- Email: [email protected]
THE DIFFICULT ART, SCIENCE, AND POLITICS OF SETTING HEALTH PRIORITIES
498
humidity and excess alcohol intake, possibly exacerbated by previous exposure to a tropical climate-has been described Long trips are associated with profound inertia and apathy in the passengers:" the consequent stasis, particularly in the cramped economy class, make swollen ankles (with inability to get shoes back on) commonplace. Pressure on the calves from the seat, possibly more common in short people,12 will exacerbate venous stasis, and, indeed, the calf veins appear
be the most common site of short as three to four hours can
to
thrombosis.2,6,8 Trips as induce DVT and pulmonary embolus,8 although longer trips are more usual.
What types of person are at risk? Sarvesvaran4 estimated that over a three-year period at Heathrow airport, 18% of the 61 sudden deaths in long distance passengers were due to pulmonary embolus. The victims tended to be women over 40 years old, with a history of DVT. However, men in their 40’s$with no predisposing medical history are vulnerable to DVT and pulmonary embolism.5,12 The timing of the pulmonary embolus is surprisingly variable. Often the first symptoms occur on disembarkation.6 However, as illustrated by our first case history, pulmonary embolus may occur many days after the flight. Two weeks may passs before sudden effort, such as tennis or jumping from the path of a vehicle, may dislodge a minor or a massive12 clot. How can the risk of DVT and pulmonary embolus be reduced? Firstly, the subject should be aware of the possible dangers and the airlines should be responsible for this. Frequent leg and body exercises are advised and regular walks from the aisle seat (avoiding the inside seat if possible) should be taken, particularly by passengers in the more cramped conditions of economy class. Smoking, which causes hypoxia and increases blood viscosity, and excessive alcohol intake should both be avoided. Regular nonalcoholic drinks should be taken to prevent dehydration. (Colonl’ gives many excellent tips to avoid venous stasis and thrombosis.) High-risk subjects should consider low-dose aspirin on either a permanent or temporary basis.s If a DVT is suspected or proven, energetic exercise that may dislodge an embolus should be avoided. Patients with venous thromboembolism should probably be anticoagulated for three to six months." Correspondence should be addressed to J. M. C., Medical Research Department, ICI Pharmaceuticals, Mereside, Alderley Park, Macclesfield SK10 4TG.
REFERENCES Gesammelte Abhandlungen zur Wissenschaftlischen Medicine. Meidinger: Frankfurt, 1856: 227. 2. Simpson K. Shelter deaths from pulmonary embolism. Lancet 1940; n: 744. 3. Horsley SD, Small PJ, Thould AK. Effects of influx of holidaymakers on an acute medical unit in Cornwall. Br Med J 1975; iv: 276. 4. Sarvesvaran R. Sudden natural deaths associated with commercial air travel. Med Sci Law 1986; 26: 35-38. 5. Holliday J. Atypical presentation of multiple pulmonary emboli in a young air traveller. J R Coll Gen Pract 1985; 35: 497. 6. Ledermann JA, Keshavarzian A Acute pulmonary embolism following air travel. Postgrad Med J 1983; 59: 104-05. 7. Hamilton M, Thompson EN. Unusual manifestations of pulmonary embolic disease. Postgrad Med J 1963; 39: 348-53 8. Symington IA, Stack BHR. Pulmonary thromboembolism after travel. Br J Dis Chest 1977, 71: 138-40. 9. Beighton PH, Richards PR. Cardiovascular disease m air travellers. Br Heart J 1968; 30: 367-72. 10. Carruthers M, Arguelles AE, Mosovich A. Man in transit: biochemical and physiological changes during intercontinental flights. Lancet 1976; i: 977-81. 11. Colón VF To help prevent circulatory problems on long trips. Med Times 1977; 105: 52-54. 12. Thomas JEP, Abson CP, Cairns NJW. Pulmonary embolism. A hazard of air travel. Cent Afr J Med 1981; 27: 85-87. 13. Editorial. Management of venous thromboembolism. Lancet 1988; i: 275-77. 1. Virchow R.
