified product is licensed for use in the exporting country to be issued only at the request of the manufacturer or the importing country. Moreover, the bill omitted the French law’s requirement for previous authorisation of exports. The French medical action group PIMED,1 together with the Agir Ici group2which campaigns for the rights of developing countries, called for amendments to the bill so that all French drugs exported to non-EC countries would require full French marketing approval. Members of the public sent about 7000 postcards to their local MPs and to the Health Minister Bernard Kouchner. Several articles appeared in the press, especially in the Canard Enchaine, a satirical journal. After the Social Commission of the National Assembly adopted PIMED’s amendment, the Minister proposed an amendment of his own, which the Assembly then accepted. The exporter must obtain from the Health Ministry a certificate stating that the exported drugs have been produced in accordance with Good Manufacturing Practices. When the drug is not licensed in France the manufacturer must explain why it is not registered. The Health Minister transmits this explanation to the Health Minister of the importing country. Drugs that have been withdrawn or suspended in France cannot be exported. The Minister may ban the export of unlicensed drugs or drugs with an unfavourable risk/benefit ratio. The Senate is likely to approve all these measures in October. Only 16% of the 3000 drugs sold by European pharmaceutical companies meet the WHO definition of essential drugs.3 These exports include products that have been withdrawn from the European market or that have not been considered for domestic registration because they are ineffective or are irrational combinations. The basic premise of export control is that the same standards should be applied for the domestic market and for the export of pharmaceuticals. The adoption of this law in France should make it easier to impose higher export standards in the other countries of the European Community.
Agnès Vitry Jean-Marie Fardeau Pour une Information Médicale Éthique etle Développement,24quaidelaLoire,75019 Pans. 2Agir Ici,
17 placedel’Argonne,75019Paris.
3. van der Heide B. Exposed: deadly exports. Amsterdam: WEMOS, 1991. (Obtainable from HAIEurope,JvLennepkade334T, 1053NJAmsterdam,Netherlands;DF125.)
Switzerland: Attempts to curb health costs in Geneva Geneva is the focus of attention in moves to curb soaring health costs (see Lancet June 6, p 1406). Six of the main sickness insurance funds-which provide coverage for about 200 000 people-are to open negotiations with doctors working in private hospitals and private wards of the cantonal (public) hospital. The funds are seeking an agreement similar to that already concluded with doctors in the neighbouring canton of Vaud who agreed in June to apply a uniform scale of charges that are 15 to 20% lower than the current fees. Fund managers regard Geneva as the worst canton in Switzerland with respect to costs; also, the local authorities there accept some prescribed pharmaceuticals not recognised as reimburseable elsewhere in the country. According to a survey in Geneva by the funds, average hospital stay for normal maternity cases (without complications) ranges from 8-43 to 11.5 days at private clinics, compared with 6-6 days for public wards at the Geneva cantonal hospital (8 days for caesareans). This variation is regarded as "inadmissible" by Jean-Paul Diserens, chief negotiator for the funds, which are also additional abolition of Geneva’s demanding pharmaceuticals list. The Geneva Medical Association has said that it is prepared to recognise in principle the notion of operations "by contract", provided that additional hospital stay necessitated by complications is taken into account. It points out, however, that this issue would no longer be relevant with the introduction of legislation, now being prepared, whereby the funds would charge a uniform premium and share the risks equitably between them. Insurance along those lines will come into force in Vaud as from January 1. The Geneva association is also prepared to accept the notion of transparency in costing by individual doctors, "provided this information is not used to bring doctors under
pressure". Negotiators
are conscious that the eyes of all Swiss doctors are upon them, not least the junior staff in Lausanne hospitals whose working conditions have just been appreciably improved. So badly done by did they feel on being referred to as "apprentices" by a municipal councillor at the turn of the year that they resorted to parading through the streets and gave the media detailed accounts of their responsibilities as well as of their excessive, inadequately remunerated, working hours.
Alan
McGregor
Europe: Homoeopathic medicine In its attempts to reconcile national rules on health products in the twelve member states of the European Community, the EC Commission has faced particular difficulties with homoeopathic treatment. In some states homoeopathy is merely tolerated; in others-notably France and Germany-it is recognised for reimbursement from health insurance systems. Yet in the European Single Market, it should in principle be possible to market products legally produced in any one member state in the other eleven. In its draft legislative proposals, the EC Commission has sought so desperately to maintain a neutral stance that the wording of two parallel directives on human and veterinary
