- Email: [email protected]
Alcohol misuse: local innovations are also important
Correspondence
too local in perspective and missed the opportunity to call for wider recognition of the importance of good prison health for public heath. 100 years ago, Winston Churchill said that “the mood and temper of the public in regard to the treatment of crime and criminals is one of the most unfailing tests of the civilisation of any country”. Despite the deficiencies to which you rightly draw attention, it would not take much for the UK’s prison health services to lead the rest of the world towards the civilised service Churchill no doubt had in mind. We declare that we have no conflicts of interest.
*Alex Gatherer, Andrew Fraser [email protected] 3 Stonehill Close, Appleton, Warrington WA4 5QD, UK (AG); Director, Health and Care, Scottish Prison Service, Edinburgh, UK (AF) 1
The Lancet. Health care for prisoners and young offenders. Lancet 2009; 373: 603.
from high levels of social capital and infrastructures at this time). In Poland, the improvement was attributed to the striking decrease in cardiovascular mortality, which is probably related to the shift from saturated fats (eg, butter, lard) to unsaturated fats (vegetable oils) and increased availability of fruits and vegetables.5 The food industry has become more willing to reduce the salt content of selected foodstuffs under pressure from various health organisations. Better health at population level could also result from improved food security as a result of the higher standards demanded by globalised production and distribution. The global effects of trade liberalisation on health are still largely unknown. In this context, it is probably sensible to develop and use conceptual models that take account of both positive and negative effects. We declare that we have no conflicts of interest.
Negative and positive effects of trade on health Chantal Blouin and colleagues (Feb 7, p 502)1 provide a theoretical framework linking trade liberalisation and health outcomes. A basic feature of their model is that it only takes account of the negative effects on health. We submit that Blouin and colleagues should explicitly allow for potentially favourable effects. From a systemic perspective, it is plausible and useful that such conceptual models allow for positive and negative effects, whether regulatory or compensatory, intended or unintended. From an observational perspective, a series of negative effects of trade liberalisation on health have been described,2,3 although the interpretation still needs further clarification.4 But some evidence also points to favourable effects.5 Life expectancy rapidly increased after trade liberalisation in some former communist countries in eastern Europe3 (although such countries also benefited 1338
*P Bovet, F Paccaud [email protected] Institute of Social and Preventive Medicine, Faculty of Medicine and University Hospital Center, rue de Bugnon 17, 1005 Lausanne, Switzerland 1 Blouin C, Chopra M, van der Hoeven R. Trade and social determinants of health. Lancet 2009; 373: 502–07. 2 Adeyi O, Chellaraj G, Goldstein E, Preker A, Ringold D. Health status during the transition in Central and Eastern Europe: development in reverse? Health Policy Plan 1997; 12: 132–45. 3 Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a crossnational analysis. Lancet 2009; 373: 399–407. 4 Anon. Mass murder and the market. The Economist Jan 22, 2009: 13–14. 5 Zatonski WA, McMichael AJ, Powles JW. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991. BMJ 1998; 316: 1047–51.
the prevention and management of alcohol misuse. The project described below is part of a whole-population approach based on research by WHO.2 Operation Floorwalk involves schools, police, voluntary organisations, local authority, and the National Health Service. A team of individuals from these organisations identifies local “hot spots” of youth drinking that are then targeted during afternoons and early evenings. Young people younger than 16 years who are under the influence of alcohol are taken to a police station for their safety. The young people and their parents or carers are then counselled and offered further support through the voluntary sector, either in the form of specialist alcohol advice, social skills training, or group work. To date, almost 300 young people have been through this innovative programme. Information gathered from the young people has helped reveal the high levels of need in this population, ways that young people obtain alcohol, and young people’s views on alcohol. Short-term data on outcomes in 100 of these young people show that 74 participants reported reduced alcohol intake. For some individuals, the support offered through the programme had a major positive effect—for example, one participant was helped to return to education after a long absence from school. Operation Floorwalk has therefore highlighted the importance of local initiatives and support for individuals. We declare that we have no conflicts of interest.
Alcohol misuse: local innovations are also important Your Editorial on alcohol misuse (Feb 7, p 433)1 highlights the need for a global response aimed mainly at preventing overconsumption. Our experience in West Lothian, UK, has shown that local initiatives are also essential in
*Graham Mackenzie, Gregor Forbes, Marsha Scott, Margot Ferguson, Helen Davis [email protected] NHS Lothian, Department of Public Health and Health Policy, Edinburgh EH8 9RS, UK (GM); Lothian and Borders Police, Edinburgh, UK (GF); West Lothian Council, Livingston, UK (MS); West Lothian Drug & Alcohol Service, Livingston, UK (MF); and West Lothian Youth Action Project, Livingston, UK (HD) 1
The Lancet. Alcohol misuse needs a global response. Lancet 2009; 373: 433.
www.thelancet.com Vol 373 April 18, 2009
Correspondence
Babor TF, Caetano R, Casswell S, et al. Alcohol: no ordinary commodity—research and public policy. Oxford: Oxford University Press, 2003.