Occasional Book THE DIFFICULT ART, SCIENCE, AND POLITICS OF SETTING HEALTH PRIORITIES
global conference entitled Health Research for the Developing World: Priorities Based on Effectiveness and Cost, held in Bellagio Italy, last year, it was startling to learn that even at the highest level of the health system, priorities are simply not set in any systematic manner. This includes all sectors of international health agencies, national governments, ministries of health, medical schools, and AT
a
research institutes. The consequences of this failure are exemplified by the Western Pacific country that built multi-million dollar institutes specialising in areas such as cardiology, renal disease, and haematology; the South Asian nation that declared leprosy and tuberculosis as its two major health priorities in the face of enormous infant and child mortality due to diarrhoeal and respiratory infections; the West African country whose primary concern was whether to do coronary bypass operations in the capital city or send patients abroad; the Latin American nation that decided its major priority, after immunising all of its children, was mental health; and the international agency that developed a programme of research on the diseases of the tropics which omitted diarrhoeal and respiratory infections. For all of these examples, matching ones can be found in the developed world-such as the North American republic that focused on artificial hearts in the presence of childhood malnutrition in its central cities. On the global level, it has only recently been recognised that support for research on "the great neglected diseases of the developing world" is grossly inadequate. From the variety of the above examples it is clear that dependence on politicians and bureaucrats to set health priorities is fraught with difficulties, including personal, family, and community biases. One alternative is to consult experts, but these show a pronounced tendency to favour their own particular diseases, organs, or disciplines-say, infectious disease, parasitology, or cardiology. Most physicians lack the knowledge of epidemiology, statistics, and economics required for priority setting, having been trained largely in tertiary health care facilities with a primary focus on rare, advanced, and fatal diseases. In the past two decades, the great international agencies essentially abrogated their responsibility to set priorities. In their "horizontal" approach, decision-making was avoided by recommendations that everything be available "education concerning simultaneously-including health and the methods or preventing problems prevailing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs1". A major aspect of this concept has been to let the "people", the "community", make the
1. World Health
Organisation. Declaration of Alma Ata (Report on the International Conference on Primary health Care, Alma Ata, USSR, Sept 6-12, 1978) Geneva WHO, 1978.
499 even in those cases where the population was illiterate. largely Establishing Health Priorities in the Developing World,2a monograph by Julia A. Walsh just published by the United Nations Development Programme, is a landmark document in an effort begun about a decade ago to systematise the establishment of priorities for the control of the major diseases of the developing world. In 1979 Dr Walsh co-authored a controversial paper entitled Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries.3 Its purpose was to disaggregate the components of the mortality and morbidity rates in the developing world in order to determine priorities based on prevalence, morbidity, and mortality. The availability of means of preventing and controlling these diseases at a reasonable cost was then determined. Where adequate cost-effective means of control were not available, research
decisions,
was
encouraged.
