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WHAT'S NEW THIS SUNDAY: TEN ITEMS ON EVERYTHING

Thursday, 30th of August 2012 Print
  • WHAT’S NEW THIS SUNDAY: TEN ITEMS ON EVERYTHING

Not quite everything. Almost.

1.      Cash Transfer Schemes and the Health Sector

2.      200 Years in Four Minutes

3.      Cochrane Review: Deworming during Pregnancy

4.      Tropical Disease in the U.S.

5.      Under-18 Marijuana Consumption and Intelligence

6.      G20 Assesses The Impact Of Poor Health Care In Developing World

7.      Dengue in Africa 

8.      A Research Agenda For The Control And Elimination Of Human Helminthiases

9.      The Burden of Acute Respiratory Infections in Crisis-Affected Populations: A Systematic Review

10.  Why Corporate Power is a Public Health Priority

 

  • CASH TRANSFER SCHEMES AND THE HEALTH SECTOR

 

Excerpt below; full text is at http://www.who.int/bulletin/volumes/90/7/11-097733.pdf

The lack of information on health systems impact must be remedied to gain a full understanding of the extent to which CTs contribute to better well-being. This is particularly true in the case of conditional CTs because their central rationale is that services are underuti­lized by those who most need them, even when freely accessible and of decent quality, a problem which a conditional incentive can help to resolve. Whether or not this is really the case, however, is difficult to determine.

CTs and other forms of social pro­tection are increasingly recognized as vital elements in improving health and reducing health inequalities. Neverthe­less, health agencies have remained rela­tively passive observers of CT schemes, rather than active participants in their design, implementation and evaluation. For example, in over 400 documents referenced in a recent evidence review of conditional CT schemes, only 15 were from public health, medical or nutritional institutions and journals.10

  • 200 YEARS IN FOUR MINUTES

Hans Rosling plots changes in income against changes in life expectancy for dozens of countries, starting in 1810. In contemporary countries ( present day China is well documented), there are intracountry differences, probably reflecting differences in living conditions and resource allocation.

http://www.youtube.com/watch?v=jbkSRLYSojo 

  • COCHRANE REVIEW: DEWORMING DURING PREGNANCY

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Effect of administration of antihelminthics for soil transmitted helminths during pregnancy

 

Note to readers: Is it time to update this review, last updated to September 2008?

Haider BA, Humayun Q, Bhutta ZA

Published Online: April 15, 2009

 

Intestinal worms (helminths) contribute to iron deficiency anaemia as they feed on blood and cause further bleeding by releasing anticoagulant compounds. They also affect the supply of nutrients and cause anorexia, vomiting and diarrhoea. Pregnancy complicated by maternal hookworm infection poses a serious threat to the health of mothers and their babies, especially in developing countries. Women who are anaemic during pregnancy are more likely to have ill health, give birth prematurely, and have low birthweight babies with low iron reserves. Antihelminthic drugs are highly effective and have minimal side-effects but information on their use during pregnancy is limited. The major concern is that the drugs may cause malformation of the fetus (teratogenic effects).

 

The review authors found only three randomised controlled trials evaluating the impact of giving a single antihelminth treatment in the second trimester of pregnancy. The studies were conducted in Sierra Leone, Peru and Entebbe Uganda. A total of 1329 women were randomly assigned to receive a single dose of albendazole or mebendazole, or a placebo. In one study, and a subset of another, the women were also given a daily iron or iron-folate supplement. Analysis of the impact of antihelminth intervention on maternal anaemia including all results showed that the intervention was not associated with any clear impact on maternal anaemia or on low birthweight, perinatal deaths or preterm births. Analysis of studies in which iron or iron-folate was also given to pregnant women along with antihelminths also failed to show any impact on maternal anaemia. The impact on infant survival at six months of age could not be evaluated because data were not available. Evidence provided so far from randomised controlled trials is, therefore, insufficient to recommend use of antihelminthics for pregnant women after the first trimester of pregnancy.

 

Background: 

 

Helminthiasis is infestation of the human body with parasitic worms and it is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries suffer from iron deficiency anaemia. Though iron deficiency anaemia is multifactorial, hook worm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious in treating hook worm but evidence of their beneficial effect and safety, when given during pregnancy, has not been established.

 

Objectives: 

 

To determine the effects of administration of antihelminthics for soil transmitted helminths during the second or third trimester of pregnancy on maternal anaemia and pregnancy outcomes.

 

Search strategy: 

 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2008).

 

Selection criteria: 

 

All prospective randomised controlled trials evaluating the effect of administration of antihelminthics during the second or third trimester of pregnancy.

 

Data collection and analysis: 

 

Two review authors independently assessed trial quality and extracted the data.

 

Main results: 

 

Three studies (1329 women) were included in this review. Analysis showed that administration of a single dose of antihelminth in the second trimester of pregnancy is not associated with any impact on maternal anaemia in the third trimester (risk ratio (RR) 0.90; 95% confidence interval (CI) 0.68 to 1.19, random effects (2 studies, n = 1075)). Subgroup analysis on the basis of co-interventions other than antihelminthics which included iron supplementation given to both groups in the study by Larocque et al, and a subset of the study by Torlesse et al, showed that a single dose of antihelminth along with iron supplementation throughout the second and third trimester of pregnancy was not associated with any impact on maternal anaemia in the third trimester as compared to iron supplementation alone (RR 0.76; 95% CI 0.39 to 1.45, random-effects (2 studies, n = 1017)). No impact was found for the outcomes of low birthweight (RR 0.94; 95% CI 0.61 to 1.42 (1study; n = 950)), perinatal mortality (RR 1.10; 95% CI 0.55 to 2.22 (2 studies, n = 1089)) and preterm birth (RR 0.85; 95% CI 0.38 to 1.87 (1 study, n = 984)). Impact on infant survival at six months of age could not be evaluated because no data were available.

 

Authors' conclusions: 

 

The evidence to date is insufficient to recommend use of antihelminthics for pregnant women after the first trimester of pregnancy. More well-designed, large scale randomised controlled trials are needed to establish the benefit of antihelminthic treatment during pregnancy.

