Junior doctors

Junior doctors' conferences are always fun, delegates being devoid of the pomposity or stand offishness of the annual BMA meetings featuring their seniors, consultants and GPs, usually held a bit later in the year, late May.
At the Marriott Hotel in Swiss Cottage, I asked the press officer, Steve Harman, what would be the main event of the day, and he said it would be the call for the resignation of Patricia Hewitt, the health secretary. In the event, the big issue of the day was the call for the resignation of the people at the top table. sitting in front of the conference and chairing it: Junior doctors' ruling committee. "A mutiny", some called it.
The JDC - headed by Jo Hilborne, an unaturally youthful, round-in-all-the right places obstetrician in her early forties - was accused of not standing up for the junior doctors interests. A series of catastrophes has befallen these prespecialisation doctors in their mid to late twenties, that much was made clear.
The application procedure for specialist training posts - the next upward career step - had been streamlined: no longer CVs and interviews, rather a standard form that had to be filled in, online. So what you might think, many organisations do that, but many juniors, the mood of the room, the quotations in BMA news, etc, felt extracurricular activities that showed their aptitude were streamlined out of the procedure., and that many deserving candidates had not even had interview offers on the basis of the blunt new application instrument.
Then there was critique that Hilborne and co had not done enough to protect junior doctors from the vicissitudes of the government's reorganisation of juniors' career progress structure. (Modernising Medical Careers, shortened to MMC) One of the aspects of modernising medical careers led to the effective release of two cohorts of junior doctors on to the market at the same time, this year, 2007, as the three year foundation programme was shortened to two years in 2005. Thirty thousand doctors will be chasing 19,000 posts. Many it seems will have to change profession, or emigrate.
Many in the media will have little sympathy that young doctors are no longer guaranteed jobs - it's life for most of us. On the other hand, there is the fact that they have trained at the taxpayers expense for five, six, seven years. One young surgeon speaker pointed out that a surgeon puts ion far more hours in training than an astronaut or a passenger jet pilot. So is that there where all the increased NHS funds are being spent, apart from feathering the nests of GPs, whose pay awards have leapt by 30% or so in the last two years?
Creating the world's best medically trained cadre of buskers and shelf stackers? One beneficiary was - well the health service of the state of Queensland had a stand outside; two wolfish looking young men in red kit refused to answer questions from this journalist. But they admitted they were recruiting.
In the end, Hilborne and co won the no confidence vote, perhaps because of a passionate intervention from Dr Johnson, the head of the BMA, a mandarin, quizzical looking man in his fifties who, like nearly all other speakers, failed to offer bullet point rationale. The level of debate was "Support them because they have protected your interests" without saying how those interests had been protected; the opposing side was equally feeble in argument. The chair of the conference, n associate of Hilborne's, would doubtless deny that the fact that the voting preferences of each delegate in favour or against Gilborne was recorded swayed the vote either way. When whether the vote should be confidential or recorded was decided on in early stages by 20 people standing up to register the former preference, several complained that they hadn't realised what they were standing for.
In the end there was the usual raucous dinner. In the day, a charity that represented alcoholic doctors hosted a stand in the corridor that saw few visitors, and young medics are known for their drinking habits. Two years ago your correspondent danced closely with Ms Hilborne, then chairwoman elect. and was allowed to play his hand up her back as they dined side by side. This time, no such luck. Perhaps she had other things to think about.

Faith healing

When Harris arrived at Manila airport, I gave him a rundown:
"I said: 'You don't understand, George. You have to describe Zen a bit more clearly. 'If you can describe Zen, it isn't Zen,' he said. 'Oh, all right then,' I had said."
Harris, who is a first class mathematician, said: "This is absurd. If course the guru doesn't like the shafts of light that open discussion brings."
I told Harris George wasn't a true believer: he was preparing himself for death, by a gradual, slow process of self-obliteration.
George was a loner: his wife, and daughters, lived in Edinburgh. A wife is the best narcotic against night time fears, as I well knew.
"Why doesn't he just kill himself?"
"I don't know: maybe he is too afraid. He says differently, of course: that Zen is his salvation."
"Is it?"
"Well, put it this way. You know what an American general said in Vietnam: we must destroy this village to save it."

In the car, I told Harris about Imelda's hole in the sky.
We were driving past a squattter camp:
"A hole IN the sky?" he said sourly.

We took a bus up to Tagaytay town. Traffic wended very slowly through the suburbs of southern Manila. The Philippines had, until 1946, been a US colony, its only major one. Many churches were clustered next to fast food restaurants, go-go bars and gas stations.
Every highway in Luzon was an endlessly long stringy town, one shack deep, of jeepney repair centres, small holdings, mango shacks, fast food restaurants, banks, cemeteries, more squatting communities, slums, Shacks, factory zones, garbage dumps. Harris was trying to read Keynes's Economic Consequences of the Peace, but was being constantly interrupted by the sellers that jumped aboard at every junction and tried to foist their
trays of pork scratchings, peanuts, chewing gum, bananas upon all.
Harris went back to biting his nails, poring over his book, dog earing pages.
At a stop, in Dasmarinas, a newspaper seller came on board.
"Must be tough to be a journalist in this country. Or a writer."
We were back in traffic again. Right now, forty heads were moving to the action of the karate video that was playing on the bus's TV screen.
"Well," I said. "literacy is over ninety percent."
* * * *

The safety paradox: because God “protected” him, the bus driver could drive faster.
There was a lake, ringed by ridges, in which monasteries, churches, Zen schools, nunneries clustered, all looking out over Taal lake with its extinct volcano island in the middle. The town itself was centred on a small roundabout where there was a McDonalds, and one day on an earlier visit I had recognised one of George's fellow lodging friends, a Canadian clairvoyant, scarfing a Big Mac.
"What are you going to do tonight?"
"I don't know yet," the clairvoyant said sullenly.
Perhaps he had heard the taunt before.
The monastery was in a converted girls' school, and indeed you were frightened of girls turning up at the end of corridors, long dead and reproachful.

* * *

"I would rather we went for a drink," said Harris.
"I healed someone's TB yesterday." said George.
"Really? Wonderful."
“He was taking penicillin, of course, as a back up."
"Have you ever tried healing someone who doesn't take penicillin?"
"Oh no. That would be unethical."
"So how do you know your healing makes the difference?"
"I am telling you, I healed him."
He put his shoes on, and kneeled down to collect something from under the bed. "My potty - it's full."
Harris and I exchanged glances.
"In Europe, we are so uptight. I love Filipinos - so spontaneous," George said.
There was a picture on the wall of a fat and sleazy looking man - Master Choa and dates of US lecture tour.
"Makes a bit of money then Master Choa?"
George didn't answer; he pursued his lips, and squeezed his big bottom into a pair of slacks.
We went to attend one of the healing teacher sessions. The woman, a fiftysomething Filipina called Faith, talked for two hours, and we had to produce a piece of a paper - a mission statement - which she also talked about for two hours.
"She is in love with Jesus," confided George.
Afterwards, on the lawn, the healer squealed with delight:
"Look, look. Do you see them! The little spirits dancing all around us!"
No. Later, we went to dinner where George fell asleep.

