Is the EU reaching SDG 3.3.? An interview with Andrew J. Amato-Gauci

“Tuberculosis is our shame; Elimination of viral hepatitis C is very possible and HIV/AIDS is more complicated.”

I have met Dr Andrew Amato at the main conference venue of the European Health Forum Gastein, which he attended for the first time. During an hour-long interview, we had an interesting and fairly open discussion on where European Union is now in reaching SDG 3.3, as well as what are the key reasons for that. I hope you would enjoy reading this article as much as I enjoyed talking to this passionate health care professional while drinking a coffee on a sunny terrace of a small café surrounded by the Alps.  

AT: The motto of this year EHFG opening plenary was “Let’s think big for Public Health in Europe”. What does it mean for you to think big?

AA: For me, it means that we should be more ambitious in our aims and our goals. Even if we know that we are being too ambitious, this is important as the political commitment to public health today is rather weak, so politicians do need aspirational goals. I don’t see a lot of public health champions among the politicians today. There is also a tendency towards adopting more populist policies. Unfortunately, this usually means the politicians will tend to only focus on policies and make promises that will provide short-term satisfaction. So, we, the public health activists, need to look at the big picture and set ourselves bigger goals that could inspire the politicians to follow suit and plan greater policies, rather than going for immediate and short-term outcomes.

For example, hepatitis C elimination in Europe is ‘easily’ achievable from a policy aspect – the only thing that needs to be done is testing of the at-risk populations and providing curative treatment, as simple as that. Of course, it would cost a lot of money initially, but the benefit such a plan is that it will have to be done only once on large scale.Obviously, I am oversimplifying to make a point, but it really can be done with the help of motivated and strong-willed politicians behind it.

Vaccination is a similar topic: we could do so much better with just a little bit more emphasis on the right legislation, a bit stricter enforcement and stronger advocacy strategies. By now, we were supposed to have eliminated measles in the EU: we have the tools, we have the money, and yet, for the lack of interest and political will, the campaigns have mostly faltered. I am convinced that a major campaign – and by “major”, I mean a suitably funded campaign with inspired leadership, which is run over 3 to 5 years,focusing only on measles –, would easily manage to eliminate measles in the EU. The USA had managed to come very close to achieving this, and then faltered for various reasons, which unfortunately include recurrent imported infections from the EU. That’s the kind of high-level policies we need, with countries coming together and agreeing that we need to work on this particular priority and putting sufficient resources there. The problem with this is that the health mandate of the EU Commission is still rather limited. Namely, there have been brave attempts in starting up major partnerships (e.g. against tobacco or cancer) and becoming more involved in public health, but it is still a work in progress. The organization of health services is still the mandate of Member States, so we have different health care services across the EU. For me, this is in a way against the spirit of the EU, which is all about crossing borders without any obstacles or differences. So, as long as health care services,disease prevention and health promotion services are different in every country, a citizen moving from one country to another will face differing services. We still have a long way to go for the EU to fix that. From the public health perspective, the DG SANTE is probably not the most influential sector of the Commission – it is nowhere near the Economics, the Finance, or the Foreign Affairs sectors, just to name a few. I think we should all work on raising the profile of health to a satisfying level.

AT: Turning to one of the SDGs, precisely to SDG 3.3 – what are the key priorities for Europe?

AA: Yes, the famous SDG 3.3…. It is unlikely that we will be able to achieve TB elimination in the EU within the target. This is a disease which is almost 100% curable with antibiotics, and yet, despite all the medical advances that we have made, we can’t seem to “fix” it in the EU. I don’t understand how we have found ourselves in this situation. It’s true that the numbers are decreasing, but the decline is very slow. We need to focus on the latent TB, especially because we have never given it the attention it deserves. MD RTB shouldn’t remain the problem it is now, there are new tools coming online quite soon which hopefully should make it less of an issue.

The SDG 3.3. refers to combating hepatitis.What does that mean? The UN has come up with numbers, planning a reduction of 90%, but I think that total elimination of HCV is what we should aim for at the EU. As I said before, we already have all the necessary tools in the EU, and we have good health care services, so why can’t we achieve that?

For HIV/AIDS, the SDG target is more complicated. We have at last begun to see a true reduction of incidence in the EU/EEA, first seen in the surveillance data of the last year, mainly in new cases of infection among men who have sex with men. This is largely thanks to the adoption of Test and Treat policies and the roll out of PrEP for at-risk populations. I think people began to realize that the more we adopt these ‘fast-track’ policies, the more we will see HIV coming down rapidly. Also, AIDS rates are dropping very fast because the treatment is working so well. On the other hand, we see epidemics of gonorrhea and syphilis in the EU. With further roll out of PrEP, we can expect to see more of these. Still, it will be hard to know whether this is due to more new infections actually happening, or because at-risk people are tested more often and thus are found to be infected. However, I think if PrEP is implemented properly, the highest-risk groups will likely attend services more often, both for their prescriptions and screening tests. This way, they will be tested and treated for syphilis and gonorrhea as well, possibly bringing these down in the longer term. So, there is a possibility of using PrEP to reach out to the most at-risk group and reduce their overall infection risks and exposure. The current rates of increase of STIs are concerning, and we are expecting to find out more about the rising rates of congenital syphilis in the USA. We haven’t seen it yet, but we can expect that this is going to happen in one- or two-year time. 

