For the full versions of articles in this section see bmj.com UK NEWS Doctors try to get speakers to boycott international conference, p 532 news World NEWS Drug related deaths continue to rise in the UK, p 532 bmj.com US health secretary pledges renewed fight against HIV BMJ lends its support to 10:10 climate change campaign Helen Mooney London A campaign to encourage public sector organisations, private sector companies, and the public to reduce carbon emissions by 10% by 2010 has been launched by the team behind The Age of Stupid, a film about climate change. The 10:10 campaign, which has the back- ing of the BMJ, has been launched to encour- age people to show the government that they have got a mandate to reduce carbon Khaled Fazaa/stringer/getty images Fazaa/stringer/getty Khaled emissions. Conditions in camps are deteriorating for thousands who have been forced to flee their homes The aim is to obtain as many signatories as possible by 21 September and to urge the government’s climate change and energy UN calls for safe humanitarian secretary, Ed Miliband, to commit the coun- try to the 10:10 target ahead of the next set of international talks on climate scheduled corridors in northern Yemen for December in Copenhagen. John Zarocostas Geneva the Hajjah governate, which workers to reach the affected A campaign spokesman said that if Mr Senior United Nations officials adjoins Sa’ada, and that an communities, and some areas Miliband committed to the target it would have called for humanitarian estimated 4000 internally have become inaccessible. allow the UK to “step forward to make the corridors to be opened in displaced people in Amran, Andrej Mahecic, a cuts deemed necessary by the science and northern Yemen as hostilities to the east of Hajjah, “were in spokesman for the UN High could potentially break the impasse at the between government forces a bad condition and needed Commissioner for Refugees, UN negotiations which have long been and the rebel Al-Houthi Shi’ite humanitarian assistance.” told reporters at a briefing blocked by political wrangling over who groups escalate. Relief aid is WHO has provided trauma last week: “The situation in will jump first.” badly needed for thousands and diarrhoea kits and two Sa’ada city in northern Yemen The national campaign also hopes to drive of civilians who have been mobile health clinics to provide remains dramatic. The fighting high profile individuals to commit to cutting displaced or are still trapped in health services for displaced is ongoing, both inside the city their own carbon emissions by 10% in one the fire zone, they say. people, officials said. and its surrounding areas. The year. “Cutting 10% . . . is at the level of lag- The UN Office for the Similarly, the International town has been practically cut ging your loft or taking one less flight,” said Coordination of Humanitarian Committee of the Red Cross said off from the rest of the world for the spokesman. Relief has described the that in the past two weeks it had a week now.” Several high profile individuals and health situation in the Sa’ada supplied two health centres António Guterres, the or­ganisations have already signed up. These governate, in the north west of west of Sa’ada city with surgical UN high commissioner for include Tottenham Hotspur Football Club, the the country, as “alarming.” dressings and oral rehydration refugees, and Ann Veneman, actors Gillian Anderson and Pete Postlethwaite, World Health Organization salts and had provided basic Unicef’s executive director, and Nicholas Stern, former head of the officials say that outbreaks medical supplies to the Yemen have also called for the opening G­overnment Economic Service and author of diseases such as malaria, Red Crescent and specialist of humanitarian corridors, of the influential report on the economics of diarrhoea, and measles “are items for treating war wounded as conditions in camps for climate change, published in 2006. likely,” because most public patients to the hospital in Hajjah thousands of people forced to Ten NHS organisations, including health programmes and health governate’s district of Harad. flee their homes deteriorate. Un­iversity College London Hospitals Founda- facilities are either unable It had also donated 100 body “It is essential that we gain tion Trust, Nottingham University Hospitals to operate or have become bags to the ministry of health in immediate and secure access Trust, South West Strategic Health Authority, inaccessible. Sana’a, Yemen’s capital. to provide urgently needed and Bristol Primary Care Trust, have already WHO officials report that six Senior UN officials say humanitarian assistance,” committed to the 10% reduction next year. cases of malaria have been that the conflict has made it Ms Veneman said. See www.1010uk.org. confirmed in al-Mezrek in difficult for humanitarian aid Cite this as: BMJ 2009;339:b3546 Cite this as: BMJ 2009;339:b3520

