David Byrne, European Commissioner for Health and Consumer Protection Portuguese Presidency of the European Union

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Volume 5 Number 4, Winter 1999/2000 eurohealth

David Byrne, European Commissioner for Health and Consumer Protection

Targets for Health

Food and Health New opportunities for health in Northern Ireland

Portuguese Presidency of the European Union – Priorities for Healtth Minister Manuela Arcanjo An increasingly important aspect of policy making within the eurohealth European Union is the role of sub-national institutions in the policy process. Nowhere is this more the case than in the LSE Health, London School of p United Kingdom, where the devolution process is creating new Economics and Political Science, Houghton Street, London WC2A 2AE, centres of decision making in the health policy field. This issue United Kingdom of eurohealth includes an article by the new Scottish Minister Tel: +44 171 955 6840 for Health and Community Care on the aims of the current Fax: +44 171 955 6803 Web Site: Executive in health policy and service delivery. www.lse.ac.uk\department\lse–health r The changing institutional structures in Northern Ireland, as EDITORIAL well as the evolving political climate there, are the focus of EDITOR: Mike Sedgley: +44 171 955 6194 several articles. In particular, they discuss the new opportunities email: [email protected] for cooperation between the North and South of Ireland in pro- SENIOR EDITORIAL ADVISER: viding health services for the populations in the border areas. Paul Belcher: +44 171 955 6377 email: [email protected] e This is an important step for all Member States, as an example EDITORIAL TEAM: of inter-institutional cooperation being used pragmatically to Johan Calltorp Julian Le Grand deliver healthcare to their populations in the most efficient and Walter Holland effective manner. The difficulties of promoting health policy, or Elias Mossialos any policy, in a party system defined by sectarianism are also SUBSCRIPTIONS discussed. The successful formation of the Northern Irish Janice Isaac: +44 171 955 6840 f Executive since the writing of these articles has, however, led to email: [email protected] greater optimism in this respect. Published by LSE Health and the European Health Policy Research In the context of the current high profile of food safety issues in Network (EHPRN) with the financial the EU, several articles discuss the development of policy in this support of LSE Health and Merck and a field. In particular, Tim Lang sets out the complexities inherent Co Inc. in developing EU food policy and the problems likely to be eurohealth is a quarterly publication that provides a forum for policy- encountered by a European Food Agency. Jeanette Longfield, makers and experts to express their views meanwhile, focuses on the Common Agricultural Policy on health policy issues and so contribute (CAP), and explains the Sisyphean task facing those attempting to a constructive debate on public health policy in Europe. c its reform to take account of diet and public health, as well as The views expressed in eurohealth are environmental factors in the production of Europe’s food. Nils those of the authors alone and not neces- Rosdahl concludes this section with a look at the food control sarily those of LSE Health and EHPRN. system in Denmark and its implications for public health. ADVISORY BOARD e Dr Anders Anell; Professor David Banta; David Byrne, the new Commissioner for Health and Consumer Mr Michael Brown; Dr Reinhard Busse; Protection, sets out his view of how the policy of the new Professor Correia de Campos; Directorate General will proceed over the coming years, and Mr Graham Chambers; Professor Marie Christine Closon; Dr Giovanni Fattore; how it will respond to the broader public health provision Dr Josep Figueras; Dr Livio Garattini; accorded the Community in the Amsterdam Treaty. The Dr Unto Häkkinen; Professor Chris Ham; Mr Strachan Heppel; Professor David Portuguese Minister of Health, Maneula Arcanjo, summarises Hunter; Professor Claude Jasmin; Professor Egon Jonsson; Dr Jim Kahan; the tasks of the current Portuguese presidency, and details the Professor Felix Lobo; Professor Guillem official programme for the coming six months. John Bowis Lopez-Casasnovas; Mr Martin Lund; Professor Martin McKee; Dr Bernard addresses the issue of mental health in Europe and the opportu- Merkel; Dr Stipe Oreskovic; nities for progress in this area within the provisions of Professor Alain Pompidou; Dr Alexander Preker; Dr André Prost; Amsterdam. Dr Tessa Richards; Professor Richard Saltman; Dr B Serdar Savas; Mr Gisbert In short, we again have a eurohealth packed with informative Selke; Professor Igor Sheiman; Professor JJ Sixma; Professor Aris and informed debate about many aspects of public health. It is a Sissouras; Dr Hans Stein; Dr Miriam Wiley debate that will continue, in the new atmosphere of accountability surrounding Europe’s institutions, as the provisions of © LSE Health 2000. No part of this publication may be copied, reproduced, stored in a Amsterdam are seen to require action to make sure that retrieval system or transmitted in any form health really is taken into account across the policy without prior permission from LSE Health. spectrum. Design and Production: Westminster European, email: [email protected] Reprographics: FMT Colour Limited Mike Sedgley Printing: Seven Corners Press Ltd Editor ISSN 1356-1030 Contents Winter 1999 Volume 5 Number 4

2 Editorial: Would the Commissioner for health please stand up? CONTRIBUTORS TO THIS ISSUE Paul Belcher MANUELA ARCANJO is Minister of Health, 2 A health strategy for the new millennium Portugal Minister Manuela Arcanjo PAUL BELCHER is Senior Editorial Adviser to Eurohealth and European Affairs Manager of 3 The European Community’s future strategy in the field of public health the European Health Management Association, Commissioner David Byrne Brussels

5 After Tampere – Mental health in Europe JOHN BOWIS MEP is UK Conservative Party John Bowis MEP Spokesman on the Environment, Health and Consumer Affairs at the European Parliament 7 Health policy in the EU – and a former UK Health Minister A basic guide Food and health DAVID BYRNE is European Commissioner for Graham Chambers Health and Consumer Protection 28 Where is European food policy going? ETTA CAMPBELL is Chief Medical Officer for Northern Ireland Tim Lang New opportunities for GRAHAM CHAMBERS is Principal Administrator health in Northern Ireland 31 Sustain, the alliance for of the Health Division, Directorate General for better food and farming – Research, European Parliament 10 Health policy in Northern The labour of Sisyphus SOFIE DE BROE is Research Assistant, Depart- Ireland: What can we expect Jeanette Longfield ment of Epidemiology and Public Health, after devolution? Imperial College School of Medicine, UK 33 Public health and food Martin McKee SUSAN DEACON MSP is Scottish Minister for safety: the case of Salmonella Health and Community Care 13 The health of the public in in Denmark TOM FRAWLEY is Director-General of CAWT Nils Rosdahl Northern Ireland (Cooperation and Working Together) and Etta Campbell General Manager of the Western Health and Social Services Board, Northern Ireland 15 ‘Cooperation and Working Together’ Improving the Health targets MIKE JOFFE is Reader, Department of Epidemiology and Public Health, Imperial health of the border 36 Targets for health: shifting College School of Medicine, UK populations in Ireland the debate Tom Frawley and Eithne TIM LANG is Professor of Food Policy at Thames Morton Warner Valley University, UK O’Sullivan JEANETTE LONGFIELD is Coordinator, Sustain – 19 Health care across borders: The Alliance for Better Food and Farming The scope for North-South American health policy and DOROTHY MCKEE, formerly Research Fellow at cooperation in hospital CHIME, University College London, services the presidential primaries Whittington Hospital, UK Dorothy McKee 38 The uninsured and the US MARTIN MCKEE is Professor of European Public presidential election Health at the London School of Hygiene and Elias Mossialos, Martin Tropical Medicine, UK Health promotion and the McKee and Alexandra Pitman ELIAS MOSSIALOS is Director of LSE Health and European Single Market a Project Director of the European Observatory on Health Care Systems, London School of Economics and Political Science, UK 21 The health impact of Health systems European single market CLIVE NEEDLE, a former UK Labour MEP and legislation European Parliament Rapporteur on the Future 43 Health of the nation Framework for EU Public Health 1998-99, is Susan Deacon 23 The regulation of now an independent public policy adviser pharmaceutical products 45 How a new English health EITHNE O’SULLIVAN, formerly Executive Officer agency can benefit European of CAWT (Cooperation and Working 24 Regulating the market in Together), Northern Ireland health development medical devices Clive Needle ALEXANDRA PITMAN, is a Research Assistant at LSE Health and the European Observatory on 24 Dangerous substances and Health Care Systems, London School of preparations Economics and Political Science, UK 48 25 Foodstuffs: harmonising a European Union news NILS ROSDAHL is Medical Officer of Health, City diverse policy area by the European Network of of Copenhagen, Denmark and President of the Danish Society of Public Health 1995–1999 Health Promotion Agencies 27 The health dimensions of and the Health Education MORTON WARNER is Director of the Welsh fiscal policy instruments Authority, England Institute for Health and Social Care and Mike Joffe and Sofie De Broe Professor of Health Policy and Strategy EDITORIAL Would the Commissioner for health please stand up?

Paul Belcher Senior Editorial Adviser, eurohealth

A casual observer of EU affairs since process of consultation with the ority setting within the new the new European Commission other EU institutions and interested Commission. Indeed, the demon- took office last year might be forgiv- parties, which was finalised before stration of how political will and en for thinking that David Byrne the previous Commission left office, concrete action can be employed in has swapped his appointed role as and it demonstrated overwhelming the field of food safety stands in Health and Consumer Protection support for the Commission’s gen- contrast to the infrequent and vague Commissioner to become eral approach to future policy. policy statements on the future ‘Commissioner for Food Safety’, as However, we are still awaiting the direction of EU health policy - let he now appears typecast by the second stage of the process and the alone the complete absence of any European media. Whether this is a publication of concrete policy pro- detailed policy proposals. Some result of the need to deal with recent posals. observers suggest that the reason food related scandals, or evidence of may lie in the failure of the much a longer-term policy shift away As the Commissioner points out in this issue of eurohealth, the resigna- heralded joining together of from the broader EU health agenda, Consumer Policy (previously is now a serious cause for concern. tion of the last Commission was a reason for the initial delay. DGXXIV) and Public Health (pre- To be fair, few could have predicted However, there is now palpable viously DGV) within the the whirlwind of food scandals that annoyance among some Member Commission. There are reports that engulfed the new Commissioner as State administrations, particularly far from being a marriage made in soon as he took office. The EU Presidency countries, as well as heaven, this has been a bed of nails European Parliament must also other interested groups who were from day one and that the partners accept its share of the blame for involved in the consultation process are barely on speaking terms. As a reinforcing the current high political in 1998–99, that proposals have still consequence, have wider health profile of food safety, by failing to not been put forward. Now, as Mr interests been marginalised by food raise wider health policy issues dur- Byrne notes, the delay has led to the and consumer concerns within the ing its questioning of Mr Byrne in inevitable discussion of ‘interim new Directorate-General for Health the hearings held prior to his measures’ to keep afloat those health and Consumer Protection? appointment – apart from the programmes which are coming to an Encouragingly, Mr Byrne has notable few such as John Bowis end. Even these interim measures, already stated publicly that wider MEP, former UK Health Minister, which have yet to be decided, may health issues do need greater atten- who also writes in this issue of themselves have to pass through a tion. At a conference on ‘Building eurohealth. lengthy process of agreement and, as Healthier Hearts’ held in Dublin on Food safety is, of course, a major a result, there is great uncertainty 5th November last year, he recog- public health issue. However, the over the future of some of the valu- nised that much of his time was Commission should not lose sight able projects and health networks indeed being taken-up with food of the fact that this is one part of a funded by the programmes. safety issues. He said that while much wider EU Treaty obligation The Commissioner announces in they are important, “they should to ensure a high level of human this issue of eurohealth that his not serve to distract our attention health protection and integrate package of proposals can be expect- from wider health issues”. The health considerations into all EU ed sometime in the next six months Commissioner will find much sup- policy areas. The high political pri- during the Portuguese Presidency of port for these sentiments among the ority given by the new Commission the European Union. But why will wider European health policy com- to press ahead with the White Paper it have taken so long to deliver these munity. However, the time has now on Food Safety and create a health proposals and are there any come for words to be translated into European Food Authority stands in conclusions to be learned from this concrete action by ensuring the contrast to the absence of proposals, for the future? For many, the timely publication of visionary now long overdue, to implement Commission resignation last year health policy proposals that inter- Article 152 on Public Health. and the subsequent focus on food pret Article 152 to the full and max- Readers will recall that in April 1998 safety scandals are not valid excuses imise the ‘added value’ which the the Commission published its ideas for the lack of activity on wider EU can make to national efforts to on the way forward for EU public health policy development. It may improve and not just protect public health activities. There followed a have more to do with political pri- health.

1 eurohealth Vol 5 No 4 Winter 1999 EUROPEAN UNION A health strategy for the new millennium Manuela Arcanjo Minister of Health of Portugal

During first the six months of the tance; the excessive use of antibiotics year 2000, the Portuguese presiden- and its consequences; and the effort cy of the European Union will play to ensure a better quality and safety an important role in the area of pub- of blood, improving control and lic health. handling procedures. First of all, we are making all efforts Included in the official programme to ensure the continuity of proposals of the Portuguese Presidency, two launched under the previous Finnish conferences will be organised, focus- presidency. These will certainly con- ing on Public Health. The first, tribute to the implementation of a “Health determinants in the global strategy for health for the fif- European Union”, will take place in teen countries that constitute the Évora, between 15th and 17th of Union. March. This conference intends to give adequate visibility in the Since becoming Minister of Health European agenda to this subject. All in Portugal eight weeks ago, I have the existing information and data been conscious of the importance of will be analysed and answers will be this presidency for Health in the “The Portuguese Presidency formulated to the problems detected European Union. Working towards at this level. that objective, we have decided to wishes to accomplish every task organise initiatives that will be at its hand. I hope … that it will The second conference, “Medicines developed in the forthcoming six and Public Health”, will take place months. I am completely confident result in a real improvement in on 11th and 12th of April in Lisbon. that they will all be highly beneficial Matters such as the impact of the use for the successful exercise of my health in the European Union. of medicines in the context of public mandate, as they will be for all of my health and health systems, under the fellow Ministers of Health in the This is our commitment.” Treaty of Amsterdam, will be dis- other fourteen Member States. cussed, contributing to debate about the role of the European Union in The recent changes to the Treaty of this field. the European Union have been of tection for consumers of Europe's great value, first by establishing a food. Finally, we hope, with the coopera- Community public health compe- tion of the European Commission, To complete the ‘farm to table’ tence (Treaty of Maastricht), and to organise an expert meeting, in approach, a major programme of then by introducing a clearer legal Oporto, to begin a political debate legislative reforms has to be under- basis for the action of the about the quality and security of taken, as well as ensuring the hori- Community in terms of health poli- organs and fabrics of human origin zontal nature of health across policy cy (Treaty of Amsterdam). These for transplantation. We hope that areas. In the Feira Council, a report changes make the horizontal charac- this initiative will lead to a proposal including the combined work and ter of the Community health policy for a Community Directive that discussions in Health, Agriculture, mandatory, implying the need to deals with these issues. Internal Market and Consumers consider the protection of public Councils will be presented. To finish, I would like to summarise health in all EU policies. our objectives in a simple way: The Tobacco, will also be a major theme, As such, the Portuguese Presidency Portuguese Presidency wishes to and we will approach the Members will focus on food safety, starting as accomplish every task at its hand. I States in relation to the proposal determined in Helsinki, with the hope that this will give us something presented by the Commission. work on the White Paper on Food to cheer, and that it will result in a and Safety, to be presented by the The work that the Portuguese real improvement in health in the Commission, aiming to reach the Presidency will continue include the European Union. This is our com- highest possible level of health pro- questions related to microbial resis- mitment.

eurohealth Vol 5 No 4 Winter 1999 2 EUROPEAN UNION The European Community’s future strategy in the field of public health

and control of communicable dis- gramme with actions in several eases at Com-munity level and regu- key fields: health information, lar reporting on health status and on rapid response and tackling health the integration of health require- determinants, which should pay ments in other policies. due attention to issues related to enlargement and to the interac- A new strategy tion with other health-related Following the conclusion of the policies; Amsterdam Treaty, which strength- – large-scale, sustainable actions, ened the health provisions of the EC involving all Member States, Treaty, and with the prospect of which would have a strong link to policy development and, eventu- David Byrne, European Commissioner of Health and Consumer ally, the preparation of legislation; Protection, here elaborates on his and the Commission’s role in – taking full advantage of the range public health, and the priorities for building on the work of the of legislative possibilities offered by the Treaty. previous Commission and developing future policy in its public The Communication stimulated a health strategy. wide debate on how the Community’s public health policy should develop. For example, the From the outset, the new German Presidency organised a Commission has put health high on future enlargement, a stock-taking major conference (in Potsdam, its agenda. For the first time a health exercise concerning the objectives January 1999); the European portfolio has been created. A new and administration of the pro- Parliament commissioned an expert Directorate General has been estab- grammes and the overall coherence study and held a public hearing (in lished bringing together public of policy took place, involving Brussels, October 1998); and many health, consumer protection, animal stakeholders inside and outside the NGOs, professional organisations and plant health, inspection and sci- Commission. There was consensus and other bodies wrote to the entific advice. This significant devel- towards developing a new policy Commission giving their views, or opment responds to the new health which ought to be highly effective, organised events at which the com- provisions contained in the well-structured, in tune with the munication and the future of health Amsterdam Treaty, which widen the strategic needs of the Member States policy in the EC was discussed. The scope of Community action in this and flexible enough to respond to overwhelming majority of opinions area. new developments. The new policy and comments received, and in par- had also to address the issue of limit- The Community’s current public ticular those of the Parliament, the ed resources and the heavy adminis- Council and the other Community health actions are based on the strat- tration burden posed by the current egy set out in the Commission’s institutions, indicated support for action programmes. the Commission’s ideas and framework for action in the field of approach as set out in the public health, published in The Commission’s communication Communication. November 1993. In this context, of April 1998 on the development of eight action programmes were intro- public health policy set out the The resignation of the Commission duced and are in the process of results of the review and suggested a in March 1999 has inevitably delayed implementation. Other activities number of priorities and options for the process of developing specific undertaken included a strategy and the future. It proposed a broader, proposals. However, it is clear that measures on tobacco and smoking; a coherent approach to tackling health developing new proposals for action strategy and a Council recommenda- issues at Community level, involv- in public health based on Article 152 tion on blood safety; the organisa- ing: of the Treaty, and a general commu- tion and coordination of surveillance – one overall public health pro- nication on the Community’s health

3 eurohealth Vol 5 No 4 Winter 1999 EUROPEAN UNION strategy, are priorities for the new will assist Member States in making Some interim measures Commission. While these would their health systems perform better The first four of the existing action reflect the debate on the and to cope with change. Activities programmes (health promotion, can- Community’s future policy in this would build upon actions undertak- cer, AIDS and other communicable field launched by the Commission’s en under the current health monitor- diseases, and drugs) will be expiring communication, they must also take ing programme, such as identifica- by the end of 2000. Since the proce- account of the recent developments tion and establishment of health dure for adopting the decision on a concerning the place and weight indicators, the interchange of data new public health programme is accorded to health in the new between administrations and the likely to take a considerable amount Commission and in public percep- analysis and evaluation of health of time, the proposal cannot be tion, as well as the lessons learnt interventions. expected to be adopted before these from recent health-related crises. programmes come to an end. The programme would also have to Therefore, there may be difficulties take on board the need to address A communication on health in pursuing actions that have proved health determinants. Health deter- strategy their worth. A solution to this prob- minants can be linked to behaviour, Although the details of the commu- lem would be to extend the action genetic predisposition, environment, nication have yet to be confirmed, programmes until the new public and socioeconomic conditions my intention is that it would have a health programme comes into effect. (including health care interventions). number of aims. First, to describe In practice, only some determinants major trends and developments in A closer look at health impact can be addressed at Community health. Then to set out the legal basis A great number of Community poli- level: examples include tobacco, for the Community’s actions related cies have an impact on the health of alcohol, drug dependence, food and to health, and to describe the various Community citizens, and on nutrition, environment and pollu- Community policies that relate to Member States’ health systems. tants, working conditions, educa- health and how they relate to each Take, for example, legislation on other and fit into an overall frame- tion, and social protection. Effective pharmaceuticals or medical devices, work. In addition, it would also strategies and measures in relation to the recognition of diplomas of health show how the new public health key determinants will be needed, as professionals, or, more generally, programme and the various legal well as the creation of links with environment and transport policies. measures to be taken under Article other health related Community It is crucial to ensure that health 152 relate to these other policies. policies such as research, taxation, issues are given due weight in the social security, environmental poli- development and implementation of The goal will be to address the cy, transport safety, educational pro- Community policies and actions. implications of Article 3(p) of the grammes, and so on. The links between these policy EC Treaty according to which the responsibilities and public health Community’s overall objective is to The third priority area mentioned by within the Commission have to be raise the standard of living and the 1998 communication involved strengthened. In my opinion, this working conditions by making a the creation of a Community sur- means that we need to review and to contribution to the attainment of a veillance, early warning, and rapid strengthen – where appropriate - the high level of health protection. reaction capability for health. The network on surveillance and control mechanisms we have established within the Commission to imple- A new programme of communicable diseases could ment the Treaty requirement on In addition to the communication, I serve as the fundamental element in ensuring a high level of health pro- also intend to submit a proposal for developing an overall alert and tection across Community policies. a decision by the European response platform. Such a mecha- Parliament and the Council adopting nism would have to link and estab- Conclusions a programme of action in the field of lish effective coordination with The development of the Communi- public health. This programme will other alert mechanisms at ty’s new public health strategy has build upon the orientations of the Community level. now come to a decisive stage. I April 1998 communication and the The new programme would also intend to present my package of resolutions of the Community insti- have to explore and to exploit the proposals under the Portuguese tutions, notably the Council and the possibilities of cooperation which Presidency, i.e. in the first half of European Parliament. are now visible as a result of the cre- 2000. I am of course aware of the Without prejudging the outcome of ation of the health and consumer fact that the delays we have encoun- the current process of consideration, protection portfolio. There might tered have led to some concerns. But I am convinced that a major empha- well be advantage in maximising I have made it clear that for me it is sis of the new programme should be synergy between these areas by important to take the time needed to on improving health-related infor- putting forward some specific pro- devise a well-balanced and struc- mation. This will enhance the ability posals complementing consumer tured strategy. Only in this way will of the Member States and of the health protection, starting with we be able to address properly and Commission to design and imple- nutrition and extending to alcohol effectively today’s and tomorrow’s ment effective health policies and and other risk factors. public health challenges.

eurohealth Vol 5 No 4 Winter 1999 4 EUROPEAN UNION After Tampere – Mental health in Europe

“The Council of the European Union … disease. In Britain we know that we lose Recognises that mental health is an indivisi- more people through suicide than we do ble part of health … Invites the Member through road accidents, that we lose some States to develop and implement action to 92 million working days a year from men- promote mental health and prevent mental tal illness and that the direct health, social illness … Invites the Commission to con- care and benefit cost to the nation is about sider … the need to draw up a proposal for £20 billion, before you take account of the a Council Recommendation on the promo- cost to individuals of lost earnings and to tion of mental health.” This extract from the country of lost wealth creation. the unanimously adopted Resolution of the To me, even more important are the statis- Health Council meeting of 18th November tics that show just how many of us are John Bowis MEP in Brussels shows just how far we have mentally ill at any one time (one in seven), come since the Treaty of Amsterdam gave how many will be during our lives (one in the European Union competence for health three) and the fact that one in three of us promotion; since the Finnish Government who visit our GP have some form of psy- decided to make mental health a priority chosocial disorder but only one in six of us for their 1999 Presidency; and since the has that diagnosed. In the words of the Conference in Tampere, Finland on the National Lottery advertisers, ‘It could be Promotion of Mental Health and Social You’ – or me, or my wife or son or daugh- Inclusion, on 10th to 13th October, 1999. ter or a close friend - and it almost certainly This brought together the Council, will be one of those. And, if it is, then Parliament and Commission, together with shouldn’t we all want there to be in place a Finnish NGOs, the WHO and representa- “In the words of the caring, humane, close-to-home facility, tives of mental health practitioners, plan- where we can be restored to health or, if ners, service users and families came National Lottery that is not possible, then that we will be together from 10th to 13th October in cared for with love and with dignity and advertisers, ‘It could be Tampere, Finland for the first EU without stigma. That must be our driving Conference on the Promotion of Mental emotion and also our cool logic in pressing You’ – or me, or my Health and Social Inclusion. forward the need for mental health to be wife or son or daughter I was privileged to represent the European promoted as an integral part of EU policy. Parliament and speak in the opening ses- or a close friend - and sion alongside the Health Council’s The opportunities of Amsterdam Finnish President, Eva Biaudet and EU The Treaty of Amsterdam takes us forward it almost certainly will Health Commissioner David Byrne. Eva in two ways: it gives a real jurisdiction for be one of those.” Biaudet and I both challenged the mental health promotion and education Commissioner to put mental health firmly and illness prevention; it also provides for and highly on his agenda and pledged our all EU policies to take account of their support for him if he were to do so. effect on health, including of course mental health. We should therefore be able to look A growing burden forward to the development and implemen- We know, from a great deal of research but tation of some form of health impact notably from the trio of reports from the assessment, to go alongside the small firm, World Bank, WHO and Harvard employment and environment impact University in 1993, 1995 and 1996, that assessments that are supposedly in place mental disorder is the fastest growing cause already. I say ‘supposedly’ because my of disability and of the global burden of experience of Europe’s institutions is that disease. We know too that five of the ten they are quick – well fairly quick – to pass leading causes of disability are psychiatric regulations and directives but abysmally and that the burden is set to rise from the slow in ensuring they are implemented – current 10.5% to some 15% by 2020, at and even slower in doing something about which point it will overtake cardiovascular it.