Of course, malaria is not that relevant in the EU for now, but if the rates of other vector-borne diseases are anything to go by, it is just a question of time. 

So, I believe HCV is where we could achieve the most. For TB we are not doing as well as we should, especially in the east of Europe. And as a side effect of PrEP we might be also combating STIs.

AT: I also wanted to talk about SDG 3.3. and migration. You have published several papers related to the issues of migration. Every now and then, something happens in the world and we have a new wave of migrants arriving to the EU, bringing new culture, traditions, languages, as well as new health-related problems. What do you think of that?

AA: Our work with migrants is limited, because ECDC’s focus lies within infectious diseases, which might not be the major public health problem for migrants. TB and, to a lesser extent, hepatitis may pose some problems, especially among irregular migrants coming from high-prevalence areas, but for HIV/AIDS this is much less of an issue. The problems for migrants go beyond infectious disease, and we don’t have a mandate there.  

A specific problem with migrants that I have is the word itself. We use “migrant” for a very broad phenomenon, and mostly synonymous with migration from outside of EU: there are people who are economic migrants, for example the North Africans, who are trying to get across in order to get work; there are war refugees like Syrians, and there are whole mix of central Asians, who are looking for a better life. Still, we tend to put all of them in one basket of “migrants”. They all have very different problems, very different issues, very different health needs. It’s such a complex issue, and our work has been very limited. Some policy advisers asked ECDC to define whether we should be testing “migrants” for certain diseases, for example. In response, we developed guidelines that specify what should be asked if a test is offered, and of course, stating that those tests should be provided only on voluntary basis. Also, if a test is provided, the treatment has to be made available, otherwise it is simply not ethical to test. TB in migrants is something that we focus more on, as many migrants come from high-prevalence areas, but hepatitis and HIV/AIDS are among the least health problems migrants face. HIV/AIDS, as we have found out, becomes a problem for the migrants after moving to the EU. There is good data showing they get infected more often after they had moved to the EU. It is quite the opposite to what right-wing politicians like to preach – that the migrants bring HIV/AIDS to the EU. Finally, as already mentioned, we use the term mostly synonymous with migration from outside of the EU, but we should also consider the impact of migrations within the EU, from Eastern European to Western European countries.

AT: To sum up, this is your first time at EHFG – what does it feel like?

AA: Yes, it is. So far, I have only seen the village (laughing) and the village is very cute and I love the mountains! So, I am very happy to be here. I am here with my director, we will have ECDC session tomorrow, and I am looking forward to our session, we will see how it goes.

This interview was conducted by a Young Gasteiner Anna Tokar

A new approach to NCD control in Europe

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Interview with Marianne Takki, Policy Coordinator, DG Sante, European Commission

“I’m here to tell everyone about the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases, and explain to organisations and other health stakeholders how the approach works.”

At the European Health Forum Gastein 2018, Marianne Takki was present to discuss the activities and role of the European Commission in non-communicable diseases (NCDs) prevention and control.

MD: You mentioned that the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases[i], which the European Commission established this summer (2018), is a totally new approach. What is so different about this approach compared to how the Commission worked on NCDs earlier?

MT: Previously, there were several disease-specific expert groups at the Commission, such as on rare diseases, cancer control, and mental health. The outputs of these groups were not effectively taken forward. We [the Commission] realised that, for plans and recommendations to be useful to someone, implementation needs to be the focus of all planning. Now, with the new steering group that officially started in July 2018, the member states are involved from the beginning. The aim of the steering group is not to create aspirational statements, nor develop new policies: instead, the steering group will address what we already have. This approach puts health in all policies into practice.

“The Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases, which is established by the European Commission in July 2018, is a new approach to non-communicable disease control in Europe. This approach is about health in all policies being integrated into practice.”

Through the best-practices portal – which is a part of this new approach – we make sure that the member states know which NCD interventions are available and which can be implemented. Preferably, these practices are already implemented in a country or region and, with some adaptation, can be implemented in other places. The best practice portal is more than just a collection of best practices, it also includes an evaluation, for which the assessment criteria are established by the steering group. Finally, the Commission provides funding to member states for the implementation of best practices

MD: NCDs are now on the political agenda, but winds might change. How can we keep NCDs on the national and European agendas?

MT: Commitment of member states is realised by having regular prioritisation exercises, where member states prioritise their own needs. There are already many agendas out there, such as the sustainable development goals (SDGs), so the steering group aims to support member states in achieving the targets and goals that are most challenging for them.

MD: What can we expect from the steering group in the future?

MT: Until today, the Health Programme was the main funding for health projects. But now, while we are moving towards the next multi-annual financial framework of the EU (2021-2027), this will change. The steering group will be the main mechanism. I’m here [at the European Health Forum Gastein] to tell everyone about the steering group and to bring forward our approach, so that it becomes clearer to organisations and other health stakeholders. It is a new approach and we are taking baby steps in the beginning. The positive feedback that we have received from the member states since the launch of the steering group is a clear indicator that we are using the right approach.