Smoking cessation: learning from experience John Britton (Feb 28, p 703)1 supports the substantial British investment in personalised smoking cessation activities, arguing against Simon Chapman’s assertion (p 701)2 that much of this should have been allocated to evidence-based strategies such as mass media campaigns. For many years the British government seemed to put large amounts into cessation programmes as a soft alternative to complete controls on tobacco promotion, protection of non-smokers, and hardhitting mass media programmes. At last the winds of smoke-free change are blowing through the UK, and few doubt that they will be rewarded by further declines in smoking. Britton, however, wonders whether smoking prevalence in Australia might now be lower, “had the admirable media campaigns run there over past decades been supported by UK-style cessation services”. Western Australia has in recent years had Australia’s lowest prevalence of smoking in adults (14·8%)3 and children (6% in 12–17-year-olds),4 with one major community cessation programme which focuses mainly on training and support activities. There is clearly a role for smoking cessation activity, but there is overwhelming evidence of the effect of well funded media programmes which, with creative advocacy by health organisations, have been the cornerstone of developments in Western Australia.5 Britton might have asked how much better even Western Australia might have done if we had been able to spend as much on public education as the British government frittered away on worthy but low-impact cessation activities. www.thelancet.com Vol 373 April 18, 2009
In 36 years of work on tobacco in the UK, Australia, and internationally, I have seen virulent opposition by tobacco companies to tough, well funded media campaigns. I have never seen or heard of any concern from the tobacco industry or its allies about personalised smoking cessation programmes. Philip Morris even runs one itself. I declare that I have no conflicts of interest.
Mike Daube [email protected] Public Health Advocacy Institute of WA, Curtin University of Technology, Perth 6008, WA, Australia 1 2 3
4
5
Britton J. In defence of helping people to stop smoking. Lancet 2009; 373: 703–05. Chapman S. The inverse impact law of smoking cessation. Lancet 2009; 373: 701–03. Australian Institute of Health and Welfare. 2007 national drug strategy household survey: state and territory supplement. Canberra: AIHW, 2008. Coase P, Miller J. ASSAD smoking report 2005: a research report prepared for the Drug and Alcohol Office WA. Perth: TNS Social Research, 2007. Wakefield MA, Durkin S, Spittal MJ, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health 2008; 98: 1443–50.
took the initiative to move towards a medicines patent pool, initially targeting the missing medicines for HIV. This patent pool, like GSK’s stated idea, will be based on voluntary contributions of patents by patent holders. The patent pool will facilitate the production of more affordable generic versions of AIDS medicines and in particular the development of fixed-dose combinations and desperately needed formulations for children. The patent holders that collaborate will receive royalties from the sales of the products. UNITAID spends about US$80 million per year on the procurement of AIDS medicines. We could do so much more with this money if the prices of newer medicines in particular came down. A patent pool can make that happen. We invite Witty and GSK to contribute to the UNITAID medicines patent pool initiative and really join the sea change in the provision of medicines to people in developing countries. We declare that we have no conflicts of interest.
*Philippe Douste-Blazy, Jorge Bermudez
GSK: please extend patent pool to AIDS drugs
[email protected] UNITAID, WHO, 1211 Geneva 27, Switzerland 1
As you state in your Feb 28 Editorial, GlaxoSmithKline’s (GSK’s) Chief Executive Officer Andrew Witty is to be commended for his announcement of GSK’s medicines pricing practices in developing countries and in particular his proposal of a patent pool to allow research into neglected diseases by others than the patent holders. But he has to go further. He should also make GSK’s patents on AIDS medicines available for the development of more affordable fixed-dose combinations for patients in poor countries. In July, 2008, UNITAID, a new financing mechanism providing treatments for AIDS, tuberculosis, and malaria, 1
The Lancet. Pharmaceuticals, patents, publicity…and philanthropy? Lancet 2009; 373: 693.
Enjoying and enduring: groups reading aloud for wellbeing What a delight to come across Jane Davis’s Art of Medicine essay (Feb 28, p 714).1 For the past 22 years at Duke University Medical Center, NC, USA, a small group of devotees has met weekly for 1 h to read aloud and be rejuvenated by poems, short fiction, and occasional essays. Finding Davis’s essay was like Crusoe’s seeing the footprint on the sand: someone else is here!
