Online First articles may not be available until 09:00 (UK time) Friday.

Press releases Saturday 17 February 2007

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://bmj.com).

(1) Are we spending too much on HIV?
(2) Exercise improves quality of life for people with breast cancer
(3) US health system getting worse, says expert?
(4) Doctors should measure the carbon footprint of their conference activities

(1) Are we spending too much on HIV?
(Head to head: Are we spending too much on HIV?)
http://www.bmj.com/cgi/content/full/334/7589/344

Billions of pounds are being spent on the fight against AIDS in developing countries. In this week±s BMJ, two experts go head to head over whether we are spending too much.

HIV is receiving relatively too much money, with much of it used inefficiently and sometimes counterproductively, argues Roger England, Chairman of Health Systems Workshop.

Data show that 21% of health aid was allocated to HIV in 2004, up from 8% in 2000. It could now exceed a quarter. Yet HIV constitutes only 5% of the burden of disease in low and middle income countries as measured by disability adjusted life years lost (DALYs). It causes 2.8 million deaths a year worldwide ± fewer than the number of stillbirths, and much less than half the number of infant deaths. More deaths are attributable to diabetes than to HIV.

Furthermore, HIV interventions are not cost effective enough to justify this disproportionate spending, he writes. Much HIV money could be spent with more certain benefits on, for example, bed nets, immunisation, or family planning. Money is also wasted in areas that reflect the interests of those on the AIDS industry payroll more than evidence.

He believes that the money could be more effective if used to strengthen public health systems rather than focusing on disease-specific programmes.

AIDS is widely acknowledged as a public health crisis and current spending is woefully inadequate, argue Paul de Lay and colleagues at the Joint United Nations Programme on HIV and AIDS (UNAIDS).

Resources currently pledged are only half of what is needed for a comprehensive response. For instance, in 2006, $9bn was available for the AIDS response but the real need was estimated at $15bn. Poor coordination between different stakeholders in affected countries also impedes effective spending. This is compounded by weak institutions and regulatory policies, poor governance, and in some cases corruption.

TThey argue that the response to AIDS needs to be seen in the context of international commitments to the millennium development goals, which also call for progress across many other developmental priorities. HIV threatens many of these goals, especially those related to poverty and health.

The cost of inaction against AIDS is huge, far greater than for any other public health crisis, they say. Current costs are so high because of the inadequacy of previous investments, but they will be higher tomorrow if we continue to underinvest.

Contacts:
Roger England, Chairman, Health Systems Workshop, Grenada, West Indies
Email: roger.england@healthsystemsworkshop.org

Paul de Lay, Director, UNAIDS, Geneva, Switzerland
Email: communications@unaids.org

(2) Exercise improves quality of life for people with breast cancer
(Benefits of a supervised group exercise programme for women being treated for early stage breast cancer: pragmatic randomised controlled trial)
http://www.bmj.com/onlinefirst_date.dtl

Group exercise sessions can help to improve the physical and psychological wellbeing of people diagnosed with breast cancer, a new BMJ study reveals today.

Breast cancer is the most commonly occurring cancer among women in the UK. Treatment for cancer, such as chemotherapy and radiotherapy, can badly affect quality of life. However, current cancer rehabilitation programmes are mainly based on psychotherapy or social support, and do not generally deal with the physical problems encountered by patients.

Researchers from Scotland set out to determine if group exercise programmes could prove beneficial to women who were having treatment for early stage breast cancer. Over 200 women took part in the study. They were split into two separate groups; the first (control group) received their usual care, whilst the second group received their usual care plus were invited to take part in a 12 week programme of exercise sessions. Participants in the second group were encouraged to attend two classes ± led by trained exercise specialists - and undertake one additional exercise session at home each week.

Following the 12 week session, the researchers analysed the physical and psychological wellbeing of the participants by measuring a number of factors, such as levels of depression, quality of life, mood, shoulder mobility, walking distances and weekly levels of physical activity. These factors were measured after 12 weeks and six months later.

Participants in the second group had better outcomes on both a physical and psychological level than those who had not taken part in the exercise programme, both at the 12 week and six month assessments. Also, after six months those who had exercised had made fewer visits to their GP, and spent fewer nights in hospital, than the participants in the control group.