In the next multi-annual financial framework, health is incorporated in the ESF+ programme, within the so-called health ‘strand’ or ‘cluster’. As stated in the proposal for the ESF + programme, article 29 in particular, the steering group would mainly be responsible for the health strand, including the work plans, prioritisation, strategy and implementation of the public health activities in the EU.[i] We are aiming for a more upstream decision-making process in the future. This would mean that the steering group can steer financial resources based on member states’ health objectives.

By the way, 7.7 billion euros are set for health research in Horizon Europe [the new research cluster]. I don’t think people see the opportunities here.

The first formal meeting of the steering group – chaired by Martin Seychell – was held on 6th of November 2018. We also plan a joint meeting between the steering group and the current Horizon 2020 research programme committee in Brussels in early spring 2019. This is to facilitate discussions between the stakeholders from research and health on ministerial level and the different Commission services on where the synergies are. This is one concrete future step in making sure that our policies are aligned, and our objectives are in synergy.

This interview was conducted by a Young Gasteiner Maaike Droogers

[i] Article 29 of ‘Proposal for a Regulation of the European Parliament and of the Council on the European Social Fund Plus (ESF+) COM/2018/382’ suggests that the steering group could have an important role in the future ESF+ health strand. Available here, https://eur-lex.europa.eu/resource.html?uri=cellar:a39e5630-640f-11e8-ab9c-01aa75ed71a1.0003.02/DOC_1&format=PDF.  

[i] Webpage of the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases is available here: https://ec.europa.eu/health/non_communicable_diseases/steeringgroup_promotionprevention_en

Patient involvement across Europe

On the 21st of May the Eurobarometer qualitative survey was published, assessing the involvement and relationship between patients and health care professionals in 15 European countries.

What is patient involvement? One of the results of the study was that both patients and health staff are not aware what the concept means:

For both practitioners and patients it was often simply equated with medical compliance and following doctors’ orders (Eurobarometer, 2012).

But doesn’t patient involvement symbolise an active dialogue between patients and health care professionals and an open form of communication and the exchange of information and feedback from both sides?

The Eurobarometer survey found that choice was one key aspect of patient involvement for some patients, being able to change doctors and being aware of alternate treatments. From a practitioners point of view the benefits of ‘patient involvement” as having more motivated and engaged patients, with increased understanding.

So what are the benefits of patient involvement and what can be done to improve it? The active involvement of patients and an open communication can lead to better diagnosis and treatment options, when e.g. symptoms, side effects or lifestyle factors are discussed between the patient and physician, thus benefiting both. Patient involvement also indicates the monitoring of symptoms, side and/or treatment effects, which is already done by many chronic disease patients e.g. having diabetes. The internet also contributed to increasing patient involvement within the last ten years, since information about symptoms, potential diagnosis and treatment options are searched and presented to the doctor for discussion.

The wish to be involved as an individual varies between the age groups patients with a higher level of education, patients with chronic conditions, and younger or middle-aged patients wanted (and often expected) more involvement, as discovered in the Eurobarometer survey.

One example of patient involvement is the TEDx of Lucien Engelen at this year’s conference on Future of Health, 2nd April 2012 in Maastricht. Lucien talks about his initiative, incorporating patients in health conferences, to involve and empower them. In his talk he also introduces Jip Keijzer, who talks about his journey of battling cancer and the AYA platform of the Radboud Hospital in Nijmegen, bringing patients and doctors together. The doctor mostly sticks to the scientific facts but for the patient having a disease and being treated, so much more plays a role and has impact on his well being.

Involving and empowering patients benefits all involved parties and the society as a whole.

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Resolution passed to prevent a new PIP breast implant scandal

On Wednesday 25th of April, Members of Parliament (MEP) unanimously voted in favor of a resolution, tackling the recent PIP breast implant scandal. Members of the Environment and Public Health Committee call for the implementation of a breast implant register, stricter checks, product traceability, and a pre-market authorisation system. Furthermore, they stressed that converting EU legislation into national laws failed to avoid the PIP defective breast implants health fraud.

400,000 PIP implants by the French manufacturer, Poly Implant Prothèse (PIP)  were sold worldwide, most of them in Germany, France and the UK, the number of harmed women is however still unknown.

This case clearly indicates the failing of implementation and translation of EU policies on both EU and national level. Compliance, traceability, coordination and surveillance of medical devices have to be improved, to secure health status of EU citizens. In addition, an EU data base of medical devices that are on the market, registration of economic operations, vigilance and market surveillance; clinical investigations, notified bodies and EC certificates issued, say MEPs.

According to MEPs: patients’ associations, patient groups and health care professionals must be encouraged to report all adverse events and harmful effects of these devices without being hampered by a great deal of red tape.

Patient’s awareness of risks and access to health information also need to be improved. Furthermore, medical professionals should improve communication towards their patients about potential health hazards.

Let’s wait and see what measurements will be introduced and implemented on both EU and national level to secure the use of medical devices for patients.