5 eurohealth Vol 5 No 4 Winter 1999 EUROPEAN UNION

There is also a degree of sensitivity to be “Amsterdam does not give the EU power to direct health overcome where any EU action on health is concerned. In this area it is Germany, I am across the Union, but it does encourage it to research and told, who is the strongest upholder of the principle of subsidiarity. The Treaties, we share best practice, to promote education on steps to good are firmly told, do not cover health, which health and away from poor health.” is entirely a matter for member states. And that is true – well fairly true. In fact public health has been a competence of the EU for young people, the workplace and elderly some time and so has health and safety at people. work and so, following a recent judgement, has the right of European citizens to benefit Changes in society have made the world a from health provision in whichever mem- less secure and stable place for many chil- ber state they find themselves. But the actu- dren. Families break up; parenting skills are al system of health service provision is and no longer handed down the generations; remains entirely a matter for each country the parent’s job and housing mobility and its government and parliament. removes children from the wider family circle; crime, delinquency, truancy and Amsterdam does not give the EU power to unemployment inhabit too many estates. It direct health across the Union, but it does is hardly surprising that child behavioural encourage it to research and share best and psychiatric problems multiply. practice, to promote education on steps to good health and away from poor health. So At work, firms that take a health at work it will be right for the Commission to policy as a matter of course, look bemused enable member states and the Parliament to when you ask to see their mental health at find a range of good practice in prevention, work policy. People with a problem con- promotion and provision but not to go the ceal it, lest it should undermine their job or next step and say what each country must chance of promotion. Employees, who are provide. It will therefore have to be done caring for a disabled relative, struggle to by example and by showing what works. cope with both and end up coping with The exact border between health provision neither, for the lack of a flexible policy for and health promotion is a little blurred; for carers at work. And when the temporary or example when one is in the area of post- permanent end of work comes, through treatment care and rehabilitation and mea- redundancy or retirement, nobody helps sures to prevent relapse, clearly the two are the person prepare for the suddenness of interdependent. the change or to make best use of the new availability of time; and we wonder why The Tampere Conference people become depressed. Tampere was an excellent coming together The lengthening of our life years is a bonus of practical experience and academic but also a challenge. Many of us will thought. We started from the quartet of become not ill but frail of body or mind. base points We have a remarkable generation of 80 and 90 year olds, particularly women, who – acknowledging the social and economic found and took positions of responsibility causes of mental ill health as well as the during the war. There is perhaps a lesson in physical and neurological ones this that a sense of purpose and of being – accepting that many if not most mental needed and valued in our later years is health problems can be cured or sta- good for our mental and physical wellbe- bilised ing. Again social and economic factors are as important to a solution as medicines and – welcoming recently published evidence medical science. that health promotion works and that “firms that take a many mental disorders can be prevented So the lesson of Tampere is a hopeful one, even an exciting one, but one that tells us health at work policy – realising that we have a long way to go Tampere alone is not enough. The Finns in developing acceptable outcome and deserve enormous praise for firing the as a matter of course, cost effectiveness measurements and starting gun but the race is now on. The indicators, without which it is difficult look bemused when Council resolution took this on the first to convince finance ministers and budget lap; Parliament and Commission must now committees of the wisdom of investing you ask to see their follow, as must the Portuguese Presidency; in health promotion and above all a budget line must be estab- mental health at work There were three areas that the conference lished. The race is a marathon, not a sprint; felt merited priority action: children and but at least we are all now up and running. policy.”

eurohealth Vol 5 No 4 Winter 1999 6 EUROPEAN UNION

Employment and Social Affairs as a result of its historical development from health Health policy in the EU and safety measures in the European Coal and Steel Treaty and Euratom, which were the forerunners of the Common Market A basic guide (EEC) and the European Union. Consumer protection questions were origi- Graham Chambers nally handled by a unit within DGXI (Environment) and then by a separate, so- called ‘horizontal’ unit outside of any DG. This is my second attempt1 to take you through the labyrinth This lasted until a new DG (XXIV) was of the European Union’s modus operandi and lead you out at created in 1993. The BSE crisis, which the other side, compos mentis. Both our tasks are simplified revealed many inadequacies in the because of the most recent changes to the ways in which the Commission’s structure, triggered large- scale reforms in which health was amalga- EU works, the Treaties of Maastricht in 1992 and Amsterdam mated with DGXXIV in a new Health and in 1998. The fallout from the 1999 ‘implosion’ of the Santer Consumer Protection Department. The Commission and nomination of the Prodi Commission numbering of DGs having been dropped in resulted in considerable changes in the Commission and in favour of departmental names. its relations with the Parliament. There are fears that consumer protection will predominate over health policy in the new department, given the current preoc- The European Union does not have a ‘gov- cupation with food hygiene and the almost ernment’ made up of Members of the theological arguments over the safety of European Parliament. Rather, there is an British beef. institutional triangle in which (very approximately), the Commission proposes, The Council of Ministers and Council and the Parliament scrutinise The composition of the Council of and jointly legislate. Ministers varies according to the policy The relative weight of the three main play- area. The Health Council is composed of ers changes and there is a permanent insti- national ministers of health or their equiva- tutional ‘tension’ between them. There is a lents. As well as the permanent Council fourth player in the centre of the triangle secretariat in Brussels, all Member States The Court of Justice, which is the guardian have permanent representations in Brussels, and ultimate interpreter and arbiter of the which regularly meet outside of ministerial “There are fears that Treaties. meetings. There are other EU Institutions. The Court consumer protection The European Parliament of Auditors scrutinises EU expenditure. The Parliament is the only directly elected The Economic and Social Committee and will predominate over European body. It was created as a coun- the new ‘Committee of the Regions’ terweight to institutional power at a (which has a health mandate) are consulta- health policy in the European level. Its Members were initially tive bodies, without legislative power. The new department, appointed by Member States from their three principal players are: own Parliaments, but direct elections had given the current always been envisaged and in 1979 the first The European Commission elections took place (the first elections to preoccupation with Headed by a ‘college’ of 20 Commissioners, an international parliament ever). including President Romano Prodi, the food hygiene and the Commission is charged with implementing Parliament now comprises 626 Members, the Treaties. This means running detailed the number from each Member State is cal- almost theological policy, where it exists (e.g. the CAP) or culated in weighted proportion to its population, but the members sit according to arguments over the developing policy, where the Treaties grant the power to do so (e.g. the Single Market.) political affiliation and not nationality. They belong to ‘political groups’, which safety of British beef.” The Commission employs about 20,000 in range from nascent European political par- Brussels and in Luxembourg. It is divided ties, at one extreme, to loose ‘technical into departments headed by a Director coordination’ groups of small parties at the General. Each Commissioner is responsible other. for one or more departments. 1. The first article ‘Inside the Parliament’s Secretariat employs about Labyrinth’ appeared in Health was previously one directorate 4000, divided into seven Directorates eurohealth, September 1996. within the Directorate General (DG) for General. The total includes the Political

7 eurohealth Vol 5 No 4 Winter 1999 EUROPEAN UNION

Group staffs and the Members’ assistants. the Council at the same time. In Parliament, it goes to the appropriate ‘lead’ Parliament’s role is to scrutinise the execu- Committee, and to one or more other tive (Commission and Council) and it does Committees for Opinion. The Committees this through its Committees, each of which (which usually have between 20 and 50 covers a policy area. Health comes under Members) are structured to reflect the the powerful Committee on Environment, overall political balance in Parliament. A Consumer Protection and Health, current- ‘rapporteur’ is appointed to shepherd the ly chaired by Dr. Caroline Jackson, a proposal through the Committee. What British Conservative MEP. emerges after voting then goes to Plenary. At various times, usually after the elections, The version that results from the Plenary when Committee Chairmanships are divid- vote is Parliament’s official Opinion. ed up between the political groups, a separate committee for health has been suggest- For a long time, Parliament’s powers were ed. This seems attractive on the surface, but impressive on paper, but difficult to use in the fact is that health probably does a lot practice. Although it could reject the entire better with the weight and power of the EC budget, it had no power to change large Environment Committee around it. parts of it and although it could vote to ‘dismiss’ the Commissioners, it had no say One result of Parliament’s increased power in who would replace them. In addition, is that it is heavily lobbied, as indeed is the Parliament was only ‘consulted’, which Commission. An entire industry has grown meant that its Opinion could be ignored. up in Brussels as a result. Often called the ‘Eurosphere’, it comprises a huge range of The direct elections of 1979 gave special interest groups, consultancies, lob- Parliament legitimacy. By the beginning of byists, lawyers and much increased local the 1980’s, the EC had run out of steam. and regional representation since the estab- Too much necessary legislation to create lishment of the Committee of the Regions. the ‘Single Market’ was stuck in the machine because of the need to obtain una- “How does the ‘white Health has its lobbyists too, although they nimity in the Council. Difficult enough tend to be less well funded than, for exam- with 6 Member States, it became impossible rabbit’ of health ple, the tobacco lobby. As well as interact- with 12 and later 15. The ‘Single Act’ ing with the EP Committee responsible, amendment to the Treaties in 1987 was fol- survive in the jungle lobby organisations interact with individ- lowed by the (Maastricht) Treaty of 1992. ual members of Parliament and in the case The effect was to put the EC (now EU) of savage beasts such of health with various intergroups, the back on the rails to greater integration by as agriculture and most prominent of which has been the completing the Single Market and creating ‘Health Forum Intergroup’ in the new or enlarged policy areas, one of which industry?” Parliament. was health. Intergroups are a parliamentary phenome- The ‘quid pro quo’ was increased power to non worth explaining. They are groupings Parliament, to counteract the so-called of Members with particular interests. In ‘democratic deficit’. From being more or themselves, they are not official organs of less a consultative organ, Parliament Parliament but they are in the main spon- obtained a second reading and a variety of sored by the various Political Groups. conciliation procedures giving it the power They can complement the work of of co-decision with the Council in many Committees by providing a useful forum areas, including health. In addition, it for discussion of issues at a prelegislative obtained the power to ‘vet’ the appoint- stage. ment of Commissioners, ratify EU Treaties with third parties and advance its agenda in The legislative procedure a number of other subtle and not so subtle The Commission (often egged on by ways. Parliament and sometimes by one or more Member States) brings forth a legislative Health policy proposal, prepared in the appropriate The earlier treaties contained few provi- Directorate General, often by fewer people sions of direct relevance to health, mainly than you might think, although the in health and safety at work. However, Commission consults widely with a range other policies including agriculture, free- of bodies, including the Economic and dom of movement, research programmes, Social Committee and the Committee of internal market provisions for medicinal the Regions. products, mutual recognition of medical The proposal is sent to Parliament and to qualifications, free movement of services

eurohealth Vol 5 No 4 Winter 1999 8 EUROPEAN UNION

and environmental and transport measures the concerns of its electorate. There is no have a considerable impact on the health of doubt that the public is becoming much the public. more sensitised to questions of health. This is partly due to the success of EU The Maastricht Treaty article 129 gave a economies, which has resulted in the popu- specific legal basis and competence in the lation living better and for longer than ever field of public health, though subject to before, raising questions of lifestyle, sus- conditions of subsidiarity. It stated that: ceptibility to illness and the quality of “the EU shall contribute towards ensuring health care. No less important is the ques- a high level of human health protection by tion of how increasingly expensive health encouraging cooperation between member care is to be paid for in the future. Health is states and, if necessary, lending support to advancing rapidly up the political agenda, their action. Action shall be directed aided by various scandals concerned with towards the prevention of diseases, in par- health, AIDS infected blood, salmonella or ticular the major health scourges, including dioxin in chickens, BSE in beef etc. drug dependence, by promoting research No one wants health services to be run into their causes and their transmission, as from Brussels and this is not on the agenda. well as health information and education. Nonetheless meetings at all levels between Health protection requirements shall form those concerned with health issues in the a constituent part of ... other policies.” EU are bound to result at the very least in The Treaty of Amsterdam, introduced on exchange of information and best practice. May 1st 1999, whilst not introducing an Current policy emphasises the need for EU health policy, nonetheless takes a num- action at EU level to bring ‘added value’ ber of steps in that direction. Article 3(p) and the Finnish Presidency of 1999 strong- sets out an overall objective “to raise the ly emphasised cooperation in the field of standard of living and working conditions mental health. by … contributing to … a high level of All EU member states face the same prob- health protection.” Article 153, replacing lems in health and there is much to be art. 129, stipulates: “a high level of human learned from shared information and expe- health protection shall be ensured in the rience. In addition, free movement of peo- definition and implementation of all ple covers not only tourists but also profes- Community policies and activities.” sionals in the health field and free move- “Despite all the talk of These provisions are very important ment of goods and services covers pharma- because they clearly put an obligation on ceuticals and indeed provision of health subsidiarity, the inter- the Commission and on member states to care (as the Kohll-Decker and other cases ensure that all other policy initiatives, be before the Court of Justice have shown). national nature of they in the environmental, transport, agri- Despite all the talk of subsidiarity, the culture or any other field, ensure a high international nature of health policy is health policy is making level of human health protection. making itself increasingly apparent. In future, pan-European, or at least trans-bor- We still have a long way to go in ensuring itself increasingly der, health insurance organisations are by that health considerations form a signifi- no means unthinkable, although the thorny apparent. In the future cant part of other policies and indeed the question of how these could relate to and burning question is, given the Treaty provi- interact with Beveridge-type national panEuropean health sions, how do we ensure that human health health service systems remains to be protection is not only ‘taken into account’, insurance organisations addressed. but forms the basis of policy initiatives in are by no means other areas. The European Parliament has shown its determination not to let health policy be Given the vested interests and consequent sacrificed on the altar of subsidiarity, as unthinkable” lobbying in areas such as trade and com- was once suggested. Most member states merce, agriculture and transport, it is per- realise that so many aspects of health policy haps unsurprising that, so far, efforts to are not limited by national boundaries. stop CAP tobacco subsidies, ban all tobac- Woolly as Article 153 is, and hedged about co advertising, and reduce traffic pollution with subsidiarity clauses, its very vagueness have so far been of limited success. How can be regarded as advantageous to the does the ‘white rabbit’ of health survive in development of an EU health policy that the jungle of savage beasts such as agricul- complements and does not replace national ture and industry? health policies. To accommodate future One answer is through the European developments, health policy in the EU may Parliament, which though lobbied hard by well turn out to be of the ‘variable geome- the ‘savage beasts’ is also highly sensitive to try’ kind.

9 eurohealth Vol 5 No 4 Winter 1999 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND Health policy in Northern Ireland: What can we expect after devolution?

or over thirty years Northern Ireland Towards a government for Ulster? Fhas seldom been out of the news If agreement between the Northern Ireland because of the relentless toll of violent political parties can be reached, an achieve- deaths, with over 3,200 people losing their ment that, at the time of writing, is looking lives since ‘The Troubles’ began in 1968. less and less certain, such a government The formal cessation of violence by the could soon be in place. A Northern Ireland main paramilitary groups, prior to the sign- assembly, operating under a complex set of ing of the Good Friday Agreement last rules to ensure that any measure has cross- year, has reduced the annual toll of politi- community support, has already been Martin McKee cally motivated murders to an all time low, elected. If the politicians can agree on even if it has not completely eliminated issues such as decommissioning of paramil- them. While each of these deaths has been itary weapons, an executive will be estab- an individual tragedy for the friends and lished, with members drawn from the family of the victim, what has received province’s elected politicians and with much less attention over this period is the responsibility devolved from the United vastly greater toll of premature death from Kingdom parliament for a wide range of causes such as heart disease, cancers, and areas, including health. If this happens, 1 accidents. Each year, about 3,000 people, what policies can we expect from the nearly as many as have died in the thirty assembly and executive on the health of the years of ‘The Troubles’, die before the age people of Northern Ireland?

Positions of the parties “The Northern Ireland diet, symbolised by the ‘Ulster fry’, This article examines the stated policies on health of each of the leading political paris notoriously bad, levels of obesity are increasing, and rates ties. (As many readers may be unfamiliar of smoking among women are remaining stubbornly high. with these parties some key points are presented in Table 1). In most cases the infor- From a global health perspective, it is these premature mation was extracted from their manifestos for the assembly elections or from specific deaths that any future government of Northern Ireland policy statements obtained from their web sites. Gathering the information was a must tackle.” somewhat depressing experience as the web sites tended to be dominated by discussions on matters that were clearly much more important to the politicians, most notably of 75 from heart disease or stroke. Death the contentious topic of parades. The sig- rates from heart disease are among the nificance of this issue may be lost on those highest in the European Union, exceeded readers not from Ireland but an explanation only by the Republic of Ireland, and life would go well beyond the scope of this expectancy at birth is more than a year less article and would certainly offend one side than that for the United Kingdom as a or other. whole. The Northern Ireland diet, symbolised by the ‘Ulster fry’, is notoriously bad, The Social Democratic and Labour Party levels of obesity are increasing, and rates of (SDLP) and Sinn Fein, neither of whose smoking among women are remaining web sites contained information on health stubbornly high. From a global health per- policy, were contacted for more informa- spective, it is these premature deaths that tion but only the former replied, also not- any future government of Northern Ireland ing that its web site would soon be must tackle. improved.

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long serving member of the health commit- Table 1 tee in the House of Commons, the lower NORTHERN IRELAND POLITICAL PARTIES — KEY POINTS house of the UK parliament. (number of seats in Assembly in brackets) Few parties had clearly identified health, as opposed to health care, policies although UNIONIST many had policies that would be of signifi- Ulster Unionist Party (28) cant importance for population health Largest unionist party. under other headings, such as education, Led by David Trimble. rural affairs, or community development. Accepts Good Friday Agreement. For example, the Women’s Coalition Blocking formation of executive because of failure of IRA to decommission argued for an integrated transport policy weapons. and the eradication of poverty.4 The Democratic Unionist Party (20) Alliance Party proposed a series of specific Second largest unionist party, led by Ian Paisley. policies designed to help the disabled.5 Rejects Good Friday Agreement as too conciliatory to nationalists. There was almost no explicit consideration Popular Unionist Party (2). of health inequalities, an exception being Small party with historic links to Protestant paramilitaries but now pursuing essentially socialist programme and promoting reconciliation. the SDLP manifesto, which noted the importance of addressing the broader In addition, three members elected as independents have formed the United determinants of health, such as poverty, Unionist Assembly Party and the United Kingdom Unionist Party, elected education and housing, although it offered with five seats, has spilt into two smaller parties. little specific guidance about what it would do. In contrast, the UUP policy focused NATIONALIST much more on improving health through health education. To the extent that Social Democratic and Labour Party (24) inequalities were considered, they were Largest nationalist party, long associated with constitutional nationalism. Led by John Hume. largely in relation to access to health care, either due to geography (UUP, SDLP) or Sinn Fein (18) between patients of fundholding and non- Led by Gerry Adams. fundholding practices (Alliance). Historically linked to the paramilitary Irish Republican Army (IRA). Unionist concerns about continuing links to IRA have blocked progress on formation of executive. Lack of a European perspective Also missing was any discussion of health CROSS-COMMUNITY policy and Europe or how the health of the people of Northern Ireland compares with Alliance Party (6). that of the rest of the Union, suggesting Draws support from both religious groupings. that the province’s poor position may not Led by Sean Neeson (a psychiatrist). be widely recognised. The failure of Linked to UK Liberal Democrats. Northern Ireland politicians to engage in Womens Coalition (2) European affairs has been noted elsewhere6 Draws support from both religious groupings. and is symbolised, uniquely in the United Explicit rejection of failure of male dominated parties to achieve solution to Kingdom, by the election of MEPs who Northern Irelands problems. believe they can combine their work in Strasbourg with membership of the United Kingdom parliament and, in one case, with The information obtained varied greatly in the additional duties of membership of the extent and nature. The Democratic Northern Ireland Assembly. Unionist Party (DUP) simply stated that it Policies concentrated largely on health was “committed to looking after your care. A universal finding was a concern interests in a caring health service, respon- about the amount of bureaucracy in the sive to local needs. We are pledged to pro- health service, with widespread calls for vide health care free for all.”2 In contrast, reductions in the numbers of health boards the Ulster Unionist Party (UUP) presented and rationalisation of provider trusts. a detailed paper from its health committee that addressed a wide range of issues relat- Another issue achieving almost universal ing to the health service.3 Their report was agreement was that the level of health care unusual in that, for many issues, it spelt out funding was inadequate. This would, how- the pros and cons of different approaches ever, be contentious in a United Kingdom and recognised the need for both further wide context, in which English regions are research and for trade-offs between com- increasingly questioning the arrangements peting objectives. This may reflect the fact whereby Northern Ireland and Scotland that their health spokesperson has been a have historically, spent somewhat more on

11 eurohealth Vol 5 No 4 Winter 1999 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND health care than the rest of the United and security issues seems to have prevented Kingdom. Successive governments have the Northern Ireland political parties from justified this on account of their more dis- taking fully on board what has already persed populations and higher levels of been done and what more is needed to deprivation and ill health. There were few bring the health of their population closer concrete suggestions to tackle the perceived to that of the rest of Europe. lack of funding. The Alliance Party advo- As many politicians in central and eastern cated hypothecated alcohol and tobacco Europe have learned, the move from politi- taxation but the Assembly will not have tax cal opposition to government is far from raising powers. easy. It would seem that, at least in health Although the distribution of hospital ser- policy, Northern Ireland’s politicians still vices has received enormous media atten- have some way to go. tion in Northern Ireland as a result of policies by the (non-elected) health boards to rationalise services, this issue was barely mentioned. An exception was the UUP Table 2 health committee report which noted that KEY AREAS IN THE EXISTING NORTHERN IRELAND HEALTH STRATEGY it was “difficult to argue against the case Family and child health and welfare for rationalisation of specialist services”, although it also argued for development of Physical and sensory disability complementary local services and good Learning disability transport provision. Mental health Several parties had identified issues of par- Circulatory diseases ticular concern to them, such as the quality Cancers of care in facilities providing long term care for the elderly (UUP), clinical research Other non-communicable diseases training (UUP), general practice fundholding (Alliance), and responsiveness of services to local communities (Popular Unionist Party),7 although few of these Post script issues had been developed into explicit Just as this edition was going to press, policies. agreement was reached among the political parties to form an executive. Sinn Fein A formidable task ahead nominated Bairbre de Brun as Minister of If the new system of devolved government Health and this was accepted by the works as planned, the executive and the Assembly. assembly will face a formidable task if they are to develop policies that will address the health needs of their population. It would, REFERENCES however, be wrong to assume that there is a health policy vacuum in Northern 1. Campbell H. The Health of the Public in Ireland. Since 1974 Northern Ireland gov- Northern Ireland. Report of the Chief ernment departments, while headed by Medical Officer. Belfast: DHSS, 1998. ministers appointed from within the 2. See http://www.dup.org.uk/scripts/ United Kingdom government, have devel- dup_s/manifestodetails.idc?article_ID=145 oped a range of innovative policies, reflect- 3. See http://www.uup.org/policies/ ing local circumstances. Bodies such as the healthis.html Northern Ireland Health Promotion Agency and the Cancer Registry have been 4. See http://www.pitt.edu/~novosel/mani- established. The Department of Health and festo.htm Social Services has developed a regional 5. Seehttp://www.allianceparty.org/html/ health strategy,8 similar to the English a-healthier.html Health of the Nation and Our Healthier Nation strategies, in which a series of key 6. Wilson R. Continentally Challenged. areas are identified (Table 2) and targets for Securing Northern Ireland’s Place in the health improvement are set. They have also European Union. Belfast: Democratic undertaken a series of seminars for Dialogue, 1997. Assembly Members to raise their aware- 7. See http://www.pup.org/manif8.html ness of the health challenges facing Northern Ireland. Unfortunately, the 8. DHSS. Health & Wellbeing: Into the almost exclusive focus on constitutional Next Millennium. Belfast, DHSS, 1997.

eurohealth Vol 5 No 4 Winter 1999 12 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND The health of the public in Northern Ireland

“it is the differences that exist in life expectancy within Northern Ireland that currently cause the deepest concern and call for concerted and sustained action”

The people of Northern Ireland are health- Comparisons within Europe show that ier than they have ever been and on a global Northern Ireland is not faring as well as scale they are healthier than many other other countries. The life expectation of populations. However, in comparison with males at birth in Sweden for example is other European countries our health could about three years better than Northern be much improved and within the Ireland. In France women can expect to Etta Campbell Northern Ireland population there are sig- live almost five years longer than women in nificant inequalities in health.1 Northern Ireland (see Figure 1). These differences pose interesting hypotheses for epidemiologists and set challenging objec- Figure 1 tives for policy makers. Many life years LIFE EXPECTANCY AT BIRTH, 1995 could be gained if we could fully explain these differences.

