Public health lives: Gro Harlem Brundtland.

Health has been a deeply personal, professional and political dimension of Gro Harlem Brundtland's life. Her decision to study breast feeding while an MPH student at Harvard in 1964, or her desire to tackle tobacco being influenced by her father sending her as a 10-year old girl to buy his cigarettes at the local store, or her deeply personal family experience of mental ill health all led her to take actions on the global stage to address these and other issues that evidence showed would have global impact. Her impact on global health started with a commitment to make a difference in the lives of people, particularly those in greatest need.

Global priority setting for Cochrane systematic reviews of health promotion and public health research.

BACKGROUND: Systematic reviews of health promotion and public health interventions are increasingly being conducted to assist public policy decision making. Many intra-country initiatives have been established to conduct systematic reviews in their relevant public health areas. The Cochrane Collaboration, an international organisation established to conduct and publish systematic reviews of healthcare interventions, is committed to high quality reviews that are regularly updated, published electronically, and meeting the needs of the consumers. AIMS: To identify global priorities for Cochrane systematic reviews of public health topics. METHODS: Systematic reviews of public health interventions were identified and mapped against global health risks. Global health organisations were engaged and nominated policy-urgent titles, evidence based selection criteria were applied to set priorities. RESULTS: 26 priority systematic review titles were identified, addressing interventions such as community building activities, pre-natal and early infancy psychosocial outcomes, and improving the nutrition status of refugee and displaced populations. DISCUSSION: The 26 priority titles provide an opportunity for potential reviewers and indeed, the Cochrane Collaboration as a whole, to address the previously unmet needs of global health policy and research agencies.

Achieving the Framework Convention on Tobacco Control's potential by investing in national capacity.

May 2003 marked a critical achievement in efforts to stem the global tobacco epidemic, as the member states of the World Health Organization unanimously endorsed the Framework Convention on Tobacco Control (FCTC). However, the adoption of the FCTC signifies only the end of the beginning of effective global action to control tobacco. Over the next several years the utility of the FCTC process and the treaty itself will be tested as individual countries seek to ratify and implement the treaty's obligations. Significant barriers to the treaty's long term success exist in many countries. It is crucial that the international tobacco control community now refocuses its efforts on national capacity building and ensures that individual countries have the knowledge, tools, data, people, and organisations needed to implement the convention and develop sustained tobacco control programmes. This paper provides a model of national tobacco control capacity and offers a prioritised agenda for action.

Trends and affordability of cigarette prices: ample room for tax increases and related health gains.

BACKGROUND: Increasing the price of tobacco products is arguably the most effective method of curbing the prevalence and consumption of tobacco products. Price increases would reduce the global burden of disease brought about by tobacco consumption. OBJECTIVES: To compare cigarette price data from more than 80 countries using varying methods, examine trends in prices and affordability during the 1990s, and explore various policy implications pertaining to tobacco prices. DESIGN: March 2001 cigarette price data from the Economist Intelligence Unit are used to compare cigarette prices across countries. To facilitate comparison and to assess affordability, prices are presented in US dollars, purchasing power parity (PPP) units using the Big Mac index as an indicator of PPP and in terms of minutes of labour required to purchase a pack of cigarettes. Annual real percentage changes in cigarette prices between 1990 and 2000 and annual changes in the minutes of labour required to buy cigarettes between 1991 and 2000 are also calculated to examine trends. RESULTS: Cigarette prices tend to be higher in wealthier countries and in countries that have strong tobacco control programmes. On the other hand, minutes of labour required to purchase cigarettes vary vastly between countries. Trends between 1990 and 2000 in real prices and minutes of labour indicate, with some exceptions, that cigarettes have become more expensive in most developed countries but more affordable in many developing countries. However, in the UK, despite recent increases in price, cigarettes are still more affordable than they were in the 1960s. CONCLUSIONS: The results suggest that there is ample room to increase tobacco prices through taxation. In too many countries, cigarette prices have failed to keep up with increases in the general price level of goods and services, rendering them more affordable in 2000 than they were at the beginning of the decade. Opportunities to increase government revenue and improve health through reduced consumption brought about by higher prices have been overlooked in many countries.

Junking science to promote tobacco.