* * *
Faith healing, indeed - let's look at the bigger subject of which faith healing is a part - the influence of religion on health - should not be dismissed per se. Such an attitude is itself unscientific. Both religion and medical care go back together, of course, a long way: were usually dispensed by the same person. Today more and more US medical schools are offering courses in religion and spirituality, and there is a continuing interest both among medical professionals and the general public in the subject.
According to an informal survey conducted at the American Academy of Family Physicians convention, 99% of US general practitioners are convinced that religion can heal, and 75 % of others believe that the prayers of others can help a patient recover.
There have many scientific studies looking at religion as an antecedent to good health - assessment of religious behaviour, frequency of church attendance, the efficacy of prayer, both intercessionary and prayer for the self. There have been assessments of the comfort it can provide, as well as examinations of health differences as a correlate of an individual’s type of religion and as a correlate of the degree of religious orthodoxy.
These findings - which are that religion plays a positive role for health - have been treated by some scepticism by other medical scientists.
A Lancet journal study of studies, while not completely closed to the possibility that religion can play a beneficial role, has found methodological errors in virtually all the studies it surveyed.
For instance, consider the studies that find that orthodox Jews in kibbutz communities and monks live longer. One simple explanation could be that they smoke, drink and eat less. Then there are the surveys that show that people who go to church are healthier, for instance less likely to have strokes. The fact is, people who have had strokes are less likely to actually make it to a service. Then there is the fact that many health factors tend to be measured simultaneously, and there is the tendency to find one that just happens to sink when religiosity falls, though this is not corroborated across a range of measures and the samples are usually unscientifically small. For instance, in one survey, high attendance in church was inversely correlated with high concentrations of interleukin 6 in the elderly but this was only one of eight outcome variables and there was no attempt to control for multiple comparisons.
If for some reason, this message has failed to reach out and or failed to convinced, physicians, who are after all scientifically trained to be sceptical of the super natural, it is not surprising that there is fertile ground among the less scientifically trained population at large for proselytisers for the virtues of prayer - and indeed there is a large industry devoted to faith healing of the masses - different from the quiet prayer at the bedside, it is an industry involving large prayer meetings and a growth in superstar healers, who have their own TV stations and claim to heal dozens of strangers at a time at their live shows which tour the world. (They live, and live plenty, by their donations.)
There's Master Choa Kok Sui, based in Asia, who specialises in pranic healing, which he teaches his faithful to perform in each other. But more famous is Benny Hinn, a fiftysomething in a Nehru jacket and middle eastern accent who touches devotees - people who say they have just been healed - and who fall backwards when treated, legs shaking, all in ecstasy. However reporters found one boy in "coca cola bottle glasses” who had appeared on TV once. "William, baby, can you see now," Hinn had said; the boy told reporters later his ten thousand dollar cheque to see him through rehabilitation had never appeared and he was still, in fact, blind. He had said he had said yes on TV because he had been caught up in the hope of the occasion. Such an example is just utterly typical; one reporter wrote "We have not found one genuine case of a person in fact being truly healed!" and refutations are numerous. There are other tales of charlatanry related:self deputising watchdogs monitor his statements – including such comments that Adam was the first superman, who flew to the moon – to demonstrate his fake nature. Another healer was exposed as using staffers who mingle with the audience in the interval so that the healer’s calling out their names out of supposedly divine inspiration are anything but; and then there's the tragedies, the people who avoid conventional treatment in favour of healing - either administered by the superstars or self administered - and die as a result: four in five children who died after their parents put their trust in faith healing could probably have survived if medical treatment had been sought, according to a study published in Pediatrics, the journal of the American Academy of Pediatrics.
In one case a child choked on a banana and showed signs of life for an hour while the family around her continued to pray. A related tragic case was one woman with cancer of the spine who was commanded to walk across a stage to meet her healer, discarding her brace that held her spine to do so; the next day her spine collapsed and she died soon after.
The Philippine speciality was the psychic surgeons; it is said that there is one loosely attached to every one of Manila's bigger hotels. They pretend to plunge their hands into the patients body, pull out the offending malignant part, and close up the wound, in seconds, leaving no scars. Their successes have created a touring industry for customers from the west. But one expose showed that the surgeons used magician's sleight of hand, bending the fingers at the first knuckle to give the impression of a plunge, with chickens' liver and blood brought forth from under the arm or table at the right moment, quickly secreted away to leave only a few drops of blood - the chicken's, not a human's. The reason why psychic surgery does work for some people is simple.
The human body can heal itself. Most ailments are self-limiting and disappear in time without any treatment. Naturally, if you visit a psychic surgeon and become well, the former will get all the credit and your cash
There is a regular columnist in the Inquirer, Manila's biggest paper, propagandising frequently for the benefits of this transparent charlatanry. "They thought Galileo was wrong too," he writes, in an effort to make people believe the psychic healers are geniuses misunderstood by the many sceptics in the west .

* * *

We were at the end of Tagaytay ridge, at the Palace of the Sky, overlooking the fields of Manila plain one one side, on the other side, the Taal lake, a huge caldera, 30km across, with a volcano island neatly in the middle. Over the plain, winds, and low cloud were sheeting. It was a bit like being in top of a welsh mountain - the play of light was like that.
It had once been a pleasure mansion; now it was just rusting concrete, with an empty concrete dancefloor, grass growing between the footpath stones that crossed what had once been a lawn on which 1970s celebrities and friends of Imelda’s such as George Hamilon and Gina Lollobrigida mingled and drunk cocktails. It had belonged to the Marcoses; it was left to ruin by the subsequent people power government.
"I hate this country," said Harris. "They like the Americans too much."
"You're not a typical anti-American are you? That's so boring," I said.
"No, it's the fact they worship them. They have the same faith and belief in America will sort out the problems of the world, before coming back to sort this country out as they do in God coming to solve their proiblems. But in neither case it's going to happen. They go to church to get God on their side; but all day long they live like votaries for the American dream: the baseball caps, obsession with the worst parts of US trash culture."
"You think Marcos was a solution?"
"They need a revolution."
We went down to see George: he had been done to one of the squatters' camps, where someone had died and was lying in wake in a shack. "Really interesting, like peasants in a Russian novel," he said. He politely accepted my printouts of articles from medical journals on faith healing, and took us out to lunch, where he got so excited by retelling old work yarns that he attempted to do pranic healing on a 26-year-old female stringer from an international news magazine. "Only take a minute," he said, drunkenly and stupidly and when we all tottered out of the Chinese restaurant, I noticed he had left the refuting documents behind.