90 Inequalities in health 86 However, it is the differences that exist in 82 life expectancy within Northern Ireland 78 that currently cause the deepest concern 74 and call for concerted and sustained action. 70 People who live in affluent areas have a 66 much better life expectancy than those who 62 live in the most deprived areas (see Figure 58 2). If these inequalities could be addressed, 54 approximately 2,000 lives could be saved 50 Sweden France Spain UK EU N. Finland Denmark Ireland Portugal each year. Inequalities in health can be Average Ireland depicted in almost every health index Males Females which is available to us. Infant mortality rates are 50% higher in the most deprived group compared to the least deprived. Figure 2 These differences are carried through into LIFE EXPECTANCY WITHIN NORTHERN IRELAND BY DEPRIVATION childhood with higher rates of death due to (c. 1990) accidents. Children living in areas of great- 82 est deprivation are 15 times more likely

80 than the most affluent to die as a result of a house fire and seven times more likely to 78 die as a result of being hit by a vehicle. 76

74 Inequalities in health are very much in evidence right through into adulthood. 72 Significant differences in health exist 70 between Northern Ireland’s electoral 68 wards. Poverty and social exclusion rob a 66 significant proportion of our people of 64 their full potential for health and in turn 62 place a huge demand on our health services. Male Female Cardiovascular disease, including coronary Most affluent Affluent Average Deprived Most deprived heart disease and stroke, is the single

13 eurohealth Vol 5 No 4 Winter 1999 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND biggest killer in Northern Ireland.2 One in three men and one in four women die from Figure 3 coronary heart disease. ISCHAEMIC HEART DISEASE: AGE STANDARDISED DEATH RATES PER 100,000, ALL AGES, 1995 Although deaths from heart disease have been falling since the early 1980s, Northern Ireland lags behind other countries in 400 Europe where the death rates are dramati- cally lower (see Figure 3). With an ageing 300 population we can expect heart disease to remain a major problem for some considerable time. In addition more people than 200 ever are now surviving their first heart attack and are living with heart disease. The 100 incidence of chronic heart disease such as heart failure and atrial fibrillation is increasing. 0 Ireland U K Germany Norway Netherlands Luxembourg Spain N. Ireland Finland Denmark Sweden EU average Greece Portugal France Breast cancer is the most common cause of death from cancer among women in Males Females Northern Ireland.3 The death rate from breast cancer in Northern Ireland is one of Notes: the highest in Europe. Provisional figures Age standardised death rates (SDR) were calculated by using the direct method and the European standard population. from the Cancer Registry suggest that at Ischaemic heart disease (IHD) refers to ICD 9 codes 410—414. long last the death rates from breast cancer Ranked by female SDR in descending order may be falling. Source: WHO (Europe) Northern Ireland has one of the highest NI rates derived from RGO (NI) mortality statistics and RGO (NI) population rates of colorectal cancer in Western estimates. Europe with about 600 new cases every year. The number of colorectal cancers is health will remain and grow even wider in falling among women but not men. Diet the foreseeable future even if concerted must remain a priority if any reduction in action is taken now. colorectal cancer is to be realised. On average, people in Northern Ireland eat fewer Signs for hope than three portions of fruit and vegetables Faced with these figures it would be all too each day, much less than the current rec- easy to give in to despair. However there ommendation of five portions. are some signs of hope. Since 1986 the Mental illness is one of the most common Regional Strategy5 for the Department of forms of ill health in Northern Ireland. It is Health and Social Services in Northern responsible for enormous costs to the indi- Ireland has been based on the principles of vidual and to society. Many working days Health for All. Whilst this strategy did not are lost as a consequence of mental illness. have the impact that we might wish, it did Using the General Health Questionnaire introduce a new language into policy devel- the Northern Ireland population is at an opment and programme implementation increased risk of mental illness when com- within health and social services. In the “trends in disease and pared to other UK regions.4 past, Government in Northern Ireland has introduced the principle of ‘Targeting the risk factors for Risk factors for ill-health Social Need’ across all Government Smoking is a common risk factor for many Department. Within the past two years the disease suggest that of the major diseases. Whilst there has been interest paid to tackling social inequalities some reduction in the numbers of people within the UK Government has given an heart disease, stroke, who smoke the number of smokers in the added focus on these issues. Importantly population is still high at 28%. the ‘Surestart’ programme of pre-school cancer and diabetes support and education may in the long- These trends in disease and the risk factors will remain as major term bring benefits if outcomes match the for disease suggest that heart disease, famous US Study, Headstart. stroke, cancer and diabetes will remain as causes of premature major causes of premature death and mor- At the moment we are all waiting to see if death and morbidity bidity well into the next century. The dis- devolution will bring the opportunity for tribution of the risk factors for these dis- better health. The new Assembly will well into the next eases across the social divide within our inevitably have its attention held by the society suggest that the inequalities in ‘local hospitals’ debate and the inevitable century”

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“the Public Health health service funding issues that distract emic qualifications, but leadership that has all Governments. There will be an urgent been won by those who can persuade, body … will require need to ensure that attention is drawn to influence, manage, but most of all inspire. the wider agenda of public health. Collaboration in public health is the only leadership … way forward. A team approach is needed. The development of public health policies leadership that has needs to be based on the best evidence. REFERENCES Expert help needs to be given in terms of been won by those who 1. Fifty years of the Health Service. Annual skills, knowledge, and insight to inform Report of the Chief Medical Officer 1997. that process. In turn Government must be can persuade, 2. The Health of the Public in Northern open enough to be informed. Public health Ireland. Report of the Chief Medical Officer influence, manage, but experts need to build the evidence-base and 1997. develop a credible corporate voice with 3. Cancer Deaths in Northern Ireland – most of all inspire.” which to inform. Analysis of Patterns and Trends. Northern To be truly effective the Public Health Ireland Cancer Registry Report 1995. body needs to be inclusive and multidisci- 4. Department of Health and Social Services. plinary and non-elitist. Northern Ireland Health and Social In addition, it will require leadership – Wellbeing Survey. Preliminary Report. leadership that is gained not by dint of Belfast: DHSS 1999. position within an organisation or by acad- 5. The Regional Strategy 1987–1992.

‘Cooperation and Working Together’

Improving the health of the border populations in Ireland

Background to the initiative Banbridge Community HSS Trust. In July 1992 the North Eastern and North CAWT Boards/Trusts share common Western Health Boards in the Republic of demographic features and common prob- Ireland and the Southern and Western lems in terms of rural isolation, infrastruc- Health and Social Services Boards in ture, population trends and unemploy- Tom Frawley Northern Ireland entered into a formal ment. There is constant cross border traffic, agreement, known as the Ballyconnell and there are examples of services provided Agreement, to cooperate in improving the in a consumer’s natural hinterland that are health and social well-being of their resi- provided by the neighbouring Member dent populations. These four Boards cover State on an agency basis. the whole of the land boundary between the Republic of Ireland and the United The primary objectives of CAWT were Kingdom and between them they comprise identified as the improvement of health and a population of one million people. social well being of CAWT’s resident populations by: With the reforms of Health and Social Services in Northern Ireland, the member- • The exploitation of opportunities for ship of Cooperation and Working cooperation in the planning and provi- Together (CAWT) was enlarged to include sion of services; Foyle Health and Social Services Trust, the • The involvement of other public sector Sperrin Lakeland Health and Social Care bodies in joint initiatives where appro- Trust, Altnagelvin Trust, Armagh and priate; Eithne O’Sullivan Dungannon HSS Trust, Newry and Mourne HSS Trust, Craigavon Area • The exploitation of all opportunities for Hospital Group Trust and Craigavon and joint working or sharing of resources

15 eurohealth Vol 5 No 4 Winter 1999 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND

where these would be of mutual advantage; SHARED RESOURCES/FACILITIES UNDER CURRENT SPECIAL SUPPORT PROGRAMME FOR PEACE AND RECONCILIATION (SSPPR) PROJECTS • Assisting border areas in overcoming the special development problems arising from their relative isolation. WHSSB SHSSB Official endorsement for the CAWT process has been given at a national level by both ministers of health and by the departments of health in Northern Ireland and the Republic of Ireland. Donegal 2 1 ¥ Areas of cooperation 2¥ CAWT has sponsored joint working across ¥ ¥ 1 a range of service areas. These include acute 6 ¥ 6 3 services, primary care, accident and pre ¥ 4 8¥ ¥ ¥ hospital care, learning disability, family and ¥ child care, mental health, health promotion Monaghan 8¥ 4 and public health. CAWT has been operat- 3¥ 7 4 ¥ ¥ ing a two track approach, concentrating on Sligo ¥ operational (across the fence, good neigh- 4 ¥7 Leitrim Cavan Louth¥ bour) cooperation in the provision of ser- 3¥ vices to the local resident populations, and 4 4 in addition developing, with the assistance ¥ of funds from the EU Special Support Programme for Peace and Reconciliation, Meath foundation projects for the further NWHB NEHB enhancement and longer term development of key service areas. CAWT has, in addition, developed a Secretariat to support and enhance ongoing cooperation and to devel- Acute Services: Linkages — Projects with SSPPR Support op a strategic direction for its future. In (1) Letterkenny/Belfast 1997 it published its Strategic Plan for the (2) Letterkenny/Altnagelvin period 1997–2001 and is at present devel- (3) Sligo/Enniskillen/Cavan oping a CAWT web page for wider dissem- (4) Cavan/Monaghan/Dundalk/Drogheda/Daisy Hill Newry Craigavon ination of its work and experience to date. Primary Care: Staff and practices from the four Board Areas NWHM/WHSSB/NEHB/SHSSB Achievements (5) Stranorlar/Castlederg Catchment Area Outlined below are key elements of the (6) Belleek/Ballyshannon programme of work currently underway (7) Carlingford/Strangford across a range of service areas. Mental Health Acute services (8) Garrison/North Leitrim Projects have now been undertaken between all of the centres providing acute services along the border: being developed in the case of (4), that is, (1) Craigavon/Drogheda/Dundalk/ between Letterkenny and Belfast. Projects Monaghan/Cavan/Daisy Hill. between Letterkenny/Altnagelvin and (2) Letterkenny/Altnagelvin. Enniskillen/Sligo/Cavan are still at an early stage and are focusing on the identification (3) Enniskillen/Sligo/Cavan. of potential areas for enhanced service (4) An acute services project is being devel- cooperation and provision. oped between Letterkenny General Hospital and a tertiary service at Belfast These projects are particularly timely with- City Hospital. in the context of the present review of acute services in Northern Ireland, and the In the cases of (1) and (4), joint service pro- strategic objective of the Health Boards in visions have been developed or are being the Republic of Ireland to extend the range developed in specified service areas. In the of acute services available in their areas. case of the Craigavon et al project, shared dermatology and teleradiology services Within the area of public health and health have been developed. Cancer services are promotion, CAWT has undertaken a breast

eurohealth Vol 5 No 4 Winter 1999 16 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND

cancer audit across the four Board areas. It communication system, and the testing of is anticipated that this audit will last a total all of the above developments within the of three years and will have strategic signif- context of a cross border major incident icance in the context of future planning for exercise in May 1999. breast cancer services. This project has also had particular strate- Primary care gic importance because of the current Review of the Northern Ireland Primary care cooperation across the border Ambulance Services and the recent Review has been developed in the following areas: of the Republic of Ireland Ambulance – Joint practice organisation. Services. It also has relevance for the cur- – Joint service developments. rent Review of Acute Services, and importantly in relation to the identification of – Community pharmacy. cross border accident and emergency ser- – Clinical practice. vices as an area for development within the – Facilities development, i.e. cross border context of the Good Friday Agreement. joint resource centres. Cooperation between specific social care – Initial work in the area of cross border groups health actions zones. Projects to enhance operational good prac- Work undertaken within practice organisa- tice within the areas of family and child tion has recently been nominated for a care, learning disability and mental health major UK award in primary care practices, have been undertaken in a number of areas. i.e. the Primary Care Management Award These include the following: 1999. 1. Family and child care: – Improved accident prevention strategies for children; “The future for cross border cooperation between Member – Protection of disabled children; – Improved parenting skills on a cross States within the context of wider European policy is border, cross community basis; crucial for the development of the Union in a way that is – Prototyping and Evaluation of youth intervention strategies; relevant and important for ordinary people.” – Drug awareness training. 2. Learning disability: – Piloting evaluation of different types of The work underway within the primary flexi care working schemes in margin- care project has particular strategic impor- alised areas; tance in the context of the primary care – Development of protocols and training groups envisaged in the reorganised for the protection of vulnerable adults Northern Ireland health services outlined within care settings. in ‘Fit for the Future’. It also dovetails with 3. Mental health: the blueprint for the development of general practice in the Republic of Ireland and – Development of a cross border resource the strategic approach being followed by all centre; the Boards for the development of primary – Community based research into suicide care services. prevention strategies; Ambulance services – Development and piloting of cross border training for mental health staff in The work undertaken within the joint cognitive therapy, and piloting support- ambulance training and developments pro- ed employment model of training for ject began between the Northern Ireland those with mental health problems. Ambulance Service and the NEHB initially, with the NWHB joining later in the Health promotion and public health project. This project focused on opera- A range of health promotion strategies has tional improvements between the ambu- been carried out under the auspices of lance services north and south of the bor- CAWT since 1992. These include major der. In this regard it concentrated on the health promotion activities in the areas of development of joint training packages, the childhood accident prevention, drug aware- piloting of a Geographic Information ness strategies, smoking cessation strate- System (GIS), the development of a joint gies, mental health promotion, suicide pre-

17 eurohealth Vol 5 No 4 Winter 1999 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND ventative strategies, examinations of com- and policy could significantly impact on pliance by elderly persons in use of medica- the problems in the border region, in par- tion. ticular on the difficulties created by the different funding and management systems in A programme of achievement the two jurisdictions. The fact that cooper- Since its inception CAWT has been suc- ation between the ministers of health in cessful in a programme of real achievement: both Northern Ireland and the Republic of Ireland over a number of years is well 1. Beginning the process of strategic, epi- established is a firm foundation for future demiological and operational planning for a development. transborder region. 2. Establishing formalised cross border cooperation within the health and social “In achieving operational cooperation … there have been care sectors in the border region. significant improvements in service cooperation, and the 3. Improving service for the CAWT population. development of new and innovative approaches to 4. In achieving operational cooperation common issues and problems.” across the range of areas outlined above, there have been significant improvements in service cooperation, and the develop- Future Developments ment of new and innovative approaches to The Good Friday Agreement recognises common issues and problems. In addition certain areas of cooperation in health as there has been a pilot provision of new being worthy of future development. These localised services on a cross border basis are: for resident populations who heretofore 1. Accident and Emergency Services. would have been required to travel to the 2. Cancer Services. main centres of Dublin and Belfast for such services. With the groundwork undertaken by CAWT, opportunities exist for a more 5. Working in collaboration with other organisational approach to planning for agencies and bodies to establish the special health and social services in the border needs of the population in the border region. To date much of the work under- region. taken by CAWT has been funded through 6. Placing health sector coordination on the European funds. It is anticipated that agenda with both Departments north and national governments will recognise: south. – The special needs of the border region; Current opportunities in a changing – The need to border proof their national political environment policies; CAWT will continue to build on opera- – The need to focus in a special way on tional cooperation and to enhance service encouraging and promoting cross border provision to its client population by means cooperation in key public service areas of strategic partnerships and alliances. within the border region, which has a Difficulties posed by back to back planning dispersed, isolated and marginalised pop- at national policy-making level and the ulation. very different natures of employment, namely in relation to terms and conditions, In simple terms CAWT has proven that practical cooperation across the border can registration etc., are seen as positive chal- enhance service provision, create lenges which, in cooperation with national economies of scale and enhance peace and and European bodies, can be overcome in reconciliation through collaborative work- an innovative and energetic way by CAWT ing. The future for cross border coopera- and other cross border public bodies. tion between Member States within the The re-introduction of an executive into context of wider European policy is crucial Northern Ireland and its potential for mak- for the development of the Union in a way ing its own stand-alone legislation and that is relevant and important for ordinary policies provide a major opportunity for people. Continued and coordinated coordination of policy making on the European, national and local commitment island. If supported by both UK and Irish to the needs of this border region can only governments and with a focus on joint produce increasingly significant and longer cooperation, much of this new legislation term benefits for the population.

eurohealth Vol 5 No 4 Winter 1999 18 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND Health care across borders: The scope for North-South cooperation in hospital services

Shared problems but individual The political settlement in Northern solutions Ireland has been accompanied by a grow- The Good Friday Agreement and the con- ing recognition, on both sides of the bor- stitutional changes that have arisen from it der, that cooperation can bring important offer scope for a reassessment of the provi- benefits. This process is being encouraged sion of acute health care in Northern by substantial funds, in particular from the Ireland. Provision of hospital services in its two governments and the European Union. border regions has long been contentious Most readers of Eurohealth will be familiar with the current pattern based largely on with the provisions for free movement of historical factors. Health authorities, in this patients within the European Union so rural region with its very low population these will not be repeated here. In addition, density, have sought, since at least the mid however, the UK and the Republic of 1960s, to concentrate facilities on fewer Ireland have a separate agreement enabling Dorothy McKee sites. It has, however, been difficult to each other’s citizens to obtain care in the introduce change in the face of widespread other state without requiring an E111 form. public and professional opposition, based largely on concerns about poor transport In 1992, health boards on either side of the links. border, signed an agreement (the Ballyconnell Agreement) to “improve the Although the border areas of both health and social well being of the resident Northern Ireland and the Republic of populations and to exploit opportunities Ireland face the same problems, proposed for cooperation, joint working and sharing “formal contact solutions have been limited to only one of resources”. This led to the establishment country. A common response, based on of Cooperation and Working Together for between official bodies cross-border cooperation, has received no Health Gain and Social Well Being in serious consideration. This is especially in Northern Ireland Border Areas (CAWT), which has devel- surprising in view of both the long tradi- oped work in areas such as mental health, tion of free movement across the border – and the Republic has prevention of childhood accidents, drug facilitated by the existence, since Irish inde- education and information technology. In been extremely limited pendence in 1921, of a common travel area addition, the border health boards are shar- within which passports are not required – ing experiences in primary care, supported and, at least in and, until relatively recently, the use of a by funds linked to the Northern Ireland common currency. Furthermore, the med- peace process. Northern Ireland, ical professions in the two countries have strong links. The Irish Royal Colleges, The Good Friday Agreement, ratified by highly contentious” which predate independence, draw mem- referendum in May 1998, provides for a bers from both parts of the island. North/South Ministerial Council, “to develop consultation, cooperation and On the other hand, formal contact between action within the island of Ireland –includ- official bodies in Northern Ireland and the ing through implementation on an all- Republic has been extremely limited and, at island and cross-border basis, on matters of least in Northern Ireland, highly con- mutual interest within the competence of tentious, extending only to matters such as the Administrations, North and South.”* fisheries and the cross-border rail link. In This has included social security and social addition, cooperation on health care has welfare. ‘Health’ seems to have been some- been complicated by different financing thing of an afterthought, specifying inclu- and delivery systems. sion of “accident and emergency services and other related cross border issues”. It seems likely, however, that emerging cross- border structures will ultimately provide a * Agreement reached in multi-party negotiations. See http:/www. basis for cooperation on other health-relat- nio.gov.uk/agreement.htm ed issues,1 building on recent developments