These ideas led to a major debate in the international health community that is still in progress-for example, Social Sciences and Medicine 1988, vol 26, no 9 was entirely given over to the controversy concerning comprehensive versus selective primary health care. This was fuelled by UNICEF’s implementation of its great Children’s Revolution inaugurated in 1983 based on "social and scientific advances" that offer four vital new opportunities for improving the nutrition and health of the world’s children--oral rehydration therapy, universal childhood immunisation, the promotion of breastfeeding, and growth charts.4 These priorities were similar to those originally suggested in Dr Walsh’s selective primary health care paper.3 The primary focus of UNICEF’s programme has been a campaign to immunise all the world’s children: it was launched in Bellagio in 1984 and was coordinated by the Task Force for Child Survival in cooperation with WHO’s Expanded Programme on Immunisation and was supported also by UNDP, the World Bank, and the Rockefeller Foundation.5 This campaign brought the world level of immunisation to over 50% by the spring of 1987, with the goal of universal childhood immunisation in the early 1990s. Other agencies are adopting targeted approaches-for instance, the US Agency for International Development’s Child Survival programme includes immunisation, control of diarrhoeal diseases, nutrition, and child-spacing.6 At the third Bellagio conference convened by the Task Force for Child Survival, in Talloires, France, this year (Bellagio II, was held in Cartagena, Colombia, in 1985) the discussion focused on the status of the immunisation campaign and its sustainability within primary health care, and the introduction of other major cost-effective health initiatives, particularly diarrhoeal disease control and family planning. Major progress made within the last four years
2
Establishing Health Priorities in the Developing World. Walsh JA. New York: United Nations Development Programme. 1988. pp 151. $US25. ISBN 0-944913029. Available from UNDP Division for Global and Interregional Programmes, United Nations Plaza, New York, NY 10017, USA (cheques payable to UNDP). 3. Walsh JA, Warren KS. Selective primary health care: An interim strategy for disease control in developing countries. N Engl J Med 1979; 301: 967-74. 4. Grant JP. (UNICEF) The state of the world’s children, 1982-83. Oxford: Oxford University Press,
attributed to focused attainable programmes that made efficient use of resources.6 Julia Walsh’s book and its publication by UNDP provides the basis for a more general effort to establish priorities for research and control for the diseases of the developing world. It begins with the status of all the major diseases of the developing world on the basis of prevalence, mortality, and morbidity for the year 1986, and the effectiveness and costs of interventions to control them. This is followed by discussions of research and development, funding, and implementation. Methods for determining priorities at all levels of the system are described, and invaluable data are presented. Walsh summarises the system as follows: was
"Balancing limited resources with needs for health improvement requires setting priorities. The status of health services and research, as well as societal, economic, and behavioral factors, all affect personal well-being... The process of prioritizing both for research and health services commences with an analysis of the major causes of morbidity and mortality. Local or national decision makers use local and regional information, while international agencies use global estimates. For those major causes of ill-health that have cost-effective control measures, research focuses on identifying better ways to utilize current measures. For conditions that lack adequate intervention (ie, current measures inefficacious, costly, inconvenient, or associated with poor compliance), research concentrates on the development of new methods. Areas of research may include epidemiology, biotechnology, health systems analysis, policy-making, socio-economics, and so forth.""
Other agencies involved in the crucial processes described in Walsh’s book are the World Bank, which has recently established a major exercise to review health sector priorities, the Rockefeller Foundation, which has focused on training of individuals for research and decision-making based on critical analysis of epidemiological and economic data through its International Clinical Epidemiology Network and Health Planning and Financing programmes, and the new Commission on Health Research for Development initiated by the Edna McConnell Clark Foundation and supported by other foundations and international agencies. Thus, the great multilateral agencies WHO, UNICEF, UNDP, and the World Bank, some of the major bilateral agencies, and the foundations are joining together in a massive effort to attack the greatest killers and maimers of 75% of the world’s population at costs affordable to those nations and the global community. This priority-setting approach has been supported by world leaders including the member nations of the South Asian Association for Regional Cooperation (in November, 1986), the Organisation of African Unity (in May, 1988) and the heads of state of the Soviet Union and the United States at the Moscow summit meeting (June, 1988). Secretary General Gorbachev and President Reagan issued the following statement: "Both leaders reaffirmed their support for the WHO/UNICEF goal of reducing the scale of preventable childhood deaths through the most effective methods of saving children." Rockefeller Foundation, 1133 Avenue of the Americas, New York, NY 10036, USA
KENNETH S. WARREN
1982.
5.
Protecting the world’s children: vaccines and immunization within primary health care, a Bellagio conference. New York: Rockefeller Foundation, 1984. 6. US Agency for International Development. Child survival: a third report to congress on the USAID Program. Washington DC: US Agency for International Development, 1988.
7. Warren KS.
659.