***

When I finish writing, I stand up, stretch, and switch off the air conditioner, and fan: damp heat soon fills the room. I look in the mirror: the humidity has aged me in only three months. I switch off the light, which has given the shuttered room a sickly yellow diorama glow, the light of the plotting bedsit
murderer. Back in one of the rich people's subdivisions.
When the ringing in my ears subsides, as I stand in the dark, see my silhouette in
the silvery light of the mirror. Sounds outside: the thump of the hostess's son
playing basketball, the Filipino national sport, potting shots into a basket in the
drive. Voices, hoarse pubescent.
"Hey. dude - go for it."
"Go lick a dog's ass."
Thud.
"That was, like, todally COOL."
Silence. Then, a television.
Stocks on Wall Street today,..." click "Do You feel your support group is helping you get over your problems!" "MTV Asia -leave the dial RIGHT there."
But the sound is drowned by - a roaring, crumping sound, rising. I go outdoors, hoping, expecting, it to be people emerging from every house, every doorway, every side street the patter of feet, of a river of people converging, hastening, rushing forwards…
But it is only the rain.

Interview with Johan Calltorp

What are the challenges and rewards of working as a foreign doctor in Sweden?
The good things are that the countryside is beautiful and empty, the cities are clean and efficient, outdoor life-styles are easily pursued; people speak good English (though for their job doctors will have to learn Swedish), Sweden has some of the best medical research traditions in the world, hospital equipment is modern and hospitals and clinics make their often Victorian NHS equivalents look intolerably shabby and chaotic. As in Australia or New Zealand, the population is fluent in British culture, yet it is only an hour away from the UK.
But the system is not perfect.
There has historically been a shortage of doctors, with brought in from abroad, but salaries are not as good as for instance the UK – the country increasingly has to attract foreign talent on quality-of-life measures. And foreign doctors will have to be aware of various challenges facing the system. Sweden’s past success came from having a highly educated, homogenous population benefiting from a great sense of solidarity, but since the 1990s, there has been an influx of largely unassimilated and mostly unemployed population of Muslim immigrant origin which is growing fast, and so there are fewer working people able to carry the burden of the ageing indigenous population – the world’s oldest. And there are healthcare management difficulties connected to the structure of its NHS-like universal access system.
Here Sweden’s top health policy academic Johan Calltorp, professor of health policy advising Sweden’s western hospital region, gives the background to the political, social, demographic challenges facing Swedish healthcare…an essential rundown for anyone thinking of working there….

How do you deal with having the world’s oldest population?

Some people think the whole thing will go to hell by 2020, with an ever lower taxbase having to pay for a growing geriatric population. I don’t think so, I am positive, but there are intense discussions going on about this at the moment.
A taxation-based health system depends on a kind of national solidarity – you pay in enormous amounts until the age of 75, then draw a lot. But twenty percent of the population is of immigrant stock, and there is high unemployment. How much they are able to pay for an ageing population – and how much next generation of Swedes is prepared to pay for ageing immigrants – is a highly sensitive issue

Is that why Sweden has the western world’s highest sick-leave rates?

Yes, partly. There is the feeling: if you are unemployed, we will take time off sick.
There is also the problem of incentivisation, when compensation for being off sick as so high as it is in Sweden. Doctors will be called upon to sign a lot of sick-leave notes…..

What other challenges are there?

The Hjertqvist report on European health systems, published last month in Brussels, rated the Swedish system the third best in Europe, but noted that Sweden performed poorly on service and access.
There waiting lists, as you have in common with all the other centrally funded systems. They are getting longer. These waiting lists are a problem of poor management, because a lot of the patients nominally on the list have recovered or died, but they are also used a political weapon by doctors to demand more money.
Partly it is just a problem of situation. The country is so huge, by European standards, with a low population density, yet there is this commitment to provide a universally high quality of healthcare, which becomes very expensive the northern, Arctic areas, which are also suffering from depopulation and an increasingly large number of elderly people. You do need an oversupply of care everywhere. But if you depopulate Lapland and resettle old people in the cities – what then? Turn it into a complete wilderness?

Do the immigrants have problems getting jobs in care?

There is a long tradition of taking in doctors from abroad; but in a broader society, the country is grappling with the problems of multiculturalism. There was a case a few days ago when a hospital banned a Muslim nurse from wearing a hijab for medical hygiene reasons, but the health ombudsman overturned this as a case of discrimination. There is a lot of ongoing debate about these issues….

Sweden doesn’t have any GPs….so what sort of environment can a foreign doctor expect?

In earlier decades Sweden had quite a good house doctor system; now there is a tradition of going straight to specialists or to emergency wards. This has meant long waiting lists for specialists and – especially old people – clogging up the emergency wards unnecessarily.
It is a matter of tradition. In the 1950s and 1960s politicians wanted to build big hospitals – it was their monument, their “Aswan dams” This is particularly true in the big towns; in smaller urban communities you have multiple doctor care centres, which are a bit like GPs’ practices.

Where else can Sweden improve?

The Hjertqvist report on European health systems, published last month in Brussels, notes that Sweden performed most poorly on service and access.
There waiting lists, as you have in common with all the other centrally funded systems. They are getting longer. These waiting lists are a problem of poor management, because a lot of the patients nominally on the list have recovered or died, but they are also used a political weapon by doctors to demand more money.
Partly it is just a problem of situation. The country is so huge, by European standards, with a low population density, yet there is this commitment to provide a universally high quality of healthcare, which becomes very expensive in Lapland, which is also suffering from depopulation and an increasingly large number of elderly people. You do need an oversupply of care everywhere. But if you depopulate Lapland and resettle old people in the cities – what then? Turn it into a complete wilderness

What is the culture of doctors like?

There is an efficiency culture of doctors – they can be a bit remote, not friendly; instead there is a premium on the role of being efficient and competent.
We are not as good as the UK as giving out information – there are no 24 hour helplines, and there is a point systems based on specialty and hospiatsl , but public awareness of this is not as developed.

The pharmacies are all state-run, are hardly ever open, and they seem expensive

Opening hours have been quite restrictive compared to the rest of Europe, but hours are being expanded.
The pharmacies, along with the alcohol shops, are a state monopoly, and are very characteristic for Sweden. Last year the European court of justice said the monopoly might have to be dismantled to allow competition under the single market rules.
The idea of controlled pharmacies was to en able a gatekeeper – the pharmacist – to be on hand to advise on medicine.is less relevant now that you have the internet.


What does Sweden do well?

We have very good patient outcomes.
There is good access to drugs, emergency care is so good, and we have very good public health indicators; our smoking rates are the lowest in Europe. Obesity is growing, but is still low internationally..