19 eurohealth Vol 5 No 4 Winter 1999 NEW OPPORTUNITIES FOR HEALTH IN NORTHERN IRELAND in cross-border cooperation on communi- Few saw any obstacles but, of those who cable disease control and cancer registra- did, the main one was political resistance to tion, although much will depend on the any kind of cross-border cooperation. A attitude of a Northern Ireland executive. few were concerned that some patients might be reluctant to cross the border, that The scope for cross-border administrative costs would be high, and “Many saw the emerg- cooperation that the flow would mainly be from South Although the purchaser-provider split in to North. Some also questioned whether ing cross-community Northern Ireland enabled health boards health boards would really be willing to and trusts to agree contracts with bodies in pay for services elsewhere that were avail- spirit of cooperation the Republic, this has had little practical able in their own country. However, many creating a new political effect. Some outpatient services are provid- saw important new opportunities for ed in Derry and Omagh, in Northern improving cross-border cooperation, such context in which col- Ireland, for residents of the Republic and as sharing ambulance services, out of hours health boards in both countries have pur- cover for primary care, and better access to laboration would be chased some elective procedures, such as specialised tertiary facilities. A common cardiac bypasses and orthopaedic proce- view was summarised by one general prac- much less contentious.” dures, from each other. titioner who said, “until border issues are dealt with, acute services will never make Nevertheless, there is likely to be an under- sense”. This view seems to be gaining sup- estimate of the scale of cross-border flows, port, with a senior nurse from Northern as there is no effective system to measure Ireland writing that “successive govern- them. There is, however, a widespread ment reviews and proposals have been impression that patients from Donegal, in based on deliberations within the context the Republic of Ireland travel to Derry, in of Northern Ireland only, and ignores the Northern Ireland – many may use address- reality concerning duplication of acute ser- es of friends or relatives there when doing vices” along the border.3 so. In August 1998, following a bomb in the Last year I examined perceptions of cross- town of Omagh that killed 29 people and border care in a survey of managers and injured over 100, health care facilities on general practitioners in a border area of both sides of the border worked together in Northern Ireland, supplemented by infor- a new, and very visible, cooperative spirit. mation from government bodies and health Many saw the emerging cross-community boards in both countries.2 Respondents spirit of cooperation creating a new politi- saw cross border flows as predominantly cal context in which collaboration would into Northern Ireland. Few general practi- be much less contentious. Despite this, tioners were aware of proposals to increase subsequent proposals for acute services in cross border cooperation in health care, the west of Northern Ireland are based on although most saw advantages outweighing patient flows within Northern Ireland and disadvantages, citing benefits such as short- fail to take account of the cross-border per- REFERENCES er waiting lists, easier access, and better ser- spective.4 1. Barrington R. The future vices. Another perceived benefit was the political, legislative and social ability to support local hospitals that are The structures that have emerged from the framework of the health ser- currently not viable but which could political settlement in Northern Ireland vices. In: Wiley MM, Leahy become so if they served both sides of the now provide a basis for much closer cross- AL (eds). The Irish Health border cooperation in the field of health border. System in the 21st Century. care. The low density, highly dispersed Those in hospitals saw similar benefits, in Dublin: Oak Tree Press, 1998. population on both sides of the border cre- particular the ability to concentrate provi- ates major challenges for those providing 2. McKee D. North-south sion while maintaining access, and several hospital services. While greater cooperation cooperation in acute health argued that greater cooperation in health will not be a panacea, it can bring real care – an idea whose time has care would bring benefits for the political benefits to those living in both countries. come? Journal of Irish Coll process, reducing mutual suspicions and Physicians Surg 1999; 28: This issue was long considered too politi- fears. 133–7. cally sensitive to discuss openly and those According to general practitioners, disad- activities undertaken together were not 3. Mullan A. Radical thinking vantages included potential incompatibility widely known. Results of my survey show needed for Health Service. of payment systems, currency transactions, that there is no serious opposition to Ulster Herald, August 13th administrative costs and competition greater cooperation from either health 1998. between the various towns to maintain ser- professionals or managers. Of course, the 4. Anon. New- build £76.5m vices. A concern, voiced by some in hospi- true test will be whether it is acceptable hospital plan for NI. Health tals, was how to ensure quality in another to all shades of political opinion in this Service Journal 1999; 22nd country. divided region. Apr: 4.

eurohealth Vol 5 No 4 Winter 1999 20 HEALTH PROMOTION AND THE EUROPEAN SINGLE MARKET

The health impact of European single market legislation

Since its early years, one of the main aims of the European Community has been to develop a unified internal market. The intended to establish. The reason for this is final step was the completion of the single market on 1st January that market forces can have a ‘levelling down’ effect: suppose food hygiene stan- 1993. The legislation that paved the way for that was the Single dards were originally higher in one European Act of 1986. The principal aim of the Act was to facili- Member State than in others. This is likely tate the free movement of goods and services, and of people to be accompanied by higher costs. The consequences of liberalising trade in such (labour). It also contained many other provisions that were circumstances are that domestic production considered relevant in this context. will be replaced by cheaper imports with From the point of view of health, the lower standards for consumers, and that the producers in that Member State will be most important was article 100a, penalised. There will also be negative impli- guaranteeing a ‘high level of health cations for the balance of trade. The setting protection’. of a ‘floor’ would prevent this happening, and the specification of a high level of health protection was intended to ensure additionally that standards would rise in those Member States that had hitherto had Commission project a lower level of health protection. The European Commission funded a short The project proposal put forward the project, which ended in early 1999, with hypothesis that after the coming into being the aim of investigating the possible health of the internal market on 1st January 1993, impact of internal market legislation. This standards had both risen, and become was carried out in the Department of Mike Joffe more uniform (except in those cases where Epidemiology and Public Health, Imperial national derogations have been agreed). College, London, in collaboration with the European Public Health Alliance. In preparation for the completion of the single market, a great deal of work was car- Its objectives were: ried out, coordinated by the Commission. i to investigate the health impact of EC Much of this was motivated by considera- policies that are relevant to the free tions of health. For the purpose of this pro- movement of goods; ject, ideally one would like to have been able to assess whether the resulting degree ii to develop the methodology of health of regulation was too low from a health impact assessment in this context; protection point of view, or possibly higher iii to establish a European network of rel- than could be justified by the evidence – as evant expertise. may be true of certain drinking water stan- The specific areas of work were pharma- dards, which are outside the scope of this project. However, it has become clear that Sofie De Broe ceutical products, medical devices, dangerous substances and preparations, foodstuffs the evidence rarely exists on which such a and fiscal policy. The European legislation judgement could be made. Little material in each of these areas was taken as the start- has been published in peer-reviewed jour- ing point for the work. In a project lasting nals, and while more information was avail- 15 months and covering such a broad able in the ‘grey’ literature, we found that range, it was necessary to rely on a critical this is an under-researched area. It is review of existing evidence, rather than on unclear why this is the case. original evaluative research. A public seminar for the project took place during October 1998 in Brussels. The effects of market forces Approximately 50 people registered, from The basic concept underlying the project the European Commission and other EU was that the health impact of internal mar- institutions, statutory bodies in Member ket policies would depend on the minimum States, industry, academia and the NGO standard that each European Directive is sector. The seminar brought together con-

21 eurohealth Vol 5 No 4 Winter 1999 HEALTH PROMOTION AND THE EUROPEAN SINGLE MARKET tributions from three of the five topic areas, complete all stages of the model, reliable fiscal policy, foodstuffs and pharmaceuti- data on actual exposure levels in all the cals, thus introducing a comparative ele- Member States would be needed. ment into the debate. Unfortunately, this was not possible for asbestos, so that the potential health gain The comparative dimension from tighter controls could not be rigor- One of the advantages of carrying out a ously quantified. project in several topic areas at once is the Another possibility in trying to assess the comparative dimension. For example, the effectiveness of EU legislation would be to EU approach in certain instances has been start from the legislation itself, for example, to develop a positive list, such as that for particular food additives for which the legal dangerous substances, and also of permit- status had changed as a result, and then to ted food additives with indications of per- relate this to scientific evidence and try and mitted uses and maximum concentrations. assess the likely health impact. This is the On the other hand, in the case of food ‘intervention driven’ approach. In attempt- hygiene a more elaborate system of Hazard ing this, however, it transpired that dis- Analysis Critical Control Point (HACCP) putes over particular items tended to relate has been introduced with the aim of to different trade-offs made by different improving the way food is handled Member States, which in turn tend to be throughout the food chain. DG XI is try- rooted mainly in their differing levels of ing to introduce ways of moving towards a prosperity and their cultural traditions. more sustainable use of plant protection products (pesticides used in agriculture): to ensure that smaller quantities are used, of less toxic compounds. “In preparation for the completion of the single market, a There are differences too in post-marketing great deal of work was carried out…Much of this was surveillance. The Directive on medical devices, which has recently been enacted as motivated by considerations of health”. Member State legislation, introduced surveillance into this area, whereas in many, probably most, Member States, no such A third approach would be a situation in requirement existed. In contrast, the phar- which an increased risk is directly inferred maceutical area has been well regulated in from a knowledge of incidents that have this respect for decades. occurred, and in which the EU has inter- Other themes that could be used to com- vened to protect health. This is the ‘inci- pare the different topic areas include pack- dent driven’ approach. An example of this aging, labelling, claims and advertising. is a type of decorative lamp with a coloured oil that appealed to children. The health Finally, a major consideration is the size of problem was serious, as children drinking the health problems involved in the differ- the oil developed inhalation pneumonia ent areas. This would have to take into with fatal or long-term consequences (see account the seriousness of the problem as below). It was possible to document the fall well as numbers. It seems reasonable that in cases following the European Directive priorities should be set according to a ‘pro- that addressed the problem. The following portionality’ rule: that the intensity of articles analyse particular topic areas in health protection should be proportional to more detail. the size of the potential health gain.

Methodology: a model to assist in POLICY/RISK ASSESSMENT MODEL (PRAM) assessing health impact During the course of the project, a model Risk Assessment: was developed to relate pre-existing risks hazard identification invariant elements to policy interventions. This is depicted in dose-response relationship} existing risk the diagram to the right. actual exposure levels variable element } It was found that different areas of work had different points of entry. For example, HEALTH with a well researched major health risk policy intervention GAIN like asbestos, the starting point would be its well understood dangers, corresponding to the invariant elements of risk assessment. new exposure levels new risk This is the ‘research driven’ approach. To

eurohealth Vol 5 No 4 Winter 1999 22 HEALTH PROMOTION AND THE EUROPEAN SINGLE MARKET

The regulation of pharmaceutical products

The analysis in this area draws heavily on work presented at the seminar that was held in the course of the project.1,2 and the fees from industry that support it; the expectation is that only about five of them will survive, which has implications for the future of the European toxicological The road to harmonisation science base. There is also a requirement for rapid evaluation: a strict time frame The background to the EU-level system is (typically 210 days) may be all that is avail- that the regulation of pharmaceuticals has a able to review an application that runs to long history, and was already well devel- thousands of pages and that took the com- oped in the Member States before effective pany many months to compile, and it is harmonisation took place. Thus, apart from difficult to maintain high quality in these the possible economic advantages of an circumstances. enlarged single market, the EU system could benefit public health by providing a This and other features of the system mean higher quality of regulation than would that the industry and the agencies have a “it is unclear whether otherwise continue to be provided at relation of cooperation rather than the Member State level, in accordance with opposition that is traditionally associated standards are likely to Article 100a of the Single European Act with the regulatory process. This situation that specified ‘a high level of health protec- is evaluated differently by different partici- rise or fall in the tion’. However, it is also possible that a pants (apart from in the industry where it is harmonisation process could lead to a future as a result of uniformly welcomed), and places a heavy reduction in standards, rather than a rise. responsibility on the peer review process. While it is generally agreed that the scien- harmonisation.” The European Community’s first Directive tific standard is high, it is unclear whether on medical products regulation standards are likely to rise or fall in the (EEC/65/65) was published in 1965. future as a result of harmonisation. Common standards for specific toxicological and pharmacological tests were subse- Two other issues deserve to be highlighted. quently issued in 1975, when the First, there is widely agreed to be excessive Committee for Proprietary Medicinal secrecy, which is usually justified in terms Products (CPMP) was set up to provide of the need to maintain commercial confi- expert scientific advice. At the same time, a dentiality. If the latter is indeed necessary, Community-wide mutual recognition sys- it is unclear why the public and the regula- tem (the CPMP procedure) was intro- tors should be expected to trust pharma- duced. This was not completely successful ceutical companies that apparently cannot REFERENCES in achieving harmonisation, especially trust each other. 1. Lewis G, Abraham J. because Member States frequently tended Secondly, the EU regulatory system pays European pharmaceuticals reg- to seek arbitration, and it was replaced in no attention to the question of need: per- ulation, science and health. In: 1985 by the multi-state procedure. A con- haps three drugs each year have something Health Impact of European certation procedure was also introduced for substantially new to offer, whereas a large Single Market Legislation, biotechnology and ‘high technology’ prod- number of apparently new products are report of a public seminar held ucts in 1987. merely versions of already available drugs. on 30 October 1998, Brussels. A major change occurred on 1st January Not only are these rarely advantageous Available from Mike Joffe. 1995, when CPMP opinions became bind- therapeutically; the proliferation of ‘me- 2. Dukes MN. European phar- ing on the Member States. At the same too’ versions has sometimes resulted in the maceuticals regulation: impli- time, the European Medicines Evaluation belated discovery that they caused prob- cations for non-EU countries Agency (EMEA) was established to admin- lems, as was the case with bromfenac and in Europe. In: Health Impact ister the new procedures, with expert mibefradil. There is now a case for moving of European Single Market advice from the CPMP. The process of har- from an essentially economic system of Legislation, report of a public monisation has thereby been greatly product regulation towards a system that seminar held on 30 October strengthened. A further major change has the rational use of pharmaceutical 1998, Brussels. Available from occurred in January 1998, when national agents as its basic aim, as occurs in certain Mike Joffe. authorisation routes effectively ended. non-EU countries (2). This would mean 3. For further information, see: reconsidering the position of the regulatory Abraham J, Lewis G. The current situation system within the Commission: pharma- Regulating Medicines in The situation now is that the regulatory ceuticals are currently the responsibility of Europe. London: Routledge, authorities are still based at national level, DG III (Industry), but health could be 2000. and that they compete for regulatory work given a larger role.

23 eurohealth Vol 5 No 4 Winter 1999 HEALTH PROMOTION AND THE EUROPEAN SINGLE MARKET

Regulating the market in medical devices

Unlike pharmaceuticals, the market in medical devices has been largely unregulated in most Member States. As this very broad and heterogeneous term embraces implantable items such as Towards effective regulation heart valves and artificial hip joints, as well as a wide variety of In 1993, a Directive concerning medical non-implantable equipment including such vital items as cardiac devices (93/42/EEC) was agreed, and this came into force in all the Member States in defibrillators, this is somewhat surprising. 1998. Its main provisions are the requirement for all medical devices to carry the A haphazard system CE mark, and provision for post-market- At best the system has been haphazard, ing vigilance. Eligibility for a CE mark either treating devices as pharmaceutical depends on safety, effectiveness, absence of products, or covering some categories but side effects and satisfactory performance in not others, for example contact lenses but use, as well as on manufacturing quality. not intra-ocular lenses, or condoms but not The vigilance procedure should make it intra-uterine contraceptive devices. possible to have earlier warning of adverse events. However, there is a problem in The situation has therefore arisen that a linking the data on individual patients, large number of essentially similar products because of data protection legislation. It exist, but some of them are inferior in seems strange that protecting the identity design and/or manufacture. There has been of patients is legally regarded as having pri- no requirement to record which product is ority over protecting their health. used, for example, for insertion of an artificial joint, and no follow up of adverse inci- Many devices have already been removed dents. There have been examples of medical from the market, and progressive raising of devices that have caused harm to patients, standards in this area is likely to result which in some cases have been serious, from the Directive. The resulting benefit of including the Shiley heart valve. A recent this legislative initiative may be quite large, example was a type of artificial hip in the but this cannot be quantified, as the data on UK which was discovered to deteriorate previous harm from medical devices is over time, and required a large number of inadequate - another consequence of the people (many of them elderly) to undergo previously anarchic situation. In addition, replacement of the joint; the product had although there is a literature on aspects of no advantage over the standard type of hip medical devices, for example from a legal prosthesis (hundreds of different types viewpoint, no work appears to have been exist). It also proved difficult to discover done that could be used to assess the public who had received this particular implant so health impact of changes in legislation and that they could be contacted about the need practice. This is an area that requires fur- for further surgery. ther research.

Dangerous substances and Assessing the regulation in place preparations In practice, serious health consequences that are known to result from exposure to Chemicals have been regulated since the 1960s, both at national dangerous chemicals are uncommon, apart from a few specific instances, notably and European Community level. As with pharmaceuticals, asbestos. This could be because the regula- Member States would have developed a comparable although tory system is functioning effectively, because there is limited potential for most more fragmented system if there had been nothing at European chemicals to cause serious illness at expo- level. Therefore to evaluate the effect of the single market would sure levels that actually occur and/or ideally imply a comparison between the existing EU system and because there is under-recognition of such effects. what might have existed without it, if this were possible. The regulatory method used is risk assess- Inevitably, more prosperous countries tend to favour greater ment, and a great deal of attention has been restrictions than poorer countries. paid to the methodology; however, it is an

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“risk assessment … is expensive and laborious process. The sys- The difficulty of banning substances tem is not only concerned with the ques- One consequence of banning is that it is an expensive and tion of approval, but also with such things possible for a useful substance to be with- as labelling, packaging etc. Labelling has laborious process” drawn despite absence of an actual risk. been harmonised, and includes symbols of This could occur if the potential level of danger, risk phrases and safety phrases. exposure to, for example, a teratogen The system is very complex, and will not would have been so low that no harm be described in detail here. A distinction is would have resulted. The converse situa- made between substances that already tion occurs with chemicals that have been existed in 1981 and are listed in the approved: there has traditionally been no EINECS inventory (there are approximate- way of influencing their usage. DG XI has ly 100,000 of these), and new substances of initiated an attempt to encourage sustain- which there are typically several hundred able use of PPP, which includes the reduc- introduced each decade. To prioritise with- tion of quantities used, and substitution of in the ‘existing’ substances, the production safer products for less safe ones. level is used, e.g. above 1000 tonnes annual- The main aim of the regulatory system is to ly (2000 substances). A second type of dis- prevent episodes of adverse outcomes tinction is between types of product, for example plant protection products (PPP - occurring. Nevertheless, it is occasionally pesticides used in agriculture), biocides possible to identify an instance where (other uses of pesticides), detergents, explo- intervention has made a difference. In early sives, etc. There can be differences in the 1997, Germany and Austria reported way these are handled, such as in the case approximately 1000 cases of children being of PPP because of the possibility of poisoned by drinking coloured oil from residues in food. A third distinction is in decorative oil lamps. One died, and many the type of toxicity: whether the hazard had serious respiratory problems that could affects human health or some aspect of the be long lasting. It is thought that in the EU environment. In the former case, a particu- as a whole, four times that number were lar group is known as CMR, because they affected. The Commission introduced an are carcinogenic, mutagenic and/or harmful urgent Directive to ban the use of coloured to reproduction; these have been with- oil in the lamps, together with other mea- drawn from the market. sures, to prevent further cases of poisoning.

Foodstuffs: harmonising a diverse policy area

Within the overall area of foodstuffs, there are three major branches to consider: additives, hygiene and nutrition. efits of restricting a possibly harmful substance against the benefits of its use, and Additives this is inevitably indeterminate given that Concerning additives, the first Directive in they are not measured using a common 1962 consisted of an indicative list. The metric; (b) the evidence to make these recent trend has been to develop a positive judgements is in any case typically incom- list, which contains every permitted sub- plete. stance, together with the foods in which it There have been trends in certain sub- can be used, and in what quantities given stances as scientific evidence has changed, the amount that is typically consumed. for example boric acid has now been This is now essentially complete. “Member States are restricted to sturgeons’ eggs. The bacterio- It is generally thought that the level of pro- cide nisin has been phased out, but is still sometimes accused of tection has been unchanged or increased in permitted in mascarpone after six people using food hygiene as an most Member States, except that those died of botulism. Member States can also countries that have traditionally been the apply for specified traditional foods to con- excuse to exclude most restrictive have had to accept a slight- tain particular substances that would other- ly longer list. It is impossible to say defini- wise not be allowed. In addition, a few dis- imports when the true tively what is the ‘best’ level of protection, agreements remain over specific com- for two reasons: (a) because this judgement pounds: for example, Denmark has been motivation is economic” would involve a trade-off between the ben- against the use of nitrates, and the use of

25 eurohealth Vol 5 No 4 Winter 1999 HEALTH PROMOTION AND THE EUROPEAN SINGLE MARKET azo colours has been contested by Sweden but this took no account of the real prob- and Finland. lems, which are more concerned with faecal contamination, temperature, and so on. A controversial area is so-called technolog- ical justification, which signifies whether or Food hygiene is an area where it is difficult not a substance is needed. This criterion is to get the balance right. It is important to potentially subject to disagreement avoid excessive regulation where the risk is between individuals and between Member low, for example in the case of cheese made States. For example, colourants are typical- from unpasteurised milk. More generally, ly less favoured in the Nordic countries food hygiene measures have developed in a where people are used to paler (un-dyed) way that favours large, vertically integrated food. Clearly a judgement of this type is companies. Such measures are a potential different when the additive is used for an threat to small and medium sized enterpris- essentially cosmetic purpose rather than for es that are so important to the food sector, health protection, as the mascarpone exam- especially in their role in maintaining tradi- ple illustrates. tional and regional specialities.

Food hygiene Nutrition Food hygiene has played a prominent role Nutrition is represented in several EU in European affairs in recent years, and Directives, including infant formulae and continues to do so. Earlier plans aimed at follow-on formulae, foodstuffs for particu- comprehensive deregulation were reversed, lar nutritional uses and nutrition labelling. and the Commission was re-structured: In general, the view is taken that the con- DG XXIV (consumer affairs) was given sumer can and should decide on dietary responsibilities that had previously composition. This has led DG III to belonged to DG III (industry) and DG VI strongly oppose the idea that fiscal policy (agriculture), as they were considered to could be used to discriminate in favour of require more orientation towards con- foods that are more beneficial to health: a sumers rather than producers. proposal from Finland that a sugar-free chewing gum should be favoured was Hygiene is clearly important in relation to rejected, although apparently other sections trade in foodstuffs: producers in Member of the Commission were willing to consid- States with traditionally high standards, er the idea. and therefore relatively high costs, com- plain that they are subject to unfair compe- Nutrition labelling, allowing the consumer “labelling may have tition from inferior produce at lower to have access to the information to make less effect on behaviour prices. Conversely, Member States are informed decisions, is compulsory only sometimes accused of using food hygiene when a health claim is made. This implies than other factors, as an excuse to exclude imports when the that the less beneficial (or most harmful) true motivation is economic. Within a sin- foods are the least likely to have informa- notably price and gle market, it should be possible to solve tion about nutrition on the label. In addi- this two-sided problem by bringing the tion, it is unclear to what extent potential availability” standards closer together. buyers can understand the type of labelling that is specified, especially if their level of The European Union has approached this education is relatively low. task by adopting a comprehensive regulatory regime: a good infrastructure and good More fundamentally, however, labelling hygiene practices throughout the food may have less effect on behaviour than chain, underpinned by HACCP (Hazard other factors, notably price and availability, Analysis Critical Control Point). The prin- especially among those sections of the pop- ciple underlying HACCP is that for each ulation who have relatively few resources. type of product, the entire food chain The pattern of nutritional intake is should be analysed to see at which points immensely important to the health of the problems could arise, and then systems are population: for example, an increase in fruit adopted both to minimise their occurrence and vegetable consumption could help to and to monitor the situation so that early prevent many common cancers as well as warning is obtained. There is general agree- coronary heart disease. While the Single ment that this is an improvement on previ- European Act may not have been a suitable ous methods. The intention has been not legal basis for policy initiatives in this area, only to make standards more similar for the health compliance clauses of the trade purposes, but also to improve food Maastricht and Amsterdam Treaties open hygiene throughout the EU. Prior to this, the way to this possibility, in their insis- scant attention was given to public health; a tence that all EU policies should ensure generally clean environment was required, health protection.