Protecting the world’s children:
an
agenda for the
1990s. Lancet
1988; i:
humidity and excess alcohol intake, possibly exacerbated by previous exposure to a tropical climate-has been described Long trips are associated with profound inertia and apathy in the passengers:" the consequent stasis, particularly in the cramped economy class, make swollen ankles (with inability to get shoes back on) commonplace. Pressure on the calves from the seat, possibly more common in short people,12 will exacerbate venous stasis, and, indeed, the calf veins appear
be the most common site of short as three to four hours can
to
thrombosis.2,6,8 Trips as induce DVT and pulmonary embolus,8 although longer trips are more usual.
What types of person are at risk? Sarvesvaran4 estimated that over a three-year period at Heathrow airport, 18% of the 61 sudden deaths in long distance passengers were due to pulmonary embolus. The victims tended to be women over 40 years old, with a history of DVT. However, men in their 40’s$with no predisposing medical history are vulnerable to DVT and pulmonary embolism.5,12 The timing of the pulmonary embolus is surprisingly variable. Often the first symptoms occur on disembarkation.6 However, as illustrated by our first case history, pulmonary embolus may occur many days after the flight. Two weeks may passs before sudden effort, such as tennis or jumping from the path of a vehicle, may dislodge a minor or a massive12 clot. How can the risk of DVT and pulmonary embolus be reduced? Firstly, the subject should be aware of the possible dangers and the airlines should be responsible for this. Frequent leg and body exercises are advised and regular walks from the aisle seat (avoiding the inside seat if possible) should be taken, particularly by passengers in the more cramped conditions of economy class. Smoking, which causes hypoxia and increases blood viscosity, and excessive alcohol intake should both be avoided. Regular nonalcoholic drinks should be taken to prevent dehydration. (Colonl’ gives many excellent tips to avoid venous stasis and thrombosis.) High-risk subjects should consider low-dose aspirin on either a permanent or temporary basis.s If a DVT is suspected or proven, energetic exercise that may dislodge an embolus should be avoided. Patients with venous thromboembolism should probably be anticoagulated for three to six months." Correspondence should be addressed to J. M. C., Medical Research Department, ICI Pharmaceuticals, Mereside, Alderley Park, Macclesfield SK10 4TG.
REFERENCES Gesammelte Abhandlungen zur Wissenschaftlischen Medicine. Meidinger: Frankfurt, 1856: 227. 2. Simpson K. Shelter deaths from pulmonary embolism. Lancet 1940; n: 744. 3. Horsley SD, Small PJ, Thould AK. Effects of influx of holidaymakers on an acute medical unit in Cornwall. Br Med J 1975; iv: 276. 4. Sarvesvaran R. Sudden natural deaths associated with commercial air travel. Med Sci Law 1986; 26: 35-38. 5. Holliday J. Atypical presentation of multiple pulmonary emboli in a young air traveller. J R Coll Gen Pract 1985; 35: 497. 6. Ledermann JA, Keshavarzian A Acute pulmonary embolism following air travel. Postgrad Med J 1983; 59: 104-05. 7. Hamilton M, Thompson EN. Unusual manifestations of pulmonary embolic disease. Postgrad Med J 1963; 39: 348-53 8. Symington IA, Stack BHR. Pulmonary thromboembolism after travel. Br J Dis Chest 1977, 71: 138-40. 9. Beighton PH, Richards PR. Cardiovascular disease m air travellers. Br Heart J 1968; 30: 367-72. 10. Carruthers M, Arguelles AE, Mosovich A. Man in transit: biochemical and physiological changes during intercontinental flights. Lancet 1976; i: 977-81. 11. Colón VF To help prevent circulatory problems on long trips. Med Times 1977; 105: 52-54. 12. Thomas JEP, Abson CP, Cairns NJW. Pulmonary embolism. A hazard of air travel. Cent Afr J Med 1981; 27: 85-87. 13. Editorial. Management of venous thromboembolism. Lancet 1988; i: 275-77. 1. Virchow R.