What makes the Swedish funding system different?

Our system is more decentralised than the UK one. It is funded through a local tax, by county councils or regions. In fact there is whole local tier of government, with its own elections, devoted entirely to health administration. These local taxes can very greatly, but the health issue as a regional political football becomes obscured by national politics – the tier above – and municipal election s – the tier below, devoted to issues like schools and public transport. . In a few years time these councils will consolidate into larger regions along the European model – we already have two, and I was the boss of one of those, for west Sweden including Gothenburg - although it is unlikely that these regions will have non healthcare political powers. Sweden is quite a centralised country and our governments are traditionally wary of the European regional power model.

What new policies were the result of the election in September last year?

Health is a very unideological issue in Swedish politics, all the parties think the same. We have this “care guarantee” policy promoted by the liberals but which has now being pushed by the ruling social democrats; it will guarantee treatment to anyone within three months, or they can receive treatment in another part of Sweden.

Or abroad?

Not yet! Though I understand EU legislation on this is in the pipeline. There are some initiatives for social and elective care collaboration with Denmark – now linked by bridge to Sweden – and Norway, in the border areas. The EU has argued that healthcare is best dispensed at a regional level, and there are a lot of cross border initiatives in Belgium, Holland and Germany. In Scandinavia most collaboration happens in research and in the pharma industry, not between hsealth systems.

Isn’t Sweden a bit too efficient at times?

The Danes are very different. They smoke more, drink more, eat less healthily and take less exercise. It is true Sweden can seem a bit over regulated. Danes die much younger; but they have more fun.

"I think too much freedom will completely upset health systems"

It is often not appreciated enough that the EU hass
wide and growing powers to affect British people’s
health. Linda McAvan MEP, 44, represents the Labour party in Europe's
party’s views on health issues - and pretty important health is in the EU too.
The rights of patients to go anywhere in Europe for treatment - putting pressure on dire domestic services. The right of health service providers - national health systems to you and me - to compete directly with their fellow systems across borders.
All is mooted and up in the air.....

Why did you become an MEP?

A colleague of mine said “If you want to be someone, go to Westminster, if you want to do something, go to Brussels.” We seldom become household names but 60 percent of national legislation is passed down from Brussels.

How did you become an MEP?

I got on my bike in 1980 aged 17 because I couldn’t get a job in England, and became a lobbyist for a youth organization in Brussels. Studying modern languages, later at university, I am fluent in French and Spanish - although today the EU institutions are increasingly English-speaking.
After working in local government back in the UK for a few years as a European specalist I was elected to the European parliament in 1998.

What do you do all day?

It is a Monday to Thursday job, the rest of the week we spend back in our home countries doing constituency work. We spend three weeks a month in Brussels, often in committee – all MEPs are members of one and they are powerful legislative bodies. Mine is health and consumer affairs. The fourth week is spent in Strasbourg where legislation is voted through in "plenary" sessions. The European parliament, confusingly, has two seats, Brussels and Strabsourg, each of which are huge, modern building complexes.
Our job is to monitor and amend – often considerably – legislative proposals that come out of the European commission. We also hold the commission to account – they can be sacked by a vote of no confidence. We control the European union’s budget.

Are British MPs jealous of what you do?

I don’t think they are aware. Their ideas about
what MEPs can do is twenty years out of date. The
growth in our powers is quite recent. We were
directly elected only in 1979, and until the mid
eighties our powers vis-a-vis the European commission
were purely consultative. In other words they could
ignore what we said; but a number of treaties in the
1990s - the Maastricht and Amsterdam treaties - have
gradually increased our powers, so that we have
codecision - equal rights to legislate - in a large
number of areas, including the environment, food safety,
public health,
transport, consumer protection and 40 or so other
areas. Many of these issues are not health-legislation per se (governments jealously guard their national health services), but they impact greatly on health.
Because this legislation passes from us to be
rubber-stamped through by national parliaments before
entering national legislation, and media tend to
report the laws as coming from national parliaments,
the European origins of much legislation affecting
British people today tends to be obscured.


Are you pro-European or Eurosceptic?

Oh, I am passionately pro-European.


What do you think of recent European Court of justice
judgments that allow patients to be reimbursed by
national health systems for care taken
abroad. Would you approve of this theoretical
expansion of choice to enjoy care anywhere in Europe?
The idea that you could go to your GP, look at a
choose-and-book menu, and having, in addition to the
offer of that hospital in Sunderland, another, say, in
the South of France, or Bavaria.

It is not a free-for-all at the moment! That choice is
subject to to the condition that there are “too long”
waiting lists in the home country! Although what the
reference point as to what constitutes an unreasonably
long waiting list is a bit unclear at the moment. Be
also aware that the patient would have to pay upfront
to the care provider abroad before applying for
reimbursement by the NHS.
I think too much freedom will completely upset health
systems’ ability to plan care. How would the Belgian
health system for instance cope if suddenly a large
number of patients come from the UK. It would be very
destabilising. There is also the complications for
the patient of travelling, language differences, and
follow up care,
I do think this is more relevant to small countries
which cannot provide the whole spectrum of care
themselves, say Slovenia or Luxembourg, and of course
border areas, where it makes sense for hospitals on
either side of the border to share responsibilities.
Neither of these conditions apply to the UK. Despite
the judgments the overwhelming majority of people in
big countries will continue to have care at
home. The number of British people using these
judgements to enjoy care abroad is very low.
I think the right to care should be enshrined in
legislation though, not ECJ judgments.

MEPs are powerful, but there doesn’t seem to be a
career progression. You can’t be tempted into loyalty
to office, on the other hand, does that make you
independent of the national Labour party?

We are whipped by the Labour party, and have quite
good relations with the party back in the UK. Not as
split as the Tories.

What opportunities are there for medical graduates in Brussels?

There are about two dozen MEPs with medical background, including a few from Britain. Health is becoming more and more important in Brussels. There are so many NGOs where a health background is useful – European Men’s Health Forum, European Public Health Alliance, European respiratory society, just to give you a flavour. The big pharmaceutical companies have operations in Brussels.


What else is coming up in terms of European medical
legislation?

There is the medical devices and alternative therapies
directive - just as authorisation for medicines is
being centralised across Europe at the European
Medicines Agency, which is based in London, so will
the regulation of medical devices and alternative
therapies be harmonised. There
is a new public health programme, and there is
nutrition and health claims directive; it will be
illegal to make extravagant and general claims about
foodstuffs such as “it is good for you” “or low fat”
without specific substantiation. Surprisingly the
industry has lobbied strongly for legislation on
this, as they prefer a single regulatory regime for
the whole of Europe, even if it sometimes more
restrictive. It will also ban basically unhealthy
foodstuffs from selling themselves in
positive claim: for instance, there are high calcium
so-called healthfood chocolate sold in Belgium.
Cereals that are high in salt won’t be able to claim
they are healthy for instance by saying they are high
in fibre also. Hopefully all this will contribute to
fighting Europe’s growing obesity problem.