The researchers say that the benefits experienced by the women may have been caused by the exercise itself or by the group experience, or a combination of both. They conclude that clinicians should encourage activity during cancer treatment for patients, and policy makers should consider including opportunities for exercise in cancer rehabilitation services.

Contacts:
Anna Campbell, Senior Researcher, Strathclyde University, Glasgow, Scotland
Email: a.m.campbell@strath.ac.uk

(3) US health system getting worse, says expert
(Uninsured in America: problems and possible solutions)
http://www.bmj.com/cgi/content/full/334/7589/346

The problems of the US healthcare system are growing, warns an expert in this week±s BMJ.

The United States is the only major industrialised nation without universal health insurance, writes Karen Davis, President of the Commonwealth Fund. Coverage varies widely between states and has deteriorated in recent years. The number of uninsured people has increased from 40 million in 2000 to nearly 47 million in 2005.

Gaps in coverage lead to inequalities in access to care, poor quality care, lost economic productivity, and avoidable deaths.

The Institute of Medicine estimates that 18,000 lives are lost annually as a consequence of gaps in coverage. It calculates the annual cost of achieving full coverage at $34bn - $69bn, which is less than the loss in economic productivity from existing coverage ($65bn - $130bn annually).

Furthermore, expanding coverage would disproportionately help people on low incomes, who make up two thirds of the uninsured, thus increasing equity in access to health care and health outcomes, says Davis.

Several states have enacted plans to make cover affordable for all uninsured residents, using state programmes to subsidise care for the poor and creating an insurance pool for small businesses and the self employed.

Although these efforts are encouraging, most are taking place in states with relatively small uninsured populations, and there is little prospect that the federal government will legislate to make insurance affordable and mandatory for all.

What is clear is that the problem is getting worse, not diminishing, she warns. The fragmented, uncoordinated healthcare system is plagued by high administrative costs and missed opportunities to control chronic conditions and prevent life threatening conditions.

If the US hopes to achieve a high performance health system that is value for money, it will have to tackle the perplexing problems of access, quality, and cost, and overcome considerable political and economic obstacles, as well as institutional resistance to change, she concludes.

Contact:
Karen Davis, President, The Commonwealth Fund, New York, USA
Email: kd@cmwf.org

Mary Mahon, Senior Public Information Officer, The Commonwealth Fund, New York, USA
Email: mm@cmwf.org

(4) Doctors should measure the carbon footprint of their conference activities
(Editorial: Reducing the carbon footprint of medical conferences)
http://www.bmj.com/cgi/content/full/334/7589/324

Doctors must lead by example on climate change by reducing the carbon footprint of medical conferences, says an editorial in this week±s BMJ.

The threat to human health from climate change ± through malnutrition, disease, and flooding ± is substantial, and in some parts of the world, immediate. It is therefore ironic that doctors, for whom protecting is a primary responsibility, contribute to global warming through unnecessary attendances at international conferences, argue Professor Ian Roberts and Dr Fiona Godlee.

For example, delegates attending the American Thoracic Society meeting in San Diego earlier this month generated an estimated 10,779 tonnes of carbon dioxide from air travel. This is equivalent to that produced by 550 US citizens in one year, 11,000 people in India or 110,000 people in Chad.

Fortunately opinions on conferences are changing. The Cochrane Collaboration is an example of an international medical organisation taking action to reduce the carbon footprint of its conferences. Its annual conference in Dublin last year piloted electronic ways of enabling people to ±attend± on the internet, and a plenary session used video conferencing to ±bring± keynote speakers from Papua New Guinea, Tunisia, and Uganda.

The BMJ is taking similar measures at the International Forum on Quality and Safety in Health Care in Barcelona in April.

The educational benefits of conference attendance must also be considered, but evidence that attending conference lectures improves practice is scant, and other methods are more effective.

But even if conferences were effective, who should decide if the benefits are worth the costs ± a doctor from Colorado or a fisherman from Chad, ask the authors?

Air travel is not the biggest contributor to greenhouse gas emissions, but it is one of the fastest growing, they write. Scope exists for ingenuity and experimentation, as well as investment in new technologies to overcome distance.

Climate change is a major threat to global public health and doctors must lead by example, they conclude.

FOR ACCREDITED JOURNALISTS

Embargoed press releases and articles are available from:

Public Affairs Division, BMA House, Tavistock Square London WC1H 9JR

(contact: pressoffice@bma.org.uk)

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)