When your fellow passengers wear surgical masks, you complete a health declaration with your landing card and, pass through a line of heat detectors before passport control, you know public health is taken seriously. Travelling to the WONCA 2009 (World Organization of National Colleges, Academies) Asia Pacific conference in Hong Kong was always going to be interesting in the context of swine flu and the organisers wondered for a long time if they should cancel it.
Public health is also a long term concern in Hong Kong with its aging population and increasing burden of chronic disease. On the last occasion this conference was held in Hong Kong in 1987 the government focus was on reorganising hospital care. This time the emphasis is on reform of primary health care. In his keynote address, Dr the Hon York YN Chow, the current Secretary for Food and Health, recognised the potential in primary care and, following a consultation process, the government is currently looking at ways to work in partnership with family doctors. It will not be easy, as 70% work in the private sector and, practice is commercially driven. There will be a further major challenge in creating multidisciplinary teams with the right skill mix and integrating traditional Chinese medical practitioners. They have ambition however while, to quote one coffee break conversation, the UK is so emotionally attached to the values of the past that it cannot grasp the future.
Really new ideas are rare in medicine but perhaps the most stimulating session of the meeting was the seminar on mental health chaired by Chris Dowrick (Liverpool) The interchange with the audience really got people thinking. Jane Gunn (Melbourne) showed work demonstrating that patients with more than one chronic illness were more likely to have depression, in a dose response relationship. Evelyn van Weel (Nijmegen) asked, from the floor, if perhaps patients with multiple morbidity should be considered generically. Iona Heath, (London) then questioned our conceptualisation of depression pointing out that these patients were almost certainly ground down by the huge burden of multiple illness. With so much illness, they were probably already prescribed multiple medication and she questioned the need to add further pills. Indeed, patients like this are the group mostly likely to be excluded from randomised controlled trials that inform treatment protocols, so there is little direct evidence that medication is appropriate. Multiple morbidity certainly challenges our clinical and therapeutic paradigm. Perhaps we need to move away from vertical thinking in single disease entities and look to managing real patients.
Judith Mackay, winner of the BMJ Lifetime Award earlier this year, gave us a fascinating insight into her battles with the smoking industry. Accepting that this medical audience would not knowingly promote tobacco products, she warned us of inadvertent support through investment of our pension funds and also cautioned us against promotion of cultural events that may, through their sponsorship, present a benevolent image of the tobacco industry. She is wary of what she described as a charm offensive; where tobacco companies support health education programmes to stop children smoking and join campaigns to ban the sale of cigarettes to minors. We should remember that these are two of the least effective smoking reduction strategies. Such partnership gives the impression of a new found social conscience and gains respect but it also deflects attention from other more important issues, including one of the greatest disincentives to children smoking; price.
On the final morning, as delegates were themselves beginning to suffer from collective cognitive decline, James Whitehouse (Case Western Univ USA) introduced us to Alois Alzheimer (1864-1915), the first Alzheimer patient, and Nissl neuro histological stains. He then proceeded to challenge the concept of Alzheimer’s disease as a single condition unrelated to aging pointing out that, with such a variety of clinical presentations, neuropathological findings, and genetic variations, we should not try to squeeze them all under a single disease umbrella. He describes Alzheimer’s disease as a myth; he doesn’t deny cognitive deterioration but is unhappy with the label. But we live in an era where a disease is defined by efforts to seek out a single pharmaceutical solution and this may restrict our ability to think more broadly. He may have a point.
Domhnall MacAuley is primary care editor, BMJ