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in brief Doctors seek speaker boycott US government increases funds to local health centres: The US Department of Health and Human of international conference Services has announced nearly $26m (£16m; €18m) in grants to boost Oona Mashta London Harvey Marcovitch, former editor of the services at 180 health centres that A group of doctors from the United ­Kingdom Archives of Disease in Childhood and ­immediate served more than 17 million “medically is trying to get speakers at a forthcoming past chairman of the Committee on ­Publication underserved” people in 2008. international medical conference in Croatia Ethics (COPE), said: “We’re letting [the FDA reviews safety of orlistat: The US to boycott it on the grounds that it is being ­speakers] make up their own mind whether Food and Drug Administration is reviewing chaired by a proved plagiarist. they should attend. But I feel that by doing so the safety of the weight loss drug orlistat The group is unhappy that the fifth annual they threaten the integrity of ­science.” (marketed as Xenical on prescription and meeting of the International Academy of Jim Neilson, professor of obstetrics and Alli over the counter). It has received 32 reports of serious liver injury, including six Perinatal Medicine—to be held in Dubrovnik gynaecology at the University of Liverpool, cases of liver failure, in people taking the in October—is being chaired by Asim Kurjak said, “Kurjak is not a suitable person to chair drug. (See www.fda.gov.) of Zagreb University Medical School. a major international meeting. I think promi- The British doctors are writing to all the nent figures in our specialty should make a EU advises on priority groups for H1N1 vaccination: All people aged over non-Croatian speakers taking part, who stand against research misconduct.” 6 months old with underlying chronic number 44, alerting them to Professor As the BMJ went to press the letter had conditions, pregnant women, and ­Kurjak’s history of plagiarism. prompted three people to pull out of the con- healthcare workers should be the first Professor Kurjak was found guilty of sci- ference: Stephen Robson, of the University priority groups for H1N1 vaccination, entific misconduct by the Croatian govern- of Newcastle’s Institute of Cellular Medicine, the European Union’s Health Security ment’s Committee for Ethics in Science and Anne Greenough, director of education and Committee recommends. See http:// Higher Education in May 2007. The com- training at the Neonatal Intensive Care Unit ec.europa.eu/health. mittee found him guilty of “violations of the at King’s College London School of ­Medicine, Study shows large variations in [committee’s] ethics code and of common and Ola Didrik Saugstad, ­professor of cervical cancer mortality: Latest norms in biomedical publishing.” ­paediatrics at the University of Oslo. figures show major differences in Professor Kurjak eluded punishment The allegations of plagiarism were cervical cancer mortality across the by Zagreb University, because the alleged ­originally made in the BMJ by Iain ­Chalmers, European Union. Age standardised mortality rates have fallen significantly offences had taken place some years previ- editor of the James Lind Library (BMJ in the older member states, but in ously and he had retired from the university 2006;333:594-7), after concerns first raised in newer member countries in eastern in September 2007 before the case was heard the late 1980s when he and a colleague were Europe and the Baltic states Gschmeissner/spl steve in October. preparing a systematic review of controlled mortality has shown The university’s “court of honour” admit- trials of epidural anaesthesia in labour. smaller falls, has ted that he had behaved unethically but Dr Chalmers commented: “I find it extraor- remained high, or has judged that the apologies submitted to those dinary that the perinatal research community risen (European Journal concerned were “adequate measures, con- is prepared to lionise a man guilty of scientific of Cancer doi:10.1016/ j.ejca.2009.07.018). cordant with the common practice for the and professional misconduct.” breaches of the Code of Teachers’ Ethics.” Cite this as: BMJ 2009;339:b3545 Audit of NHS records reveals fewer coding errors: More than 12% of the clinical codes for diagnoses and procedures were wrong UK drug related deaths are still rising say two reports finds a review of medical records by the Audit Commission. However, this Susan Mayor London number of deaths involving cocaine increased was an improvement on last year’s The numbers of people dying because of by 20% from 2007. figure of 16.5%; and improvement ­poisoning from legal and illegal drugs are still The numbers of deaths related to prescrip- in specialist trusts was particularly increasing, warn two UK reports published tion drugs also rose. notable (see www.audit-commission. this week. A second report, from the national pro- gov.uk). The latest figures for England and Wales gramme on substance abuse deaths at St UK government launches study from the Office for National Statistics show George’s, University of London, showed a into female genital mutilation: GPs that the numbers of deaths recorded as being 2.7% rise in the number of drug related deaths and health professionals working in related to drugs have risen to their highest confirmed by inquest in the UK (1952). maternity, obstetrics, gynaecology, and level since 2001. Heroin and morphine accounted for most sexual health are being asked to take part in a study into genital mutilation There were 2928 deaths from drug poison- of these deaths, being implicated in 45% to improve services for women and ing in 2008, 11% higher than the 2007 figure of cases in England, Wales, and Northern girls affected. Visit http://surveys. of 2640. More than two thirds (2075) of those ­Ireland and 64% of cases in Scotland. redhouselane.com and enter the who died were men. Deaths Related to Drug Poisoning is at password fgmsurvey. Almost a third of deaths where specific www.statistics.gov.uk/pdfdir/dgdths0809.pdf. Cite this as: BMJ 2009;339:b3548 drugs were mentioned on the death certifi- The St George’s annual report is at www.sgul.ac.uk. cate were related to heroin or morphine. The Cite this as: BMJ 2009;339:b3536