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Tobacco excise duty in some Member States where an appreciable increase has The health dimension of occurred (not adjusted for inflation) fiscal policy instruments FRANCE Francs 50,000 The EU has weaker legal powers in the area of fiscal policy than 40,000 in the other four areas, limited principally to exhortation and monitoring. In the late 1980s, the Community encouraged an 30,000 increase in the level of taxation (excise duties) on cigarettes, espe- 20,000 cially in the hitherto low tax Member States of southern Europe. 10,000

0 Member State actions 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 To assess the effects of this, Member States’ data for the years 1988–97 (provided by DG XXI) were examined. It was clear that the low tax countries ITALY Lira had greatly increased the level of excise duty: in Greece it rose six-fold, in 12,000 Spain and Portugal it trebled, while in Italy and France it merely doubled. On the other hand, most of the high tax countries had rather stable levels, 10,000 although there are some exceptions to this, notably the UK. 8,000 A tax rise is not the same as a price rise: for example, if tax forms half of the 6,000 price, and it is then doubled, the overall price rise will be 50%. This assumes 4,000 that the tax rise is passed on to consumers. If this does not happen, the man- 2,000 ufacturer loses the corresponding amount of profit. 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 The effects of tax increases It is well established that a higher price leads to a fall in consumption. The GREECE economics literature suggests that for each 1% rise in price, consumption Drachmas will fall by 0.3 to 0.6%, partly from quitting and partly from cutting down. 500,000

In addition, one would expect fewer new smokers to be recruited during 400,000 childhood. 300,000 Assuming that these figures apply without modification in all Member States, it is possible to estimate the effects of a price rise on cigarette con- 200,000 sumption. For example, consider a population of 35 million adults of whom 100,000 28% are current smokers: thus, there are 9.8 million smokers (these figures approximately represent the situation in the United Kingdom). If there were 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 a five percent increase in the price, adjusted for inflation, approximately 1% of smokers would give up smoking, meaning that almost 100,000 people would become ex-smokers. A comparable magnitude of reduction in con- PORTUGAL Escudos sumption would be seen from cutting down, and a further fall from non- 200,000 recruitment. The benefit to health is thus likely to be large from a price rise 180,000 of this magnitude, after a lag corresponding to the latent period of the vari- 160,000 ous diseases. 140,000 120,000 100,000 Other consequences 80,000 Apart from the health gain and the benefit to the exchequer, three other 60,000 40,000 consequences need to be borne in mind, and these are less welcome. First, 20,000 there is an adverse effect on equity, since increases in price disproportionate- 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 ly affect people who are unable to quit, and these tend to be people who are on low incomes or who are disadvantaged in other ways. Secondly, excise SPAIN duties have not been raised on other forms of tobacco, which is likely to Pesetas lead smokers to switch from manufactured to hand rolled cigarettes which 500,000 are more harmful. Thirdly, the tobacco industry is responding to the loss of its market in the developed world by expanding sales in developing coun- 400,000 tries. 300,000

Overall, the findings in the area of fiscal policy support the hypothesis that 200,000 was originally proposed for this project as a whole, that (a) standards have risen, and (b) they have become more uniform. The term ‘standards’ here 100,000 needs to be understood as ‘those conditions which most effectively promote 0 health’, and therefore corresponds to a high price of tobacco in this instance. 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

27 eurohealth Vol 5 No 4 Winter 1999 FOOD AND HEALTH Where is European food policy going?

Uruguay Round of the General Agreement Tim Lang, Professor of Food Policy at Thames Valley on Tariffs and Trade (GATT), the reality is University, wonders if the proposed European Food still that about half of all EU expenditure is on farm support. Anti-CAP Member States Agency will clarify or add further confusion to EU food such as the UK love to portray CAP as the promoter of inefficient farming. The reality and public health policy. is more complex. Born out of a very real experience of hunger and of food chaos in With astonishing speed, a new map of World War II, the CAP set out to bring European food policy is emerging in which stability and to ensure that Europeans food safety now rates as high a political never suffered hunger again. profile as the farm politics of the Common Who today remembers that the Agricultural Policy (CAP). Besides staring Netherlands suffered a famine in 1944? Or in wonderment as this new terrain is altered that the UK’s war-time reliance on US as the volcanic eruptions over consumer lend-lease to feed itself nearly brought it to safety lead to food wars within the EU and its knees after the war ended, when the tap between the EU and particularly the USA, of Uncle Sam’s food beneficence was there is also an urgent need to subject this (understandably) turned off in the late new map to proper public policy analysis. 1940s to give priority to feeding Germany What are its new fault-lines? Where will and to keep it from falling to the USSR? the next eruptions come? Who, if anyone, Critics argue that the past rationale for is in control? Is the political process in CAP is irrelevant today. But it would be a charge of public policy? Will the new food foolish politician who allowed Europe to agencies at EU and member state level paci- stop feeding itself and to put its currencies fy or exacerbate public concerns about and affluent consumers onto the roller- food safety? coaster of world commodity markets. The European Union is being drawn inex- The political challenge for CAP negotia- orably into food policy without having any tions today is not so much whether there is clear overall official policy. As with so a CAP but what the expenditure is for? many areas, the EU has bolted new initia- The EU is breaking its own commitment to tives on to the core that is, and is likely to scrutinise all policies for health by ignoring remain, the Common Agricultural Policy the health impact of CAP.2 One might (CAP). The reaction in 1996 to the BSE cri- have thought that the neo-liberal policy sis was supposedly going to change this agenda would have latched on to this emphasis but in reality it has not. Within opportunity to tame CAP. It has for years days of his appointment, Commissioner sought the nirvana of dismantling all subsi- David Byrne promised a new European dies. Neo-liberals like to portray CAP as a Food Agency and in December 1999, in trough filled endlessly by conned con- response to a request by the then Director sumers who as a result pay too much for General of DGXXIV, three academics pro- their food, but the reality is again more duced an outline of what a European Food complex. Although producer subsidies are and Public Health Authority could look high in the EU, as the OECD constantly like.1 This January the EFA was announced shows, the price farmers get for their prod- but in a weaker form than the Professors “The EU is breaking ucts is a small, and for some commodities a proposed. It will be part of the EC, not decreasing, proportion of end consumer its own commitment to free-standing. Excellent though this might prices. The food supply chain is lengthen- be, it is unclear whether such a body could ing all the time. This means that even when scrutinise all policies for resolve the tensions already manifest within food is cheap, many costs are externalised. EU food policy and institutions. A number Who pays for food poisoning or pollution health by ignoring the of fissures are key. of land and waterways? A team led by Prof Jules Pretty at Essex University has now health impact of CAP” Producer versus consumer interests calculated for the UK alone, extra environ- The first is the tension between consumer mental costs amount to £208 per hectare.3 and producer interests. Although political This did not include diet-related costs such rhetoric now gives primacy to consumers, as for heart disease or diabetes. The former, producer interests still carry the legacy of a for example, costs an annual £10 billion in municifent past. Despite supposed subsidy the UK. For EU policy-makers, the lesson reductions negotiated in 1994 under the last is clear. To assess the full costs of EU food

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policy we need more accurate and compre- ing out into the open, the EP-EC tensions hensive studies. over handling of food policy meant that when further scandals happened – a likeli- The new importance of food quality hood as certain as night following day – the The second fissure in modern EU food pol- EC would be on the defensive again. icy links directly from this issue of cost. If Hence the alacrity with which David CAP was set up to (re)build quantity, now Byrne, Ireland’s EC Commissioner for its challenge is quality. Since the early Public Health and Consumer Affairs 1980s, a wave of scandals has made con- stepped into his job with promises to make sumers sceptical about the commitment of food safety his primary concern. I have lit- industry to quality. Europe’s food proces- tle doubt that Mr Byrne means what he sors and retailers have been driven by other says but can he deliver without setting drivers such as building brands, searching longer-term goals? The short answer is for new products, beating competitors, ‘no’. He is setting out on the false premise squeezing primary producers. This, ironi- that better controls and management of cally, has generated an opportunity that microbiological contamination is all that politicians have so far not grasped. EU food policy needs to clean up the food Consumers are sending consistent messages system. This is wrong. The problems are “Consumers are that they want changes in HOW food is more deep-seated and will take decades to produced. So far, the mass market has been sort out. Sweden, for instance, which had a sending consistent dominated by intensive production, but cataclysmic outbreak of food poisoning in now different messages are coming. messages that they 1952, killing 100 people, set up a pro- Euromonitor polls, let alone the public gramme to eradicate salmonella from its want changes in HOW mood since the 1996 BSE crisis, show that poultry flock. This took decades. In Britain, since the late 1980s Europeans have been food is produced. So for instance, which had its salmonella-in- prepared to fund farm support but not at eggs scandal in late 1988, a period when far, the mass market any price. They want farming to change, to over one in three carcasses sold to the pub- be more environmentally sound, and now, lic were contaminated, companies privately has been dominated by above all, they want the food supply to be admit that they still cannot eradicate conta- safe. They are right. The safety scandals mination. Rates are dropping but to achieve intensive production, that used to be associated with the British low counts, let alone zero, will take years. are now seen to be more systemic. France but now different mes- has been found to have been feeding The broader issues of food policy sewage to animals, and Belgium to have sages are coming.” This brings us to the major fault-line in released excessive dioxin in meats. modern EU food policy. While political Everywhere there is unease, if not fury, at priority is given to food safety, a real food perceived big business backing for genetic policy – one the consumer can trust - modification (GM) foods but support for would be like a good chair, built on four the EC to hold firm before a US inspired legs: safety, nutrition, environment and assault via the World Trade Organisation. social justice. In practice, the approach to Big business is now backing away from safety is crisis management rather than sys- GM under consumer pressure. No wonder temic. The approach to nutrition is next to food safety is now such a priority for the non-existent, bar a reliance upon labelling Commission. Intensive farming, not just (which has little proven impact on improv- national incompetence or ministries over- ing food-related ill-health unless accompa- zealous in their support for insensitive nied by a battery of measures – precisely farmers, is under scrutiny. what the EU currently refuses to imple- The European Parliament, just as much as ment.) The approach to the wider environ- national Parliaments, has seized the oppor- ment is marginalised to the edges of agri- tunity to admonish and curtail excesses of cultural policy through measures such as EC farm support programmes. The humili- the agri-environment programme. Social ation of former President Santer following justice through food policy barely registers. the publication of the damning European Any social audit of EU food would have to Parliament report on the handling of the conclude that there is little concern from BSE crisis in 1996 was a defining moment. public policy makers for feeding low- Many at the time expressed a more cynical income consumers – unless they are to get view that M Santer’s Japanese-style self- US-style hand-outs of surplus commodities criticism was merely playing to the gallery.4 through the Surplus Food Disposal It was a clever smokescreen, they argued, Scheme, which systematically ignores the to disguise a desire to return to ‘business as major potential gain of such schemes, usual’. That may have been so, but by com- namely to give poor people good fruit and

29 eurohealth Vol 5 No 4 Winter 1999 FOOD AND HEALTH vegetables. This, as a Swedish National microbiological or is comprehensive. Institute of Public Health report has point- Although food safety has recently demand- ed out, is a scandal within such a rich agri- ed the most time of politicians, for the EU food zone as Europe. 5 to have a mature and sensible food policy, it will require equal policy weight to be Even if the current concern for food safety given to nutrition, environmental health were – wrongly – the sole concern for the and social justice, as well as safety. The EU, there would still be one thorny final focus in the White Paper is likely still to be problem. Which state level is to have upon consumer information, which bucks responsibility for safety – EC or Member the challenge by putting the onus on con- States? This policy hot potato has been sumers to protect themselves. Everyone served up by the row between the UK and agrees that Europe should have good France over beef. The handling of this labelling, but information is not the only ‘food war’ bodes ill for the role of national plank of a food policy. There is also the food agencies. France’s new Food Safety question of what sort of information and Agency, set up in the wake of a national labelling we should get.Will a label on, for outcry about contaminated blood samples, example, a chicken give lots of information made a pronouncement that it wanted about the brand and price or will it say British beef kept out. Its credibility for something like this: ‘This chicken is likely putting consumer safety was on the line. to contain pathogens. Please handle and The UK, whose Food Standards Agency cook it well. If you don’t, you are likely to has only just received legal approval and get food poisoning and we will blame you. will not come into existence formally until It’s your choice not our responsibility.’ autumn 2000, received advice from its embryonic agency (mostly drawn from the The White Paper emphasises a Rapid Alert old Ministry of Agriculture) that the System to facilitate information flow in changes made to UK beef slaughtering now crises between member states. The idea for meant British beef was safe. Scientists sepa- a RAS was developed by the former rated by a narrow strip of water apparently nuclear energy division in the old DGXI. came to different conclusions. Like other measures in the White Paper, REFERENCES the goal is to modernise and simplify. In The EC meanwhile had been patiently tak- 1. James P, Kemper F, Pascal the 84 proposals, legislation is to be simpli- ing the UK through a number of safety G. A European Food and fied, and there will be a new focus of clari- procedural hoops begun back in 1996 when Public Health Authority: the fying sources of scientific advice, which can future of scientific advice in the the cases of new variant Creutzfeld Jakob’s be circulated faster. Centralisation and har- EU. Brussels: DOC/99/17, 13 Disease (CJD) were confirmed. At stake monising member state controls are to go December 1999. here is a tussle over subsidiarity and the hand in hand. Other measures are to legacy of the 1987 Single European Act. 2. Weil O, McKee M, Brodin include the production of a positive list of The SEA had swept away national food M, Oberlé D (eds). Priorities ingredients for animal foods; safeguard laws in return for harmonising EU rules to for Public Health Action in the clauses in legislation; maximum limits for allow speedier passage of goods (including European Union. Vandoeuvre- contaminants; improvement of controls for food) throughout the Community. Critics les-Nancy: Société Francaise GMOs; better nutritional monitoring and at the time feared that public health was de Santé Publique, 1999. data; and simplification of food safety rules. being put second to the trade imperative. 3. Pearce F. Crops without So it is ironic that 13 years later, the EC is All of this makes sense but it is above all profit. New Scientist, 18 being forced by public pressure, now on one feature that characterises the real, as December 1999. the global stage, to resist the USA trying to opposed to rhetorical flavour, of the new 4. Santer J. Speech by Jacques force its version of the biotechnology revo- Commission’s food policy. Consolidation Santer, President of the lution through the WTO disputes system. and harmonisation make some sense, but European Commission at the Oh what irony! setting up the EFA carries considerable Debate in the European political dangers. It both plays to the Parliament on the report into What direction policy now? gallery – the EC is seen to be more con- BSE by the Committee of Against this structural analysis of the real sumer-friendly – and delivers what Enquiry of the European challenge facing EU food policy, what is Europe’s powerful and rich food industry Parliament. Speech 97/39, the current thinking of Commissioner long has wanted, one voice for it to deal February 18 1997. Byrne? My understanding is that the White with rather than 15 fissiparious, divergent 5. Whitehead M, Nordgren P Paper will establish a new European Food countries. As we have already seen with (eds). Health Impact Agency but whether this has a narrow food the UK-French tension over BSE, food Assessment of the EU safety focus or a wider public health role, policy is a minefield. Whether the EFA can Common Agricultural Policy. including nutrition as the three Professors’ reduce rather than add to difficulties A Policy report of the Swedish report recommended, remains to be seen. remains to be seen. The White Paper makes National Institute for Public The credibility of EU public health policy it clear that power is to reside with the EC. Health. Stockholm, November hangs on whether the focus is narrowly I see trouble ahead. 1996.

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Sustain, the alliance for better food and farming The labour of Sisyphus

According to legend, Sisyphus, one of the Titans, was condemned forever to push a boulder up a hill. The boulder repeatedly rolled back to the bottom. for 30 years or more that diets high in fat, sugar and salt, and low in fibre, vitamins and minerals increase the risks of developing cardiovascular disease, a range of cancers, and a number of other fatal or debili- Talk to anyone engaged in trying to reform tating conditions. This agreement is only the Common Agricultural Policy (CAP) now coming to be recognised formally by and they will tell you that Sisyphus had it the EU policy making process, with a easy. Despite years of patient research and group of experts convened by the Health determined lobbying, the CAP seems as and Consumer Protection Directorate cur- resistant as ever to attempts to change it rently developing food based dietary guide- into an environmentally sustainable system lines. that produces wholesome food and creates The phrase ‘food-based dietary guidelines’ high quality jobs while respecting the may not be the most elegant in the lan- rights of other living creatures. Today, the guage, but it is critical to avoiding the CAP remains a juggernaut, piled with ‘nanny state’ accusations that are routinely mountains of produce for which there is no hurled at any agency trying to improve market, under the wheels of which jobs are public health by shifting the balance of the Jeanette Longfield destroyed, the environment is damaged and food supply. In practice it means that a animals suffer. dietary guideline of, say, a maximum of Admittedly, part of the problem has been – 30% of the total energy in the diet from fat, and will continue to be – the fact that the can be met by choosing from a very wide patient and determined lobbyists are often range of foods. In Northern Europe, it is lobbying against each other, allowing likely that much of this fat will come from politicians to ignore proposals or ‘cherry dairy and meat products, whereas in pick’ policies that, outside the framework Southern Europe a higher proportion will for which they were devised, work less well be made up of olive and other vegetable or not at all. Another is the sheer scale and oils. Similarly, a dietary guideline to complexity of the many policies that make increase the proportion of complex carbo- up the CAP. It seems appropriate, some- hydrates in the diet will encourage some how, that the CAP should attract legends people to eat more potatoes, others bread, of its own (for example, that only three while some will opt for rice and others “Today, the CAP people have ever understood the CAP: one pasta. has died, one has forgotten, and the one In other words, people’s physiological that still understands it has gone mad). remains a juggernaut, requirement for particular nutrients gener- piled with mountains Arguably, though, the most fundamental ally does not vary, but our way of meeting obstacle is that the CAP was designed to those needs can do, and is fulfilled by a of produce for which solve a problem that we no longer face in huge range of foods. Thus food-based Europe – lack of food. Shaped as it was by dietary guidelines that apply across the EU there is no market, post-Word War II shortages, the CAP has are emphatically not a way of ‘Brussels been spectacularly successful in solving that bureaucrats’ telling us what to eat. under the wheels of problem, but the costs have been high. This article will focus on just one of these: diet- which jobs are Vested interests related diseases. Doubtless this is a distinction that will be destroyed, the environ- lost on leader writers in the popular press. Food and health They will be aided and abetted in fuelling ment is damaged and Despite popular belief that experts on food popular prejudices by powerful sectors of and health are in a state of perpetual dis- the food and agribusiness industries that animals suffer” agreement, the consensus has been growing are unable or unwilling to diversify out of

31 eurohealth Vol 5 No 4 Winter 1999 FOOD AND HEALTH the food sectors that should shrink, and applying them and to those, particularly into the food sectors that should grow, children, consuming pesticide residues. according to food-based dietary guidelines. Environment And make no mistake, a CAP based on such guidelines would be radically A wide range of sustainably produced hor- reshaped and require some serious invest- ticultural products could create diverse ment to ease the process of diversification. wildlife habitats, improve soil fertility and reduce agri-chemical pollution. Working on the 1997 CAP budget, fully Fresh produce consumed close to the area one-third of the ECU 41,438 million was of production could reduce energy use and spent on meat and dairy products. Arable pollution linked to processing, packaging, crops (excluding several that are listed sep- transport and storage. arately) consume an even larger slice, at around 40% of the budget. Much of this Employment will support cereal production that, on the For all EU citizens to consume a healthy face of it, seems positive, since we should amount of fruit and vegetables each day, be eating far more cereal-based products, production within the EU would have to particularly in their whole, unrefined form. increase. Even if prices fall, farm incomes But, since it has been estimated that over a should rise because of increased sales. half of cereal production is destined to be eaten by animals, a large proportion of this expenditure should be allocated to meat and dairy production, bringing total CAP “the consensus has been growing for 30 years or more that expenditure in this area to over half the total. This is without allocating any of the diets high in fat, sugar and salt, and low in fibre, vitamins substantial funds spent on product promotion, anti-fraud policies and accompanying and minerals increase the risks of developing cardiovascu- measures. lar disease, a range of cancers, and a number of other fatal Contrast this with the derisory amounts spent on fruit and vegetables. In the same or debilitating conditions” year this amounted to ECU 1,661 million or four per cent of the CAP budget; slightly less than was spent on the sugar regime. The situation is even worse than the figures Horticulture is understood to be more suggest since most of the money is spent on labour intensive than other parts of agricul- destroying fresh produce to keep it off the ture so, provided good working conditions market and avoid prices falling. Stable can be established and maintained, it would prices, while good for growers, are less offer good employment opportunities. good for low income families who, in the UK at least, seem to be consuming smaller Development and smaller proportions of these health Since it would be neither possible nor enhancing foods. desirable to produce all our vegetable and fruit requirements within the EU, increased What now? consumption could offer opportunities to It doesn’t have to be like this. The increase the export earnings of countries in Amsterdam Treaty clearly gives the EU the the Southern Hemisphere. Sustainable pro- power to take action that “…shall be duction methods would reduce the occupa- directed towards improving public health, tional risks to farm workers in the South, preventing human illness and diseases…” who are currently at highest risk from Shifting cash into promoting sustainable global pesticide use. production and increased consumption of A number of policy instruments already fruit and vegetables would have the follow- exist that would begin the shift in the ing advantages: desired direction, including: Health – free distribution, rather than destruc- Eating at least five portions of vegetables tion, of all temporary surpluses (fresh, and fruit could help prevent cardiovascular frozen or minimally processed) diseases and several types of cancer, still the EU's major killers. – changes in quality standards to reduce the proportion of edible produce A reduction in incorrect use or over-use of removed from the market pesticides used in horticulture would diminish the health risk to farm-workers – funding for conversion to and mainte-

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“the derisory amounts nance of environmentally sustainable Fruit and vegetables are not a major or production methods, in urban as well as complex part of the CAP compared to spent on fruit and rural areas other sectors. Changes in this sector would not, therefore, have an immediately pro- – ending payments for grubbing up vegetables … is spent found or far-reaching impact, particularly orchards on destroying fresh if the amounts spent, directly and indirect- – support (funding and training) for mar- ly, on supporting meat and dairy produc- produce to keep it off keting schemes (including promotion of tion were left untouched. However, given regional specialities) the size of the alliance of different interests the market and avoid – local or regional support for a wide that could be constructed around this positive agenda, the chances of success are – prices falling.” range of retail outlets for vegetables and fruit (to reduce reliance on supermar- arguably – reasonable. It might be one kets) small stone that we manage to push to the top of the hill without it rolling back down – major media campaigns, supported by again. local activities, to provide the skills and confidence for people to incorporate vegetables and fruit into their daily diet REFERENCES – shifting subsidy away from some types Lobstein T, Longfield J. Improving Diet and of crops (tobacco and sugar beet are Health through European Union Food obvious candidates) to support sustain- Policies. Health Education Authority, able production of vegetables and fruit London: 1999.