 

This record should be cited as: 

Haider BA, Humayun Q, Bhutta ZA. Effect of administration of antihelminthics for soil transmitted helminths during pregnancy. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD005547. DOI: 10.1002/14651858.CD005547.pub2

Assessed as up to date: 

September 30, 2008

 

  • TROPICAL DISEASE IN THE U.S.

Dengue fever has been reported in parts of South Texas like Brownsville.

By PETER J. HOTEZ

Published: August 18, 2012

Houston

IN the United States, 2.8 million children are living in households with incomes of less than $2 per person per day, a benchmark more often applied to developing countries. An additional 20 million Americans live in extreme poverty. In the Gulf Coast states of Louisiana, Mississippi and Alabama, poverty rates are near 20 percent. In some of the poorer counties of Texas, where I live, rates often approach 30 percent. In these places, the Gini coefficient, a measure of inequality, ranks as high as in some sub-Saharan African countries.

Poverty takes many tolls, but in the United States, one of the most tragic has been its tight link with a group of infections known as the neglected tropical diseases, which we ordinarily think of as confined to developing countries.

Outbreaks of dengue fever, a mosquito-transmitted viral infection that is endemic to Mexico and Central America, have been reported in South Texas. Then there is cysticercosis, a parasitic infection caused by a larval pork tapeworm that leads to seizures and epilepsy; toxocariasis, another parasitic infection that causes asthma and neurological problems; cutaneous leishmaniasis, a disfiguring skin infection transmitted by sand flies; and murine typhus, a bacterial infection transmitted by fleas and often linked to rodent infestations.

Among the more frightening is Chagas disease. Transmitted by a “kissing bug” that resembles a cockroach but with the ability to feed on human blood, it is a leading cause of heart failure and sudden death throughout Latin America. It is an especially virulent scourge among pregnant women, who can pass the disease on to their babies. Just last month, the first case of congenital Chagas disease in the United States was reported.

These are, most likely, the most important diseases you’ve never heard of.

They disproportionately affect Americans living in poverty, and especially minorities, including up to 2.8 million African-Americans with toxocariasis and 300,000 or more people, mostly Hispanic Americans, with Chagas disease. The neglected tropical diseases thrive in the poorer South’s warm climate, especially in areas where people live in dilapidated housing or can’t afford air-conditioning and sleep with the windows open to disease-transmitting insects. They thrive wherever there is poor street drainage, plumbing, sanitation and garbage collection, and in areas with neglected swimming pools.

Most troubling of all, they can even increase the levels of poverty in these areas by slowing the growth and intellectual development of children and impeding productivity in the work force. They are the forgotten diseases of forgotten people, and Texas is emerging as an epicenter.

A key impediment to eliminating neglected tropical diseases in the United States is that they frequently go unrecognized because the disenfranchised people they afflict do not or cannot seek out health care. Even when there is a clinic or community health center in an impoverished area, it often lacks the necessary diagnostic tests, and the staff is rarely trained to recognize and manage neglected tropical diseases.

We have an opportunity to stop these diseases, but we need to act. First, we need programs of active surveillance and monitoring to obtain more accurate information on the true prevalence of these diseases and how they are transmitted. We also need better diagnostic tests; worm infections like cysticercosis and toxocariasis can often be treated effectively with antiparasitics and anti-inflammatories, but they are frequently misdiagnosed.

Finally, we need safer and more effective drugs and new licensed vaccines. For instance, there are drugs to treat Chagas disease, like benznidazole and nifurtimox, but they are hard to procure, often not effective in adults after the symptoms of heart disease begin and so toxic they cannot be taken by pregnant women. And unfortunately, with a few exceptions — like some promising new dengue vaccines under development — the major pharmaceutical companies see little financial advantage in investing in better treatments or vaccines for these diseases.

With the looming possibility of budget cuts to the Centers for Disease Control and Prevention and its excellent Parasitic Disease Branch, others will need to step up. Texas and the Gulf Coast are home to some of the country’s greatest universities and medical schools, and they can bring considerable brainpower to bear on this problem.

In Houston, the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development have organized a research unit to develop new vaccines and diagnostics. And Baylor College of Medicine created a new tropical medicine school to teach doctors and other health care providers to recognize, diagnose and treat these infections. A key component is a tropical disease clinic outside Houston where patients show up every Friday. On recent Friday mornings just over the last month, the clinic’s director has treated a young woman with cutaneous leishmaniasis, three people with brain lesions from cysticercosis and a middle-aged man with Chagas disease.

While immigration is sometimes blamed for introducing neglected tropical diseases into the United States, the real issue is that they are now, to varying degrees, also being transmitted within our borders. Without new interventions, they are here to stay and destined to trap people in poverty for decades to come. Fifty years ago, Michael Harrington’s book “The Other America: Poverty in the United States” became a national best seller. Today more people than ever before live in poverty in this country. We must now turn our attention to the diseases of this Other America.

Peter J. Hotez is the dean of the National School of Tropical Medicine at Baylor College of Medicine and the president and director of the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development.

A version of this op-ed appeared in print on August 19, 2012, on page SR4 of the New York edition with the headline: Tropical Diseases: The New Plague of Poverty.

 

  • UNDER-18 MARIJUANA CONSUMPTION AND INTELLIGENCE

Teens who smoke pot can damage memory, intelligence

By Kate Kelland

LONDON | Mon Aug 27, 2012

LONDON (Reuters) - Teenagers who become hooked on cannabis before they reach 18 may be causing lasting damage to their intelligence, memory and attention, according to the results of a large, long-term study published on Monday.

Researchers from Britain and the United States found that persistent and dependent use of cannabis before the age of 18 may have a so-called neurotoxic effect, but heavy pot use after 18 appears to be less damaging to the brain.

Terrie Moffitt, a psychology and neuroscience professor at King's College London's Institute of Psychiatry, said the scope and length of the study, which involved more than 1,000 people followed up over 40 years, gave its findings added weight.

"It's such a special study that I'm fairly confident cannabis is safe for over-18 brains, but risky for under-18 brains," she said.

Before the age of 18, the brain is still being organized and remodeled to become more efficient and may be more vulnerable to damage from drugs, she added.

Moffitt worked with Madeleine Meier, a post-doctoral researcher at Duke University in the United States, to analyze data on 1,037 New Zealanders who took part in the study. About 96 percent of the original participants stuck with the study from 1972 to today, she said.