Health is a subject close to people’s hearts. Do you
get a bigger mailbag than your colleagues?

Not really. But I do get a lot of letters, especially
complaints about the new European healthcard. It has
not been made clear enough in the literature
accompanying the card that the free acute healthcare
applies only to public hospitals in Europe, not the
private clinics that dot many holiday resorts.
Private care can be very expensive. Also, the card
obviously does not cover transport home - one person
wrote in because her husband was killed and had to pay
thousands of pounds to bring the body home. There is a
danger that the card fosters false sense of security;
it is definitely NOT a substitute for travel
insurance. In fact, one of the proposals that might be
under discussion in the EU soon is compulsory travel
insurance for all travellers in Europe.

Do you enjoy living in Brussels? It is possible to
have quite a good life here, especially if you are on
a tax free commission salary!

I don’t really like to say I am “living” here, nor
that I “live it up”. I come here from Monday to
Thursday and stay in my office from 830 am to 830 pm.
But my home is Sheffield. To be honest I don’t really
like Brussels. Everyone is so status conscious: at
parties everyone sizes you up. ‘So what do you do? Ah,
you are an A-grade.'


Where do you stand on Indian doctors?

Well, the demand for work permits was a British
government decision. Nothing to do with the EU! The right of EU doctors to come to the UK to work is a basic EU right, though.
s

REACH, PFOA and teflon

It will be interesting to see how REACH, the new European chemicals policy, deals with PFOA, the main component of Teflon; indeed, how it deals with Teflon itself
PFOA, perfluoroctanic acid, is the main component in the making of Teflon, the non-stick, heat resistant, highly useful and versatile fluoropolymer used in countless industry and household products. PFOA is made at DuPont , West Virginia , at a site next to the Ohio river , the Mississippi ’s largest tributary
DuPont have long denied any links between elevated rates of cancer and exposure to chemicals at its plants, but the company has also attracted the attention of negative research. A great amount of this has focused on PFOA.
Local residents living downstream from the DuPont plant have had their water supplies contaminated by PFOA for fifty years, and say that local paediatricians report a manifold higher than average rate of early childhood caries – where children’s adult teeth fall out at 12.
James Dahlgren, a California toxicologist, has found a statistically significant excess of prostate, breast and cervical cancers compared to the US average in both plant workers and residents.
I recently interviewed Kathie Ball, 52, who has had three cancers after working on the production line at DuPont for 10 years. She was eventually fired after complaining of sexual harassment – her supervisor wanted to touch her silicone breasts – and because she had taken too much time off. Since this time off was due to the cancers she had contracted, this is a rather cheeky complaint. Kathie sounded like one of life’s victims, a former homecoming queen and high school cheerleader whose chief character trait was to be too trusting and chose the wrong job because it was well paid.
Activists I spoke to in West Virginia say that the heavy concentration of chemicals firms in this rural, hilly, indeed beautiful Appalachian state find it convenient that its population is relatively poor, unconnected, ill-educated.
DuPont have moved on criticisms: last year they settled a $100 m class action law suit with 80,000 local residents, without however admitting liability.
The Environmental Protection Agency has launched its own lawsuit against DuPont for failing for two decades to report health risks associated with PFOA.
The sum will be settled in January and could amount to as much as $300m, the largest corporate environmental fine in US history. Earlier this year, the EPA said PFOA was a likely human carcinogen. There has been a lot of US media coverage about this, with many headline puns on the themes of criticism “sticking” and DuPont being “in the frying pan”.

How does this relate to REACH? Neither DuPont US nor DuPont UK return calls. But according to a source in the green movement who has connections with the working group that classifies chemicals into the groups of high concern, PFOA is imported into Europe in quantities of about 100 tonnes a year, where, presumably, locally, it is made into teflon. Because of the ridiculous way that the tests for toxicity under REACH that have to be carried out are dependent only on individual amounts made by each producer, imported by each importer, PFOA could be quantified according to the 1 – 10 tonne range – if there are, say, 11 importers.
This is the lowest quantity range band, and requires provision to the EU chemicals agency of the absolute minimum of data – such as boiling point - unless the chemical in question has been classified as carcinogenic, mutagenic or harmful to reproduction.
Only then will the substance be subject to further tests and possible authorisation.
REACH is based on self assessment – the chemicals industry might call it an “invitation to commit suicide”. A commission source says the company itself has to determine and state whether a substance is carcinogenic, based on definitions in a previous EU directive. But on further examination this argument is circular, because that too talks about carcinogenic without defining it further.

Question: is DuPont going to call PFOA carcinogenic?

Supposing it doesn’t. its low quantities, and low risk also means companies would be given the longest possible deadline to register PFOA – 11 years – and, as said, could well escape the need for authorisation altogether.
There is a provision for the commission to check suspect dossiers; and it may do so for PFOA – because DuPont is a big company, PFOA is on the greens’ hitlist, star attraction of their alarming brochures, and because of articles like this. DuPont may also declare PFOA as a carcinogen. Then, another question poses itself
Teflon is a polymer; and polymers are blanket exempted from need for registration at all. It is also generally believed to be harmless. <<<<<<<<<<<<<<<<<
However, there is increasing American evidence that the Teflon used in greaseproof wrapping under the brand name zonyl comes off in small amounts during eating and enters the stomach. The stuff is used in hamburger wrappers.
In the stomach it degrades i7nto PFOA, findings by US scientists show. A Teflon carpet spray meanwhile that impregnates carpets against stains and spills is believed to contain alcohol residues of PFOA- alcohol which evaporate easily into the atmosphere – and are likely to enter the lungs of babies crawling around the house. According to Canadian scientist Scott Mabury, head of chemistry at Toronto university, under atmospheric action it also degrades into PFOA, which is why the chemical is found in the blood of polar bears in the arctic, albeit in tiny concentrations. Toxicologists say that PFOA’s advantage, the strong carbon fluorine bonds that give it its anti stick, heat resistant properties, also makes it one of the most persistent chemicals on the planet. One American chemicals campaigner said morosely of this entirely manmade chemical: “When mankind and all our civilisation has come and gone, this will be our pathetic signature. Aliens arriving on the planet in the distant future will know this as Earth’s PFOA age.” Even the much-malign PCBs, already banned, degrade slowly.
PFOA may not - unlike at the DuPont plant – enter the average European’s body in sufficiently dangerous quantities to be banned.
It will be interesting to see what happens next- how the EU deals with it. DuPont is subject to another lawsuit, in Florida . The plaintiffs are calling for five billion dollars to replace the planet’s pots and pans.