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German medical academics accused of accepting cash bribes

Ned StaffordHa mburg Medical academics are among about 100 professors in Germany who are being inves- tigated for accepting cash bribes to help stu- dents obtain doctoral degrees. Günther Feld, the senior prosecutor in Cologne who is leading the investigation, g es confirmed that “several” medical school pro-

fessors were being investigated and could face ima g etty criminal prosecution. Medical doctors were also among those who may have illegally obtained doctoral degrees, he told the BMJ.

It is illegal for professors to accept money U g arte/afp/ P edro for supervision of dissertations for doctoral Only 5% of resources allocated to fighting cancer globally are spent in the developing world degrees in Germany, said Mr Feld. The academics work in various disciplines; only a few are full professors with tenured Billions of dollars are needed to close positions (www.nw-news.de, 24 Aug 2009, “Korruption bei Professoren schockt Unis”). global spending gap on cancer care They came to the attention of prosecu- tors during a court case last year involving Karen McColl Dublin countries of Africa, Asia, and Latin America,” the Institute for Academic Consultancy in An annual investment of $217bn (£134bn; said Andreas Ullrich, a cancer expert at the suburban Cologne. The institute, which has €152bn) is needed to meet the shortfall in World Health Organization, who attended the been in business for 20 years, charged up global spending on cancer care and treat- Livestrong Global Cancer Summit in Dublin, to €20 000 (£18 000; $29 000) to help doc- ment, says a report from the Economist at which the report was launched. toral candidates. Participating professors Intelligence Unit. “Even in middle income countries, like reportedly received between €2000 and The report, which was commissioned by Brazil, India, and China, this growing can- €5000 for each candidate, according to Neue the Lance Armstrong Foundation, calculates cer burden is of major public health concern Westfälische. that of the estimated 12.9 million new cancer since their health systems need to be devel- Annette Schavan, German minister for cases in 2009, almost two thirds (61%) will oped to deal with the complexity of cancer education and research, said that the scandal occur in low or middle income countries. Yet prevention and control,” he added. This is could damage the country’s international aca- only 5% of the resources currently allocated why WHO’s focus remains on primary pre- demic and research reputation. to fighting cancer globally are spent in the vention and the development of health sys- Cite this as: BMJ 2009;339:b3498 developing world. tems, he said. New cases of cancer will cost $305bn this Access to palliative care is another problem year alone, based on treatment and care, lost for patients with cancer in poorer countries. UK drug related deaths are still rising say two reports productivity, other non-medical costs, and “There is a human and ethical obligation to cancer research ($19bn), says the report. offer palliative care,” said Dr Ullrich, add- DEATHS IN ENGLAND AND WALES FROM DRUG To arrive at the current funding short- ing that politicians must be engaged with RELATED POISONING AND DRUG MISUSE, 2004-8* fall, the report defined a “global treatment the issue. National legislation on controlled Men: all drug related poisoning expenditure standard,” derived from spend- drugs, for example, can be an obstacle to Men: drug misuse ing estimates for the country with the low- access to opiates for pain control. Women: all drug related poisoning est case fatality rate for each type of cancer. The report calls for greater visibility for glo- Women: drug misuse Almost 90% of the $217bn needed to bring bal cancer initiatives. The international com- 80 all countries up to this standard is needed in munity is well aware of this growing challenge 60 low and middle income countries. but has failed to act, it says. “Cancer has never The growing burden of cancer and other been high on the global health agenda,” said 40 chronic diseases in poorer countries is a Doug Ulman, president and chief executive ­challenge for under-resourced health sys- of the Lance Armstrong Foundation. “We felt 20 tems that are already struggling to cope with it was imperative to have a financial figure 0 ­widespread communicable diseases. to enable us to say that if we invest these 2004 2005 2006 2007 2008 “To treat cancer you need access to resources we can close that gap.” No of deaths per million population ­services—for surgery, chemotherapy, and Breakaway: The Global Burden of Cancer—Challenges * Figures for 2008 are provisional All mortality rates are age standardised to the European standard population ­radiotherapy—and capacity to deliver. Both are and Opportunities is at www.livestrong.org. Source: Office for National Statistics often not available in low and middle income Cite this as: BMJ 2009;339:b3499