Photolibrary
2
1339
too local in perspective and missed the opportunity to call for wider recognition of the importance of good prison health for public heath. 100 years ago, Winston Churchill said that “the mood and temper of the public in regard to the treatment of crime and criminals is one of the most unfailing tests of the civilisation of any country”. Despite the deficiencies to which you rightly draw attention, it would not take much for the UK’s prison health services to lead the rest of the world towards the civilised service Churchill no doubt had in mind. We declare that we have no conflicts of interest.
*Alex Gatherer, Andrew Fraser [email protected] 3 Stonehill Close, Appleton, Warrington WA4 5QD, UK (AG); Director, Health and Care, Scottish Prison Service, Edinburgh, UK (AF) 1
The Lancet. Health care for prisoners and young offenders. Lancet 2009; 373: 603.
from high levels of social capital and infrastructures at this time). In Poland, the improvement was attributed to the striking decrease in cardiovascular mortality, which is probably related to the shift from saturated fats (eg, butter, lard) to unsaturated fats (vegetable oils) and increased availability of fruits and vegetables.5 The food industry has become more willing to reduce the salt content of selected foodstuffs under pressure from various health organisations. Better health at population level could also result from improved food security as a result of the higher standards demanded by globalised production and distribution. The global effects of trade liberalisation on health are still largely unknown. In this context, it is probably sensible to develop and use conceptual models that take account of both positive and negative effects. We declare that we have no conflicts of interest.
Negative and positive effects of trade on health Chantal Blouin and colleagues (Feb 7, p 502)1 provide a theoretical framework linking trade liberalisation and health outcomes. A basic feature of their model is that it only takes account of the negative effects on health. We submit that Blouin and colleagues should explicitly allow for potentially favourable effects. From a systemic perspective, it is plausible and useful that such conceptual models allow for positive and negative effects, whether regulatory or compensatory, intended or unintended. From an observational perspective, a series of negative effects of trade liberalisation on health have been described,2,3 although the interpretation still needs further clarification.4 But some evidence also points to favourable effects.5 Life expectancy rapidly increased after trade liberalisation in some former communist countries in eastern Europe3 (although such countries also benefited 1338
*P Bovet, F Paccaud [email protected] Institute of Social and Preventive Medicine, Faculty of Medicine and University Hospital Center, rue de Bugnon 17, 1005 Lausanne, Switzerland 1 Blouin C, Chopra M, van der Hoeven R. Trade and social determinants of health. Lancet 2009; 373: 502–07. 2 Adeyi O, Chellaraj G, Goldstein E, Preker A, Ringold D. Health status during the transition in Central and Eastern Europe: development in reverse? Health Policy Plan 1997; 12: 132–45. 3 Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a crossnational analysis. Lancet 2009; 373: 399–407. 4 Anon. Mass murder and the market. The Economist Jan 22, 2009: 13–14. 5 Zatonski WA, McMichael AJ, Powles JW. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991. BMJ 1998; 316: 1047–51.
the prevention and management of alcohol misuse. The project described below is part of a whole-population approach based on research by WHO.2 Operation Floorwalk involves schools, police, voluntary organisations, local authority, and the National Health Service. A team of individuals from these organisations identifies local “hot spots” of youth drinking that are then targeted during afternoons and early evenings. Young people younger than 16 years who are under the influence of alcohol are taken to a police station for their safety. The young people and their parents or carers are then counselled and offered further support through the voluntary sector, either in the form of specialist alcohol advice, social skills training, or group work. To date, almost 300 young people have been through this innovative programme. Information gathered from the young people has helped reveal the high levels of need in this population, ways that young people obtain alcohol, and young people’s views on alcohol. Short-term data on outcomes in 100 of these young people show that 74 participants reported reduced alcohol intake. For some individuals, the support offered through the programme had a major positive effect—for example, one participant was helped to return to education after a long absence from school. Operation Floorwalk has therefore highlighted the importance of local initiatives and support for individuals. We declare that we have no conflicts of interest.
Alcohol misuse: local innovations are also important Your Editorial on alcohol misuse (Feb 7, p 433)1 highlights the need for a global response aimed mainly at preventing overconsumption. Our experience in West Lothian, UK, has shown that local initiatives are also essential in
*Graham Mackenzie, Gregor Forbes, Marsha Scott, Margot Ferguson, Helen Davis [email protected] NHS Lothian, Department of Public Health and Health Policy, Edinburgh EH8 9RS, UK (GM); Lothian and Borders Police, Edinburgh, UK (GF); West Lothian Council, Livingston, UK (MS); West Lothian Drug & Alcohol Service, Livingston, UK (MF); and West Lothian Youth Action Project, Livingston, UK (HD) 1
The Lancet. Alcohol misuse needs a global response. Lancet 2009; 373: 433.
www.thelancet.com Vol 373 April 18, 2009
Correspondence
Babor TF, Caetano R, Casswell S, et al. Alcohol: no ordinary commodity—research and public policy. Oxford: Oxford University Press, 2003.