At age 38, all participants were given a battery of psychological tests to assess their memory, processing speed, reasoning and visual processing.

Those who had used pot persistently as teens scored significantly worse in most of the tests. Friends and relatives regularly interviewed as part of the study were more likely to report that the heavy cannabis users had attention and memory problems such as losing focus and forgetting to do tasks.

The researchers also found that people who started using cannabis in adolescence and continued for years afterwards showed an average decline in Intelligence Quotient (IQ) test scores of 8 points between the age of 13 and 38.

"Study subjects who didn't take up pot until they were adults with fully-formed brains did not show similar mental declines," Moffitt said.

"MARIJUANA IS NOT HARMLESS"

She said the decline in IQ could not be explained by alcohol or other drug use or by having less education, and Meier said the key variable was the age people began to use pot.

Meier said the study's message was clear: "Marijuana is not harmless, particularly for adolescents."

While 8 IQ points may not sound like a lot on a scale where 100 is the mean, Meier said an IQ drop from 100 to 92 would mean dropping from being in the 50th percentile to being in the 29th.

Higher IQs also correlate with higher levels of education and income, better health and longer lives, she said. "Somebody who loses 8 IQ points as an adolescent may be disadvantaged ... for years to come," she added.

Robin Murray, a professor of psychiatric research at King's Institute of Psychiatry, who was not involved in this work, said the study was impressive and the findings should be taken "very seriously".

"It is of course part of folk-lore among young people that some heavy users of cannabis seem to gradually lose their abilities and end up achieving much less than one would have anticipated," he said in a statement. "This study provides one explanation as to why this might be the case."

Previous research on cannabis use has also pointed to potential long-term psychiatric effects.

A study published in March last year found that people who use it a lot in their youth dramatically increase their risk of psychotic symptoms, and that continued use of the drug can increase the risk of developing a psychotic disorder.

Meier pointed out that it was not possible to say from this latest study what a safer age for persistent pot use might be, or what kind of dosage level causes damage.

According to the 2011 United Nations Office for Drugs and Crime (UNODC) global drugs report, which used data from 2009, between 2.8 and 4.5 percent of the world's population aged 15 to 64 - or between 125 and 203 million people - had used cannabis at least once in the previous 12 months.

 

  • G20 ASSESSES THE IMPACT OF POOR HEALTH CARE IN DEVELOPING WORLD

By Palash R. Ghosh | November 10, 2010

Also at http://www.ibtimes.co.uk/articles/80384/20101110/aids-hiv-africa-health-care-government-budget.htm

One of the greatest challenges facing the developing world lies with their limited access to quality healthcare, a situation that threatens to jeopardize or undermine economic growth in these nations.

A group of healthcare executives and experts attending the G20 business summit in Seoul, South Korea has implored the body to adopt global health care as a permanent agenda at all future summits.

The health care advocates cited various data illustrating how poor medical services hurts economic growth in the developing countries.

For example, examining tea workers in Kenya, employees who were HIV-positive are about 33 percent less productive than their healthy peers.

The discussion panel looked closely at sub-Saharan Africa (SSA), where lack of health care is at crisis levels. According to the World Health Organization (WHO), in much of the continent, there are less than 2.5 hospital beds per 1,000 population (the average for the world excluding SSA is about 3.8). Deaths among children as a result of diarrheal diseases, pneumonia, malaria, HIV-AIDS and even measles are widespread here and far outpace the frequency of such deaths in the remainder of the world.

One of the speakers at the health care forum, Cynthia Carroll, chief executive officer of mining company giant Anglo-America, cited how her firm, which operates in 40 countries, including many developing countries, has seen first-hand the impact of ill, untreated workers on business. For example, with respect to the spread of HIV-AIDS in its southern Africa workforce, messages of prevention have failed to stop the incidence of the disease.

Carroll estimated that in 2000, a full 25 percent of her southern African workforce were HIV-infected, creating a significant burden on the company's finances. Specifically, the overall cost impact of HIV/AIDS was estimated to be equivalent to 3.4 percent of the company's payroll.

By 2002, Anglo-American resolved to provide free HIV testing and treatment to its African workers.

"AIDS sickness and deaths were reduced dramatically," she said. "Morale improved and our shareholders supported our measures. Investing in health care has improved our businesses."

Carroll indicated that in South Africa alone, her company has a total of 110,000 full-time employees and contractors, of whom 17 percent are infected with AIDS (or about 14,000 people). The company is spending about $10-million per annum on HIV-AIDS treatment/prevention; and has spent a total of $100-million thus far on these efforts.

Another speaker at the forum, Yasuchika Hasegawa, president of Takeda Pharmaceutical Co. Ltd., one of the largest Asian drugmakers, pointed to the so-called "Takeda Initiative" which has committed to spending 1-billion yen (or more than $10-million) over ten years to help strengthen health care systems throughout the developing world and has challenged other companies to join in this effort. In addition, Takeda hopes that sovereign government start spending more significant amounts of their budgets on health (such as the 15 percent pledged by African leaders in 2001).

"The emerging markets represent the future of business growth around the world," she added. "It will require collective action to deal with a problem of this magnitude; we can't leave it to governments alone. Companies need to get involved; it's in our collective long-term interest."

 

  • DENGUE IN AFRICA

Paediatrics and International Child Health

Paediatr Int Child Health. 2012 May; 32(s1): 18–21.

The dengue situation in Africa

Abstract below; best viewed, in full, at

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3381440/?tool=pubmed

Dengue outbreaks and epidemics have been reported in all regions of Africa, and it is believed that all four dengue virus serotypes are in circulation. Available data suggest that dengue is endemic to 34 African countries and that Aedes aegypti mosquitoes – the primary vector for dengue transmission – are known to be present in all but five countries. Whether populations in Africa are susceptible to dengue at the same rates as in Asia and Latin America is difficult to determine from the available data. Several factors may affect the transmission of dengue in Africa, including vector efficiency, viral infectivity, host vulnerability and environmental factors, such as increasing urbanisation. Current dengue prevention strategies in Africa focus on vector control, although the primary aim of such efforts is typically the prevention of malaria. Further research is needed to characterise the epidemiology of dengue in Africa and to better understand the factors involved in differences in vulnerability to dengue across Africa.