Public health and food safety: the case of Salmonella in Denmark1

The main concern of food control is safe- ence of ‘stomach trouble’ during the pre- guarding of human health dealing with a ceding three months. Only a limited num- range of chemical and biological factors. ber of these incidents are related to foods This article addresses primarily Salmonella, and even fewer to salmonella. The adult but the considerations are relevant to other respondents recorded a total of 927 inci- infectious agents. dents of ‘stomach trouble’ over the combined six months period and for the The development in Denmark has features approximately 750 children in the house- comparable to those in other European holds 688 incidents. We calculated that countries, but there are also unique ele- ‘stomach trouble’ in the 5.2 million Danish Nils Rosdahl ments. Denmark has experienced signifi- population are responsible for at least cant changes in the food control system 800,000 annual contacts to the health ser- over recent decades, some with potential vices, usually telephone consultations to public health implications. the patients` own general practitioner.2 These figures are significantly higher than The size of the problem those reported in a recent British multi- The true incidence of salmonella infections practice study.3 is not known in any country. Several coun- Figure 1 shows microbiologically con- tries have figures for microbiologically firmed cases in Denmark over time. In confirmed cases, but they probably need to 1980, 823 cases were recorded rising to be multiplied by at least a factor ten to give 3,460 in 1988, followed by a decline, which the real incidence. in the early 1990s was followed by an In 1992, we conducted two telephone inter- increase to 4,276 cases in 1994. From 1996 views asking representative samples of to 1997, an increase of more than 50% approximately 1,500 Danes about experi- resulted in a new record of 5,049 cases. In

33 eurohealth Vol 5 No 4 Winter 1999 FOOD AND HEALTH

1998, the number decreased by 30% and Directorate and the National Food this trend continued in the first part of Agency. 1999. Microbiologically confirmed cases of In 1995, a report from the Academy of Campylobacter infections are still increas- Technical Sciences5 recommended unifica- ing. In Norway with a population similar tion of the state food control system under to Denmark and in Sweden with a 60% a slogan similar to the British ‘from plough larger population, recorded cases in 1997 to plate’. were only one fifth of those in Denmark. There might be differences in criteria for In a 1996 government reshuffle, the present performing stool examinations in various Ministry of Foods, Agriculture and countries and there have undoubtedly been Fisheries was born. The National Food changes over time. Agency was merged with the Veterinary Directorate into the Danish Veterinary and As is seen in Figure 2, Salmonella Food Administration. The Danish Enteritidis has for most of the time been Parliament in 1998 passed a bill consolidat- the predominant serotype, but S. ing existing food laws into one common Typhimurium dominated from 1987 to food law. According to the law, local gov- 1990. The changes between serotypes are ernment food control units are being trans- linked with the food origin of the bacteria. ferred to the state and reduced in number. In the past 15 years Denmark has had three major sources of Salmonella infections.4 ‘The Salmonella crisis’ From 1984 to 1988 the main culprit was Denmark experienced an increase in human chicken, followed by pork around 1991 to infections caused by Salmonella from 1985. 1994, while in the second half of the 1990s No single factor can be held responsible. it is eggs. The estimated sources of human Increased centralisation both in the pro- salmonellosis in Denmark in 1995 were duction sector and in the slaughtering eggs with 40–50%, poultry with 15–20%, industry has without doubt played a signif- pork with 10–15% and travel abroad with 10–20%.4 Beef and other sources only con- Figure 1 Confirmed cases of Salmonella and Campylobacter in Denmark stituted minor proportions.

The multiresistent S.Typhimurium DT104 Incidence per 100,000 constituted 6.1% of all S. Typhimurium 100 isolates from humans both in 1995 and 90 1997. 80 70 Organisation of the Danish food 60 control 50 Denmark has a long tradition of state- 40 organised control of foods for export, 30 organised through the Ministry of 20 Agriculture. Control of domestically con- 10 sumed foods was a local government 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 responsibility administered through Campylobacter Salmonella Ministry of the Interior legislation. In the 1960s, an Institute of Foods was developed, which due to its administrative duties was renamed the National Food Agency. Figure 2 Predominance of Salmonella serotypes in Denmark In 1972, a Ministry of the Environment was created, of which the National Food 6000 Agency became a part. When a Ministry of Health was established in 1987, the 5000 National Food Agency was moved to that 4000 ministry. 3000

However, the Ministry of Agriculture 2000 retained responsibility through its Veterinary Directorate for animal infec- 1000 tions and parts of microbiological control 0 of foods. Consequently, local government 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 food control units were professionally Salmonella total S. Typhimurium S. Enteritidis accountable both to the Veterinary

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“the Ministry of icant role. Spread of Salmonella within Enterididis are detected in a flock, produc- flocks in chicken farms and in pig raising tion is terminated and the flock destroyed. Agriculture retained ‘factories’ has been seen repeatedly. Eggs are not systematically monitored for Centralisation of fast food production has Salmonella. Screening including 14,800 eggs responsibility through also been responsible. The involved indus- in 1995 showed one in 1,000 eggs contami- its Veterinary tries were slow to recognise publicly these nated with Salmonella. In 1998 this figure factors and to take appropriate action. For decreased by a factor of ten. The control of Directorate for animal quite a time, the authorities and industries pigs and pork is based on continuous mon- tended to place the responsibility for the itoring of all breeding and multiplier pig infections and parts of increase in human cases on the lack of con- herds and all herds producing more than sumers to adhere to the so-called good old 100 pigs annually for slaughter, combined microbiological control housekeeping practices. with control after slaughter. Beef is con- trolled after slaughter and a random sam- of foods.” In the early 1990s, it became apparent that something had to be done. In 1993, the pling in 1996 showed 0.7% positive sam- Danish Zoonosis Centre at the Danish ples. Veterinary Laboratory was established. It An independent expert review concluded in was to follow the development by collect- 1997, that the control programme with ing and collating data from all sources, regard to pigs and pork has substantially establishing excellent working relations reduced the level of Salmonella in pork with the national institute for human products and the incidence of human infec- microbiology, Statens Serum Institut. In tions related to the consumption of pork.6 the following years, state financed action A revised plan from 1997 concerning egg plans were developed, aiming at expanding production has been followed by a reduced the monitoring system at all levels of the incidence of human S. Enteritidis infec- food chain and subsequently imposing cer- tions. tain measures on the industry. Monitoring schemes carry out some two Conclusions million investigations annually. The system Human salmonellosis in Denmark is based on regular controls of broiler increased for ten years before serious flocks as well routine sampling after attempts were taken to control the ‘epi- slaughter. Egg production is primarily con- demic’. trolled through routine monitoring by The food industries were late in recognis- serological and microbiological analysis of ing their responsibility – and obvious self- flocks of layers. If S. Typhimurium or S. interests – in providing safe food products. The National food control authorities were slow to initiate measures to safeguard animal products from microbiological conta- REFERENCES mination. 1. Based upon a paper read at the United Kingdom EU Presidency Monitoring the industry helped identify Conference “Developing EU Public Health Policy”, London 19 May 1998, the major trouble areas, but the initial up-dated with recent data. action plans tended to focus on partial 2. Rosdahl N, Scmidt K. Hyppighed af gastroenteritis og deraf følgende solutions, and the Salmonella problem lægekontakter bedømt ved befolkningsinterviews (Frequency af gastroenteri- moved from one food sector to another. tis and subsequent medical contacts estimated by population interviews) Denmark has, however, reacted to the Zoonose-Nyt 3:5 December 1996:5–6. problems, which is unfortunately not the 3. Wheeler JG, Sethi D, et al. Study of infectious intestinal disease in England: case in some other countries. Recent devel- rates in the community, presenting to general practice, and reported to nation- opments look positive, but fluctuations al surveillance. British Medical Journal 1999; 318:1046–50. have occurred earlier, and Campylobactor 4. Ministry of Food, Agriculture and Fisheries. Annual Report on Zoonoses in infections are still increasing Denmark 1997. Copenhagen, 1998. Health services have a responsibility to 5. Danish Academy for Technical Sciences. Mål og midler i fremtidens kontrol provide information on the relationship med levnedsmidler (Goals and means for the future food control). between disease and environmental factors, Copenhagen, 1995. including microbiological, and public 6. Skovgaard N, Wegener HC, Willeberg P. Evaluering af planen til kontrol health authorities and should present the og bekæmpelse af salmonella i svinebesætninger og svinekødsprodukter data on the magnitude of such problems. (Evaluation of the plan to control and combat Salmonella in pig herds and Salmonella infections in Denmark continue pork products). Copenhagen, 1997. to cause 3–4,000 hospital admissions and 7. Lundstedt C, Rosdahl N. Er vore fødevarer farlige? (Is our food haz- some 30 deaths annually, and in persons ardous?). Ugeskr Læger 1999;161:2789. (Editorial). without predisposing illness.7

35 eurohealth Vol 5 No 4 Winter 1999 HEALTH TARGETS Targets for health: shifting the debate September 23 and 24, Paris

An international policy conference sponsored by the European Public Health Association, the European Healthcare Management Association and Merck Sharp & Dohme

After more than 20 years in which Hygiene and Tropical Medicine European states have, to different went further: “if you are trying to degrees, introduced health targets, motivate people, this is a real chal- much has been learned. A total of 17 lenge and one which authorities in of 32 countries in the WHO England have not addressed”. The European region had targets in 1989. other danger is “that the targets Now 27 of 51 countries use them. involve non-medical agencies but This wide spread of experience they are being monitored through ensured a sharp interchange of ideas the health service”. in Paris in September, as 200 politi- Accountability can also be vital to cians, doctors, nurses and other Morton Warner the success of hitting health targets, healthcare professionals and policy but targets are usually set way into makers shared their experiences. element of democratic support into the future. By then the politician or Merely setting a specific, time-relat- the scheme. planner who conceived it is proba- ed goal for reduction in disease and bly sitting at another desk, or By contrast, England pursued a top- death can be powerfully beneficial. retired. As Dr Anna Ritsatakis, of down approach in its 1992 Health of But things are seldom as simple as the WHO European Centre for the Nation programme. David they appear. Delegates concluded Health Policy put it: “Politicians Hunter, from the Nuffield Institute that target-setting can be ineffective like to be seen as visionary, but tar- of Health in Leeds, gave this as a or may even exert untoward effects. gets can be so distant, it is difficult reason for overall failure, which And the public must be involved. to get them involved.” went deeper than simply missing the targets. Failure to win public sup- But as Dr Birgit Weihrauch, head of Winning public support port could negate targeting. In the health protection for North Rhine Jean-Pierre Poullier, a WHO advis- successor document, “Saving Lives: Westphalia, stated: “The process of er, singled out Sweden for making an Our Healthier Nation”, the Chief introducing targets can be as impor- ‘enormous and unique’ effort to Medical Officer gives his top ten tant as the targets themselves. Target consult the public. But “it is a very difficult exercise to get informed consent to targets,” he said. “Failure to win public support could negate targeting … they Lena Rydin-Hansson, from Ostergotland in Sweden, explained are about not eating fatty food, not smoking, not sunning how it can be done. All political parties were consulted in formulating yourself in the park. It is all about not doing things … That outcome-related targets for the county in 1990 and 1995. These will be the downfall of targets.” included lifestyle goals and accident prevention. Health experts, lay people and non-governmental organisa- tips. “If you look at them they are setting sets people thinking and tions were invited to contribute. about not eating fatty food, not encourages compromise between Public meetings were held and the smoking, not sunning yourself in rival interest groups”. county’s 400,000 silent majority was the park. It is all about not doing reached through surveys, and the things. Negative approaches and Calcification through targetting strategy was supported by media blaming individuals is no way to Taken too far, targets threaten to campaigns. Rydin-Hansson conced- enlist public support. That will be become a bureaucratic game, more a ed that the Swedish tradition of vol- the downfall of targets”. Naomi test of massaging statistics than untarism helped inject the strong Fulop, from the London School of improving health. In the UK, where

eurohealth Vol 5 No 4 Winter 1999 36 HEALTH TARGETS health service managers are judged The poorest health record is in the gets. Some regions have set 100 tar- by several hundred performance capital, said Ib Haurum, of the City gets, the average is 45. Juan Cabases, indicators, there is a potential for of Copenhagen Health Administra- an economist from Navarra, pointed calcification, with 41 indicators and tion. In an example of how local to the Basque Country as one of the 200 public sector agreements. health drives can be put into effect, most advanced regions in targeting. he said the city instituted public Services are organised on internal David Hunter added: “It is easy to health initiatives in schools and the market lines, with providers and have too many outcome-orientated workplace, and support services for purchasers of healthcare. Targeting targets and for managers to manipu- alcoholics were set up. The plan was is effective because purchasers take late the data to give the Government based on the WHO European it into account when they draw up what they want, even if the reality is Healthy City Project and was contracts. This helps to ensure they that it creates all kinds of other dis- refined to reflect local public opin- are hit – a model borrowed from tortions in the system locally.” ion as to target choice. Five-year earlier developments in Wales. targets were set in 1994 and have Other lessons are that ‘health’ tar- Does targeting work? now been met. Health indicators are gets should be backed by ‘health- Several delegates were even sceptical beginning to improve, although care’ targets: and progress should be about putting too much value on Copenhagen remains behind other assessed on quality as well as quanti- targets at all. Nick Bosanquet, from cities in Europe. Public enthusiasm ty. Imperial College, London, com- is encouraging health planners to set It was argued by one delegate that mented that target setting is “a fairly new targets. the Spanish model, where money harmless activity by middle level follows the target, is a form of bureaucrats in international agen- North Rhine Westphalia: link- rationing in a cash-limited system. cies.” But he added later that they ing to the insurance model Non-targeted conditions will get are still a good idea, provided they Germany is often seen as having a less. But this also can also be used as were limited in number. Smoking model dominated by health insur- a way of sparking public interest, and traffic accidents are good target ance funds, financing acute care at which can be crucial to the whole areas. the expense of health promotion; exercise.

Where should the targeting “It is easy to have too many outcome-orientated targets and drive come from? Targets need to be realistic and dis- for managers to manipulate the data to give the Government tinguish between those that are high what they want, even if the reality is that it creates all kinds of and low level. In Poland, a high level target might be cutting blood cho- other distortions in the system locally.” lesterol levels in the population and, by contrast, seeing that stroke patients are properly diagnosed is a low-level target about which doc- The Danish answer and this was the case until recently, tors and managers should liaise. Denmark provides a startling exam- but in some of the Länder this is ple of what can happen if you insti- changing. Distinguishing between types of tar- tute good healthcare but fail to set get is also important because of Giving details of introducing targets long-term health goals and monitor accountability. There have been in the North Rhine Westphalia in effectiveness. Allan Krasnik, of the cases in which health authorities 1995, Dr Weihrauch said they had University of Copenhagen, recount- have been charged with reducing come about through a conference ed how his country had been seen as accidents. Hardly appropriate! initiated four years earlier. The a model in health terms. So deep- meeting drew in state and local Ultimately though, the meeting con- rooted was the feeling that WHO politicians, health professionals, cluded different rationales are at public health initiatives were health insurers, welfare organisa- play when it comes to targeting – deemed relevant only to “Africans tions and others. Greater rationality the political and the technical. It is and nurses – certainly not for med- in healthcare, more transparency for the combining of these that gives ical interventions in our part of the patients, and better evaluation of rise to a process of health targeting, world”. treatments is the result – as well as at the end of which there is the Self-satisfaction, he said, was rudely closer cooperation between profes- requirement for decision-making shattered in 1993 when Danes sional groups. about the allocation of resources. realised that they were not among This is a political act, and politicians the world leaders in health, having Devolved in Spain are confronted by the realities of dropped from fifth to seventeenth Spain has autonomous, regionally scarcity and the difficult require- place in the OECD league of life run health services, but these are ment that they might have to be expectancy, with 6,000 excess deaths required by federal law to have explicit about both prioritisation a year. ‘integrated’ health services and tar- and rationing.

37 eurohealth Vol 5 No 4 Winter 1999 AMERICAN HEALTH POLICY AND THE PRESIDENTIAL PRIMARIES The uninsured and the US presidential election

The United States is the only industrialised country that fails to provide for universal health care coverage for its citizens. In his first term, President Clinton attempted to introduce wide ranging health care reform but failed. Health care reform has, however, been placed on the political agenda again, primarily by potential Democrat candidates for the 2000 presidential campaign. This paper examines the arguments for and against the different proposals and, drawing on the experience of the Clinton reforms, discusses their feasibility in a changing context in America. Bradley’s proposals are most developed and would achieve the widest coverage, but would be most expensive. Gore’s proposals are more limited and less detailed. Among Republican potential candidates, health care reform has a low priority.

The United States is the only major indus- chance of coverage continually recedes. trialised country that has failed to provide The fate of those who experience a period basic health care cover for all its citizens. of unemployment is especially difficult. Indeed, between 1989 and 1997 the number This includes growing numbers of people of Americans with no health insurance who are falling victim to an increasingly cover increased by over 10 million, to an Elias Mossialos ‘flexible’ economy. A third of respondents estimated 45 million.1 By the time of the in a 1996 New York Times survey said 2000 presidential election it is likely to have either they or a household member had increased by a further 500,000. experienced redundancy in the previous 15 Traditionally, those without cover were the years, whilst three-quarters reported that most disadvantaged, in particular the poor, they or someone close to them had done the unemployed, and non-whites. These so. Despite the 1986 COBRA legislation, groups have continued to be affected, and subsequently extended by the Kennedy- the largest absolute increases in the unin- Kassebaum legislation, which requires sured have been among black and Hispanic employers to provide access to their group populations and those in poor or middle insurance scheme (if they have one) for up income families. However, since the early to eighteen months after redundancy, albeit 1990s they have increasingly been joined at the individual’s expense, few unem- by others who, in previous years, might not ployed people could keep up payments. have considered themselves to be at risk of Furthermore, after this period they must Martin McKee losing cover. Downsizing by employers has purchase individual plans that are much created a large pool of people in their late more expensive, prohibitively so if there is 50s and early 60s who, while no longer any evidence of a pre-existing condition, as 4 employed, are too young for Medicare premiums are risk-related. cover.2 Many small employers do not offer A further concern is the adverse effects of health insurance cover, so that 80% of the this system on children, up to 11 million of uninsured are now actually in employment whom are uninsured,5 accounting for up to or in families of someone who is.3 Indeed, 30% of children in low income families in some of the increases in the numbers of some states.6 1997 legislation making avail- uninsured have been in north-eastern states able $24 billion over five years to expand that have achieved greatest economic health insurance for children has had limit- growth. Although cross-sectional studies ed impact, with less that 25% of the funds will capture many people who are experi- available being used. Adolescents and espe- encing a short period of uninsurance, with cially those in disadvantaged families are one in four Americans uninsured for at especially vulnerable.7 However, even chil- least one spell in a two year period, there dren and young people with nominal cover Alexandra Pitman remains a large number of people whose are falling foul of tighter eligibility rules,

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In these circumstances, in which deductible and co-payments to be those on middle incomes are increas- charged; ingly insecure, there is a high level of – employers were to make premi- 12 support for change. Despite the um payments to the alliances on failure of President Clinton’s 1994 behalf of their employees, with proposals, a majority of voters the promise of federal subsidies nonetheless favour covering the cur- for the smallest companies “Downsizing by employers rently uninsured and particularly (employers of low wage earners); children and those with low has created a large pool of incomes. This is reflected in the deci- – consumer choice for health plans sions of both leading Democratic on the basis of price to encourage people in their late 50s and candidates, Gore and Bradley, to cost-containment; early 60s who, while no make access to health care a central – regulation of the rate at which issue of their campaigns. In this alliance premiums could rise, with longer employed, are too paper we examine the various plans, a national cap forming the budget asking whether they have any under which competition would young for Medicare cover.” greater chance of success than the operate. failed Clinton plan. In particular, The plan is said to have failed for a will they resonate with the American number of reasons. These include electorate, especially given that lack of coalition building or attempts many of those most disadvantaged to achieve public support, unantici- by the existing system either do not pated crises both at home and have a vote, being children, or are abroad that distracted government among the approximately 50% of attention from reform, a loss of pres- adults who, while eligible, choose idential credibility as control of con- not to vote? gress appeared to slip away, pressures from small businesses (many of with growing evidence that they are The Clinton reforms – why they which felt threatened by the reform), facing obstacles to uptake of ser- failed vices.8 These failings are attracting and aggressive lobbying by the Clinton’s health initiative to provide growing public attention, with the health care industry, particularly health insurance for all Americans American Academy of Paediatricians medium and small insurance compa- was sent to Congress in 1994 as an launching its own proposals for uni- nies which would have been forced effort to provide ‘universal cover- out of business by the legislation. versal child coverage. age’, following promises made dur- Although it may be argued that the ing his bid for the presidency in1992. Although many in the industry did system does ultimately provide some He ran on a strong programme to favour the reforms in principle, they forms of acute care for the unin- develop comprehensive health were unwilling to make any form of sured, this care is often of poor qual- reform, which contrasted strongly sacrifice themselves, either in terms ity and typically is received late in with Bush’s laissez-faire attitude. of profits or disrupted regimes and the course of the disease, when com- Health care reform had been seen as they spent in excess of $100 million plications are more likely.9 It is also a way of winning middle-class votes to raise public doubts. increasingly difficult to find as from the Republicans. The plan The healthcare industry was sup- providers are forced to eliminate seemed to be a compromise between ported by anti-government conserv- internal cross-subsidies between dif- marketists and medicalists, falling atives working through a network of ferent categories of patients. between market tendencies and gov- organisations and the media (includ- Furthermore, while the uninsured ernmental involvement in health ing the influential Christian 13 might receive treatment in emergen- care. It was designed to produce Coalition, and the National cies, they are substantially less likely ‘competition within a set national Federation of Independent to receive preventive services despite budget’ and relied on five basic ele- Businesses). These groups were their greater need.10 ments: highly effective in spreading the message that acceptance of the At state level, some legislatures have – the creation of ‘regional health Clinton plan would lead to a ‘wel- attempted local solutions, such as alliances’ to organise and regulate fare state’ with health care rationing. expansion of Medicaid and various the regional health insurance mar- The media seized on this, with insurance reforms (such as low-cost ket; Readers’ Digest, Policy Review and plans, subsidies, risk pooling, open – quality and regulatory standards talk radio shows portraying the enrolment, continuity of coverage for health insurers and managed- Clinton plan as a bureaucratic take- requirements, and community rat- care plans, determining the price over which would increase costs and ings). However few have succeeded at which products could be sold tax many jobs and businesses out of in increasing health insurance cover- through the health alliances, existence. age and those that have worked have which products each health plan achieved only limited impacts.11 must include, and the level of Clinton’s reforms were also intro-

39 eurohealth Vol 5 No 4 Winter 1999 AMERICAN HEALTH POLICY AND THE PRESIDENTIAL PRIMARIES duced at arguably the worst possible employed in small businesses.14 time. The president faced the legacy Adults in a family of four earning of 12 years of Republican rule that less than $16,400 and those currently had created a massive federal budget enrolled in Medicaid will receive an “Although the Clinton plan deficit and an accentuation of the annual tax rebate of $1,800 which would ultimately have traditional climate of distrust of the can be used to contribute to a health role of government in American life. insurance premium (although this offered coverage to millions The policy was constrained by the will leave a considerable out-of- perceived need to avoid words such pocket payment and leave coverage of uninsured Americans …it as ‘tax’ or ‘government’. In this cli- unaffordable for many). In addition, mate, critics of the federal govern- there will be a sliding scale of tax also entailed many new ment found it easy to accuse the plan credits for those making up to of hurting small businesses, individ- $32,800 a year. regulations that would uals and health providers as well as The plan places a particular emphasis challenge insurance warning of rising taxes and the on children, seeking to provide destruction of choice. Ultimately cover for all under age 18 from companies, health care some used the health plan as a con- birth.15 This will be achieved by venient opportunity to pursue their providers, employers and means of refundable tax credits equal attacks on the institutions of govern- to the value of complete insurance ment. state governments.” coverage for children in families Although the Clinton plan would with less than $32,800 in annual ultimately have offered coverage to income, with smaller subsidies for millions of uninsured Americans and families earning up to $49,200. Both promised new security to those adult and child premiums are already insured, it also entailed many deductible from federal income tax, new regulations that would chal- even by the self employed. lenge insurance companies, health The estimated cost of $55 million care providers, employers and state income tax. Indeed, while attracting will be provided from the projected governments. While explicit opposi- some criticism from liberals for fail- surplus arising from the 1997 tion concentrated on criticism of the ing to offer universal coverage, he Balanced Budget Act as well as from bureaucracy involved rather than has attracted praise from moderate efficiency savings due to reductions admitting to pure self-interest, in Republicans for the use of tax in unnecessary medical procedures reality many were convinced that the credits.16 and administration. plan would bring few benefits except Despite attracting support from to the currently uninsured. The pro- Bradley has anticipated many of the moderates of both parties, some posals were defeated in Congress in possible criticisms, drawing exten- have voiced concern about its ability 1994 and not resurrected. sively on the lessons of the Clinton to cover the uninsured and support plan. Clinton’s vision of regional We now turn to the proposals by the the growing cost of Medicare should health alliances was criticised for leading Democratic candidates, Bill there be an economic downturn. creating more bureaucracy, and Bradley and Al Gore. Others have argued that it will be Bradley has refused to follow suit. difficult to set fair premiums for new Following another lesson from the Bradley’s proposals entrants to the FEHBP without rais- past he will allow consumers to rely Bradley plans to offer health covering costs for existing members. A on existing private or Government age to lower income adults and chil- third criticism reflects its potential insurance plans, allaying the fears dren, either by expanding access to success as, it is argued, it may stimu- about loss of choice that had plagued the Federal Government employees’ late small businesses to cease their Clinton. Indeed, by opening access existing schemes and leave employ- health insurance scheme for its to the Federal Employees Health ees to enrol in the new scheme, thus employees or by providing subsidies Benefits Programme (FEHBP), transferring costs to the federal gov- for private health insurance. He which covers government workers ernment.17 claims that his plan is an improve- and their dependents and which ment on Clinton’s because it is sim- offers generous benefits, he can be Gore’s proposals pler, requires less bureaucracy, and considered to have enhanced choice. Gore’s proposal is more modest than gives people greater say over their Bradley’s plan has been described as Bradley’s. It proposes extending insurance plans. “less extensive and regimented than coverage to all children and about a The plan is based on an extensive Clinton’s complicated proposal” and third of the adults currently unin- programme of tax credits designed it is clearly designed to appeal to sured. He guarantees that under his to improve access to health care by middle class voters in that it plans to plan every child in the nation would providing funds to cover insurance reduce health care costs for people in have access to affordable healthcare to those on low incomes as well as higher income brackets by excluding by 2005. He proposes a step-by-step the self-employed and those all health insurance premiums from approach to changing managed care,

