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Press releases Friday 13 June 2008

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(1) Global war deaths have been substantially underestimated
(2) Government resources urgently needed to reduce childhood injury, say experts
(3) Should doctors be “selling” drugs for the pharmaceutical industry? BMJ TV

(1) Global war deaths have been substantially underestimated
(Fifty years of violent war deaths from Vietnam to Bosnia: analysis of data from the world health survey programme)
www.bmj.com/cgi/content/full/bmj.a137
(Editorial: Measuring deaths from conflict)
www.bmj.com/cgi/content/full/bmj.a146

Globally, war has killed three times more people than previously estimated, and there is no evidence to support claims of a recent decline in war deaths, concludes a study published on BMJ.com.

Current survey-based techniques used to estimate violent war deaths have been criticised for their potential biases and inaccuracies. For instance, surveys estimating war mortality on the basis of household deaths, such as those recently done in Iraq, were alleged to be statistically invalid, and to incorporate politically motivated over-reporting of deaths.

But the alternative technique used during most ongoing conflicts including Iraq - passive data collection from eyewitnesses and media reports - is also subject to major biases, including the fact that high levels of war deaths occur in dangerous areas where eyewitnesses are least likely to go.

To overcome some of these biases, Ziad Obermeyer and colleagues from the Institute for Health Metrics and Evaluation in Seattle, designed a new method of estimating violent war related deaths using data on the siblings of respondents in large household surveys conducted in peacetime.

According to the researchers, by comparing passive surveillance data of violent war deaths (mainly from eyewitnesses and the media) in 13 countries over the past 50 years, to peacetime data collected after conflicts in the UN's World Health Surveys, they were able to provide more accurate data on war deaths. For example, say the researchers, the new technique avoids the constraints imposed by active combat, and using siblings' histories rather than household deaths, reduces double counting and exaggeration of deaths.

They estimate that 5.4 million deaths occurred as a result of war in the 13 countries studied between 1955 and 2002, from 7000 in the Democratic Republic of Congo to 3.8 million in Vietnam.

The researchers point out that these estimates are on average three times higher than those obtained from previous reports. For example, they estimate that 378 000 people died a violent death as result of war each year between 1985 and 1994, compared to previous estimates of 137 000 people during this time.

The largest differences, they say, were in Bangladesh where, during the conflict for its independence, they estimate there were 269 000 violent war deaths, compared to previous estimates of 58 000. And in Zimbabwe where they estimated 130 000 deaths, compared to previous estimates of 28 000.

Importantly, say the authors, these new data do not support the prevailing view that war deaths are declining and have been since the mid-twentieth century, or that recent wars have killed relatively few people thanks to technological and strategic innovations designed to minimise civilian deaths. In light of the substantial differences in estimates, conclude the authors, these claims need to be re-evaluated.

Even these figures are still likely to underestimate the importance of conflict as a cause of death because they only address violent deaths, cautions Professor Richard Garfield from Columbia University in an accompanying editorial. "In the poorest countries, where most conflicts now occur, a rise in deaths from infectious diseases often dwarf the number of violent deaths during a conflict".

Garfield argues that the "promising method" pioneered by Obermeyer and colleagues will force us to re-evaluate our assumptions about these deaths "The importance of war as a public health problem and a social problem makes this imperative", he concludes.

Contacts:
Ziad Obermeyer, Brigham & Women's and Massachussetts General Hospitals, Boston, USA
Email: ziad_obermeyer@hms.harvard.edu
Editorial: Richard Garfield, Professor of Clinical International Nursing, Columbia University, New York, USA
Email: rmg3@columbia.edu

(2) Government resources urgently needed to reduce childhood injury, say experts
(Editorial: Preventing Injury in Childhood)
www.bmj.com/cgi/content/short/336/7658/1388

Childhood injury surveillance in the UK is under-resourced and lags behind other European countries, say experts in this week's BMJ, ahead of UK Child Safety Week on 23 June.

Most injury is avoidable and preventable, write Graham Kirkwood and Allyson Pollock from the Centre for International Public Health Policy at the University of Edinburgh, but because the UK does not have a comprehensive childhood injury surveillance system, the causes, risks factors, and consequences of childhood injury are unknown. This has made it difficult to implement evidence based injury prevention strategies, they argue.