Keywords: Dengue, Africa, Epidemic, Epidemiology, Race

Dengue Risk Areas and Epidemic Activity in Africa

The World Health Organization (WHO) currently estimates that there are 50 million cases of dengue infection each year, with approximately 500,000 requiring hospitalisation. Of these severe dengue cases, approximately 5% will die.1 Aedes aegypti mosquitoes – the primary vector for dengue transmission – are known to be present in all but five countries (Western Sahara, Morocco, Algeria, Tunisia and Libya), for which data are not available (Fig. 1).2

 

Figure 1

Dengue and Aedes aegypti in Africa.2 The 34 countries in a dark colour indicate those in which dengue has been reported, including dengue reported only in travellers, and the presence of Aedes aegypti mosquitoes. Light-coloured areas indicate the 13 countries (more ...)

Dengue epidemics have been reported in Africa since the 19th century, in countries including Zanzibar (1823, 1870), Burkina Faso (1925), Egypt (1887, 1927), South Africa (1926–1927), and Senegal (1927–1928).2 Between 1960 and 2010, 20 laboratory-confirmed outbreaks were reported in 15 African countries, with most occurring in Eastern Africa. All four dengue virus (DENV) serotypes have been isolated in Africa, with DENV2 reported to cause the most epidemics.2

Available data suggest that dengue is endemic to 34 countries across all regions of Africa (Table 1, Fig. 1).2 Of these, 22 have reported local transmission, which is laboratory-confirmed in 20 countries, while two (Egypt and Zanzibar) do not have laboratory confirmation. The remaining 12 countries have only diagnosed dengue in travellers who had returned to non-endemic regions.

 

Table 1

Countries reporting transmission since 20002

More detailed epidemiological data are required to assess the impact of dengue in Africa. Data on incidence and prevalence are not available for Africa, despite the fact that outbreaks have been recorded.2 Under-reporting and under-recognition of dengue are key concerns, since the majority of febrile illnesses are treated as presumptive malaria.2

Factors Influencing Transmission of Dengue Virus

Vector efficiency

The principal vector for dengue fever, A. aegypti, originated in Africa and has spread throughout the continent and to other tropical regions.2 Other Aedes species present in Africa, which also act as potential vectors, include A. albopictus, A. africanus and A. luteocephalus.

Susceptibility of different mosquito strains to DENV has been shown to vary geographically. African strains of A. aegypti and A. albopictus have shown uniformly lower susceptibility to all four subtypes of DENV in laboratory settings.35 This reduced vector efficiency for dengue transmission may explain the apparent lower than expected prevalence in Africa, though further study is urgently needed.2

Viral infectivity

Dengue is caused by four genetically related but antigenically different viruses (DENV1–4) and all four serotypes are present in Africa and maintained in enzootic cycles, most likely between non-human primates and arboreal mosquitoes.6,7

Although the enzootic forms of DENV may be becoming less infective in Africa, there is still a potential for endemic forms of the virus to emerge from sylvatic cycles between mosquitoes and non-human primates.7 However, more infective varieties from Asia and the Western Pacific may be increasing in Africa due to travel, and it is thought that recent African outbreaks are due to spill-over from other regions rather than from sylvatic cycles.2,8

Host vulnerability

Race may be a factor in resistance to dengue infection, with some studies suggesting that black patients are more resistant. During a 1981 epidemic in Cuba, a country with a majority white but significant black population, white individuals were disproportionately susceptible to dengue infection, as well as to severe dengue and fatality.9,10 Dengue cases were reported in Los Angeles in 1998, but only among Hispanic and white ethnic groups.1 Genetic polymorphism in cytokines and coagulation proteins has been proposed as a potential mechanism conferring resistance to black individuals.1

Age is also a key factor in terms of vulnerability to dengue infection. While dengue fever is often thought of as a childhood disease, it has been observed that the incidence of dengue haemorrhagic fever is increasing in older age groups.1

Travellers may be more susceptible to dengue infection than locals. This is particularly the case for travellers from non-endemic to endemic areas. It is not certain whether partial immunity among the locals may be responsible for this phenomenon.11

Environmental factors

Increasing urbanisation creates favourable conditions for increased transmission, increases in the vector population and perhaps changes in the ecological balance of different strains.12 Since the 1950s, there has been a three-fold increase in urban population density across Africa.13 Informal settlements can be associated with increased risk of dengue infection, since artificial water collection increases the available habitat for vectors.

Recent reports are however showing a global increase in rural epidemics, especially in Africa. This is one of the emerging paradigms of dengue fever. It is not certain whether this is related to modernisation of villages or deforestation shifting the vector nearer to settlements.1

Recent Epidemics and Dengue Prevention in Africa

Dengue epidemics have occurred in all regions of Africa in the 5 years between 2006 and 2011 (Table 2).2 It is likely that all four subtypes of the dengue virus are present but the lack of formal laboratory testing or surveillance initiatives means that it is difficult to verify this.

 

Table 2

Overview of most recent epidemics in Africa2

Given the occurrence of dengue epidemics and the paucity of diagnostic infrastructure, preventative measures are required across Africa. Current dengue prevention strategies in Africa focus on vector control, although the primary aim of such efforts is typically the prevention of malaria.14,15 Reduction of breeding sites and targeted destruction of vector populations with insecticides are used throughout all regions. Insecticide-impregnated bed nets are also provided in many regions, but inconsistent provision and low uptake may attenuate the benefits of this measure.15 Personal protection is available for travellers, including insect repellants and information to raise dengue awareness.

Robust surveillance programmes must be established in Africa to accurately determine the true burden of dengue and – particularly in the dengue vaccine era – assess the effectiveness of prevention programmes.

Conclusions

Dengue fever outbreaks and epidemics are frequently reported in Africa, with recent outbreaks occurring predominantly in the Eastern region.2,16 However, many outbreaks in Africa are not well characterised, due to the poor surveillance infrastructure and under-recognition of the disease. Whether populations in Africa are susceptible to dengue at the same rates as in Asia and Latin America is difficult to determine from the available data. The African population is thought to be less vulnerable to infection than other ethnic groups, and there may be differences in terms of vector efficiency and viral infectivity between Africa and other dengue-endemic regions. However, environmental factors, including rapidly rising urbanisation in Africa, are associated with increased transmission. Further research is needed to characterise the epidemiology of dengue in Africa and to understand in more detail the factors involved in differences in vulnerability to dengue across Africa.