Smoking cessation: learning from experience John Britton (Feb 28, p 703)1 supports the substantial British investment in personalised smoking cessation activities, arguing against Simon Chapman’s assertion (p 701)2 that much of this should have been allocated to evidence-based strategies such as mass media campaigns. For many years the British government seemed to put large amounts into cessation programmes as a soft alternative to complete controls on tobacco promotion, protection of non-smokers, and hardhitting mass media programmes. At last the winds of smoke-free change are blowing through the UK, and few doubt that they will be rewarded by further declines in smoking. Britton, however, wonders whether smoking prevalence in Australia might now be lower, “had the admirable media campaigns run there over past decades been supported by UK-style cessation services”. Western Australia has in recent years had Australia’s lowest prevalence of smoking in adults (14·8%)3 and children (6% in 12–17-year-olds),4 with one major community cessation programme which focuses mainly on training and support activities. There is clearly a role for smoking cessation activity, but there is overwhelming evidence of the effect of well funded media programmes which, with creative advocacy by health organisations, have been the cornerstone of developments in Western Australia.5 Britton might have asked how much better even Western Australia might have done if we had been able to spend as much on public education as the British government frittered away on worthy but low-impact cessation activities. www.thelancet.com Vol 373 April 18, 2009
In 36 years of work on tobacco in the UK, Australia, and internationally, I have seen virulent opposition by tobacco companies to tough, well funded media campaigns. I have never seen or heard of any concern from the tobacco industry or its allies about personalised smoking cessation programmes. Philip Morris even runs one itself. I declare that I have no conflicts of interest.
Mike Daube [email protected] Public Health Advocacy Institute of WA, Curtin University of Technology, Perth 6008, WA, Australia 1 2 3
4
5
Britton J. In defence of helping people to stop smoking. Lancet 2009; 373: 703–05. Chapman S. The inverse impact law of smoking cessation. Lancet 2009; 373: 701–03. Australian Institute of Health and Welfare. 2007 national drug strategy household survey: state and territory supplement. Canberra: AIHW, 2008. Coase P, Miller J. ASSAD smoking report 2005: a research report prepared for the Drug and Alcohol Office WA. Perth: TNS Social Research, 2007. Wakefield MA, Durkin S, Spittal MJ, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health 2008; 98: 1443–50.
took the initiative to move towards a medicines patent pool, initially targeting the missing medicines for HIV. This patent pool, like GSK’s stated idea, will be based on voluntary contributions of patents by patent holders. The patent pool will facilitate the production of more affordable generic versions of AIDS medicines and in particular the development of fixed-dose combinations and desperately needed formulations for children. The patent holders that collaborate will receive royalties from the sales of the products. UNITAID spends about US$80 million per year on the procurement of AIDS medicines. We could do so much more with this money if the prices of newer medicines in particular came down. A patent pool can make that happen. We invite Witty and GSK to contribute to the UNITAID medicines patent pool initiative and really join the sea change in the provision of medicines to people in developing countries. We declare that we have no conflicts of interest.
*Philippe Douste-Blazy, Jorge Bermudez
GSK: please extend patent pool to AIDS drugs
[email protected] UNITAID, WHO, 1211 Geneva 27, Switzerland 1
As you state in your Feb 28 Editorial, GlaxoSmithKline’s (GSK’s) Chief Executive Officer Andrew Witty is to be commended for his announcement of GSK’s medicines pricing practices in developing countries and in particular his proposal of a patent pool to allow research into neglected diseases by others than the patent holders. But he has to go further. He should also make GSK’s patents on AIDS medicines available for the development of more affordable fixed-dose combinations for patients in poor countries. In July, 2008, UNITAID, a new financing mechanism providing treatments for AIDS, tuberculosis, and malaria, 1
The Lancet. Pharmaceuticals, patents, publicity…and philanthropy? Lancet 2009; 373: 693.
Enjoying and enduring: groups reading aloud for wellbeing What a delight to come across Jane Davis’s Art of Medicine essay (Feb 28, p 714).1 For the past 22 years at Duke University Medical Center, NC, USA, a small group of devotees has met weekly for 1 h to read aloud and be rejuvenated by poems, short fiction, and occasional essays. Finding Davis’s essay was like Crusoe’s seeing the footprint on the sand: someone else is here!
Photolibrary
2
1339