Despite the tobacco industry's claims that it has changed its practices, the toll of tobacco-related disease and death continues to grow worldwide, and the industry continues to use a vast array of strategies to promote its products and increase profits. This commentary discusses the ways the tobacco industry has created controversy about risk assessment and about the scientific evidence of the health hazards of secondhand smoke. The authors recommend that policymakers be more vigilant and that they demand transparency about affiliations and linkages between allegedly independent scientists and tobacco companies. They also urge policymakers to be prepared for new and continuing challenges posed by the tobacco industry, because, despite the industry's claims, there is little evidence of fundamental change in its objectives.

Globalisation of tobacco industry influence and new global responses.

The globalisation of tobacco marketing, trade, research, and industry influence represents a major threat to public health worldwide. Drawing upon tobacco industry strategy documents prepared over several decades, this paper will demonstrate how the tobacco industry operates as a global force, regarding the world as its operating market by planning, developing, and marketing its products on a global scale. The industry has used a wide range of methods to buy influence and power, and penetrate markets across the world. It has an annual turnover of almost US$400 billion. In contrast, until recently tobacco control lacked global leadership and strategic direction and had been severely underfunded. As part of moving towards a more sustainable form of globalisation, a global enabling environment linked to local actions should focus on the following strategies: global information management; development of nationally and locally grounded action; global regulation, legal instruments, and foreign policy; and establishment of strong partnerships with purpose. As the vector of the tobacco epidemic, the tobacco industry's actions fall far outside of the boundaries of global corporate responsibility. Therefore, global and local actions should not provide the tobacco industry with the two things that it needs to ensure its long term profitability: respectability and predictability.

Promoting equity in health.

There is evidence that widening income gaps are a global phenomenon; that in many advanced industrialised countries unemployment rates are rising; that globalisation of the world economy has led to several countries becoming marginalised with a concomitant increase in poverty; and that the absolute number of poor has steadily increased over the last decade. All of these phenomena emphasise the need to focus on equity as a global concern.

Health for all: analyzing health status and determinants.

An analysis of health status and determinants is presented as a basis for health for all renewal and in order to provide a model linking the health for all vision with strategy and action. Equity and gender, at the core of health for all, directly concern health status and the distribution of health determinants. The role of the various transitions (demographic, epidemiological, health risk and technological) is described, the need to strengthen the link between data and decision-making for health is explained, and the range of health determinants--macroeconomic, demographic/nutritional, environmental, tobacco and alcohol and their implications for policy--is outlined.

PIP: Responding to efforts to renew the "health for all" vision and link it with strategy and action, this article explores the relationship between health status and proximal and distal determinants (macroeconomics, environment, sociodemographics, and education). Next, the pivotal relationship of equity and gender to health status and determinants is considered, and the challenges posed by transitions in health, demographics, epidemiology, health risk, and technology are reviewed. After noting the necessity to strengthen the links between health data and decision-making, the article summarizes current knowledge about global health status for 1990-2020. Following a brief explanation of the need to adopt a lifespan approach to health, the next section describes some key proximal and distal health determinants and their relationship to health status and illustrates this relationship with a model that traces the pathway connecting health status, determinants, and interventions. Finally, the article reviews the importance of sectoral health determinants and ways to enhance health decision-making and considers 1) the implications of the change in the distribution, intensity, and nature of the global burden of disease and injury; 2) the relationship between poverty, equity, and health status; 3) the importance of sectoral health determinants; and 4) the role of governments, the health sector, international organizations, and the World Health Organization.

Develop and strengthen public health law.

The rule of law consists of one of the key requirements to implement policy reforms. The new global health policy, "Health for All in the 21st Century", indicates the role of public health law to attain its values and objectives. This article studies the status retained to secure both international and national law in the new policy, and identifies two initiatives to be undertaken by WHO to develop and strengthen public health law. The usefulness and efficiency of international law depend on national capacities to implement law. Thus, this article concludes that the Organization should adopt international legal instruments and that it should, simultaneously, assist Member States to build institutional and human capacity in public health law. However, these initiatives require that all Member States confirm political determination to link economic and social reforms with legislative reforms.

The globalization of public health, II: The convergence of self-interest and altruism.

The transnationalization of disease and health risks will require global awareness, analysis, and action and indicates a need for global cooperation. Transnational actions must be built on firm local and national foundations, but they also require new forms of transnational collaboration in order to minimize risks and build on opportunities. In a world characterized by the globalization of public health, countries and communities will need to look beyond their narrow self-interests in defining and confronting the shared problems that are emerging. In fact, a strong case can be made that enlightened self-interest and altruism will converge in the increasingly interdependent world being shaped by the process of globalization.