In the UK, unintentional injury is a leading cause of death and injury and the most common cause of hospital admission in children and accounts for two million accident and emergency department visits each year at a cost of £146 million to the NHS. And it is children from the poorest families who suffer the most-death rates from unintentional injury are three times higher in children from the poorest families.

The Audit Commission, Healthcare Commission and the European Child Safety Alliance have all voiced their concerns over the fragmented nature of UK injury policy and the lack of monitoring and surveillance systems.

The authors point out that part of the problem is that responsibility for children is shared across many sectors and agencies—including Local Education Authorities, the NHS, and the Health and Safety Executive - with no one integrated injury surveillance system.

But according to the authors, the key issue is the lack of political support for surveillance systems essential for monitoring childhood injury at country level, despite the UK government prioritising the health and well-being of children.

The authors suggest that because many non-fatal unintentional injures in children result from sport, the 2012 London Olympics could act as a catalyst. Not only, as the government hopes, to encourage physical activity and help lower levels of obesity in children in the UK, but also to promote the development of injury surveillance systems and prevention strategies to help children participate in 'safe' sport and reduce inequalities in injury rates across the social classes.

Examples of good practice such as Sweden, the Netherlands and Denmark all have well established area based population injury surveillance systems and the lowest mortality rates from unintentional injury in children in Europe, the highest levels of sport participation, and Sweden has half the obesity levels of the UK.

"If the UK governments are really committed to the health and wellbeing of children and to ameliorating inequalities then much more is needed…[they] must now find the resources to develop population based injury surveillance systems so that the true incidence, causes, risk factors, and long-term sequelae of injuries can be used to inform evidence based intervention", they conclude.

Contact:
Allyson Pollock, Director, Centre for International Health Policy, University of Edinburgh, Edinburgh, UK
Email: allyson.pollock@ed.ac.uk

(3) Should doctors be "selling" drugs for the pharmaceutical industry? BMJ TV
(Feature: Key opinion leaders - independent experts or drug representatives in disguise?)
www.bmj.com/cgi/content/short/336/7658/1402
(Head to head: Should the drug industry work with key opinion leaders?)
Yes: www.bmj.com/cgi/content/short/336/7658/1404
No: www.bmj.com/cgi/content/short/336/7658/1405

Are senior doctors who help drug companies sell their drugs independent experts or just drug representatives in disguise, asks Ray Moynihan from the University of Newcastle in Australia, in this week's BMJ.

Moynihan exposes the reality behind the practice with some candid revelations from industry insiders.

Pharmaceutical companies regularly sponsor leading specialists with "generous fees to peddle influence" and promote drugs to the profession and the public, writes Moynihan.

Drug companies will pay influential doctors up to $400 an hour to act as key opinion leaders, and some doctors earn more than $25 000 a year in advisory fees.

Kimberly Elliot, a former award-winning drug company sales representative interviewed* by Moynihan, reveals that drug companies desperately need key opinion leaders in order for doctors to believe what they are saying and prescribe their products, because drug representatives are often not believed. Essentially, she says, key opinion leaders are just salespeople.

So how independent are these doctors who have long term financial arrangements with drug companies?

According to Richard Tiner, medical director at the Association of the British Pharmaceutical Industry, although "the work might help to promote a particular medicine" it should be considered payment for work done, and not a bribe. The best antidote to concerns about independence would be more transparency - all company payments to speakers should be routinely disclosed at medical meetings, he adds.

But David Blumenthal, from Harvard University, believes that payments to key opinion leaders are not in the public interest or in the interests of the patients served by these doctors, and calls for a major cutback in industry influence over the medical profession and its education.

In an accompanying head to head, Charlie Buckwell, Chief Executive of the Complete Medical Group and Professor Giovanni Fava, from the University of Bologna, debate whether drug companies' use of medical experts is essential for medical advancement or whether it risks scientific integrity.

Notes to Editors: *Click here to view brief BMJ TV interviews with Kimberly Elliot: http://press.psprings.co.uk/bmj/june/Elliot1.wmv
http://press.psprings.co.uk/bmj/june/Elliot2.wmv

Contacts:
Ray Moynihan, Visiting editor BMJ and conjoint lecturer, University of Newcastle, New South Wales, Australia
Email: ray.moynihan@newcastle.edu.au
Head to head:
Charlie Buckwell, Chief Executive, Complete Medical Group, Cheshire, UK
Email: charlie.buckwell@complete-grp.com
Giovanni Fava, University of Bologna, Italy
Email: giovanniandrea.fava@unibo.it

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