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he does not see such a move being A changed context? necessary but it is now clear that In the aftermath of Clinton’s Gore is seeking to make health care attempts to reform healthcare, candi- reform a major issue in differentiat- dates in the 1996 Presidential cam- ing the two Democrat contenders.21 paign, such as Bob Dole, repeatedly “At first sight Bradley’s plan reminded the electorate of the plan’s seems to reach many more The Republicans’ plans failure, and criticised the involve- In contrast to the two leading ment of the First Lady. However people than Gore’s…it may Democrat contenders, Republican Clinton comfortably won his second hopefuls have had little to say on term in office and did not seem to be be that the scale of Bradley’s health care reform. We have been damaged by the health reforms. unable to find any reference to pro- Indeed a pre-election poll showed proposed premium subsidies posals by George W Bush. John that 58% of Americans thought they McCain has been slightly more would have been better off had the for the uninsured are active but proposals have been limit- plan been passed.27 So have things insufficient to provide ed. He has argued for federal sup- changed? port for health care provided to ille- In 1993 America was in recession. gal immigrants that is currently adequate health care This was an inopportune time to funded by states, no doubt reflecting effect major social change. Yet fol- benefits, or that those the high cost to states bordering lowing the 1994 elections, incoming Mexico, such as Arizona, which Republicans also attempted to subsidies may contribute to Senator McCain represents.22 He has reform health care, planning to cut also supported extension of a pro- rising costs in healthcare. “ spending on Medicare and Medicaid gramme that tackles the shortage of so as to eliminate the federal budget health facilities in rural areas.23 deficit while reducing taxes. This Finally, drawing on his personal also met with public opposition, in experiences after adopting a part because of its adverse impact on Bangladeshi child with a severe cleft the elderly. expanding existing structures like palate, he has put forward a bill that the Children’s Health Insurance would prevent Health Maintenance Major change has now been tried by Programme and Medicaid to cover Organisations from refusing to fund both parties and has failed at both more families and individuals. As yet reconstructive surgery on children attempts. Instead, there seems more Gore has not announced how he with severe deformities, as is increas- enthusiasm for incremental changes, plans to finance the proposal, an ing the case in the US.24 some of which have been passed, such as the Kennedy-Kassebaum omission underlined by Bradley, but Some clues about a possible claims that it should not involve a health legislation which requires Republican approach emerge from tax increase. The key attraction of employers to continue coverage for ideas pursued by the present House this plan to the American public is employees who switch jobs or Republican leaders who, in its provision for small businesses to become unemployed, without regard September 1999 passed their own come together to negotiate lower to ‘pre-existing’ medical condi- health plan, subsequently vetoed by rates for their workers’ coverage and tions.28 the President. This would have been in providing a 25% tax benefits for much less wide ranging than that put The nature of the public debate may the health insurance policies they forward by Bradley or even by also have shifted. Health offer.18 Small businesses proved to Gore. It envisaged tax breaks for Maintenance Organisations may be a powerful lobbying force in the people buying health coverage as have dampened spiralling increases debate about the Clinton plan. well as a provision to allow opting in healthcare costs. However they The incremental nature of the plan out of the current health insurance have raised concerns about the quali- has attracted favourable comment, market to buy medical savings ty of healthcare, a new issue for with some arguing that the boldness accounts, which are savings plans politicians to address. of Clinton’s plan contributed to its with no risk pooling that produce One key factor may not have failure.19 On the other hand, Gore’s high risks for the insured.25 changed. The political composition proposals are seen by some as over This is opposed by many Democrats of Congress is likely to remain hos- cautious, with some commentators on the grounds that it transfers an tile to expanded coverage. The calculating that a more ambitious undue element of risk to the individ- Democrats seem unlikely to regain plan would yield considerable ual. The legislation would also give control of Congress in the immedi- economies of scale.2 small businesses the option to buy ate future and, since 1994 some Recently Gore has seized on a com- health insurance under federal rather moderate Republicans have been ment by Bradley that he felt so than state regulation, exempting replaced by conservatives while divi- strongly about health care reform them from state mandates that larger sions have appeared amongst that he would even be prepared to self-insuring companies now Democrats, with some in favour of raise taxes. Bradley has stressed that avoid.26 introducing market forces, and oth-

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ers committed to universal coverage REFERENCES Health Care Issue. Washington Post 1 using existing programmes. 1. Carrasquillo O, Himmelstein DU, October 1999 page A33. Woolhandler S, Bor DH. Trends in 16. Dao J. Bradley Presents Health The challenge ahead health insurance coverage, 1989–1997. Plan for Almost All the Uninsured. Presidential candidates seeking Int J Health Serv 1999;29:467–83. New York Times 29 September 99. change must address the needs of the 2. Promises, promises. The 17. Hacker J. Bradley does healthcare. bottom three fifths of the income Economist. 27 March 1999 p. 662. The Nation 25 October 1999. distribution who face real insecurity from the threat of illness with no 3.Rovner J. The health care system 18. Vice President Offers Reform money for essential care. However evolves. Lancet 1996;348;1001–2. Package Targeting Uninsured. New York Times 7 September 1999. they face a major challenge from 4. Editorial. Uninsured in the USA, powerful anti-government forces. and still waiting. Lancet 1996;347:703. 19. So alike, so different The Economist. 25 September 1999. At first sight Bradley’s plan seems to 5. Gottlieb S. Paediatricians propose reach many more people than Gore’s plan to insure every US child. BMJ 20. Thorpe KE, Florence CS. and it also seems to have attracted 1999;319:1087. Covering uninsured children and their parents: estimated costs and considerable support or, at least, 6. Long SH, Marquis MS. Geographic numbers of newly insured. Med Care limited opposition, although this variation in physician visits for unin- Res Rev 1999;56(2):197–214, discus- may change as Gore increasingly sured children: the role of the safety sion 215–9. attacks it. There are, however, many net. JAMA 1999;281:2035–40. details yet to be clarified. It may be 21. Balz D, Connolly C. Bradley 7. Newacheck PW, Brindis CD, Cart that the scale of Bradley’s proposed health plan won’t fly, Gore says. CU, Marchi K, Irwin CE. Adolescent premium subsidies for the uninsured International Herald Tribune 7 health insurance coverage: recent are insufficient to provide adequate December 1999. p 3. changes and access to care. Pediatrics health care benefits, or that those 1999;104:195–202. 22. Press Release from Senator John subsidies may contribute to rising McCain Kyl, McCain want Feds to 8. Halfon N, Inkelas M, Newacheck costs in healthcare. pay states and localities for processing PW. Enrolment in the State Child and detaining illegal immigrants who A key question will be how many of Health Insurance Program: a concep- commit crimes, and for Federally the uninsured actually assert their tual framework for evaluation and mandated health care. 7 October democratic right to vote. Voter par- continuous quality improvement 1999 URL: http://mccain.senate.gov/ ticipation has declined significantly Milbank Q 1999;77:181–204. imcrime.htm in recent decades, and is particularly 9. Nelson DE, Thompson BL, Bland marked amongst lower income 23. Press Release from Senator John SD, Rubinson R. Trends in perceived Americans. In the 1989 McCain Graham, McCain offer bill to cost as a barrier to medical care, continue funding of rural health care Congressional elections health care 1991–1996. Am J Public Health 1999; program. 13 June 1997 URL: http:// (specifically Medicare reform, the 89(9):1410–3. uninsured and managed care reform) mccain.senate.gov/ahec.htm 10. Mainous AG, Hueston WJ, Love were perceived as important issues at 24. Press Release from Senator John MM, Griffith CH. Access to care for the polls, but not the most important McCain Senator John McCain floor the uninsured: is access to a physician ones. It is notable however that statement on health care & HMOs 14 enough? Am J Public Health 1999;89 those who voted for Democratic July 1999. URL: http://mccain.sen- (6):910–2. candidates ranked health care higher ate.gov/cleft.htm 11. Sloan FA, Conover CJ. Effects of than did those who voted for 25. Saltman RB. Editorial debate. state reforms on health insurance cov- Republican candidates. In a contra- Medical savings accounts: a notably erage of adults. Inquiry 1998;35 dictory fashion voters seemed to uninteresting policy idea. Eur J Public (3):280–93. view health reform as a priority for Health 1998;8:276–78. the next Congress rather than as a 12. Kohut A, Toth RC, Bowman C. 26. House debates the uninsured voting issue in the election of the The Public, Their Doctors, and along with patient rights. New York time. Whilst voters seem keen for Health Care Reform. New York: Times 6 October 1999. health care reform (particularly of Times-Mirror Center for the People Medicare and managed care) they and the Press, 1993. 27. Skocpol T. Boomerang; Clinton’s appear to be less affected in their Health Security Effort and the Turn 13. Glied S. Chronic Condition; Why Against Government in US Politics. choice of candidate at the polling Health Reform Fails. Boston: NY: Norton, 1996. p. 227. station. This may be because Harvard Univ Press, 1993. although the majority believes that 28. Kuttner R. The Kassebaum- 14. Bradley’s NHS. The Economist 2 radical health care reform is needed, Kennedy bill—the limits of incre- no-one can agree on how it can best October 1999. mentalism N Engl J Med 1997;337: be done. 15. Dionnne EJ. Resuscitation of the 64–7.

Acknowledgement: We are grateful to Richard Saltman for many helpful comments.

eurohealth Vol 5 No 4 Winter 1999 42 HEALTH SYSTEMS Health of the nation The new Minister for Health and Community Care in Scotland reflects on the opportunities created by the Scottish Public health is central to the Scottish Executive’s priorities and there is now a Parliament and Executive for improving the health of the commitment to tackle the years of neglect, which have seen the health of our poorest Scottish people. She sets out the aims of the current Executive people get worse and inequality flourish. and the policy programme planned to achieve them. Improving public health for this Executive is not just a necessary task. It is a convic- tion, an imperative. Good health is the most precious individ- Statistics that show 400,000 people in ual possession. Sadly, too many Scots are Scotland on income support, 27,000 houses deprived of this. Now, as a nation, we have classified as below tolerable standard, and the unparalleled opportunity offered by the over 530,000 houses affected by dampness new Scottish Parliament to rid Scotland of and condensation, demand action. These its reputation as the ‘sick man of Europe’. statistics translate into ill health. Health is Scotland now has its first democratically worst where people are poorest. Where elected Parliament in over 300 years. A deprivation is greatest, adults die prema- Scottish Parliament promises to deliver a turely, the rate of teenage pregnancies is better quality of life and better opportuni- highest and children have the poorest oral ties for the people of Scotland. health. In July 1999 I became be the first Scottish The Scottish Executive will not tolerate this Susan Deacon Minister for Health and Community Care. situation in the future. Health inequalities Immediately obvious was the fact that are an intolerable blight on the modern, nowhere can the Scottish Parliament better equal Scotland that the Scottish Executive demonstrate a capacity to make a real is determined to achieve. improvement to the lives of those we repre- Scotland is now getting workable strategies sent than in the fight to improve the health that strike at the heart of the problem and of the people of Scotland. provide solutions and that will deliver The Scottish Parliament offers scope for long-term success. These are substantial distinctive Scottish solutions and flexibility measures, which make the best use of what to concentrate resources and coordinate we have got, and bring every potential con- efforts to the best effect. The health pro- tributor together in an all-out offensive to gramme, which has since been set out, improve the health of Scots. recognises the necessity of tackling the root A foundation to this is the White Paper causes of ill-health and their links with ‘Towards a Healthier Scotland’, published poverty. in February 1999. It was fully endorsed by the Scottish Parliament in the following Recognising the problem September, and is a watershed in the histo- Much of Scotland’s ill health is preventable. ry of public health in Scotland. Yet, previous Governments chose to ignore the most telling cause of poor health: Reflecting the complexities of ill- poverty. Times have changed. It is no health longer acceptable to attempt to address the This document demolished once and for all symptoms of ill health, without diagnosing the argument that poverty, unemployment, the causes and then prescribing the cure. environment and social exclusion had no impact on health. Instead it proposed a concerted, three pronged approach – tack- “public health has been designated a crosscutting issue by ling life circumstances, encouraging health- the Scottish Cabinet … the National Health Service in ier lifestyles, and homing in on particular topics such as coronary heart disease, chil- Scotland does not carry a health improvement monopoly. dren’s health and teenage pregnancies. Underpinning all this was an assault on Ministerial colleagues in Education, Enterprise and Justice health inequalities. The White Paper is the platform on which the Scottish Health all have a part to play.” Programme will build.

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To achieve a healthier Scotland we need to Diet too remains a real concern in Scotland. be bold, imaginative and brave, and practi- The appointment, in the near future of a cal as well, catching the tide of change national diet coordinator is a vital step in within society. the drive to accelerate, yet further, the implementation of the Scottish Diet Action Public health is defined as “the science and Plan. The Plan provides the comprehensive art of preventing disease, prolonging life framework within which we are working and promoting health through the organ- to tackle our dietary problems. Low- ised efforts of society”. The “organised income communities experience the worst efforts of society” are particularly impor- health of all the population, and their diets tant. Individual responsibility is right and it are a particular priority. The Scottish is essential; but to reach their full potential, Community Diet Project and an increasing individuals need the organised support of number of Community Food Initiatives, the society around them. are making a particular, and major, benefi- This might mean good quality education, a cial impact on the diet, and health, of many warm and comfortable house, a safe envi- Scots. ronment, the feeling and reality of being part of a community – to feel included. That is what the Scottish Executive is all “The Scottish Parliament offers scope for distinctive about. Better schools and housing, a clean- Scottish solutions and flexibility to concentrate resources er environment, safer communities, social inclusion, higher employment and worth- and coordinate efforts to the best effect … we have the while jobs. unparalleled opportunity … to rid Scotland of its Identifying solutions A new childcare strategy; helping parents reputation as the ‘sick man of Europe’.” into work or training. The new community schools programme assisting pupils to increase their educational achievement The challenge is to ensure that all these through the integrated provision of ser- welcome, health-enhancing measures are vices, including health and social work. The brought together in a coherent way, which ‘Warm Deal’ for the elderly … all of these ensures maximum health gain. That is why are the essential ingredients of a long-term public health has been designated a cross- solution, creating the conditions in which cutting issue by the Scottish Cabinet. good health can flourish. Transforming, Implicit in that is recognition that the slowly but surely, life circumstances, hith- National Health Service in Scotland does erto the harbinger of sickness and disease, not carry a health improvement monopoly. into a catalyst for better health. Ministerial colleagues in Education, Enterprise and Justice all have a part to In relation to lifestyle, a determined drive play. against smoking is being mounted. We are totally committed to an advertising ban. That, too, is equally true in the front line. We will give practical help as well for those Local authorities, schools, voluntary who want to give up but have difficulty in organisations, as well as the NHS, have a doing so, especially the disadvantaged, by crucial role to play in health improvement. providing funding specifically for smoking The key is maximising their contribution. I cessation, and for the provision of initial am setting up structures that bring together free supplies of nicotine replacement thera- representatives from the key sectors with py for the less well off. an interest in health to monitor, support and push forward the implementation of Drug misuse commands the headlines, and the White Paper. for good reason. The collective will and resources of the Scottish Executive are Programmes of action being brought to bear in confronting this There are two particular, medium-term, pernicious modern scourge. Tackling drugs public health priorities. The first is to misuse is a priority that requires crosscut- improve child health and the other is to ting action across traditional departmental tackle teenage pregnancies and sexual and organisational boundaries. Alcohol health. It is increasingly clear that improv- misuse is another feature. We are working ing the health of mothers and children lays on a national Alcohol Strategy to ensure the basis for better health in later life. effective coordinated action across Maternal health, breastfeeding, maternal Scotland. and early childhood nutrition, parental

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lifestyles, the home environment, parenting (for example, healthy diet, exercise and skills and child care, have a profound avoidance of tobacco) will help reduce the impact on patterns of health and disease in incidence of cancers and strokes. later life. Cancer, stroke and heart disease ‘The Cancer Challenge’ will add a screen- rates, as well as mental health are all affecting programme for the early detection of ed by childhood health. colorectal cancer to existing screening pro- Four health demonstration projects grammes (for breast and cervical cancer) announced in the White Paper – backed by and take forward the new measures to £15 million of new resources – will all be combat the cancer-promoting effects of “previous under way by spring 2000. They should tobacco smoking. help make considerable inroads into reduc- Governments chose to Fluoridating the water supply is also back ing health inequalities and provide test- on the agenda. It is a controversial issue ignore the most telling beds for bringing together the principles set that needs to be tackled in order to bring out in the White Paper, building on best lasting improvements to child dental cause of poor health: practice from UK and abroad, developing health, especially those who are disadvan- new approaches and providing scope for taged. We await the conclusions of a cur- poverty.” innovation and new thinking. rent review of the safety of fluoridation. ‘Starting Well’ will focus on the promotion The Scottish public will be fully engaged of health and protection from harm in the and informed in the debate on this impor- period leading up to birth and throughout tant issue. the first five years of childhood. We have an unprecedented opportunity to ‘Healthy Respect’ will foster responsible create a healthier Scotland and to drive down health inequalities. All the necessary sexual behaviour on the part of Scotland’s ingredients are there. A new Parliament. young people with emphasis on the avoid- An energetic and committed Executive. I ance of unwanted teenage pregnancies and want a committed public health workforce sexually transmitted diseases. – ministers included – empowered, ‘The Heart of Scotland’ will focus on the resourced and energised in order to claim a prevention of heart disease, recognising new future for our people – a prosperous that many of the measures likely to be used and healthy Scotland.

How a new English health agency can benefit European health development

“While the new H.D.A. is being born in England, to play a full role it is essential that it grows up in Europe.” nent questions about what will be a demanding infancy. However, although he didn’t mention that M word, he excluded Forget the Millennium Bug. Is Millennium the E word too. While the new H.D.A. is Fever (MF) treatable as a communicable being born in England, to play a full role it disease? Politicians display the worst is essential that it grows up in Europe. Let symptoms – an inability to pen an article me explain why. without standing on the threshold of a new age – but it does seem rife throughout The role of parliament much of the media, commerce, sport, and During the coming year alone, health relat- also …… European health policy? Well, ed issues will play a hugely significant role M.F. does have an inevitable dynamic and a in EU development. Come with me heady mix of desirable and dangerous ele- amongst the ‘chattering glasses’ of the ments, so there are some parallels. European Parliament to visit its newly reformed committees that scrutinise every Donald Reid’s welcome for the bright new matter affecting 400 million citizens: English Millennium baby, the Health Development Agency (eurohealth 5:3), Stop first at the traditional home of health, Clive Needle avoided such clichés but posed some perti- the Committee on Environment, Public