Occasional Book THE DIFFICULT ART, SCIENCE, AND POLITICS OF SETTING HEALTH PRIORITIES
global conference entitled Health Research for the Developing World: Priorities Based on Effectiveness and Cost, held in Bellagio Italy, last year, it was startling to learn that even at the highest level of the health system, priorities are simply not set in any systematic manner. This includes all sectors of international health agencies, national governments, ministries of health, medical schools, and AT
a
research institutes. The consequences of this failure are exemplified by the Western Pacific country that built multi-million dollar institutes specialising in areas such as cardiology, renal disease, and haematology; the South Asian nation that declared leprosy and tuberculosis as its two major health priorities in the face of enormous infant and child mortality due to diarrhoeal and respiratory infections; the West African country whose primary concern was whether to do coronary bypass operations in the capital city or send patients abroad; the Latin American nation that decided its major priority, after immunising all of its children, was mental health; and the international agency that developed a programme of research on the diseases of the tropics which omitted diarrhoeal and respiratory infections. For all of these examples, matching ones can be found in the developed world-such as the North American republic that focused on artificial hearts in the presence of childhood malnutrition in its central cities. On the global level, it has only recently been recognised that support for research on "the great neglected diseases of the developing world" is grossly inadequate. From the variety of the above examples it is clear that dependence on politicians and bureaucrats to set health priorities is fraught with difficulties, including personal, family, and community biases. One alternative is to consult experts, but these show a pronounced tendency to favour their own particular diseases, organs, or disciplines-say, infectious disease, parasitology, or cardiology. Most physicians lack the knowledge of epidemiology, statistics, and economics required for priority setting, having been trained largely in tertiary health care facilities with a primary focus on rare, advanced, and fatal diseases. In the past two decades, the great international agencies essentially abrogated their responsibility to set priorities. In their "horizontal" approach, decision-making was avoided by recommendations that everything be available "education concerning simultaneously-including health and the methods or preventing problems prevailing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs1". A major aspect of this concept has been to let the "people", the "community", make the
1. World Health
Organisation. Declaration of Alma Ata (Report on the International Conference on Primary health Care, Alma Ata, USSR, Sept 6-12, 1978) Geneva WHO, 1978.
499 even in those cases where the population was illiterate. largely Establishing Health Priorities in the Developing World,2a monograph by Julia A. Walsh just published by the United Nations Development Programme, is a landmark document in an effort begun about a decade ago to systematise the establishment of priorities for the control of the major diseases of the developing world. In 1979 Dr Walsh co-authored a controversial paper entitled Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries.3 Its purpose was to disaggregate the components of the mortality and morbidity rates in the developing world in order to determine priorities based on prevalence, morbidity, and mortality. The availability of means of preventing and controlling these diseases at a reasonable cost was then determined. Where adequate cost-effective means of control were not available, research
decisions,
was
encouraged.