Acknowledgments

Editorial support was provided by Hazel Urwin of Interlace Global and funded by Sanofi Pasteur.

References

1. Guha-Sapir D, Schimmer B. Dengue fever: new paradigms for a changing epidemiology. Emerg Themes Epidemiol. 2005;2 doi:10.1186/742-7622-2-1.

2. Amarasinghe A, Kuritsk JN, Letson GW, Margolis HS. Dengue virus infection in Africa. Emerg Infect Dis. 2011;17:1349–54. [PMC free article] [PubMed]

3. Gubler DJ, Nalim S, Tan R, Saipan H, Sulianti Saroso J. Variation in susceptibility to oral infection with dengue viruses among geographic strains of Aedes aegypti. Am J Trop Med Hyg. 1979;28:1045–52. [PubMed]

4. Gubler DJ, Rosen L. Variation among geographic strains of Aedes albopictus in susceptibility to infection with dengue viruses. Am J Trop Med Hyg. 1976;25:318–25. [PubMed]

5. Diallo M, Ba Y, Faye O, Soumare ML, Dia I, Sall AA. Vector competence of Aedes aegypti populations from Senegal for sylvatic and epidemic dengue 2 virus isolated in West Africa. Trans R Soc Trop Med Hyg. 2008;102:493–8. [PubMed]

6. Guzman MG, Halstead SB, Artsob H, Buchy P, Farrar J, Gubler DJ, et al. Dengue: a continuing global threat. Nat Rev Microbiol. 2010;8:S7–16. [PubMed]

7. Vasilakis N, Holmes EC, Fokam EB, Faye O, Diallo M, Sall AA, et al. Evolutionary processes among sylvatic dengue type 2 viruses. J Virol. 2007;81:9591–5. [PMC free article] [PubMed]

8. Monath TP. Dengue: the risk to developed and developing countries. Proc Natl Acad Sci USA. 1994;91:2395–400. [PMC free article] [PubMed]

9. Sierra de la C.B, Kouri G, Guzman MG. Race: a risk factor for dengue hemorrhagic fever. Arch Virol. 2007;152:533–42. [PubMed]

10. Kouri GP, Guzman MG, Bravo JR, Triana C. Dengue haemorrhagic fever/dengue shock syndrome: lessons from the Cuban epidemic, 1981. Bull WHO. 1989;67:375–80. [PMC free article] [PubMed]

11. Wilson ME, Weld LH, Boggild A, Keystone JS, Kain KC, von Sonnenburg F, et al. Fever in returned travelers: results from the GeoSentinel Surveillance Network. Clin Infect Dis. 2007;44:1560–8. [PubMed]

12. Gubler DJ. Epidemic dengue/dengue hemorrhagic fever as a public health, social and economic problem in the 21st century. Trends Microbiol. 2002;10:100–3. [PubMed]

13. United Nations. Demographic Year Book, 1950–2007 [cited 13 February 2012]. Available from: http://unstats.un.org/unsd/demographic/products/dyb/dyb2.htm.

14. Coetzee M. Malaria and dengue vector biology and control in Southern and Eastern Africa. In: Knols B G J, Louis C, editors. Bridging Laboratory and Field Research for Genetic Control of Disease Vectors, vol. 11; Wageningen: Frontis-Wageningen International Nucleus for Strategic Expertise, 2006.

15. Fontenille D, Carnevale P. Malaria and dengue vector biology and control in West and Central Africa. In: Knols B G J, Louis C, editors. Bridging Laboratory and Field Research for Genetic Control of Disease Vectors, vol. 11. Wageningen: Frontis-Wageningen International Nucleus for Strategic Expertise, 2006.

16. Sang R. Geneva, Switzerland: WHO; 2006. Dengue in Africa. Report of the Scientific Working Group on Dengue, working paper 3·3; pp. 50–2.

 

 

  • A RESEARCH AGENDA FOR THE CONTROL AND ELIMINATION OF HUMAN HELMINTHIASES

http://www.ploscollections.org/article/browseIssue.action?issue=info:doi/10.1371/issue.pcol.v08.i03

 

A Collection from PLoS Neglected Tropical Diseases

More than half of the world's population is at risk of helminthiases, and hundreds of millions of people are currently infected with one or more helminth species. Consequences of chronic infection include suffering, stigmatization, subtle and gross morbidity, and premature death. These infections are associated with low work productivity, poor cognitive performance, and slow socioeconomic development, thereby contributing to accentuate poverty and inequality. In the April 2012 issue of PLoS Neglected Tropical Diseases, the Disease Reference Group on Helminth Infections (DRG4) put forward a series of eight reviews that, taken together, outline a compelling research and development (R&D) agenda for the control and elimination of helminth diseases of humans. Emphasis is placed on six major helminth diseases: soil-transmitted helminthiasis; schistosomiasis; lymphatic filariasis; onchocerciasis; food-borne trematodiasis; and cysticercosis/taeniasis. Additionally, an Editorial from Jürg Utzinger provides an overview to all eight reviews and emphasizes the importance of continued research on these six diseases, which together have an enormous global health impact.

DRG4 is part of an independent “think tank” of international experts, established and funded by the Special Programme for Research and Training in Tropical Diseases (TDR), to identify key research priorities through the review of research evidence and input from stakeholder consultations. For more information on the TDR Think Tank and the resulting reports, please visit: www.who.int/tdr/stewardship/research-thin-tank/en/

 

Editorial

A Research and Development Agenda for the Control and Elimination of Human Helminthiases

Jürg Utzinger

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001646

 

Reviews

A Research Agenda for Helminth Diseases of Humans: Towards Control and Elimination

Boakye A. Boatin, María-Gloria Basáñez, Roger K. Prichard, Kwablah Awadzi, Rashida M. Barakat, Héctor H. García, Andrea Gazzinelli, Warwick N. Grant, James S. McCarthy, Eliézer K. N'Goran, Mike Y. Osei-Atweneboana, Banchob Sripa, Guo-Jing Yang, Sara Lustigman

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 |

A Research Agenda for Helminth Diseases of Humans: The Problem of Helminthiases

Sara Lustigman, Roger K. Prichard, Andrea Gazzinelli, Warwick N. Grant, Boakye A. Boatin, James S. McCarthy, María-Gloria Basáñez