Caravanes medicales

In the old days, caravans used to carry salt and
slaves across the Saharan wastes. These days, they
carry medicine

It is perhaps hard to believe of western Europe’s
nearest neighbour. Despite a relatively peaceful
recent history, within eyeshot of Spain and strong
links to France, Morocco’s social indicators -
literacy and school enrolment - and health indicators
- infant mortality, say - are astonishingly poor --
even by Arab standards. According to WHO, mothers are
fives times as likely to die in childbirth as in
Tunisia; and children have a fifty percent greater
chance living to the age of five. Syria, hardly a
poster boy of progressivism, has half the infant
mortality and a quarter of the rates of tuberculosis..
The figures are bad because Moroccans score poorly on
another social statistics, that of access to care,
where the discrepancies with comparable Arab countries
are as bad, if not worse, leading for instance, to
many women choosing traditional midwives for births.
Lebanon, despite being long racked by civil war, still
manages to have five times as many doctors and has ten
times as many dentists.
Jordan has five times has many pharmacists and three
times as many trained nurses per capita. And these
countries are small, while Morocco is large and with a
heavy concentration of such care there is around the
northern coastal cities, making effective
discrepancies in access to trained medical staff for
large parts of the population even worse, compared to
its Arab cousins.
Groups of urban Moroccan doctors from the francophone
urban elite, fed up with their country’s poor record
on access, have recently taken matters into their own
hands. The elites of Casablanca and Rabat, elegant,
European, the most modern parts of Morocco, have
sometimes seemed to indulge its guilt in frivolous
campaigns such as civil society caravans, even fashion
caravans, bringing culture and political knowhow to
the regions for a weekend or two But inspired by
these a caravan movement of doctors has been launched,
whose benefits have turned out to be far more
substantial. Convoys of trucks and buses have with
filled with doctors from areas where they are most
concentrated - the big cities - and they have been
moved out to the provinces for weekends at a time to
carry out their duties free of charge in the remotest
desert areas of Morocco, where normally there might be
just one doctor per ten thousand population..
One of the leading lights of the so-called caravanes
medicales idea has been Dr Abdel El Hairy, 48, who
began the project after his father left a bequest to
build a village school and well. The Moroccan
bureaucracy insisted that any gift had to be
channelled through an NGO, and so he started one, AMI,
whose initials stand for locales in his father’s home
region. With money left over, the NGO funded a weekend
expedition, with three doctors, who carried out ten
consultations, in the local village hall. Since then
the idea of roughing it for a few days out of social
responsibility has grown hugely in popularity.
Word got out on the doctors’ grapevine, in Casablanca,
Morocco’s commercial capital and richest city, and
the numbers increased. Helped by French charity money,
which paid for the drugs, the most recent excursion,
in July, some sixty urologists, obstetricians,
dermatologists, gynecologists, paediatricians and
other doctors – many wealthy, with private clinics in
Casablanca - joined the caravan. In the evenings, they
had food cooked by berber women and compared rare
pathologies under the stars; in the daytime, they
carried out consultations – lots of cases of
tuberculosis, child meningitis; cancer of the uterus,
in adult males, skin and eye problems, were common.
They saw over three thousand in three days – in
chaotic conditions, with nomads arriving on camels
from a radius of dozens of kilometres away, and
patients queuing for hours .


Traditional cure

For what is the healthcare alternative for these
deprived Moroccans? In the company of some Casablanca
journalists, I went to see what an example of the
traditional medicine many Moroccans use, in the
impoverished Casablanca suburb of Hay Mohammadi.
Islamic parties are strong here, mainly because
Islamic activists have fulfilled some of the role of
the welfare state for the poor residents. Here, being
the city, there is theoretical access to medicine,
unlike the desert. But, in a country where 20 percent
of the population earns less than a dollar a day, few
can afford to have a basic consultation with a state
doctor, let alone a private one So they rely on
traditional doctors, the hajjamas - in the same way
the desert nomads are usually forced to do, though in
their case it is lack of access.
The traditional doctors work from shed-like workshops
on the edge of the quarter, and they seem to have one
cure-all treatment: la saignee, the bloodletting,
using crude instruments.. They often double as
barbers, and that is also an alibi.
Mohammed, aged 60, had teeth that did not look like a
brilliant advertisement for hygiene and care. At first
he denied he worked as a doctor, “I only did this in
the past”. (The practice is allegedly illegal). But
soon he confessed with a smile: “I still have to work
because my children are lazy. My son just smokes hash
all day.” With a colleague in another shop he was then
quite keen to show how the saignee worked. . The
patient – usually elderly - sits in the barber’s
chair in front of a mirror, the usual hair dressing
bric-a-brac – lotions, razors. Always a portrait of
Hassan II and his son Mohammed VI, past and present
kings. After partaking in several cups of mint tea,
his hair is ritually shaved, a 5cm incision is made in
the back of the head (cheeks if a woman) and blood is
withdrawn by attaching a pipe like object to the back
of the head. sucking produces a vacuum which draws
blood into the receptacle. “It cures everything,” said
Mohammed said confidently.
Others are less convinced. One Moroccan journalist,
Rida Addam, medical correspondent for Le Matin
newspaper, described to me witnessing another saignee
nearby: a 78-year-old night guard entered a nearby
shop with his twenty something son, who was clearly
sceptical.
As tea was prepared, the son angrily told Addam about
the way he was spoken about by the hajjama. "I tell my
father that this won’t cure his health problems.. But
the hajjama just says 'does Little Mohammed want some
tea, as if I was still the little boy he once
circumcised'."
He sighed deeply, ignoring the glances of pity from
the two elders, and finally rose to leave. His father
wished him good luck, and then proceeded to have the
blood letting. Ten minutes later he rose, looking
rather weak, said Addam. “One is always under the
protection of saints,” affirmed the “doctor”, one of
Mohammed’s many colleagues in the area. The old man
staggered out, accusing his son of “lacking faith”,
while the doctor cleaned his equipment in preparation
for another patient.

Mobile hospital

It is clear that the caravanes medicales play a useful
role in those areas they can are able to cover. They
make the role of the local hajjama redundant, even
carrying out circumcisions. “Entirely voluntarily,”
said one urologist, who normally runs a clinic off the
fashionable boulevard Hassan II. “And safer.”
Fortunately their popularity as caught on – not just
in numbers within caravans, but the number of regular
caravan projects has now grown to about twelve,
including one comprised of dentists, Enfant Sourire,
(Child’s smile.). Each dentist will see up to 50
patients a day.
The caravan concept itself is beginning to move on,
too – thanks to another Moroccan expatriate Dr Hassan
Zahouani, a professor in Lyon.
Until now, the projects have worked out of the largest
building in the village, or in tents if in desert. But
from next June a prototype mobile hospital, a 450
square metre structure that can be set up and
dismantled in hours, will be ready. Its design will
be modular, adaptable to different demands, reducible
into smaller-sized units, says Zahouani, who once
worked for the European Space Agency and was inspired
by
the modular design of the international space
station, Sponsored by the French firms Dassault, a
defence contractor, and L’Oreal, the cosmetics firm,
the 1m euro hospital will be made of covered steel
especially adapted to the desert’s extreme conditions
and have laser-equipped operating theatres to deal
with that scourge of the UV-rich desert, cataracts,
which have already made 150,000 Moroccans blind. The
hospitals could also be useful for other desert areas,
Iraq say, said Zahouani.