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increase in that number, but the change won’t appear within a short time.” From 1993 to July 2009 the number of liver transplants registered with the registry was 16 062, of which 0.8% were organs from brain stem dead donors, 6.5% from living donors, and 92.7% from what the ­transplant centres providing data to the registry described as “non-heart beating donors.” “The use of executed prisoners’ organs is something that has long been known, but this was the right time for Dr Huang to make that comment,” said Professor Fan. “If China wants to join the international trans- plant community it must do away with using organs from executed prisoners.” The Chinese Medical Association announced an agreement in 2007 to restrict

s image Stringer/afp/getty the use of organs from executed prisoners to Two thirds of organ donors in China are still executed prisoners donation to immediate relatives; and in the same year the government introduced regu- lations aimed at curbing transplant tourism China moves closer to abandoning use and organ trafficking. However, it is widely acknowledged in China that a vibrant black of organs from executed prisoners market in organs exists, that illegal transplan- tations for foreigners are conducted, and that Jane Parry Hong Kong plants,” he told the China Daily newspaper. demand for organs far outstrips supply. Only China’s Ministry of Health and the Red The new donor system, launched on 25 10 000 transplantations are carried out each Cross Society of China have jointly launched August, covers five major cities—Nanjing, year, but 1.5 million domestic patients need a pilot organ donation system to harvest Shanghai, Tianjin, Wuhan, and Xiamen— organs, according to official statistics quoted organs from brain stem dead patients. The and the provinces of Guangdong, Jiangxi, in China Daily. system is a step towards bringing transplant ­Liaoning, Shandong, and Zhejiang provinces. The number of prisoners given the death organ procurement procedures into line with It has been welcomed by observers as a small penalty is a state secret in China, and no internationally accepted practices. but important step in the right direction. published data exist on the source of organs Announcing the programme, China’s dep- “The number of organ donations from for transplantation. uty health minister, Huang Jiefu, admitted brain stem dead patients remains quite small,” Sam Zarifi, director for the Asia Pacific that more than 65% of current organ donors said Fan Sheung-tat, professor and head of region of Amnesty International, said, “We are executed prisoners, with only a tiny pro- the department of surgery at the ­University of fear there will always be a black market, but portion of organs coming from brain stem Hong Kong’s Li Ka Shing Faculty of ­Medicine, we hope this announcement will address the dead people. “Executed prisoners are defi- which administers the China Liver Transplant issue of demand.” nitely not a proper source for organ trans- Registry. “I anticipate that there may be some Cite this as: BMJ 2009;339:b3567 Global warming is more harmful for people with respiratory problems, warns specialist society Rory Watson Brussels attention to the effects of global forest fires, and dust storms. professionals receive more The estimated increase in the risk warming on people with asthma, Its research shows that an education on the consequences of premature death among people rhinosinusitis, chronic obstructive increase in temperature of 1°C would of global warming “to ensure that with respiratory problems that pulmonary disease, and respiratory produce a 1-3% increase in all cause patients are adequately informed would result from a 1°C rise in global tract infections. mortality in the general population of how changing weather patterns temperature is more than double In a position statement but a 6% increase among people could affect their health.” that in the rest of the population, the published in its journal (European with respiratory illnesses. It also advises that respiratory European Respiratory Society says. Respiratory Journal doi:10.1183/ The society emphasises the need physicians should check on As pressure mounts on 09031936.00003409) the society for more research into improving vulnerable patients, carrying out governments to agree tougher points out various factors that could predictive models, supplemented medical assessments ahead of measures to tackle climate change all affect respiratory diseases. These by continuous prospective the summer season, and should at negotiations in Copenhagen include extreme temperatures, measurement and assessment advise on routine care, including shortly before Christmas, the changes in air pollution, floods, of the key exposures that affect fluid intake and adjustment of drug society is urging policy makers and damp housing, thunderstorms, respiratory health. treatments during hot weather. health professionals to pay greater changes in allergen disposition, It recommends that health Jon Ayres, director of the Institute

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Developing nations pour cash Perverse financial incentives reward into attracting medical tourists poor quality care John Zarocostas Geneva Mark Pownall London “Medical tourism” is forecast to expand New funding systems are needed to over- ­rapidly in the next few years, triggered by ris- come the perverse financial incentives that ing healthcare costs in wealthy nations, says reward the treatment of sick patients even a new report. Countries in Asia and Latin when the ill health is caused by the system America are becoming major destinations. itself, concludes a major review of the evi- The Rise of Medical Tourism estimates that dence on quality improvement and costs. the global market in medical tourism will Healthcare providers in the United be worth $100bn (£60bn; €70bn) by 2012, ­Kingdom should bear more of the costs of up from around $60bn in 2006 and $40bn poor quality care, which includes an absence

in 2004. The analysis, compiled by Grail P icone/alamy of preventive health care, it says.

Research LLC, a global research company, Jack The review, by John Øvretveit, ­professor suggests that increasing medical tourism is Maco Antonio Sterringa has started an agency for of health innovation and management at driven in part by emerging countries invest- medical tourists at the BKK Hospital, Bangkok the Karolinska Institute in Stockholm, was ing large sums in a bid to capture a slice of commissioned by the think tank the Health this lucrative niche market. tertiary care teaching hospital, planned to ­Foundation, partly in response to the “Contrary to some perceptions, the services open in 2011. ­imminent 5% reduction in the NHS budget provided reach beyond cosmetic procedures The report says that in 2007 Thailand was between 2011 and 2014. and include more complex, longer-term and the healthcare destination for 1.54 ­million It identifies hospital associated infections, costly care,” the report says. This includes people from other countries, India for adverse drug events, surgical complications, ­dentistry, major surgery, organ ­transplantations, 450 000, Singapore for 410 000, and ­Malaysia pressure ulcers, and falls as common and and stem cell ­transplantations. for 290 000. costly consequences of poor quality care. The report tracks the increasing investment More than 700 000 Americans travelled Risk assessment, monitoring, and timely by some countries to attract medical tourists. abroad for medical procedures last year, action can often prevent the most com- India announced plans in 2007 to invest spending an estimated $35bn. US patients can mon adverse events of inpatient cardiac or $6.5bn to “boost its medical tourism indus- save up to 94% by travelling to other countries ­respiratory arrests, it says. try,” and Thailand aims to invest $21.7m for cardiac and orthopaedic surgery. Poor communication, particularly during between 2008 and 2011 on its service sector, The authors say that medical tourism may handover from one team to another and dur- “with a focus on medical tourism.” pose challenges for public health services ing discharge from hospital, is the common- Mexico is supporting the development of in developing nations and that hospitals in est cause of poor quality care, it says. a “health city” that will provide facilities for rich countries may suffer loss of revenue and The review also highlights potential causes medical tourists. Similarly, Harvard ­Medical expertise, with physicians moving to foreign of adverse events caused by underuse of flu International, a non-profit subsidiary of institutions. vaccination, overuse of antibiotics, and mis- ­Harvard University, and Dubai Healthcare See www.grailresearch.com. use of antidepressants. And it points out that City have collaborated to develop a 400 bed Cite this as: BMJ 2009;339:b3541 an estimated 40% of drug treatments and 25% of radiological procedures are unnecessary. The costs of poor quality care can be enor- mous, it says. These include, in the UK, a Global warming is more harmful for people with respiratory problems, warns specialist society total of £1bn (€1.1bn; $1.6bn) for hospital of Occupational and Environmental change will alter the incidence of associated infections, £600m for adverse Medicine at the University of some infections, with some, such drug events, and £11 500 for every fractured Birmingham and lead author of the as tuberculosis, increasing, while femur caused by a fall. position statement, notes that much others, such as respiratory syncytial The review accuses purchasers, policy mak- higher temperatures in the summer virus infections, become less of a ers, and professional associations of focusing have a “marked” effect on patients problem. The timing and duration of unduly on new treatments and ignoring exist- with lung diseases. respiratory syncytial virus infections ing treatments, tests, and services. He said, “If we can provide better have already changed since the And many improvements never achieve warning systems and information mid-1990s, with the season ending their full potential because they are badly for respiratory patients and earlier and attacks becoming less managed, “especially the people aspect,” encourage stronger [European severe as temperatures have risen. says Professor Øvretveit, acknowledging that

s image G allup/getty Union] action to mitigate the effects The society also emphasises the hierarchies, territorial suspicion, and a lack

Sean Sean of climate change fewer people will need for lifestyle changes to reduce of resources hamper change in health care. Car use contributes die unnecessarily.” energy consumption. Does Improving Quality Save Money? is at to global warming The report says that climate Cite this as: BMJ 2009;339:b3530 www.health.org.uk. Cite this as: BMJ 2009;339:b3549

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