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October 2009

The health service under the BNP

Ami Banerjee
Last edited 17th March 2010

It’s unlikely that anybody living on this island missed the furore surrounding the appearance of British National Party’s chairman, Nick Griffin, on the BBC’s Question Time. I will not comment on Mr Griffin’s misguided views and statements, because they have been covered and analysed to death in the broadsheets, the tabloids, the radio waves and the TV screen
this week. However, I did check out the BNP’s website to look for their health policies, listed under “First Class Health Service for a First World Nation: BNP Health Policy”.

Just like Griffin, the policy statements on the surface may seem vaguely sensible to some people, but you only need look just below the surface to see the true colours: ill-thought-out nonsense. If racism is the fundamental tenet of a political party, it is difficult to hang coherent policies from that hook. Firstly, the BNP would “replace 100,000 NHS bureaucrats with doctors, nurses and dentists” but it does not mention anything about healthcare managers, health economists, and many allied health professionals needed in a modern health service, or how it would conjure up these home-grown 100 000 health workers! Secondly, they would “Train and pay to retain British doctors, nurses and dentists instead of looting the Third World of staff who are desperately needed in their home countries”. Although many doctors and nurses are attracted to work in the UK as economic migrants, they are free to do so as long as there is a demand for health workers in this country. Ethical recruitment from poor countries is a key goal for all UK employers and the brain drain has been increasingly recognised and debated in recent years. However, forcing British doctors to stay in the UK or African doctors to stay in Africa is no more feasible than closing UK’s borders tomorrow. The BNP should acknowledge the extent to which the NHS has relied upon foreign health workers throughout its history and the contributions that ethnic minorities in this and other employment sectors have contributed to the richness of life in Britain today.

The medical literature is rife with examples of the negative health effects of racial disparities from around the world. There is no example yet that racial discrimination will be good for the population as a whole, or for any individual element of the population. Much more reasonable and human ways to address inequalities than the BNP proposals are: better data collection and the use of ethical and human rights frameworks to make sure that every member of our society has access to healthcare.

Perhaps the most chilling policy statement reads “We will see to it that no money is given in foreign aid while our own hospitals are short of beds and the staff to run them”. Mr Griffin and his supporters would do well to read about where government money is currently being spent. It is not just British people that grossly overestimate how much they spend on foreign aid, the Americans do it too. The BNP’s misconception is deeply worrying because the rich nations are already underspending in terms of the UN target of
0.7% of GDP for international development assistance, and there are better ways to save government money.

Remarkably, the BNP is pro-prevention: “….more emphasis must be placed on healthy living with greater understanding of sickness prevention through physical exercise, a healthier environment and improved diets”. This, as far as I can tell, is the only positive in the health service under the BNP.

How many randomized trials are published each year?

Carl Heneghan
Last edited 17th March 2010

I thought it was worth re-examining how many randomized controlled trials (RCTs) are published each year. To determine the number this number per year I used the Medline (Pubmed) Trend database. The page displays the number of entries (articles) in PubMed (Medline) published every year which conformed to the following search strategy (randomized and controlled and trial).

The graph highlights the growth from 39 RCTs in 1965 to 26,017 in 2008. Some notable landmarks include the 1000 barrier being broken in 1976 and the 10,000 in 1994. Approximately every 10 years there is a doubling of the number of RCTs: 25,361 in 2007 versus 12,040 in 1997. At current rates we can expect to see 50,000 RCTs per year published by 2018-9.

RCTs per year

Breaking these numbers up by week you would have to read 500 RCTS per week in 2008 to cover the published RCTs in PubMed, the 100 barrier was broken in 1988. Per day it equates to 71 RCTs but I figured no-one submits and publishes on the weekend and if we consider only reading RCTS on weekdays then we have now have to read 100 RCTs Monday through Friday. To put this in perspective in 1980 you only had to read one RCT per day to cover all of the published RCTs. Today you have no chance of keeping up to date.

RCTs per week and per day

If you want to know how much is in PubMed in total. Well as of June 2007, approximately 1,000,000 items were archived and this is growing at 7% per year. Get reading quick!

Diarrhoea-a neglected cause of child mortality

Ami Banerjee
Last edited 17th March 2010

This week, the Lancet released two articles in its “Online First” section, both concerned with the second leading global cause of infant death: diarrhoea. A staggering one in every five child deaths—around 1•5 million a year —is due to diarrhoea, which kills more children than AIDS, malaria, and measles combined. I have previously blogged about the Zimbabwean cholera crisis and the tragedy of the long-established, but poorly translated treatments for diarrhoea. The first article draws attention to a new UNICEF report: “Diarrhoea: why children are still dying and what can be done”, and suggests a seven-point plan for diarrhoea control:

Prevention

  1. Rotavirus and measles vaccinations
  2. Promotion of early and exclusive breastfeeding and vitamin A supplementation
  3. Promotion of handwashing with soap
  4. Improve water quantity and quality, including treatment and safe storage of household water
  5. Promotion of community-wide sanitation

Treatment

  1. Fluid replacement to prevent dehydration
  2. Zinc supplements
    The authors find that only 39% of children with diarrhoea in developing countries are receiving these simple, cheap interventions.

The other, more hopeful Lancet article concerns a trial of a new cholera vaccine in more than 65 000 individuals, including children older than 1 year, living in an urban slum in India. Clusters of households were either allocated two doses of the vaccine or the placebo. At 2 years, the vaccine did not have any more side effects than the placebo and was 67% effective in protecting against cholera in the entire population. The vaccine was 49% protective against cholera in children aged 1—5 years, although its effectiveness dropped if the vaccine was not given in two doses. This vaccine is both effective and affordable, giving it great potential for mass immunisation programmes in cholera-endemic areas.

What's the craic with crack? Do heroin treatment programmes work?

Ami Banerjee
Last edited 14th September 2012

In 1964, Dole and Nyswander treated 22 heroin addicted patients in New York with methadone, a drug previously known as a potent, addictive painkiller. They demonstrated that coupled with psychosocial interventions all these patients stopped heroin use and could resume family and social responsibilities. Since then methadone has been widely used in heroin addiction treatment programmes throughout the world. Whilst working as a pharmacy assistant in Hull over 15 years ago, I remember seeing heroin addicts coming to collect methadone and other opiate replacement therapy. I was struck by the scale of the social and public health problem, but I was also left questioning whether the treatment programmes worked.

In 2006–07, for every 1000 adults in England, 8 were heroin users and 5 were crack cocaine users, and 29%of people in treatment programmes were using both drugs.In 2008/09, £800million was spent on national drug treatment services, a tripling in spending over the decade, with particular focus on methadone treatment and specialist counselling. Therefore the question of whether treatment programmes are effective in reducing heroin addiction has never been so pertinent.

Using data from the National Drug Treatment Monitoring System (NDTMS), the follow-up of nearly 15 000 heroin or crack users enrolled in treatment programmes was studied in 2008/09. One third of heroin users and half of crack cocaine users had abstained from drug use after 19 weeks of treatment. A higher proportion of users of heroin only abstained than did users of both heroin and crack cocaine. There was an overall reduction of 15 days of heroin use and 8 days of crack cocaine use.

The authors of this study acknowledge that longer-term follow-up studies are needed to look at the effectiveness of treatment programmes over a longer timescale, particularly with respect to psychosocial interventions. The National Treatment Agency for Substance Misuse recently reported that among 18 to 24 year olds, the number newly presenting for treatment for heroin and crack has fallen 30% since 2005/06, whereas in the over 35s, there has been a 20% increase in those seeking treatment, suggesting that the problem is declining among younger people. Given the scale of the heroin use in the UK, more data is required, particularly relating to cost-effectiveness and the long-term reduction in heroin addiction.

Five sensible evidence-based policies for swine flu

Carl Heneghan
Last edited 17th March 2010

It seems every day now there is new emerging information on swine flu and what we all should be doing that isn’t backed up by the evidence. Therefore, given no-one involved in policy seems to take a blind bit of notice of the evidence, I’m setting out my sensible evidence policies (SEP for short) for the way forward.