Western Sahara

All good? It might be churlish to raise any criticism
of all these projects, given that access to health in
Morocco is so poor. The projects have been lauded in
Morocco’s francophone media. But if a small criticism
may be made a foreign critic might note that, in the
choice of places to visit, the ostensibly independent
caravans have chosen, unwittingly or not, destinations
that further the government’s political agenda.
Tafilalet for instance, where the hospital will
circulate, is uncontroversial, because it has always
been part of Morocco. But several caravans have
visited the Morocco-controlled Western Sahara, where
the Polisario armed independence movement has been
agitating for independence on behalf of the ethnically
different Sahrawis since 1975. The area is secured,
and so is safe for NGOS. Here the caravans have been
helping the Sahrawi people, showing up the contrast
with the many refugees displaced by the Moroccan army
into Algeria in 1975, and have spent all their lives
in that country, in refugee camps, under terrible
conditions. Morocco may need to win hearts and minds:
a UN peace process, which looks as if it will restart
after dormancy, is trying to broker an agreement that
would lead to a referendum on the future final status
of western Sahara..
Providing health is perhaps one means of killing
yearning for independence by kindness, in the same way
the government has provided the western Sahara with a
superior road and buildings infrastructure, though
leaving the area undermedicalised..
The caravans' effects given absence of other
healthcare may be good, but could the help dispensed
be interpreted as an endorsement of the brutal way
Moroccan government deals with relatively peaceful
expressions in favour of independence?
Just two months ago, a Moroccan court jailed 12
Western Saharan separatists, handing out sentences of
up to eight years for charges including “vandalism,
resisting arrest and joining an armed crowd”. The
activists were among fifty arrested in May when
demonstrating for independence. The conflict is
complex and by no means black-and-white.
The world’s longest serving prisoners of war, 404
Moroccan ex soldiers, were released a few weeks ago by
Polisario having been held captive for an appalling 20
years in detention camps in southern Algeria. Yet the
sense of injustice at the arrest is clearly enormous:
12 have recently (14 September) been transferred into
hospital after having been on hunger strike for over
five weeks.
It is difficult to get a straight answer on this, part
of the circumspection comes from the need for local
military logistics cooperation, partly because, I
suspect, doctors I spoke to, like many in their
profession, just want to get away from politics and do
their jobs. Yet politics is there all the same.

The future

The caravans, for all the help they give, are clearly
not a sole solution, since they reach relatively few
people, thousands rather than millions.
But the government seems to be doing something. “The
new king, Mohammed VI, who is just 37, really cares
about the people,” said one doctor. “He really wants
to help poor communities.” In the support of this
statement, the doctor pointed to the king – whose
power is great in Morocco – launching a slum clearance
programme as one of the key priorities of his reign.
Meanwhile the health ministry says has looked at
medical caravans as a possible model for public funded
similar action in rural areas. There will be an
extension of health insurance, assurance de maladie,
from five to ten million – though that will still
leave 20 million Moroccans without health insurance..
The national literacy campaign has doubled its
efforts, targeting women, whose literacy rate is a
modest 38 per cent, the third worst in the muslim
world, after Afghanistan and Somalia.
This illiteracy is said to result in women still using
traditional midwives - because of apparent ignorance
rather than lack of money, since one of the few perks
of the poor is to have free births in hospital. The
Islamic family code is being replaced by laws that ban
child brides and put partners on an equal footing in
the hope that empowered women hold the key to rural
health education – though established practices are
hard to abolish with the stroke of a pen. The health
budget, insists the government, has risen by ten
percent a year since 2002.
Zahouani disputes the rosy picture, saying the
government stil lacks a serious strategy for dealing
with its rural communities.. Other doctors say that,
though health spending may have increased, it has been
inexpertly targeted: the capping of doctors’ salaries
as a proportion of the health budget has led to
doctors being put out of work, emigrating to France,
and leaving newly built hospitals being closed.
Both government and its critics might agree though
that, whether developments are going in the right
direction or not, Morocco still has a long way to go
before catching up with the rest of the Arab world.
“We had no oil money, but that is no real excuse. We
also had an elite that was only interested in fighting
for and securing well-paid public sector jobs, no
entrepreneur class, as in Lebanon, interested in
creating wealth. No one paid attention to rural
poverty,” said one doctor. “The neglect will take a
long time to be put right.”
One small positive side to the neglect, though, has
been that Morocco has pioneered a concept that has
tentatively been copied in other undermedicalised,
large countries, Egypt for instance. But the concept –
both the caravan andn the mobile hospital – deserves
to be spread even further, says El Hairy – Afghanistan,
perhaps, or Sudan, if those countries ever achieved piece.
In Morocco, meanwhile, the caravans keep rolling on.

The heart healer

Pekka Puska was born in Vaasa, northern Finland, in 1945. He was director of the North Karelia Project in eastern Finland from 1972 to 1997. Between 2001 and 2003 he was director of the department of non-communicable disease prevention at the World Health Organization in Geneva, Switzerland. He has a PhD in epidemiology and has published more than 400 scientific papers. He has also served as a member of the Finnish parliament. He is married with two young children

Why North Karelia?

In the 1970s North Karelia had the highest mortality rate from heart disease in the world. The local governor signed a petition to the government demanding that something be done about it. At the time I was a young assistant in the department of public health in Turku. I had degrees in political science and medicine. I was also a member of President Urho Kekkonen's Centre party - he was one of my heroes, he had many radical ideas.
I had been active in student politics, and was president of the national students' union. I was part of the generation that all over the world wanted more democracy - in Finland there were riots in 1968. The Centre party was strong in rural areas. In 1972, as a result of the petition, Kekkonen sent me and other young researchers to North Karelia.

What was it like?

North Karelia is a remote, cold, rural area on the Russian border. Finland had had a very difficult second world war, fighting the Russians. The country was poor; it was not the "Nokia country" you see today.
But in the 1950s and 1960s, people started to dream of a better life. Before the war, their diet had been simple and healthy. People died mainly of infectious diseases. After the war, people started to eat more and more dairy products. They had more money. In 1972, a typical meal in North Karelia consisted of high-fat dairy products and sausages. Anything green was dismissed as "animal food".
I said to people: "You are eating as if every day was Sunday." When I went to the province, one-third of the young children had fathers who had died of chronic heart disease.

