Jeffrey P Koplan

Towards a common definition of global health

This commentary makes the argument for the necessity of a common definition of global health.

Hong Kong: a model of successful tobacco control in China

China is the world’s largest tobacco grower, cigarette producer, and consumer, with 35% of global tobacco market-share and 30% of the world’s smokers. Tobacco will cause 2 million deaths yearly in the country by 2025. China has begun to engage in tobacco control through activities by the Ministry of Health, the Chinese Center for Disease Control and Prevention, and non-governmental organisations, along with external funding from the Bill & Melinda Gates Foundation and the Bloomberg Initiative. China was a signatory to the Framework Convention on Tobacco Control and is committed to its enforcement. Nevertheless, the country faces an immense public health challenge and is at an early stage of eff ectively addressing the tobacco threat. A bright spot for tobacco control can be found in Hong Kong, a Special Administrative Region of China. For more than 20 years, Hong Kong has sought to diminish the health burden of tobacco use, and has been remarkably successful. The strategies and approaches used, although typical of eff ective tobacco-control programmes world wide, might serve as a useful bestpractice example for programmes underway or being considered in other cities and regions throughout China. Beginning with a health ordinance focusing on tobacco in 1982, Hong Kong started a step-by-step approach to tobacco control involving multipronged strategies aimed at reduction of supply and demand for tobacco use. Approaches have included legislative amendments, increased tobacco taxation, publicity and education, support for cessation, and gearing up of anti-tobacco leadership by the medical community. Information about knowledge, attitudes, and practices of the population and subgroups has been carefully obtained to monitor progress and setbacks 1 Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol 2006; 36 (suppl 2): 121–25. 2 UN. Report of the United Nations Scientifi c Committee on the eff ects of atomic radiation. July 10–18, 2008. http://unbisnet.un.org:8080/ipac20/ ipac.jsp?session=Y2681O42W2625.454146&profi le=bib&uri=full=310000 1~!874144~!40&ri=1&aspect=subtab124&menu=search&source=~!horizo n#focus (accessed March 8, 2010). 3 Huda W, Nickoloff EL, Boone JM. Overview of patient dosimetry in diagnostic radiology in the USA for the past 50 years. Med Phys 2008; 35: 5713–28. 4 Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005; 293: 2609–17. 5 Fenton JJ, Deyo RA. Patient self-referral for radiologic screening tests: clinical and ethical concerns. J Am Board Fam Pract 2003; 16: 494–501. 6 Frush DP. Radiation, CT, and children: the simple answer is...it’s complicated. Radiology 2009; 252: 4–6. 7 Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med 2007; 357: 2277–84. 8 Oikarinen H, Meriläinen S, Pääkkö E, Karttunen A, Nieminen MT, Tervonen O. Unjustifi ed CT examinations in young patients. Eur Radiol 2009; 19: 1161–65. 9 Malone JF. New ethical issues for radiation protection in diagnostic radiology. Radiat Prot Dosimetry 2008; 129: 6–12. 10 American College of Radiology. ACR appropriateness criteria. September, 2009. http://www.acr.org/secondarymainmenucategories/quality_safety/ app_criteria.aspx (accessed March 11, 2010). 11 Royal College of Radiologists. Making the best use of clinical radiology services: referral guidelines (6th edn). London: The Royal College of Radiologists, 2007. 12 IAEA. Mission statement. http://www.iaea.org/About/mission.html (accessed March 11, 2010). 13 IAEA. International basic safety standards for protection against ionizing radiation and for the safety of radiation sources. 1996. http://www-pub. iaea.org/MTCD/publications/PDF/ss-115-web/Pub996_web-1a.pdf (accessed March 8, 2010). 14 IAEA. Measures to strengthen international co-operation in nuclear, radiation, transport and waste safety: international action plan for the radiological protection of patients—report by the Director General. July 31, 2002. http://www.iaea.org/About/Policy/GC/GC46/GC46Documents/ English/gc46-12_en.pdf (accessed March 11, 2010). 15 IAEA. Comprehensive clinical audits of diagnostic radiology practices: a tool for quality improvement. 2010. http://www-pub.iaea.org/MTCD/ publications/PDF/Pub1425_web.pdf (accessed March 8, 2010). 16 IAEA. Proceedings of the international workshop on justifi cation of medical exposure in diagnostic imaging. Brussels: International Atomic Energy Agency, Sept 2–4, 2009. 17 Lau LS. Leadership and management in quality radiology. Biomed Imaging Interv J 2007; 3: e21.