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001582

A Research Agenda for Helminth Diseases of Humans: Intervention for Control and Elimination

Roger K. Prichard, María-Gloria Basáñez, Boakye A. Boatin, James S. McCarthy, Héctor H. García, Guo-Jing Yang, Banchob Sripa, Sara Lustigman

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001549

A Research Agenda for Helminth Diseases of Humans: Diagnostics for Control and Elimination Programmes

James S. McCarthy, Sara Lustigman, Guo-Jing Yang, Rashida M. Barakat, Héctor H. García, Banchob Sripa, Arve Lee Willingham, Roger K. Prichard, María-Gloria Basáñez

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001601

A Research Agenda for Helminth Diseases of Humans: Social Ecology, Environmental Determinants, and Health Systems

Andrea Gazzinelli, Rodrigo Correa-Oliveira, Guo-Jing Yang, Boakye A. Boatin, Helmut Kloos

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001603

A Research Agenda for Helminth Diseases of Humans: Modelling for Control and Elimination

María-Gloria Basáñez, James S. McCarthy, Michael D. French, Guo-Jing Yang, Martin Walker, Manoj Gambhir, Roger K. Prichard, Thomas S. Churcher

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001548

A Research Agenda for Helminth Diseases of Humans: Basic Research and Enabling Technologies to Support Control and Elimination of Helminthiases

Sara Lustigman, Peter Geldhof, Warwick N. Grant, Mike Y. Osei-Atweneboana, Banchob Sripa, María-Gloria Basáñez

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001445

A Research Agenda for Helminth Diseases of Humans: Health Research and Capacity Building in Disease-Endemic Countries for Helminthiases Control

Mike Y. Osei-Atweneboana, Sara Lustigman, Roger K. Prichard, Boakye A. Boatin, María-Gloria Basáñez

PLoS Neglected Tropical Diseases:
Published 24 Apr 2012 | info:doi/10.1371/journal.pntd.0001602

  • THE BURDEN OF ACUTE RESPIRATORY INFECTIONS IN CRISIS-AFFECTED POPULATIONS: A SYSTEMATIC REVIEW

Abstract below; full text is at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829474/?tool=pubmed

Crises due to armed conflict, forced displacement and natural disasters result in excess morbidity and mortality due to infectious diseases. Historically, acute respiratory infections (ARIs) have received relatively little attention in the humanitarian sector. We performed a systematic review to generate evidence on the burden of ARI in crises, and inform prioritisation of relief interventions. We identified 36 studies published since 1980 reporting data on the burden (incidence, prevalence, proportional morbidity or mortality, case-fatality, attributable mortality rate) of ARI, as defined by the International Classification of Diseases, version 10 and as diagnosed by a clinician, in populations who at the time of the study were affected by natural disasters, armed conflict, forced displacement, and nutritional emergencies. We described studies and stratified data by age group, but did not do pooled analyses due to heterogeneity in case definitions. The published evidence, mainly from refugee camps and surveillance or patient record review studies, suggests very high excess morbidity and mortality (20-35% proportional mortality) and case-fatality (up to 30-35%) due to ARI. However, ARI disease burden comparisons with non-crisis settings are difficult because of non-comparability of data. Better epidemiological studies with clearer case definitions are needed to provide the evidence base for priority setting and programme impact assessments. Humanitarian agencies should include ARI prevention and control among infants, children and adults as priority activities in crises. Improved data collection, case management and vaccine strategies will help to reduce disease burden.

 

  • WHY CORPORATE POWER IS A PUBLIC HEALTH PRIORITY

The marketing campaigns of multinational corporations are harming our physical, mental, and collective wellbeing. Gerard Hastings urges the public health movement to take action

Text below; best viewed, with graphics, at http://www.bmj.com/content/345/bmj.e5124

BMJ 2012; 345 doi: 10.1136/bmj.e5124 (Published 21 August 2012)

Gerard Hastings, director

Author Affiliations 1Institute for Social Marketing, University of Stirling and the Open University, Stirling FK9 4LA, UK

gerard.hastings@stir.ac.uk

The work of Professor Richard Doll provides two key lessons for public health. The first, that we must do all we can to eradicate the use of tobacco, has been well learnt and is being energetically acted upon. The second, more subtle learning—that our economic system has deep flaws—remains largely ignored. And yet, lethal though tobacco is, the harm being done to public health by our economic system is far greater.

Industrial epidemics

Furthermore, the two are intimately connected: tobacco has remained such an intractable problem only because our economic system allows free ranging corporations to market it. The same applies to the other two “industrial epidemics”1 that constitute such a large share of the public health burden: alcohol misuse and obesity. In each case evocative promotion, ubiquitous distribution, perpetual new product development, and seductive pricing strategies are used to encourage unhealthy consumption. And in each case painstaking research and review have shown the obvious truth that this marketing effort succeeds, especially with the young.2 3 4 The consequence has been the inevitable escalation of lifestyle illnesses such as cancer, heart disease, cirrhosis, and diabetes.

However, the impact of marketing on public health goes much deeper than this. Marketing textbooks lionise the consumer: our complete satisfaction is the essence of successful business (provided we can afford to pay). The result is an unstinting hunt for new needs and wants (or, increasingly, whims) to satisfy, and a population that has a burgeoning sense of entitlement. The damaging effect of this favouritism is shown in the pharmaceutical business, which pays more attention to the trivial complaints of the rich than the life threatening sicknesses of the poor. As Bakan points out, “Of the 1400 new drugs developed between 1975 and 1999, only 13 were designed to treat or prevent tropical diseases and three to treat tuberculosis. In the year 2000, no drugs were being developed to treat tuberculosis, compared to eight for impotence or erectile dysfunction and 7 for baldness.”5 This dangerously indulgent focus starts at birth, because children offer the corporate marketer a lifetime of profitability (box 1).

