Woken up yesterday morning by a series of SMS messages – colleagues with the benefit of time differences had already heard the news from Ashgabat that Saparmurat Niyazov, the president of Turkmenistan, had died. Apart from a general interest in current affairs why, you might ask, should anyone want to share this news about the leader of a far away country with me? Some time ago, with my colleague Bernd Rechel, we tried to understand what was happening to the health of the population of Turkmenistan. Our problem was that the Turkmen government had stopped sending health data to the WHO in 1998. What data did emerge was barely credible, such as the admission that there were 2 (two) cases of HIV infection in the country, despite its location on the edge of the region with the fastest spreading epidemic in the world, despite the presence of a thriving sex industry, and despite the existence of extensive drug trafficking, with credible evidence that senior members of the regime were involved in it.
At that time Turkmenistan mainly attracted attention in the international media as a figure of fun (remember, this was before Borat drew attention to Kazakhstan). We occasionally saw pictures of the golden statues depicting himself that were adorning Ashgabat, or heard about his injunctions against beards, music on car radios, and gold tooth fillings. Indeed, there seemed no end to his eccentricities, including renaming much of the country after himself, or rather his adopted name Turkmenbashi, or leader of the Turkmens, and what he didn’t name after himself he named after his family – he was orphaned as a child. He published his thoughts in a book entitled the Ruhnama, which soon became required reading for all Turkmens. It is worth looking at for an insight into his deranged thinking. Yet there was a sinister side to his regime that was not reported. After a failed assassination attempt (or at least that was how it was portrayed – there is credible evidence that it was a setup) he launched a purge against opponents, or at least those he imagined to be opponents. Those unlucky to be caught up in his purges were tortured and many fled into exile. He then launched a sustained attack on the health and education systems, and indeed anything he didn’t understand. Other casualties were opera and ballet, which he described as “unnecessary”. Universities and the Turkmen Academy of Sciences were closed. His attack on health care was also severe. All hospitals outside the capital were closed and health workers were sacked, to be replaced by untrained military conscripts. We summarised all of this in a book, which we wrote by searching for snippets of news from the growing émigré sources, as well as information from some people who were working within the country in various organisations. We described a country in which outbreaks of serious contagious disease, including plague, were suppressed. Anyone seeking health care had to pay for it, often incurring catastrophic expenses. Health workers themselves struggled to survive. Many nurses drifted into sex work. Doctors demanded that women wanting immunisations for their children prove they were suitable mothers by undergoing internal examinations, which of course they had to pay for. Inevitably, Turkmenbashi was unwilling to share the privations being suffered by his compatriots. He knew he had heart disease and each year he flew in a group of German doctors to check him out.
After we published the book, Lucy Ash and Sian Glaesnner, two BBC reporters, went to Turkmenistan, posing as tourists. The programme they made was horrifying, allowing Turkmen people to recount the experience of everyday life. Shortly afterwards I went with Lucy and Sian to describe our findings to UN agencies in New York and to the State Department and USAID in Washington. We were accompanied by a Turkmen former journalist who described a graphic example of field epidemiology, in which he counted the growing number of gravestones for infants in a local cemetery. A number of international agencies used our work to exert pressure on the Turkmen government but there was little they could do when the leading western and ex-Soviet governments were unprepared to act.
So where now for Turkmenistan? The omens are not good. His deputy, Gurbanguly Berdymukhamedov, has been given the job of arranging the funeral and is acting prfesident, even though this is actually a departure from the procedure set out in the constitution. He is a former dentist and, in addition to being deputy prime minister, served as minister of health. Formally, he is ineligible to stand as president when the position is decided in a few months, although the constitution in Turkmenistan seems to be somewhat flexible. Another one to watch is Agageldy Mamedgeldyev, the defence minister. Unfortunately, neither has a reputation suggesting that they will depart from the policies of their predecessor. There is, however, another possibility, that Turkmenistan will fall victim to the tribal tensions that are just underneath the surface. Tragically, the precedents of what happens when a strong leader leaves the scene, in Iraq or Yugoslavia for example, are not encouraging.