Communication during public health emergencies.

A public health emergency has many parallels with an acute health crisis in an individual—but also some key differences. Understanding those differences can tell us a lot about crisis communication and the unprecedented demands placed on public health decision makers in this new century. In an individual health emergency, such as injuries sustained in an automobile collision, the health care team enjoys the relative luxury of being able to concentrate on the victim and the surgical treatment the victim’s injuries may require. The family and friends waiting outside the operating room do not expect a running, real-time commentary from the surgeon while the operation is in progress. By contrast, since the fall of 2001, just such a constant stream of communication has come to be expected from public health officials. Such communication is considered a feature of the investigative effort. This is so despite the fact that taking time out to face the microphones diverts public health practitioners from their functions and responsibilities during a major crisis—no less so than such an undertaking would distract and divert a surgeon. Traditionally, communication has been understood as one of the important components of a public health response to an emergency. But including a communications specialist on a team, as one colleague among many, was viewed as an adequate way to address this need. That calculus may have shifted forever with the anthrax attacks of 2001. During the anthrax crisis as in no other, it became obvious that public communication had become in some sense fully as important as—if not even more important than—the line duties of senior decision makers. If this lesson was not totally clear during those harrowing October days, it has become indelibly apparent in subsequent ‘‘crises’’ involving mass preemptive vaccination for smallpox, West Nile Virus outbreaks, and the recent eruption of SARS (Severe Acute Respiratory Syndrome). Also arguing for an unprecedented degree of top-level attention to communications issues is the increasingly complex nature of messages and audiences. As never before, these audiences include:

Improving the world's health through national public health institutes

Globalization is as applicable to health issues as to those of trade and economics (1). The increased frequency of travel, distribution of goods, migration, spread of communications and marketing of new lifestyles have promoted a set of risks and health challenges shared by all countries of the world, despite their varied resources, levels of development, demographics and other important considerations (2). The ability of any one country to solve these new challenges on its own is increasingly difficult and certainly inefficient.In many countries, health authorities have established scientific entities that serve as national resources to prevent and control health problems through research, interventions or the development of policies. There is an increasing tendency to merge these entities and develop more comprehensive public health institutes to deal with the various issues from a public health perspective. We describe the current nature and status of such national public health institutes (NPHIs) and consider the elements that might make them increasingly effective in preventing disease and promoting health in an increasingly interdependent world.An NPHI is an organizational unit of a national govern-ment health ministry (not of a state or province), which serves the whole country as a source of technical public health expertise and would be the unit called upon to respond to public health

Childhood obesity: successes and failures of preventive interventions

Despite progress toward assuring the health of todays young population, the 21(st) century began with an epidemic of childhood obesity. There is general agreement that the situation must be addressed by means of primary prevention, but relatively little is known about how to intervene effectively. The evidence behind the assumption that childhood obesity can be prevented was discussed critically in this roundtable symposium. Overall, there was general agreement that action is needed and that the worldwide epidemic itself is sufficient evidence for action. As the poet, writer, and scholar Wittner Bynner (1881-1968) wrote, The biggest problem in the world could have been solved when it was small.

New academic partnerships in global health: innovations at Mount Sinai School of Medicine.

Global health has become an increasingly important focus of education, research, and clinical service in North American universities and academic health centers. Today there are at least 49 academically based global health programs in the United States and Canada, as compared with only one in 1999. A new academic society, the Consortium of Universities for Global Health, was established in 2008 and has grown significantly. This sharp expansion reflects convergence of 3 factors: (1) rapidly growing student and faculty interest in global health; (2) growing realization-powerfully catalyzed by the acquired immune deficiency syndrome epidemic, the emergence of other new infections, climate change, and globalization-that health problems are interconnected, cross national borders, and are global in nature; and (3) rapid expansion in resources for global health. This article examines the evolution of the concept of global health and describes the driving forces that have accelerated interest in the field. It traces the development of global health programs in academic health centers in the United States. It presents a blueprint for a new school-wide global health program at Mount Sinai School of Medicine. The mission of that program, Mount Sinai Global Health, is to enhance global health as an academic field of study within the Mount Sinai community and to improve the health of people around the world. Mount Sinai Global Health is uniting and building synergies among strong, existing global health programs within Mount Sinai; it is training the next generation of physicians and health scientists to be leaders in global health; it is making novel discoveries that translate into blueprints for improving health worldwide; and it builds on Mount Sinais long and proud tradition of providing medical and surgical care in places where need is great and resources few.

Stronger national public health institutes for global health

Although strengthening health-care systems is receiving increased attention, strengthening public health systems and institutions could save far more lives at lower cost. Public health institutes monitor, implement, and oversee programmes to prevent disease. Life-saving and cost-saving programmes include immunisations, control of communicable diseases including diarrhoeal disease, reduction of motor-vehicle crashes, and tobacco control. Over the past decade, many countries have considered, strengthened, or created national public health institutes (NPHIs), often following a major event such as the outbreak of severe acute respiratory syndrome. The core function of an NPHI is monitoring and responding to health threats. Monitoring requires refer ence laboratories and surveillance. Response requires outbreak control and implementation of evidence-based public health actions. NPHIs can include disease-specifi c control programmes, support to state, provincial, or local public health entities, surveillance and control for non-communicable diseases and injuries, occupational and environmental health, and vital registration (table). These functions can be done by more than one institution in a country, and some countries have collaborated to establish regional institutions. Eff ective public health responses often require a multidisciplinary team, including skills needed for communicable and non-communicable disease control programmes. For example, the response to biosecurity threats involves expertise in infectious diseases, chemical hazards, engineering, environmental remediation, and risk communication.

Smoking Experimentation among Elementary School Students in China: Influences from Peers, Families, and the School Environment

The aim of this study was to investigate experimentation with smoking among primary school students in China. Data were acquired from a recent survey of 4,073 students in grades 4 to 6 (ages 9–12) in 11 primary schools of Ningbo City. The questions were adapted from the Global Youth Tobacco Survey (GYTS). Results suggest that although the Chinese Ministry of Education (MOE) encourages smoke-free schools, experimentation with cigarettes remains a serious problem among primary school students in China. Peers, family members, and the school environment play important roles in influencing smoking experimentation among students. Having a friend who smoked, seeing a family member smoke, and observing a teacher smoking on campus predicted a higher risk of experimentation with smoking; the exposure to anti-tobacco materials at school predicted a lower risk of experimentation with smoking. The evidence suggests that public health practitioners and policymakers should seek to ensure the implementation of smoke-free policies and that intervention should target young people, families, and communities to curb the commencement of smoking among children and adolescents in China.

Smoking behaviours and cessation services among male physicians in China: evidence from a structural equation model

Objective To investigate smoking prevalence and cessation services provided by male physicians in hospitals in three Chinese cities. Methods Data were collected from a survey of male physicians employed at 33 hospitals in Changsha, Qingdao and Wuxi City (n=720). Exploratory factor analysis was performed to identify latent variables, and confirmatory structural equation modelling analysis was performed to test the relationships between predictor variables and smoking in male physicians, and their provision of cessation services. Results Of the sampled male physicians, 25.7% were current smokers, and 54.0% provided cessation services by counselling (18.8%), distributing self-help materials (17.1%), and providing traditional remedies or medication (18.2%). Factors that predicted smoking included peer smoking (OR 1.14 95% CI 1.03 to 1.26) and uncommon knowledge (OR 0.94 95% CI 0.89 to 0.99), a variable measuring awareness of the association of smoking with stroke, heart attack, premature ageing and impotence in male adults as well as the role of passive smoking in heart attack. Factors that predicted whether physicians provided smoking cessation services included peer smoking (OR 0.82 95% CI 0.76 to 0.89), physicians’ own smoking (OR 0.87 95% CI 0.81 to 0.93), training in cessation (OR 1.36 95% CI 1.27 to 1.45) and access to smoking cessation resources (OR 1.69 95% CI 1.58 to 1.82). Conclusions The smoke-free policy is not strictly implemented at healthcare facilities, and smoking remains a public health problem among male physicians. A holistic approach, including a stricter implementation of the smoke-free policy, comprehensive education on the hazards of smoking, training in standard smoking-cessation techniques and provision of cessation resources, is needed to curb the smoking epidemic among male physicians and to promote smoking cessation services in China.

The role of national public health institutes in health infrastructure development

Science based and often relatively apolitical, they deserve 10% of donors funds