Box 1: How corporate marketers view children

According to a leading business textbook:

“Children are important to marketers for three fundamental reasons:

They represent a large market in themselves because they have their own money to spend

They influence their parents’ selection of products and brands

They will grow up to be consumers of everything; hence marketers need to start building up their brand consciousness and loyalty as early as possible” 6

Sadly, as any philosopher or theologian would predict, such pampering does not bring happiness. Once basic needs are satisfied, the correlation between material possessions and contentment rapidly dissipates. But marketing keeps us craving more: the paradox of a system devoted to our satisfaction is that it depends on our perpetual dissatisfaction; after all once we are satisfied we stop shopping. In this way it undermines our mental as well as our physical wellbeing.

The customer always comes second

Furthermore, the corporate marketers’ focus on customer satisfaction is in reality specious; the fiduciary duty of corporations gives them a legal obligation to prioritise the needs, not of the consumer, but of the shareholder. How else could we have tobacco companies, who are consummate marketers, continuing to produce products that kill one in two of their most loyal customers? The corporate marketers’ self centred purpose, then, is “to recognise and achieve an economic advantage which endures.”7 Not an economic advantage for the customer—just for the company. This is the same single minded and dysfunctional principle that continues to drive the financial sector.

A key function of marketing is to mask these uncomfortable truths by disguising inanimate corporate monoliths as benign friends under the guise of branding. The role of branding in youth smoking8 and drinking9 has been well documented, and a recent study in California among 3-5 year olds showed that children’s food preferences are being moulded by McDonald’s branding even before they have learnt to tie their shoelaces.10 Items that came in McDonald’s wrappers were thought to taste better, even if they were foods like carrots; on the other hand McDonald’s products didn’t taste as good without the liveried packaging. These effects were apparent across the group, but most marked among those who had been most exposed to McDonald’s and its advertising. Marketers are clearly succeeding in their aim “to start building up their brand consciousness and loyalty as early as possible.”6

However, susceptibility to the “emotional benefits” of branding reaches way beyond toddlers and teens; it touches us all. The 2005 Health Select Committee investigation into the pharmaceutical industry showed that it is even being used to influence general practitioners’ prescribing practices (figure). No wonder the committee’s final report expressed “over-riding concerns about the volume, extent ,and intensity of the industry’s influence, not only on clinical medicine and research but also on patients, regulators, the media, civil servants, and politicians.”11

 

Branding prescription drugs: the diagram, which is from internal pharmaceutical industry documents, shows equal importance being attached to the role of rational and emotional dimensions in the development of strong brands12

Collective harm

The harmful consequences of corporate marketing are even more apparent at a collective level. Marketers, as I noted above, are only interested in catering for the needs of those with money; as the business textbooks put it, target markets have to be accessible, responsive, and (above all) viable. The key concern is to reach people with persuasive marketing campaigns, and having done so, be confident that they will be both willing and able to make the purchase. So even as the “haves” get more, the “have nots” get less—and the resulting exacerbation of inequalities damages the health and wellbeing of both rich and poor.13 The distortions in the pharmaceutical market described above only serve to underline the systemic nature of the problem.

Not that disadvantaged groups completely escape the attentions of corporate marketers. Once the well-off are sated, or become disenchanted with product offerings, the disadvantaged get their turn in the sun. So now the beverage alcohol industry has got people in the developed world consuming as much booze as is humanly possible, it is turning its attention to developing countries.14 Similarly the social patterning of smoking in the UK has led tobacco companies to focus their efforts on poorer groups—hence the expansion in economy brands and price promotions.15

On a broader scale, marketers also recognise that context matters—that norms, mores, and, above all, laws have a big impact on our consumption behaviour. They therefore market to stakeholders and politicians in a bid to influence the policy agenda and thereby undermine what is public health’s most important armamentarium. The alcohol industry’s activities in the UK provide an instructive example. Corporate social responsibility efforts have included the funding of midwife training, support for non-governmental organisations in areas such as schools education,16 and addiction services,17 and the establishment of the Drinkaware Trust (set up to promote “the facts about alcohol”). All are carefully designed to position the industry as part of the solution rather than the problem. The subsequent decision by the UK government to implement its public health responsibility deal, which has made the alcohol industry (and other corporate interests) partners in the policy making process, shows that the strategy worked. It also points out the potential for public health harm, as an evidence base that has established the urgent need to reduce per capita consumption falls prey to the business model that demands growth.

Thinking more broadly still, the biggest effect that all this remorseless corporate marketing has on public health comes even further upstream—at a planetary level. We have built a system where continuous growth, fed by marketing driven excess consumption by the already well-off, is inevitably coming into conflict with the limits of a finite planet. This is now threatening public health far more seriously than the activities of any one industry—even one as egregious as tobacco— will ever do.

Broadening public health

These are massive problems that demand urgent attention and radical measures. There are some signs that public health is up for this challenge. The Framework Convention on Tobacco Control—“the world’s first global public health treaty”18—shows that the global reach of corporate power can be controlled. Similarly, Marmot’s pioneering work on the social determinants of health shows that there is an appetite for taking a broad perspective and “turning public health knowledge into political action.”19 And, more recently, Rayner and Lang have called for a broader “ecological” perspective which recognises that “public health is often improved by movements and people prepared to challenge conventional assumptions and the status quo.”20

However, Rayner and Lang also point out that “public health remains strangely marginal in public discourse as well as patchy in execution”20—and there are telling signs that we are failing to address this larger agenda. Our focus has become increasingly narrow and technocratic. We are, it seems, happier conducting randomised controlled trials of leaflet interventions or calculating algorithms that mean little outside the laboratory than challenging a system that is both deeply unfair and hopelessly unsustainable.

Public health workers have also become increasingly fragmented into disciplinary silos. Tobacco experts rarely speak to those in alcohol, nutrition, or sexual health, with no apparent recognition that, far from being unique and separate, the behaviours they all address comprise a typical Saturday night out for large sectors of the population. This also blinds us to the importance of individual empowerment. We beetle away at micromanaging specific behaviours and ignore the key message emerging from the public health evidence base—that for the first time in human history we now know how we can take a measure of control over our own health and longevity. By the same token we barely acknowledge the harm being done by our economic system, which undermines our critical faculties and sense of agency with perpetual messages of materialism and unwarranted entitlement. L’Oreal’s corrosive slogan, “Because we are worth it,” has become the leitmotiv of society on our watch.

It is little surprise, then, that corporate capitalism has gone from strength to strength and is taking over what should be core public health roles; we have got the responsibility deals we deserve. And our timorous protestations at this preferment of the fox to the keeper of the chicken coop can so easily be brushed aside because we have no public profile; we jettisoned that along with the Health Education Authority, when we failed to protect it from government closure.