One can only hope for a better 2007 for the people of Turkmenistan. Unfortunately I’m not optimistic.

14th December. Final trip of the year. The same as the first one last January, to Brussels on Eurostar. This time for the Steering Committee of the Observatory. This is our six monthly opportunity for all the partners to meet together. It has been an incredibly busy and productive year, measured not just in the books, articles, and policy briefs we have published but also the many interactions with policy makers. A highlight was our work to support the Finnish EU presidency in September and next year we will be working closely with the Germans and Portuguese. This time we had a staff retreat after the Steering Committee. Although we senior staff see each other regularly, often weekly in different countries, it is very easy for the people who do the real work to become isolated from one another when they are scattered between London, Brussels, and Berlin. It was an excellent opportunity for everyone to share experiences and to understand the scale of the operation. We are constantly amazed by how much our products are used, and where. However, we were somewhat puzzled by a recent request to translate our Health Systems in Transition report on Norway into Chinese! After dinner we all went for a stroll in the Grand Place, which was beautifully decorated for Christmas. A perfect ending to the working year (almost).
Home on Saturday (I’m catching up on this week’s blog on the train). Sitting in the Eurostar lounge I read in European Voice how the new member states will join the Schengen Agreement in 2008, so that I won’t need to go through frontier controls when I travel among them. Yet some things never change. After check in at Brussels I go through Belgian passport control, only to stand in line 10 metres further on to clear British immigration. Surely, you ask, could the two governments not find some way to combine their operations? Of course not. That would require the British government to concede that it really is part of Europe. And if it did that, the next step would be the adoption of the Euro….. And then, of course, the world would end…

Arrived at Heathrow Terminal 4 on Wednesday after a flight from Tel Aviv of over 5 hours. Given the consistency of my experiences here over recent weeks, it was little surprise to be told that we had to wait 40 minutes for the steps to be brought to the plane! I’m beginning to think it might be easier to take the Eurostar to Paris and fly from there when I travel (I’m actually writing this a few days later, by which time the Christmas rush has hit my favourite terminal – amazing how the Christmas holidays appear without any warning – and the news reports show queues snaking into the car parks – a marked contrast to Tel Aviv where it took less than 5 minutes to get through security, showing that security and endless queues don’t have to go together, but only if, unlike BAA, you can actually manage an airport).
This afternoon is one of the highlights of my year. The students on my course on Issues in Public Health have to present a strategy to prevent cardiovascular disease in another European country in the most informative and, especially, entertaining way possible. The goals are to get people from different cultures to understand where they each come from, to learn about somewhere else, and above all to realise that public health does not have to be boring (OK, I know it often is, but not what I do).
Once again, the students excelled themselves. The Austrian strategy was in the form of the TV quiz programme “The weakest link”. The Portuguese one had a football theme, with the group clad in Portuguese football shirts and a referee who shoed the yellow or red card to team members who persisted in smoking and eating unhealthy food. The Estonian group created an “Estonian Rhapsody” in which the elements of their strategy were accompanied by musical extracts from Queen. The French group offered a demonstration of healthy cooking featuring an extremely passionate (in all senses of the word) television cook (I wonder who she was modelled on – Nigella) supported by Zinidine Zidane, and accompanying by an attempt to bribe the judges with wine a cheese (an approach taken, in various forms, by several teams). Norway had an integrated programme featuring walking longships (instead of the more usual walking school buses, in which a children join a growing line walking past their houses to school) as well as a system of food labelling in which healthy foods get a Viking stamp while unhealthy ones get a troll stamp. The goal is to maximise the Viking: Troll ratio in shops! The Albanian strategy was built on the Matrix films, combating attacks from secret agents representing fat, tobacco, and alcohol. The Ukrainian strategy began with a health minister clearly modelled on Borat inviting the audience to a lard eating festival while complaining about public health experts who tried to stop vodka drinking and unsafe sex. His speech was interrupted by an ivasion of the stage by other students in orange boiler suits who launched the second Ukrainian revolution, in this case against cardiovascular disease, which would provide for oranges to be eaten by all. However the winner was the Bulgarian group. Who staged an e-mail exchange between a wealthy Russian magnate and a Bulgarian public health doctor he had met at a conference. His attempts to woo her involved offers of money, a diamond (which she gave to the local orphanage, hospitals (which she also rejected, pointing out that Bulgaria has enough hospitals already), and eventually €10,000 to all unhealthy Bulgarians. They finally agreed that he would support the construction of a public health institute (he offered 100 of them) and they finally met. Yet, as they embraced against a background entitled “the agony and the ecstasy” he collapsed with a heart attack!