These ideas led to a major debate in the international health community that is still in progress-for example, Social Sciences and Medicine 1988, vol 26, no 9 was entirely given over to the controversy concerning comprehensive versus selective primary health care. This was fuelled by UNICEF’s implementation of its great Children’s Revolution inaugurated in 1983 based on "social and scientific advances" that offer four vital new opportunities for improving the nutrition and health of the world’s children--oral rehydration therapy, universal childhood immunisation, the promotion of breastfeeding, and growth charts.4 These priorities were similar to those originally suggested in Dr Walsh’s selective primary health care paper.3 The primary focus of UNICEF’s programme has been a campaign to immunise all the world’s children: it was launched in Bellagio in 1984 and was coordinated by the Task Force for Child Survival in cooperation with WHO’s Expanded Programme on Immunisation and was supported also by UNDP, the World Bank, and the Rockefeller Foundation.5 This campaign brought the world level of immunisation to over 50% by the spring of 1987, with the goal of universal childhood immunisation in the early 1990s. Other agencies are adopting targeted approaches-for instance, the US Agency for International Development’s Child Survival programme includes immunisation, control of diarrhoeal diseases, nutrition, and child-spacing.6 At the third Bellagio conference convened by the Task Force for Child Survival, in Talloires, France, this year (Bellagio II, was held in Cartagena, Colombia, in 1985) the discussion focused on the status of the immunisation campaign and its sustainability within primary health care, and the introduction of other major cost-effective health initiatives, particularly diarrhoeal disease control and family planning. Major progress made within the last four years
2
Establishing Health Priorities in the Developing World. Walsh JA. New York: United Nations Development Programme. 1988. pp 151. $US25. ISBN 0-944913029. Available from UNDP Division for Global and Interregional Programmes, United Nations Plaza, New York, NY 10017, USA (cheques payable to UNDP). 3. Walsh JA, Warren KS. Selective primary health care: An interim strategy for disease control in developing countries. N Engl J Med 1979; 301: 967-74. 4. Grant JP. (UNICEF) The state of the world’s children, 1982-83. Oxford: Oxford University Press,
attributed to focused attainable programmes that made efficient use of resources.6 Julia Walsh’s book and its publication by UNDP provides the basis for a more general effort to establish priorities for research and control for the diseases of the developing world. It begins with the status of all the major diseases of the developing world on the basis of prevalence, mortality, and morbidity for the year 1986, and the effectiveness and costs of interventions to control them. This is followed by discussions of research and development, funding, and implementation. Methods for determining priorities at all levels of the system are described, and invaluable data are presented. Walsh summarises the system as follows: was
"Balancing limited resources with needs for health improvement requires setting priorities. The status of health services and research, as well as societal, economic, and behavioral factors, all affect personal well-being... The process of prioritizing both for research and health services commences with an analysis of the major causes of morbidity and mortality. Local or national decision makers use local and regional information, while international agencies use global estimates. For those major causes of ill-health that have cost-effective control measures, research focuses on identifying better ways to utilize current measures. For conditions that lack adequate intervention (ie, current measures inefficacious, costly, inconvenient, or associated with poor compliance), research concentrates on the development of new methods. Areas of research may include epidemiology, biotechnology, health systems analysis, policy-making, socio-economics, and so forth.""
Other agencies involved in the crucial processes described in Walsh’s book are the World Bank, which has recently established a major exercise to review health sector priorities, the Rockefeller Foundation, which has focused on training of individuals for research and decision-making based on critical analysis of epidemiological and economic data through its International Clinical Epidemiology Network and Health Planning and Financing programmes, and the new Commission on Health Research for Development initiated by the Edna McConnell Clark Foundation and supported by other foundations and international agencies. Thus, the great multilateral agencies WHO, UNICEF, UNDP, and the World Bank, some of the major bilateral agencies, and the foundations are joining together in a massive effort to attack the greatest killers and maimers of 75% of the world’s population at costs affordable to those nations and the global community. This priority-setting approach has been supported by world leaders including the member nations of the South Asian Association for Regional Cooperation (in November, 1986), the Organisation of African Unity (in May, 1988) and the heads of state of the Soviet Union and the United States at the Moscow summit meeting (June, 1988). Secretary General Gorbachev and President Reagan issued the following statement: "Both leaders reaffirmed their support for the WHO/UNICEF goal of reducing the scale of preventable childhood deaths through the most effective methods of saving children." Rockefeller Foundation, 1133 Avenue of the Americas, New York, NY 10036, USA
KENNETH S. WARREN
1982.
5.
Protecting the world’s children: vaccines and immunization within primary health care, a Bellagio conference. New York: Rockefeller Foundation, 1984. 6. US Agency for International Development. Child survival: a third report to congress on the USAID Program. Washington DC: US Agency for International Development, 1988.
7. Warren KS.
659.
Protecting the world’s children:
an
agenda for the
1990s. Lancet
1988; i: