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October 2010

Recognising the global importance of research

Ami Banerjee
Last edited 22nd October 2010

Evidence-based medicine is one arm of a global movement to apply proven research findings in day-to-day decision-making in healthcare. Research is needed to provide this evidence. Healthcare systems need a research agenda so that they can produce and use relevant evidence. Like many global inequalities in healthcare, from the burden of disease and access to simple drugs, to human and financial resources, the gap between research in low-income countries and research in developed countries is wide.

In 1990, the Commission on Health Research for Development estimated that only about 5% of the world's resources for health research (which totaled US$ 30 billion in 1986) were being applied to the health problems of low- and middle-income countries, where 93% of the world's preventable deaths occurred. In 1998, the Global Forum for Health Research first coined the term, “10-90 gap”, to capture the fact that 10% of resources were being spent on the diseases that made up 90% of disease burden. The gap is even wider when you look at research that is published in the major journals such as the New England Journal of Medicine: more like a 2-98 gap.

Things happen slowly in global health policy but they seem to be finally happening. The theme of the 2012 World Health Report: Better Research for Better Health will actually be health research and its role in improving healthcare and health systems. By doing this, the WHO is sending a clear message to all countries of the world of the powerful role of health research and its role in evidence-based practice and evidence-based policy.

Over the last 2 decades, we have seen rising aid and development budgets and a multiplication in the number of donors at the table, particularly in the field of HIV/AIDS, TB and malaria. The World Health Organisation has been leading a global movement to raise the profile of chronic diseases such as cardiovascular diseases (mainly stroke and coronary heart disease) and cancer since they account for nearly 60% of global disease burden.

This week, I attended a series of stakeholder meetings in Geneva organised by WHO, which is developing a prioritised research agenda for chronic diseases and will set out a roadmap of how research can and should be done, even in the most resource-poor settings. The themes of public-private partnerships and increased capacity-building and growth of links between research institutions in developed and developing countries permeated the meetings. There have been many calls for action from scientific and broader communities, and the time for action is now here.

prostate 'magic drug', the case of the changing headline

Carl Heneghan
Last edited 12th October 2010

Earlier today the headline from the BBC read – Prostate trial drug like 'magic'. This headline concerened me for a number of reasons, as false hopes are raised by what I consider poor practice. The study was presented at this week's meeting of the European Society for Medical Oncology in Milan, Italy.

Funded by Johnson & Johnson it reports patients with advnaced prostate cancer survived on average four months longer, some did even better: I assume some did worse than this. But for those interested in the results there is no way of verifying the methods or the data. Unless someone can point me in the direction of the paper.

The following quote says it all: ‘This study was presented at a medical conference. The findings should be considered preliminary as they have not yet undergone the "peer review" process.

It hasn’t been peer reviewed, yet its making the major news. There could be major flaws in this study, which may invalidate the results. Unfortunately I can’t tell you, as I haven’t yet learnt how to do critical appraisal without the paper, whether published or unpublished.

By late afternoon the BBC had downgraded the headline to Trial confirms prostate drug promise. I'd have gone for 'prostate trial confirms conference proceedings lack of peer review

This is a worrrying trend in medicine and it’s about time something was done – important results should be released with the publication.

Oh, by the way the drug hasn’t even got a European license yet. What's magic about that.

We have known since case reports from the early 1970s that heavy drinking in pregnant mothers leads to problems with growth and development in the foetus. The “foetal alcohol syndrome” has been well-characterised since then. What is not so clear is whether “light drinking” is as harmful during foetal development and later childhood. Print and web media have been obsessing all day about whether pregnant mothers are alright to have the odd gin-and-tonic or glass of wine. It is a comment on the prominent place of alcohol in UK culture that all the commentaries are calling for relaxation of current recommendations which advise abstinence during pregnancy, rather than calling for a cautious re-examination of data.

The furore is due to findings based on the UK Millenium Cohort Study, which looked at over 11 000 infants
born across the UK, selected “such that disadvantaged residential areas are over-represented”. These infants were seen at 9 months, 3 years and 5 years and detailed data about the health and behaviours of mother and child were recorded. So immediately, we see that the authors can only comment about childhood upto 5 years of age and not beyond. This study has previously claimed that at 3 years of age, children of mothers who drink 1-2 drinks of alcohol per week are not at increased risk of behavioural or learning difficulties.

In the current study, the authors compared behavioural and learning difficulties in children of mothers in light, moderate and high drinking categories with children of mothers who were always tee-total. They adjusted their findings for possible confounding factors:e.g. child's age, birth weight, mother's age at time of birth, number of children in the household, mother smoked during pregnancy and other socioeconomic factors. The p-values for odds ratios are not reported in the paper, but the implication is that children of mothers who stopped drinking during pregnancy were worse off than children of mothers who were light drinkers. They did find a much higher prevalence of learning and behavioural difficulties in children of mothers who drank heavily though, and so they refer to a “U-shaped relationship” between alcohol consumption and risk of disease, which has previously been documented in adults. That is to say that a bit of alcohol is good for you, in fact it is better than none at all, but a lot of it is bad for you.

Importantly, the authors found that “light drinkers were more socioeconomically advantaged compared with mothers in all other categories. The socioeconomic profile of mothers in the ‘not-in-pregnancy’ group was more advantaged than the ‘never-drinker’ group but less advantaged than the ‘light’ drinking group”. The authors themselves admit that the effects may be explainable by socioeconomic status, i.e. mothers who are light drinkers have other beneficial environmental factors which may explain any differences in development of the children more plausibly than alcohol. Unsurprisingly, this was not reported by any of the blogs or newspapers I read today. Thankfully the Department of Health is being a bit slower to open the floodgates to heavy boozing during pregnancy. Surely, longer follow-up and more studies are required before we recommend all mothers to drink during pregnancy.

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