I know the judges (Stig Pramming and Christine Hancock from the Oxford Health Alliance and my colleague Dina Balabanova (purely a coincidence that one of the judges is Bulgarian!) were really impressed, not only at the creativity and imagination shown by the students but also because, underneath the entertainment, they had really got to know the health problems and policy responses in the countries allocated to them. Who said public health is boring!

To Jerusalem. Two reasons. The first is a meeting of the International Advisory Committee of the Israel National Institute for Health Policy and Health Services Research. This is an organisation established in the early 1990s, in preparation for the introduction of a national health insurance system in 1995. This introduced universal coverage with contributions paid from taxation and distributed according to a weighted capitation formula to one of four Health Maintenance Organisations (HMO). The full story of how this came about, despite opposition from powerful vested interests, is told in the Israeli Health System in Transition report. One element of this reform was the creation of the Israel National Institute for Health Policy and Health Services Research. It was funded by “up to 0.1%” of contributions to the HMOs. It is always important to get the wording of legislation absolutely correct, a point that the UK government consistently fails to grasp. In this case it was the “up to” that caused the problem as it was too easy for this to be clawed back when the economic situation was unfavourable. Yet notwithstanding budgetary cuts, the Institute has supported a wealth of mainly small but useful studies providing answers to practical problems. Looking ahead, the Institute faces the same issues as any policy-relevant research funder. Do you wait for investigator instigated research or do you take a more proactive stance, identifying emerging issues and seeking to encourage proposals that will address them in a timely way so that the answers will be available when needed.
The second reason was to speak at the Institute’s international conference on health care reforms. We had an almost complete participation from the European Observatory’s senior staff at the conference and there were lots of excellent presentations. I especially enjoyed Steven Schroeder’s critique of the US health care system and learned a lot from Naoki Ikegami’s presentation on long term care insurance in Japan. Hans Stein gave a superb speech on globalisation.
There were four parallel streams and I was giving the plenary introduction to the one on chronic disease. It had been organised superbly by Leon Epstein, with lots of really good papers (I leave others to comment on my own of course!). With my colleagues Ellen Nolte and Dina Balabanova, we have been thinking a lot about this over recent years. We have a new book coming out from the Observatory in 2007 and have contributed to the World Bank’s new strategy on non-communicable diseases in low and middle income countries. Complex chronic diseases are clearly the main challenge facing health systems in the 21st century yet many politicians simply don’t get this. They persist in their simplistic ideas of individual patients making one-off trips to a health professional for a self-limiting condition. Of course they never make this model explicit but it is clear that it underpins the paradigm they inhabit, dominated by attempted to measure individual encounters, patient treatment episodes, and the like, as well as, at least in England, to promote “patient choice” as a value above all others, including the more usual ones such as equity, effectiveness, and efficiency. Yet it is all too clear, from even the most superficial review of the literature, that the key to effective management of chronic diseases is integration, not fragmentation. Ellen Nolte and I have highlighted how, in a country characterised by fragmentation of care, the USA, outcomes, in the form of death rates from diabetes and other chronic diseases among young people, are many times higher than in Europe, although even here we could often do better. Yet bizarrely those advising English ministers seem determined to attract American providers of chronic disease programmes, persisting in this goal even in the face of recent evidence from the early examples in England that they are no better than what was already there.