So what did you do?

Our researchers discovered that most risk factors came from the environment and from lifestyle. The Finnish focus at the time was very much on hospital treatment - the old cardiological establishment was very sceptical of our approach. I told North Karelians to reduce saturated fats, salt, meat and sugar, and to add fibre, bread, vegetables and fruit. "What is the difference between fruit and vegetables?" I asked them. They defined fruit as "something you import". They said eating fruit would not be supporting Finnish agriculture.
Our policy was "boots deep in the mud": really going deep into the rural communities. I visited dairy farmers and lumberjacks and tried to persuade them to adopt a diet low in saturated fat. I encouraged them to diversify into crops such as berries and apples. We had to visit them many times to persuade them. People said: "Why deny us our small pleasures?" But one sausage maker who had had a heart attack agreed to make sausages out of mushrooms instead of pork. And I persuaded one bakery owner to halve the salt content in his bread, and switch to vegetable oil instead of animal fat.

How did you get the message through at the community level?

We went to churches, where priests were very supportive of us. We stood in supermarkets issuing health leaflets. We had a non-smoking pledge in schools, for which pupils promised not to smoke for a year. Community competitions featured cooking courses and the local grocer was asked to persuade customers to buy fewer sausages and to cook with vegetable fat instead of animal fat. I also worked with small companies to develop juices and jellies. At the housewives' organisation called Marta, I organised recipes using less salt, more vegetables, lower fat. And I told housewives to start substituting low-fat milk for high-fat. When their husbands complained, I said they should pour low-fat milk into high-fat containers and serve this at the breakfast table, which they did.

How did people take to your campaign?

I was on a weekly TV programme that measured the blood pressure of 10 North Karelians. The series was very popular and ran for 15 years. It became a talking point - people all over Finland followed it. When a new episode was about to air, people would say, "Dr Puska, I'm curious. Has that girl from the previous show managed to stop smoking?" I remember after one of these programmes a Helsinki bus driver stopped his vehicle and called me up to the front. He took a cigarette packet from his shirt pocket, crushed it and put it in my hand. Then he said: "That was my last cigarette."
A lot of people did not realise there was a connection between blood pressure and heart disease. I introduced yellow cards for every health clinic visitor, and every time patients visited a doctor or nurse they took a new reading and entered the new figure on their card. It was a simple step but it enabled people to take control of their lives. People used to show me their cards in the street and were very proud.
I have a collection of newspaper cartoons about the project. One has a waiter pointing to a customer at a table and telling another waiter, "Make sure he doesn't try to sneak his own salt into the food." The joke is funnier if you appreciate that Finns used to smuggle small bottles of spirits into restaurants and pour them into their drinks.

Did all this effort pay off?

Between 1972 and 1997, when the North Karelia project ended, the number of deaths from coronary heart disease dropped by 82 per cent. Life expectancy among men went up eight years, from 65 to 73. Blood cholesterol in the population dropped 20 per cent. It was like putting the whole population on cholesterol-reducing drugs. The consumption of fruit and vegetables went from the lowest in Europe to the highest in northern Europe. In 1972, 90 per cent of the population put butter on their bread; now only 7 per cent do. Salt consumption halved. Smoking went down drastically among men, though it increased among women. In Finland as a whole, between 1969 and 2002 deaths from chronic heart disease dropped by 76 per cent among men aged 35 to 64. People used to come up to me and shake my hand and say, "Thank you Dr Puska, you have saved my life." It amused me. Perhaps health experts are the modern priests.

And people lost weight?

We never targeted weight or calories. These were big men in hard-working physical occupations from farming communities. Finland's body mass index - a measure of body fat based on height and weight - has remained constant among women and risen a little among men in the past 30 years.

Would deaths have dropped even more if you'd also had a weight-loss programme?

Coronary heart disease is the biggest global killer today. The greatest risk factor is high blood pressure, and that has nothing to do with obesity. Cholesterol, the second biggest risk factor, is slightly related to obesity. Smoking, the third-biggest contributor, has nothing to do with obesity. Obesity is a sign that diets are going wrong, and not itself a cause of ill health. Weight-reduction programmes that aim just to lose weight without changing diets are a waste of time.

Have any of your family suffered heart disease?

My father had a heart attack when he was 45. He changed his lifestyle and lived to be 80.

Is anyone trying to do what you did in North Karelia? Can it be done elsewhere?

Over the years I have helped to develop pilot projects in Tianjin in China, the island of Mauritius, Valparaiso in Chile, Isfahan in Iran and Nizwa in Oman, after their health experts came to Finland to study the North Karelia project. Nowadays it is much more difficult to do what I did. In the International Journal of Epidemiology in 1973 they described what I was doing as "shotgun prevention". They said I was using mass action without evidence. Nowadays everything has to be evidence-based.
These countries had some of their own challenges. For example, how can women get enough exercise if they have to wear veils? And exercise is difficult in countries where summer temperatures are more than 50 °C. The Chinese had serious problems with hypertension because soy sauce is high in salt; they started using low-salt sauce in schools. In Mauritius they eat a lot of unhealthy palm oil so the government encouraged use of sunflower oil instead.
“My father had a heart attack when he was 45. He changed his lifestyle and lived to be 80”

Did it work for them?

The pilot projects led to a drop in coronary heart disease. But the real problem is translating a pilot project into a national project: getting industry and business to collaborate in developing and selling healthy foods, getting non-governmental organisations and the media to promote healthy living. In this, other countries have been less successful: they are much bigger than Finland. We have had a lot of interest from western European countries such as the UK but these societies are much more heterogeneous than ours. On the other hand, they are more open to new ideas. North Karelia was a very traditional area, hostile to innovation. Campaigners have to use the specific strengths of each culture to push through their goals.

What has happened in Finland recently?

The fall in the Finnish heart disease rate has levelled off and has a long way to go: we are still only average in Europe. Joining the European Union in 1995 affected things: our schools went from low-fat milk to high-fat because the EU paid farmers subsidies for high-fat milk. But in the past few years the EU has been positive at promoting restrictions on tobacco smoking. Today it is harder to change people's habits because there are many more lifestyle choices: more TV channels, for example, and too much choice of processed and high-fat food in the supermarkets. But the global food industry is increasingly on my side - the guy who said hello to me just now is a very senior director at Nestlé. That company realises that healthy foods can be profitable.

What do you remember most about your time in North Karelia?

Visiting farmers in the snow and wind at -40 °C. I remember an elderly man in a small village near the Russian border who came to me after my talk and said: "Doctor, I have a question: you keep telling us what kind of fat we should use on our bread. You never tell us if what I put on my bread is healthy or not." What do you put on your bread, I asked. "Bear's fat," he replied.