1) Wash your hands: in this week’s BMJ a systematic review by Tom Jefferson and colleagues report on Physical interventions to interrupt or reduce the spread of respiratory viruses. Many simple and low cost interventions reduce the transmission of epidemic respiratory viruses, of which, hand washing 10 times daily halves the spread of respiratory infections.

2) Where is the burden of proof for mass vaccination? It would seem straight forward that a mass vaccination programme is backed up by robust evidence. Well it isn’t. Again Jefferson’s work is important on this issue: Influenza vaccination: policy versus evidence. On the whole, systematic review evidence reveals inactivated vaccines have little or no effect; most studies are of poor methodological quality; there is also a paucity of evidence on the safety of these vaccines and reasons for the current gap between policy and evidence are at best unclear.

3) Antiviral should not be handed out to everyone: This is probable the most sensible policy and should be initiated hence forth. The benefits of these drugs are fairly limited. In children Neuraminidase inhibitors provide only a small benefit by shortening the duration of illness in children with influenza and have little effect on asthma exacerbations or the use of antibiotics. Their effects on the incidence of serious complications and on the current A/H1N1 influenza strain are unknown. Using antivirals liberally runs the risk of generating resistance. We have known this for donkey’s years; this is exactly what happened for antibiotics.

4) Extend primary care emergency out of hours into the day: from the echelons of health policy I have been given the reason why we continue with the current policy - there is no alternative strategy that they can think of to replace the current one. Emergency care in general practice normally starts at 6.30 pm and runs throughout the night. What we should do is extend this into the daytime, have one central practice for all suspected patients with influenza to be seen by clinicians. With the time saved in practice not seeing suspected cases (probably about 4 hours per practice per week) we could staff it with GPs at no extra cost and who could then sift out those with more severe disease and at greatest risk of complications. Not evidence based yet but sensible.

5) No school closures: The evidence for social distancing policies is at best weak and flawed, and the evidence to date we have on school closures is primarily based on modeling studies. School closure are commonly suggested as a containment strategy, yet there is no consensus on the scale of the benefits to be expected and models assume that there is a high rate of transmission (50%) occurring in schools, and children don’t mix when kept of school. Well I can tell you now, if my kids are off and I’m supposed to be at work I’ll palm them off on anyone who’ll have them. Also the economic cost per week is estimated to be between £0·2 billion and £1·2 billion; cost of a 12-week school closure may be as high as 1·0% of GDP.

There are my five - well four evidence-based and one sensible. If you have a policy to add to the SEP list then I’d be grateful to hear from you.

Previous observational studies and small randomised trials have given conflicting clinical data about the effects of various proton pump inhibitors (PPIs) on outcomes in patients given clopidogrel, leading to warnings and uncertainty about taking these drugs at the same time.

However, when you look at these studies they are heavily confounded, or to put it simpler the results are distorted by the fact that patients taking the two drugs together are generally older and have more co-morbidities than do those not on a PPI.

Fortunately, the TIMI investigators have recently brought some rationality to this arena by conducting analyses in their large-scale clinical trials. Firstly, PPI treatment did have a pharmacological interaction with clopidogrel, in patients undergoing coronary intervention. Secondly, PPI treatment did not affect the primary cardiovascular outcomes of patients given clopidogrel in a trial of more than 13,000 patients with acute coronary syndromes. For the first time these findings provide reliable evidence that there is no need to avoid concomitant use of PPIs, when clinically indicated, in patients receiving clopidogrel.

This study highlights another important area in which more joined-up thinking is required. In response to mentioned smaller observational studies with significant confounding, both the European Medicines Agency and the US Food and Drug Administration released statements or communications warning of a potential interaction between PPIs and clopidogrel, and discouraging their combined use in the absence of a 'strong' indication. Instead of causing widespread uncertainty and panic to thousands of clinicians and patients, would it not have been more sensible for them to work with academia and the pharmaceutical industry to resolve these questions more reliably? The EMEA and FDA hold great power as regulatory authorities, but with this comes great responsibility - if we cannot trust the evidence from them, who can we trust?

Neeraj Bhala
Neeraj Bhala
Neeraj Bhala is a MRC Research Fellow at the Clinical Trial Service Unit University of Oxford, UK and regularly meets in the 'Golden Triangle' with the founders of TrustTheEvidence

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