Of course you need to do more than simply integrate services. You need to establish mechanisms that allow them to respond to patients’ needs, to adapt to changing technologies, evidence, and expectations, and to find ways to develop the new types of workers that will be needed for these changing models of care. Yet the introduction of market-based reforms in many countries is actually making this more difficult. Unfortunately, these reforms are driven by ideology rather than evidence. In my talk I drew initially on some examples from other sectors in the UK, where apart from the USA (and to a lesser extent, The Netherlands) this paradigm has taken root most firmly among the political elite. These were the break-up of the telephone directory enquiry service, long seen as a natural monopoly and run cheaply and efficiently by British Telecom. The government, in its wisdom, decided that the service would be improved by competition. There was a feeding frenzy as companies, many with no experience in telecommunications, moved into the market. Like any market there were winners and losers. The winners were the advertising companies who were the beneficiaries of vast campaigns to attract customers to the different providers. Of course everything has a cost and this was recouped by higher charges (albeit somewhat opaque as they developed incredibly complex pricing structures) and cuts in those providing the service. The result? Service quality and later calls to directory enquiries have plummeted and the leading provider is now abandoning its main product in favour of a computerised “voice recognition” model. Prepare to receive even more wrong numbers! The second example was railway privatisation, where the government’s subsidy to the private operators is now double what it was under state ownership. A reduction in expenditure on track maintenance was associated with some high profile crashes, in which people died. The company owning the track failed and was taken back under state ownership, since when quality has improved and it has turned a loss into a £750 million profit! Yet still we are told that market solutions are needed so that the private sector can sort out the inefficiencies of the public sector! Given that one of the UK Prime Minister’s former health advisers was also speaking at the conference, extolling the virtues of patent choice, it was perhaps a little insensitive of me to compare Mr Blair’s campaign of modernisation with Mao Tse Tung’s Great Leap Forward. However I leave it to others, especially those who have the misfortune of trying to implement the constant stream of contradictory initiatives emanating from Whitehall, to decide whether the analogy is valid.
The final reason for being in Israel was to move forward on our existing collaborations with Israeli colleagues. They have been developing an important new initiative entitled Healthy Israel 2020, in which a number of committees have been established to design a health strategy linked to achievement of health targets. A key goal has to be the reduction of smoking. There is a ban on smoking in public places but it is not enforced, something I called attention to in an op-ed in Haaretz where I argued for a smoke-free Israel earlier in the year. One obvious way forward is to levy large fines on bar and restaurant owners who allow smoking on their premises. At last it seems that the Knesset will support such a move. The next challenge is to get the Finance Ministry to provide the funds that are needed for the Healthy Israel programme to move forward.
I can’t finish a blog about a trip to Israel without addressing the political situation. A number of people invited to the conference refused to attend because of their political beliefs, a view I can understand, even if I disagree with it. After a lot of thought I’ve taken the decision to work with Israeli colleagues because many of those I work with have done a great deal to bridge the divide with their Palestinian colleagues. They are as horrified as I am by the atrocities by both sides in this ongoing tragedy. What’s more, I can hardly blame others for the actions of their government, given some of the things mine does. Unfortunately as in my own Northern Ireland, those advocating mutual understanding on both sides are in the minority.

To Taipei this week, to give the plenary speech at the 2006 Global Health Leaders Forum. This is the second year that the Taiwanese government have organised a major conference on health. My involvement with Taiwan came about in a very roundabout way. Last year I was Armenia, at a time when a gamily just across the border in Turkey was infected with avian flu. Turkey has an effective surveillance system, appropriate measures were taken, and the international community was soon alerted.
Yet the occurrence of a bird-borne disease in this part of the world raised important questions. Few people can be unaware of the war in Chechnya yet this was only one of a number of local conflicts that took place in the aftermath of the collapse of the USSR. The result has been that, in the Caucasus and Moldova, a number of territories broke away from the then newly independent republics. During our discussions in Armenia we were focusing on Nagorno-Karabach, an area populated by Armenians but entirely surrounded by Azerbaijan. Our question was what would have happened if an outbreak of avian flu had occurred there, or in one of the other enclaves in this region. This set us thinking because, of course, there are a number of places across the world that are not recognised as independent states but are not fully under the control of a government recognised by the international community. Other examples include Western Sahara, the Republic of Northern Cyprus, Kosovo, and the Palestinian Territories.
With my colleague Rifat Atun, from Imperial College, we set out to discover what arrangements were in place in these territories. The picture was very variable. In some, reporting channels of varying degrees of formality existed. For example, the Palestinian Authority works closely with the Eastern Mediterranean Regional Office of WHO. In others, such as the Trans-Dniestr republic that has declared its independence from Moldova, any information flows were intermittent at best. In most of these cases there were problems with both surveillance infrastructure within the territories and communication channels to the outside world.
There was, however, one exception among the places we were looking at. After the Chinese civil war at the end of the 1940s the government of China withdrew to the island of Taiwan, leaving the mainland under the control of Mao’s communist party, which declared itself the government of the new People’s Republic of China (PRC). [see Wikipedia for fuller description]. Until 1971 the government in Taiwan was recognised by most countries as the legitimate government of China but following the Richard Nixon’s rapprochement with China, this recognition was shifted to the government in Beijing. For reasons too complicated to go into here, Taiwan is considered as a province of China and the government of the People’s Republic is considered to represent it in international affairs. Why is this relevant to avian flu, you ask? Because the international surveillance system, co-ordinated by the WHO, is based on communications between WHO and the governments of its member states. Although the PRC government claims to be able to speak for Taiwan, it has no formal means of communicating with Taiwan and the WHO was unable to contact the Taiwanese authorities without getting permission from Beijing.
In the course of our research on these areas outside the global surveillance system we obtained a copy of a memorandum of understanding between the WHO and the PRC that set out the circumstances in which contact with Taiwan could take place. While it was an honest attempt by the WHO to make things work, the guidance was totally inappropriate for dealing with an emergency. Permission had to be sought from the Chinese contact point in Geneva 5 weeks in advance of making contact. The PRC contact point could decide which Taiwanese experts should be contacted. If Taiwanese experts were invited to technical meetings an expert of similar status should be included. Taiwanese citizens were not permitted to attend WHO meetings as members of NGO delegations. Most bizarrely, because writing “Taiwan” on an envelope (necessary if it was to reach its destination) would imply recognition of its independence in the view of the PRC, all paper communications had to be faxed.
This system was put to the test during the SARS outbreak, when e-mails from the Taiwanese authorities to the WHO went unanswered for weeks. This is a ludicrous state of affairs, not only because of the consequences in cases of emergency but also because it denies the very considerable Taiwanese expertise to the WHO.
So that is how I became involved with Taiwan….
Anyway, the conference was excellent, with some really thought provoking presentations. Among the most noteworthy were a set of presentations on migration of health workers, a huge challenge for many countries especially in sub-Saharan Africa. Yet there is some hope, and we heard about the integrated approach being taken by the government of Malawi to stem what has been a haemorrhage of skilled staff, so that this country of over 12 million people does not have a single cardiologist or urologist. The strategy described was multi-faceted; a core element was to raise salaries of health professionals and to improve their working conditions. Early results suggest that it may be working.
Others looked at a range of complex ethical issues. Barry Pakes, from the University of Toronto, discussed the many ethical challenges posed by pandemics, especially those arising from limited stocks of vaccine, while Alireza Bagheri, also from Toronto, discussed the challenges posed by the market for organ transplants in Asia. All in all, much to think about on the long flight home.

Another excellent ECOHOST seminar this week. Professor Larry Brown, a political scientist from Columbia University in New York, chose a deliberately provocative title: “Why does the US health system not just collapse”. As Larry noted, people have been predicting its collapse for decades yet it still managing to limp on. I stress “limp” because, not only is it ridiculously expensive, but as Ellen Nolte and I have shown, it achieves appalling outcomes, with death rates from chronic diseases (the real test of a modern health care system) about 4 or 5 times worse than in any western European country. In passing, this highlights the rClearly this was a question that many people wanted an answer to – while we are normally delighted if we attract 30 people to our seminars in Russia, in this case there was standing room only, with the audience spilling out into the corridor!