Indeed, far from tackling and challenging the corporate marketers, we seem set on doing their bidding. We work with them on the Drinkaware Trust, in full knowledge that this makes us no more than junior executives in a textbook example of stakeholder marketing. The Health Select Committee, having warned us of the unwarranted influence of the pharmaceutical industry on our work, thinks it is necessary to stress the need “to examine critically the industry’s impact on health to guard against excessive and damaging dependencies.” But we lack the vision to do so, and even were we to regain it, have ceded our place at the top table. Our job is to keep quiet and clean up the mess made by the big boys; we have become janitors when the urgent need is for janissaries.

Moving beyond the topic specific, where is the public health contribution to such pressing problems as the corporate takeover of the Olympics—an event that should be a beacon of healthy activity not another shopping opportunity—or the debate about the coalition government abandoning its green agenda; or the financial crisis and corporate greed? Would a journalist even think about coming to public health for a comment on any of these?

As Rayner and Lang argue, public health needs a radical shake up; we have to revitalise—reinvent—our discipline. This reinvention has to recognise the increasingly unhealthy dominance of corporate marketing on our lives; Marmot’s focus on the social determinants of ill health needs to be matched with an equal concern for the commercial determinants of ill health. As a contribution to this debate, I offer the following suggestions:

Independent public health body— We urgently need to re-establish a public health body in the UK that is linked to but clearly untrammelled by government—and completely insulated from vested interest. We have to start once again speaking unfettered truth to power. Through this we can also begin to rebuild a respected relationship with the public; now more than ever people need a champion to speak up for their real needs, rather than the phoney ones teased and tempted by corporate capitalism.

Wider vision—We have to lift our eyes above the quotidian: to remember that public health is not just about pump handles but also water resources. We can and should be offering a geopolitical vision with greater equality as its central pledge. This vision must consider the relationship between business and society. Multinational corporations will continue to be an important part of our economic system, if only because complex societies need the logistics and efficiencies they can deliver. It is difficult, for instance, to see how a city like London could continue to feed itself without supermarkets. However, public health has a legitimate and crucial role in asking questions about the extent of their power, the crassness of the fiduciary imperative, and the almost complete lack of responsibility being taken for externalities.

Rein in marketing—Unbridled marketing should also be energetically challenged. If, for example, the advertising of tobacco can be banned because smoking harms the individual, should not all advertising be much more circumscribed because the consumption it engenders harms the planet? Similarly, marketing is currently a right taken for granted; given its effect on inequalities should it not more properly be seen as a carefully controlled responsibility? Or again, what would be the pros and cons of requiring all corporations to show the effect that their marketing is having on health and welfare?

Challenge profit as a measure of success—More positively, we should question the legitimacy of marketing, which we know to be so powerful, being used simply to boost consumption and corporate profitability. Broader conceptions of success are needed that move beyond finance and focus instead on human welfare. Public health is perfectly equipped to lead this new enlightenment, starting with the WHO’s multifaceted definition of health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.”

Regain political leverage—We must demand a seat at the political top table, not just in health but in finance. Recent events in the banking sector confirm an age old lesson that fiscal policy has at least as much effect on morbidity and mortality as anything done in health ministries. Public health is too important to be left to economists and politicians, prey as they so obviously are to the cynical ministrations of the corporate marketer.

Think global—Finally, we have to recognise that our public health travails in the UK have global echoes and reverberations. Marketing campaigns have long since superseded mere national boundaries, WHO has been under well evidenced pressure from corporate interests for decades,21 and the public health mistakes we have made in the UK will be visited ever more energetically on poorer countries. When we flirt with the corporates developing countries get ravished. Everything we do should respect this international agenda and related responsibilities.

An ambitious pitch

I accept this is an ambitious pitch. Public health has to demand a place at the macroeconomic table; it has to contribute to the debate about where corporate capitalism is going and ensure that the public health implications of business decision making are fully appreciated. The business sector is certainly not shy of putting forward its view of how the world should be organised for the greater good of business (see box 2 for example). If public health can develop a similar boldness of purpose we will be able to graduate from the post hoc reduction of specific harm, to a pre-emptive quest for an economic system that actively promotes better public health. We have to take the lead in a movement away from a world driven by abeyance to the corporate bottom line and the enrichment of an elite to one that prioritises physical, mental, social, and planetary wellbeing.

Box 2: Leading business thinker Michael Porter presents his new world vision in the Harvard Business Review22

“It is not philanthropy but self-interested behaviour to create economic value by creating societal value. If all companies individually pursued shared value connected to their particular businesses, society’s overall interests would be served. And companies would acquire legitimacy in the eyes of the communities in which they operated, which would allow democracy to work as governments set policies that fostered and supported business.”

The implications of this view for our way of life are profound. For example, Porter emphasises that his new world will certainly not involve any equalising of current wealth: “Nor is it about ‘sharing’ the value already created by firms—a redistribution approach. Instead, it is about expanding the total pool of economic and social value.” This is a massive political statement which raises questions about relative rather than absolute poverty, the current inequities in society (ironically thrown into relief by corporate pay) and the sustainability of perpetual growth.

Challenges for public health

Marketing by multinational corporations presents a major threat to public health; children are especially vulnerable

As well as lifestyle illnesses such as lung cancer and liver cirrhosis, marketing threatens our mental wellbeing, exacerbates inequalities, and encourages unsustainable consumption

Public health should take a lead in addressing these issues, revitalise its upstream, political functions, and regain its role as a champion of the underprivileged

Public health should also be leading a quest for an economic system that actively promotes better public health

Footnotes

Contributors and sources: GH is the director of the CRUK Centre for Tobacco Control Research; a principal investigator on the International Tobacco Control Study, the UK Centre for Tobacco Control Studies, and the MRC funded APISE study; and a member of the Public Health Research Consortium. In these roles he has conducted research, advised national and international public bodies, and written articles and books on the impact of business on society. His latest book. The Marketing Matrix: How the Corporation Gets Its Power and How We Can Reclaim It, will be published by Routledge later this year.

Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Wilkinson R, Pickett K. The spirit level: why equality is better for everyone. Penguin, 2010.

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