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Health and Consumer Policy. In the transport and environment be driven on? “When the glaring Autumn edition of eurohealth its new Where the EU is a lifeline for seventy of Chair, Dr. Caroline Jackson, reminded us the poorest countries in the world, how are nonsense persists of a of the range of issues before it. Very soon it Europeans ensuring health gets the priority will consider the urgently needed new it deserves in Trade and Development too? pittance spent to fight health framework and a new Directive on That poses enough questions to demon- cancer against a for- blood, as well as the massive high profile strate how the decisions being taken now in body of work on food and consumer safe- the name of the new century will be having tune ploughed into ty. Given the parliament’s power of co- a lasting effect on health as a whole, not the decision, there will be some big tests of narrow interest implied by the old ‘public tobacco, where is the MEPs’ priorities on integration, inequali- health’ attribute. The ‘public’ should be coherence between the ties, impact assessments and interpretation more to the fore in the decision making of the Amsterdam Treaty as well as bud- process. Dr Jackson did not mention that Agriculture, Budgetary gets, and some fascinating tests of their every European can scrutinise the work of readiness to distinguish between populist parliamentarians without traipsing to and Environment single issue campaigns and evidence based Brussels or Strasbourg. Agendas, minutes, horizontal measures. Clearly information many speeches, voting records and Committees?” sources will be crucial. documents can all be accessed via But we have little time to pause, for in the www.europarl.eu.int/, and every MEP has sixteen other committees decisions are email provided in his or her office. Health being taken affecting health back home. professionals should keep in touch. The question is whether the politicians MEPs are, of course, just one inexpert understand that they are affecting health; access point into the European decision and how are they coordinating their work? making process. But in seeking to inform The background is the imminent enlarge- them, how much does the world outside ment of the EU, with the myriad of health know? I have been impressed to discover problems and opportunities that are belat- how many exciting international health edly being addressed, from capacity to cul- developments and projects exist, but ture to cross border freedoms. The acquis alarmed at how little appreciation the communitaire may be modest – but the majority of national and local health pro- opportunities and challenges are huge, and fessionals have of them, and therefore how largely under emphasised until recently. much their value is diminished. The EU’s existing Internal Market is also creating responsibilities as well as rights. Independent agencies and bodies European judges already have before them The useful news briefing in Autumn several key tests of those new boundaries eurohealth was largely provided by your that could impact on services and products editors and the Network of Health in the health sector; an eye-opening semi- Promoting Agencies (ENHPA), one of a nar run by EHMA in Brussels in handful of invaluable organisations, like the November demonstrated how far reaching European Health Management Association those rulings could become. So are the (EHMA) or the European Public Health MEPs in the Economic, Legal Affairs or Alliance (EPHA), who graft from Brussels Citizen’s Rights Committees consulting to inform and influence health develop- with patients and health professionals, or ment across the continent. Ironically just governments? ENHPA was partly created by support from a body that ended with the century, New technologies are revolutionising the UK Health Education Authority, and potential diagnoses, treatments and preven- one that had to change to survive, the tion; the ways in which health products are European Commission. So there is good being traded is changing beyond recogni- work at EU level, but is it getting national tion. So what is the health basis for deci- support in the UK? Let us look at three sions in the Media or Industry committees? pieces of evidence readily to hand, from the How are health inequalities tackled in the UK Health Service Journal of 25th Social Affairs, Equal Opportunities or November: Regional Policy Committees? When the – A survey of Primary Care Groups iden- glaring nonsense persists of a pittance spent tifies clinical governance, prescribing, IT to fight cancer against a fortune ploughed and commissioning as priorities. Health into tobacco, where is the coherence improvement does not feature in the between the Agriculture, Budgetary and report. Environment Committees? How will the 1999 ministerial declaration on health, – One year after the Acheson Report, a

eurohealth Vol 5 No 4 Winter 1999 46 HEALTH SYSTEMS

review praises forthright government rate information and communication for economic actions, but fears health mutual benefit. inequalities may worsen with relative That is where the new UK Health poverty increasing and growing regional Development Agency can ideally meet imbalances. needs. As Donald Reid rightly pointed out, – The renowned Professor David Hunter an initiative to provide a coordinated, evi- bemoans the rarity of UK health ser- dence – led base for public health in vices seeking to learn from abroad. He England is welcome. That role is clearly calls for a new way of “capturing separate from any delivery or programmes. knowledge gained across healthcare sys- It must be about communication, and coor- tems and using it to inform policy dination is vital. When I recently asked changes in various countries” rather how a new English regional observatory than “needlessly reinventing the wheel.” might link into European networks, I was met with puzzled looks. That should not It seems there is scope for some health happen after years of discussion about EU improvement. “Although the health health monitoring in the current frame- Simultaneously, Tilman Togel, a German work. representative in the Committee of the of the continent’s There is terrific work on integrated health Regions, a consultative body for EU development policies underway across regional and local governments, has pro- citizens may never Europe, but it tends to be too fragmented duced a series of recommendations on how and staccato. There are several sustainable have been better as a those bodies should play a greater role in urban networks but they are often seen as developing European health policies. Other driven by competition for resources rather whole, the potential conferences talk of local government ‘seiz- than collaboration for common good. All ing’ the new health agendas. Every day, threats are clear and those initiatives exploding from newly printers chatter in regional offices across devolved regional or national bodies (the the continent as new links and programmes exacerbated by splendid Welsh proposals on health are formed. impacts have just arrived as I write) need a isolationism or restric- Yet who decides which are the appropriate spider sitting at the hub of the web, not to tion of debate to researchers, what are the reliable evidence control, but to empower. The new Health bases, who forms the networks, which Development Agency, working with oth- narrow regimes.” skills are exchanged, even who goes to the ers, can start to be that spider, coordinating seminars? When the projects are underway, in England and communicating beyond. It how are results evaluated, communicated should not be spinning a web to suit any and disseminated? Are valuable funds being government alone, for it must merit a most properly used or just shared amongst non-arachnidan confidence and trust from cliques? Who advises government advisors the communities with whom it seeks part- and the health attaché network in Brussels? nership. As new opportunities beckon and How accountable are all those scientific, awareness increases, not least amongst technical and management committee rep- patients and users, so do pressures to deliv- resentatives who determine the actual pro- er, from leaders in the capital cities, in grammes? Would it not be better to ensure Brussels or Geneva, to the front line all that information is collated and easily providers. accessible? Where better could a new agency start to provide a useful service? Time for a new politics It is a most stimulating, fascinating, The need for communication and unprecedented time for international health coordination development. That is why a year ago I The new Commissioner and Director urged MEPs, Ministers and Commissioners General for Health and Consumer Policy to set out a European Decade for Health. have had an unenviable start, full of argu- Although the health of the continent’s citi- ments over dioxins and beef. They deserve zens may never have been better as a every encouragement and will need all pos- whole, the potential threats are clear and REFERENCES sible support from the health community, exacerbated by isolationism or restriction 1. Health Service Journal, 25th not least to press on from principles to pri- of debate to narrow regimes. Professor November 1999. orities, within an imaginative new frame- David Hunter concluded by urging “a new 2. Togel, T. Role of the local work that received a wide consensus of politics to confront the public policy chal- and regional authorities in the support when proposed in draft in 1998. lenges posed by globalisation … combining reform of European public That support has to be practical, and the vision with leadership.” That seems to me health systems, COM –5/021, best way to demonstrate the added value of to be an antidote to Millennium Fever November 1999. international cooperation is to ensure accu- worth striving for.

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FOOD SAFETY AND THE WHITE PAPER ON FOOD Anglo-French Dispute on British Beef Revelations about food manufacturing practices, the recent dioxin and BSE crises, and uncertainty about the effects of hormone treated beef and genetically modified The dispute between the UK and food have generated much public concern about the issue of food safety. France arose because of French failure to lift the ban on British beef, The Commission has presented a concerning food safety. The EU has despite the fact that EU veterinary White Paper on Food and Safety, already reinforced the European experts pronounced that it is safe which includes an Action Plan that Food and Veterinary Office (FVO), for human consumption. Germany sets a clear timetable for action over which has recently moved from has also refused to lift its ban, Brussels to Dublin. The owing to obstruction in the the next three years, including Bundesraat by some Lnder. options for the establishment of a Commission will present options to European Food and Public Health further improve scientific advice at Exports of British beef were Authority. All Commission pro- European level and a number of abruptly halted in March 1996 posals, including a fundamental options concerning a European after UK scientists identified a review of food law, shall be put for- Food and Public Health Authority. potential link between BSE and ward before the end of 2000. On this The report A European Food and CJD (new variant Creutzfeldt- basis the EU will establish a coher- Public Health Authority: The future Jakob disease), a disease that can be ent and up-to-date body of food leg- of scientific advice in the EU, con- fatal to humans. This worldwide islation by 2002. tains recommendations on the cre- ban was lifted on August 1, 1999. ation of a European Food and Public France, however, informed the During the Food and Tobacco European Commission on Federation Conference on the 19th Health Authority (EFPHA). The report is available on: http:// October 1, 1999 that it would not November 1999, the EU’s Health lift its embargo on British beef, on europa.eu.int/comm/dg24/health/sc/ and Consumer Protection the basis of advice from its recently future/_food_en.html Commissioner, David Byrne elabo- established National Food Agency. rated upon the contents of the White The third aim of the White Paper is The EU’s Scientific Steering Paper and its three aims. to reinforce food controls ‘from sta- Committee (SSC) evaluated the ble to table’. Currently, food control The first aim of the White Paper is evidence presented by France and is conducted at three different levels. to modernise food safety legislation on October 29 concluded unani- Industry conducts its own checks. and to develop a single, coherent mously that there was no need to Member States have the responsibili- body of legislation that is flexible change their previous opinions on ty to carry out controls at all levels enough to respond to advancing sci- the safety of British beef. On of the food chain, and the entific knowledge, new production November 16, The European Commission’s Food and Veterinary techniques and the discovery of new Commission decided to initiate Office (FVO) controls the perfor- health hazards. formal legal proceedings against mance of national authorities in France for not fulfilling its obliga- The White Paper’s second aim is to Member States and third countries. tions under Commission Decisions increase the capability of the EU’s The Commission believes that addi- 98/256/EC and 99/514/EC relating scientific advice system to respond tional legislative proposals are need- to the lifting of the embargo. rapidly and effectively to situations ed to improve the functioning of the David Byrne has called on the system. The Commission should, for German government to act on its example, be given more legal author- promise to lift the import ban on ity to control and inspect at all levels BST considered risk free British beef. of the feed and food chain. BST (Bovine Somatotrophin) is a hormone that increases milk production when injected into dairy SLUDGE cows. In the opinion of the European Medicines Evaluation France’s continued ban on British beef was made more politically sensitive by Agency on Veterinary Products the disclosure of findings by the Commission’s veterinary inspectors that some (CVMP), which has reviewed all French animal feed manufacturers have been using treated sewage sludge, which the scientific data currently avail- might include human faeces, as a protein rich ingredient for meat meal. able, there are no public health The Commission’s Food and Veterinary Office inspection was carried out from grounds for establishing a 19-20 August, in response to press reports on the use of sludge in animal feed. Maximum Residue Limit for There have been similar allegations against feed manufacturers in other coun- BST. The Commission therefore tries, including Belgium and the Netherlands. decided on December 8 that BST is risk free, having earlier adopted Sewage sludge is included amongst the list of ingredients whose use in com- a proposal to ban the use and pound feedstuffs is prohibited by Commission Decision 91/516. The European marketing of BST in the EU from Commission has brought forward legislative proposals that will prohibit the use January 2000. of all residues obtained from wastewater processes in feed manufacture.

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HEALTH COUNCIL MEETING The Health Council, under the Finnish Presidency met on the 18th of November 1999.

Community Strategy in the Field of Public Health Promotion of Mental Health

Commissioner Byrne informed the and activities and to set up a net- The Council adopted a Resolution on Council about the proposal for an work of experts to advance the use the promotion of mental health, one Action Programme on Public of methods, skills and common ter- of the priorities of the Finnish Presidency. Health, which is currently being minology applicable at Community The Resolution ‘recognises that developed and about the Fourth level. In addition, the Resolution mental health is an indivisible part Report on the Integration of urges Member States to take health of health’. Amongst other things, it Health Protection Requirements impact into account in all invites Member States to give due in all Community Policies, that was Community policies that they pro- attention to mental health and to recently adopted. The Council wel- pose and implement, and to assess strengthen its promotion in their comed the plans of the Commission the health impact of Community policies. The Commission should for the Action Programme, which policies and activities implemented consider incorporating activities on according to the Finish Health at the national level. the theme in the future Action Council President Eva Biaudet will An interim Report from the Programme for public health and represent a new qualitative step for Commission to the European develop and implement a public health in Europe. The Council, the ECSC and the Community health monitoring sys- Council noted the need for a wide Committee of Regions on the imple- tem. It should consider producing a cooperation in the sector and wel- mentation of the Commission’s report on the issue and analyse the comed the Commissioner’s idea of Action on the prevention of cancer, impact of Community activities on creating a European Health Forum. AIDS and certain communicable mental health. The Council also The Council acknowledged that, in diseases and drug dependence within invites the Commission to consid- order to achieve a high level of the Framework for Action in the er, after consultation with the health protection in Europe, existing field of public health (1996–2000) is Member States, the need to draw mechanisms had to be strengthened available on: http://europa.eu.int/ up a proposal for a Council and new ones possibly created. comm/dg24/health/ph/pro- Recommendation on the promo- The Council adopted a Resolution grammes/pr01_en.html tion of mental health. on ensuring health protection in all Community policies and activities. The Resolution “reaffirms the previ- Tobacco Consumption ous invitations to the Commission The Council heard a presentation by Commissioner Byrne on a proposal for a regarding the protection of health in directive adopting measures regarding the manufacture, presentation and sale of Community policies and activities”. tobacco products which aims at strengthening the existing directives concerning It invites the Commission to include the labelling and content of tobacco products. The Council adopted in the Action Programme ideas on Conclusions on the Commission’s report on progress achieved in relation to the elements and structures that public health protection from the harmful effects of tobacco consumption. should be introduced to ensure that During a policy debate on this issue Member States welcomed the all Community policies meet the Commission’s proposal and outlined action that could be taken at Community obligation to protect public health. level to support national efforts to combat tobacco consumption. It also encourages the Commission to further develop a health impact assessment of Community policies Health Issues beyond the Pharmaceutical Dossiers Present Borders of the Union The Council took note of the In accordance with the conclusions progress achieved on the delibera- Antibiotic Resistance adopted by the Council on 26 tions concerning a proposed The Council took note of the October 1999, the Council will eval- Directive on the implementation Commission’s intervention and of uate, on a regular basis, the progress of good clinical practices in the the Presidency’s intention for made in the aim to increase coopera- conduct of clinical trials on medi- future action following a tion in the sphere of public health cinal products for human use. It Resolution that was adopted on between applicant countries and EU proposed an amendment to the Antibiotic Resistance in June 1999. Member States. The Council agreed Directive concerning medical The Council’s conclusions, which on a negotiating position in relation devices, regarding medical devices focus primarily on veterinary and to the Euro-Mediterranean incorporating stable derivatives of feeding stuffs-related aspects of Conference of Health Ministers that human blood or human plasma. antibiotic resistance, were submit- was held in Montpellier, 2–3 Both proposals are based on Article ted to the Agriculture Council in December 1999, in the framework 95 of the Amsterdam Treaty and December 1999. of the Barcelona process. (See News are discussed in the framework of in Brief) the Internal Market Council.

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A NEW DIRECTORATE GENERAL ON “HEALTH AND CONSUMER PROTECTION” Further Commission Reform

Amongst the first series of reforms committees concerned with con- Following the first series of changes, the Commission is now implemented by the Prodi sumer health and carry out inspec- embarking on the creation of an Commission in the effort to “… re- tions within the EU and outside, to overall reform programme. engineer, adapt and improve the ensure that rules of hygiene and The reform programme aims at organisation to make it more effi- food safety are respected throughout introducing a culture of change cient and more effective” has been the food production process. The within the Commission, to the establishment of a new new DG will aim to protect con- increase the institution’s efficiency, Directorate General (DG) for sumer’s economic interests by, accountability and transparency, “Health and Consumer Protection”. amongst other things, proposing and and to foster the ethos of public The Commission’s Unit on Public monitoring legislation, reinforcing service. The measures to achieve Health, which previously fell under market transparency, and improving this will be set out in the Reform the Employment and Social Affairs consumer confidence, especially Strategy Programme that includes Directorate, has been incorporated through more complete and effective detailed plans for future change into this new DG. information and education. On and a full timetable for implemen- The mission of the new Directorate Public Health, the new Directorate tation. This Programme will be General is to ensure a high level of will assure a high level of human published in February 2000. A new protection of consumers’ health, health protection in the development Task Force for Administrative safety and economic interests as well of all Community Policies, and take Reform (TFAR) has been set up to as of public health at the level of the actions to improve public health in steer the process. European Union. To this end, the the European Union, to prevent For more information about DG has been organised into six human illness and diseases and to Strategic Reform Issues, see the Directorates: Consumer Policy, remove sources of danger to human Communication by Commission Scientific Health Opinions, health. Vice President Neil Kinnock on this Coordination of Horizontal David Byrne, former Attorney subject, available on: http://www. Questions, Food and Veterinary General in Ireland, has been europa.eu.int/comm/reform/index_ Office, Public, Animal and Plant appointed Commissioner of the new en.htm. Health, and Public Health. DG. Mr. Robert John Coleman, a In the area of consumer safety and qualified lawyer who studied at health the DG’s main activities will Oxford University and in the be to propose and monitor legisla- United States and who previously Commission Communication tion in the areas of veterinary, ani- headed the Transport Directorate- mal feed and phytosanitary matters. General, has been appointed the new on the Precautionary Principle It will manage European scientific Director-General. Before the end of the year, the Commission shall present to the For more information on the DG Health and Consumer Protection look at the Council and the European website http://www. europa.eu.int/comm/dgs/health_consumer/index_en.htm Parliament a Communication on the precautionary principle. The Communication aims to determine the criteria and situations under which the precautionary EU AND US LEADERS MEET TO DISCUSS TRADE ISSUES principle should be applied. The idea behind the precautionary prin- During their meeting in October to discuss the agenda for World Trade talks, ciple is that provisional safety mea- European Commission President Romano Prodi and US President Bill Clinton agreed to launch a dialogue between EU and US scientists in a bid to defuse dam- sures should be taken when there aging trade rows over food safety issues such as genetically modified foods. are safety concerns and where scientific information is incomplete. The move aims to close the gap review this new programme, and Given the constantly advancing between the two scientific commu- reassess the situation regarding nature of science, scientific infor- nities over controversial health exports of beef from the US. In mation is always incomplete. The issues and is designed as an interim view of the wish to stimulate ‘trade Communication therefore tries to measure until the EU sets up its creation’ rather than ‘trade distor- clarify how complete scientific own food and drugs agency. The tion’, the two parties are looking knowledge must be, how much of a leaders also discussed a new “Non- into compensatory measures to health concern there must be and in Hormone Treated Cattle” (NMTC) replace the retaliatory measures that whose mind it must exist, before programme that was launched in the the US imposed upon the EU over trade restrictive measures are intro- US in September 1999. The EU’s the latter’s ban on hormone treated duced on the basis of the precau- Food and Veterinary Office will beef. tionary principle.

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MENTAL HEALTH

A European Conference organised by the Finnish presidency on the Promotion of Mental Health and Social Inclusion was held from the 10-13 of October 1999 in Tampere, Finland. In an address to the Conference, to give recommendations concern- develop common concepts and Commissioner David Byrne con- ing data collection. A ‘key concepts’ actions. Health service, education, curred with the conference state- project is addressing the need for employment policy and social wel- ment that “there is no health with- clearer European definitions of fare should all coordinate efforts at out mental health” and discussed mental health and for better indica- the regional level to design joint the role that the EU can play in tors to measure the effects of mental strategies for mental health promo- making a real contribution to pro- health promotion and care. tion. Comparable and reliable informa- moting improved mental health. All Another issue discussed during the tion will lead to the further develop- Community policies should be Conference was the application of ment of mental health policies. closely monitored for their potential information and communication contribution to mental health, in Mr. Byrne stated that the technology in the prevention of accordance with provisions of the Commission is to present its recom- mental heath. According to Teuvo Amsterdam Treaty. mendations on the promotion of Peltoniemi, Head of the Mr. Byrne stated that while mental mental health to the Council. He Information Unit of the Finnish A- health has not been given direct pri- believes that mental health will have Clinic Foundation, telematic meth- ority within the EU’s current public a significant place in the public ods in substance abuse prevention health framework, it has received health framework that will replace have proved to be very advanta- much emphasis under the Health the existing framework after 2001. geous and user-friendly. Mr. Henry Promotion Programme and the Preparations for this new frame- Haglund, Head of Unit for the Health Monitoring Programme that work are currently underway. Information Society Promotion Office at the European fall under this framework. Under One of the issues discussed during Commission, presented a new pro- the Health Promotion Programme, the Conference were the effects of gramme by the Commission that for example, concrete priority has unemployment on mental health. opens possibilities for providing been given to mental health promo- According to Professor Augustin telematic services to all citizens. tion for children up to 6 years of Ozamis from the Basque Health age. Under the Health Monitoring Service, unemployment clearly has For more information on the confer- Programme, a European network of various negative effects on mental ence please contact: Professor Ville mental health promotion has been health. He believes that the EU’s Lehtinen, STAKES, Finland e-mail established to collect information employment policies should include [email protected] or look at about existing relevant databases, a mental health component, and that the STAKES website http//www. information systems and indicators Member States should cooperate to stakes.fi

LIFE WEEK The LIFE programme is a Community action devoted to supporting environmental protection in Europe and in bordering regions. CLIMATE CHANGE

The programme supports environ- years through the LIFE programme. The Environment Commissioner mental policy by funding innovative Set up initially in 1992, the LIFE Margot Wallstrom launched an local initiatives, testing new ideas action programme in mid October and techniques at grass root level, programme was extended for a second phase until the end of 1999. It is to combat climate change, as part and providing good practices of sus- of her efforts to persuade EU now about to enter its third phase tainable development. LIFE“ governments to do more to cut and the LIFE III programme Week”, held in Brussels 20–23 greenhouse gas emissions. October, encouraged the dissemina- (2000–2004) is currently under dis- tion of knowledge in environmental cussion in the European Parliament The Commission released its annu- protection accumulated over seven and the Council of Ministers. al ozone reports that give an overview of ozone pollution in the Global Assessment on Environmental Programme EU for 1998 and for the summer of 1999. The reports conclude that On November 24, 1999 the European Commission adopted a Global ozone pollution in the EU is still a Assessment on the overall results of the European Union’s Fifth Environmental threat to human health and vegeta- Action Programme. Serious environmental problems such as increasing tion. amounts of waste, summer smog in cities, chemical dispersion into the environ- The reports are available on: ment, climate change and bio-diversity losses, remain in Europe and globally. http://europa.eu.int/comm/dg11/ai The Report will be available on the Environment DG’s website: r/ozonerep.htm http://europa.eu.int/comm/environment/newprg/index.htm

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NEWS IN BRIEF

First Meeting of Euro- exceed the levels considered safe by imise resources available. Scientific Mediterranean Health Ministers scientists. The Decision marks the participants at the Conference rec- first time that the Commission has ommended that the best way to do The first meeting of 27 Euro- instigated an immediate ban under this would be to offer healthy people Mediterranean Health Ministers was the General Product Safety only those screening tests that have held in Montpellier, France on the Directive. The Decision will enter proved to decrease the incidence of 2nd and 3rd of December, 1999. The into force before the end of 1999. (1 cancer. At present these methods Conference emphasised that health December) are: pap smear screening for cervical threats, such as communicable dis- abnormalities starting at the latest by eases, know no borders, and are New Directive on the protection age 30 and not before age 20, mam- therefore relevant to both the of workers at risk from mography screening for breast can- Northern and Southern dimension explosive atmospheres cer in women aged 50-69, and faecal of the European Union. The European Parliament and the occult blood screening for colorectal Vaccinations are cost-effective Council of Ministers have confirmed cancer in men and women aged 50- means to combat diseases. Equally the full agreement on rules for the 69. The Commission services will important are measures outside the protection of workers at risk from examine, on the basis of these precise actual health sector, such as safe explosive atmospheres. The success- guidelines, a proposal for a Council drinking water and safe food. The ful result of this conciliation proce- recommendation on cancer screen- Euro-Mediterranean ministers dure is particularly noteworthy as it ing in the EU. adopted the first political declaration is the first legal act in the health and on future cooperation in the field of safety area to be adopted under the The Commission adopts funding health. co-decision procedure as a result of provisions for its annual animal entry into force of the Amsterdam disease eradication programme High level Committee Meeting Treaty. (1 December) on Health In the year 2000, as in previous years, the European Union will co- About thirty high-level civil servants Labelling GMOs finance programmes of the Member working in the field of health in EU EU governments backed the States aimed at the eradication of Member States met in Helsinki on European Commission’s proposal to animal diseases and at the prevention 26-27th October to discuss the require companies to provide infor- of zoonoses. The diseases targeted future of public health programmes mation labels on foods if any ingre- by the programmes have implica- in the EU and the impact of other dient in a product contains more tions for both human and animal EU policies on health. than 1 percent of genetically modi- health. The European Commission Representatives of applicant coun- fied soya and maize. Although the has adopted two decisions listing 41 tries were invited to take part in the decision applies only to these two programmes covering 14 diseases second day of the meeting, where substances, it is likely to set a prece- and qualifying for a 50% financial they discussed their participation in dent for other substances. The pro- contribution from the EU. activities relating to the EU’s health posal will probably be followed by a policy. formal Commission proposal. Environmental Groups such as Commission presents report on EU ban on phthalates in Greenpeace have argued that the human exposure to dioxin childcare articles and toys threshold of 1 percent is too high The Environment Commissioner The European Commission will and the proposals are likely to face Margot Wallstrom has presented a adopt proposals for an emergency opposition in the European study on the most current dioxin ban on sales of some oral baby toys Parliament exposure and health data in the EU, softened with chemicals believed to entitled “Compilation of EU Dioxin be toxic. Representatives on the Conference on screening and Exposure and Health Data”. The Emergencies Committee set up early detection of Cancer report concludes that despite the fact under the General Product Safety A European Conference on screen- that dioxin levels have been decreas- Directive, composed of representa- ing and early detection of cancer, ing in recent years, in all countries tives of Member States, unanimously sponsored by the “Europe Against for which data is available for the endorsed the Commission’s draft Cancer” Programme and organised last 10-15 years the daily intake of decision (approved on 10 by the Austrian Cancer Society of dioxins and dioxin-like compounds November) to ban certain oral baby Vienna, took place in Vienna on the remain above the recommended lev- toys made from polyvinyl chloride 18-19th of November 1999. The els for some parts of the population. (PVC) that have been softened with ultimate goal of the Conference was The study can be downloaded from phthalates. Tests have shown that to adopt European guidelines to the following website: http://europa. babies may ingest quantities of two implement cancer-screening pro- eu.int/comm/environment/dioxin/in phthalates (DINP and DEHP) that grammes in such a way as to max- dex.htm

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