So what is the answer? One reason is that the picture most of us have of the US system, characterised by employer- or individual-funded insurance plans, is really quite misleading. About 15% of the population have no coverage but they are able to receive care (of a sort), mainly from publicly funded facilities. A further 40% of the population receive care through other publicly funded mechanisms, such as Medicaid, Medicare, and the Veteran’s Administration, as well as the S-CHIP plan that covers children that would otherwise be excluded. Thus, a full 45% of health care funding, covering 55% of the population, is from government sources. In other words, the system that we think of has failed, but the state has taken action to pick up the pieces.
However, that is not the whole story. We heard of examples where sophisticated private hospitals had stepped in to help rescue county hospitals facing financial problems, either by direct financial help or by lobbying for local taxes to support them. This seems strange behaviour in what we are led to believe is a competitive market. The reason is, of course, clear. Some of those county hospitals have the greatest experience with trauma and, while the wealthy wouldn’t go there for their hip replacement, they want to know that there is someone with lots of experience if they are unlucky enough to get shot. However, even more importantly, if those county hospitals closed then they would have to do something to help the uninsured, people whom their normal customers pay good money to stay away from (except when they need a gardener or a maid). In other words, the US health system is clearly failing its citizens but it is not being allowed to collapse. What will happen in the future? One person in the audience asked about the proposal by Massachusetts to mandate universal coverage. An interesting idea, but will it be feasible given the enormous costs in the US health care system?
While it was great having so many students from LSHTM present, the people who really need to hear this are some of those advising our Prime Minister, who seem to have some idealised vision of health care across the Atlantic and who seem determined to introduce their distorted vision here. Still, given their ability to hear the same messages as the rest of us but to interpret it in a way that is completely different, maybe it would just be a waste of time.
That leads me nicely to a series of conversations I have been having this week. Patricia Hewitt has confidently predicted that the NHS in England will be in financial balance this year. Maybe it will. Yet maybe that is not the question we should be asking. Rather, will it be in a form that is recognisable. OK, maybe the consequences of present policies won’t become entirely apparent this year, but unless there is a major policy reversal they certainly will in a few years.
The problem is this. For the past few years we have been putting in place a system of hospital financing that is unique internationally in its inflexibility. New developments funded by private finance require the hospital to pay (very) large sums of money for years in the future (mostly 30 years but in a few bizarre cases, for 60 years). Now think how much hospitals have changed even in the past decade. Unfortunately, the contracts are so tightly specified that any changes will be prohibitively expensive. In other words, the costs facing hospitals are to a large degree fixed.
In marked contrast, the new funding system is, in international terms, uniquely volatile and unpredictable. Hospitals will be funded on the basis of the numbers of patients treated (adjusted for their severity and complexity). Sounds simple. Of course, it is not. While lots of countries have such systems in place, none have ever introduced one so quickly, covering such a broad range of patients (from the relatively easy to categorise, such as simple elective surgery, to patients with multiple complex chronic diseases that defy simple categorisation), and with such a high proportion of total cost being variable (100%). Everyone else has introduced it incrementally, and has included lots of safety mechanisms.
The implications of fixed costs and unpredictable income, with both largely outside the control of hospital managers, seem fairly obvious, but clearly not to everyone.
As if that was not enough, the NHS governance systems are struggling to emerge from a wide-ranging reorganisation that has led to the early retirement of many talented staff and the almost complete loss of institutional memory. However, just in case the NHS might be able to survive this situation, a large number of privately owned independent treatment centres are being funded, many benefiting from highly preferential funding packages, in which, in some cases, they don’t even have to do the work they were contracted for to be paid.
The Secretary of State may be right that the overall NHS budget will be balanced by the end of the year but there will be many winners and losers, with specialist services, and in particular children’s and orthopaedic hospitals, the most vulnerable. I cannot help but be reminded of the quotation from a US Army Major in Vietnam after the destruction of the village of Ben Tre - "It became necessary to destroy the village in order to save it." It is difficult to avoid concluding that a similar mind set holds sway in Whitehall.