'Health-for-All' in the twenty-first century: a global perspective.

Changes in the broad determinants of health since the Alma Ata Conference in 1978 necessitate a renewed examination of the underlying principles and focus of the Primary Health Care (PHC) strategy. The PHC approach has been adopted by most countries and has led to improved access to certain basic health services. However, the health gains in other areas are less encouraging. Some elements of the PHC approach, for example, the effective implementation of equity-oriented health policies and the need to improve management principles within health services, have yet to be fully implemented. Moreover, to address the underlying determinants of health status, the World Health Organization's (WHO) renewed global health policy will have to include certain issues that were not considered at Alma Ata. For example, the health impacts of global recession and globalization and the need for human-centered sustainable development strategies were not considered at Alma Ata. A renewed global health policy will also have to consider demographic, epidemiological, environmental and technological changes that have emerged since 1978. It is important that WHO's renewed policy be based on sound evidence, a commitment to ethical principles and broad use of partnerships for health at global, national and local levels. One implication of this new context of health development for the renewed health policy will be that 'thinking globally and acting locally' will have to complemented by stronger global action to protect local and national health.

Tobacco in Africa.

Tobacco has been a common commodity in Africa for over three centuries. By 1993, some 500 000 tons of tobacco were being grown in 33 African countries, with only two countries exporting more than they import. Attempts to measure the current and potential impact of the tobacco business on health, society and the environment are still in their early stages, but the need for preventive action is already inescapably clear. Comprehensive control strategies are urgently required to prevent a major epidemic of tobacco-related disease in Africa.

Renewal of the health-for-all strategy.

It will soon be 20 years since the much-publicized Alma-Ata Declaration calling for health for all through primary health care. This article aims to stimulate debate on the successes and failures of past efforts, on the values that should guide policy-making in national and international health work, and on approaches to promoting equity and solidarity in future health strategies.

Tobacco advertising in South Africa with specific reference to magazines.

RATIONALE: A ban on tobacco advertising forms an integral component of tobacco control strategies, and needs to be considered in South Africa as a matter of urgency. OBJECTIVES: To obtain baseline data on tobacco advertising expenditure in the South African media, and to compare brands used to target different groups in magazines. METHODS: Advertising expenditure (totals and tobacco-related) for 1991 and 1993 was obtained from Adindex. Ten magazines, each with circulations of over 100,000, directed at four different target groups, were selected. For 3 months in 1993, total and tobacco advertising expenditure, brand placement and magazine demographics were determined. RESULTS: Tobacco-related expenditure constituted 4.8% of the R3 billion spent on advertising in 1993. Print (including magazines) and radio together accounted for 72% of all tobacco advertising, while cinema and outdoor advertising were most dependent on the tobacco industry for revenue. Annualised advertising spending for the 10 magazines reached an estimated R230 million, of which tobacco 'adspend' accounted for 6.4%. The highest percentage of tobacco adspend (20.3%) was for a men's 'soft-porn' magazine. For 26 of 30 issues studied, tobacco adverts were on the back cover. Brand targeting was evident in black, women's, and family magazines. There was not a single feature article on the adverse effects of smoking on health in any of the magazines during the 3-month period. Only 2 magazines had single sentences in their health columns mentioning that smoking was bad for health. In a third magazine, one opinion piece devoted a full page to criticising the anti-tobacco lobby! CONCLUSION: Tobacco advertising, through radio and outdoor advertising, reaches children and illiterate communities in peri-urban and rural areas. Tobacco advertising in magazines targets specific consumers, such as blacks and women. For most magazines, tobacco adspend constitutes less than 10% of the total. A total ban on tobacco advertising in the media in general and certainly in magazines would not have adverse economic effects and would promote health.

Smoking in the black community of the Cape Peninsula, South Africa.

The purpose of this study was to determine tobacco-use and related factors in the black population of the Cape Peninsula. About 52% of the men, but only 8% of the women used tobacco regularly. Men and women who smoked cigarettes, smoked 9.6 and 4.3 cigarettes on average per day, respectively. Although many men smoked, 80% perceived smoking to be harmful to health as did 92% of the women. For women, smoking was inversely related to their level of education, while for men it was directly related to being employed. Smoking was also related to the use of alcohol in both genders. Women below 45 years who had spent less than a third of their lives in the city had lower smoking rates than those who had spent more than a third of their lives in the city. Smoking is one of the most important public health issues facing the black community of the Cape Peninsula.