The EarlyBird Study

Our CLAHRC, like many sibling CLAHRCs, has a primary prevention theme partnering with local authorities. Local authorities are having to deal with increasingly constrained budgets. Dr Ewan Hamlett, adviser to the Birmingham Council, recently drew the CLAHRC WM Director’s attention to the EarlyBird study.

This unique study, based in Southampton, follows a cohort of five year-olds to see what factors are associated with obesity and insulin resistance, and detailed information relating to metabolism is collected from participants. Results are starting to emerge and many are highly policy-relevant.[1]

Some headline, policy-relevant findings include:

  • Provide more school playing fields if you wish, but not because it will increase exercise or tackle obesity – it won’t do either of these things.
  • As with education, don’t wait until school age to tackle the problem – children are programmed to over-eat before they go to school.
  • Obese parents produce obese children, yet they tend to be oblivious to the problem. Follow policies to get parents ‘on-side’.
  • Among children, the mean weight has shot up, but the median has not. A subgroup of children with fat parents is at greatest risk.

— Richard Lilford, CLAHRC WM Director


  1. EarlyBird Diabetes Trust. “Key Findings from EarlyBird.” 2015. [Online].

For Educationalists

Clinical skills are increasingly tested in simulations rather than real world (clinical) settings. A noble exception, where skill was tested in real world settings rather than simulation scenarios, was published recently.[1]

Nevertheless, performance in a simulation seems to be a good surrogate for the latter according to a recent systematic review.[2] Only one study in the review examined the effect of a change in score in a simulation on the score in actual clinical practice and found that they were correlated.[3]

— Richard Lilford, CLAHRC WM Director


  1. Laiou E, Clutton-Brock TH, Lilford RJ, Taylor CA. The effects of laryngeal mask airway passage simulation training on the acquisition of undergraduate clinical skills: a randomised controlled trial. BMC Med Educ. 2011; 11: 57.
  2. Brydges R, Hatala R, Zendejas B, Erwin PJ, Cook DA. Linking Simulation-Based Educational Assessments and Patient-Related Outcomes: A Systematic Review and Meta-Analysis. Acad Med. 2014. [ePub].
  3. Yudkowsky R, Luciano C, Banerjee P, et al. Practice on an augmented reality/haptic simulator and library of virtual brains improves residents’ ability to perform a ventriculostomy. Simul Healthc. 2013; 8: 25-31.

Prevention of CVD in Nairobi Slums

CLAHRC Africa collaborators at the African Population Health Research Center have recently produced a health economic model for cardiovascular risk reduction in slum areas (abstracted at a recent conference). Populating the model with evidence from the literature suggests that an intervention to prevent hypertension, costing only $1 per person per year, would be both effective and cost-effective. The full publication is awaited with great interest.

— Richard Lilford, CLAHRC WM Director

Extraordinary claims require extraordinary evidence

The subject of last issue’s quiz was the results of a study from The Tufts Center for the Study of Drug Development regarding the new estimates of the costs of developing a new drug. As is rightly stated the estimate was $2.6 billion. This study is an update of the original study by DiMasi and colleagues,[1] whose finding that the costs (in 2000 USD) of drug development were close to $1 billion, has achieved near canonical status. However, considerable doubt has been thrown on these claims, and the criticisms of the original study should be applied to this new research. Light and Warburton’s critique [2] [3] drew on a number of points: the lack of comparability and reliability about the original survey data as well as the lack of transparency (as the data were not made publicly available); there was a clear interest for pharmaceutical companies to overstate their costs in survey responses; neither the firms nor the drugs considered were random samples; the only drugs considered in the study were “self-originated new chemical entities” (NCEs) whose costs of development are many times higher than acquired or licensed-in NCEs, new formulations, combinations, or administrations of existing drugs, and yet only comprise around 22% of new drug approvals; government subsidies were not deducted; and, there was no adjustment for tax deductions and credits, to name but a few.

Articles in major journals based on industry sponsored research are three to four times more likely to report results favourable to the sponsors than articles with independent funding.[4] [5] Considerable variation therefore exists in estimates of the costs of drug development. Light and Warburton have estimated the median figure to be roughly a tenth of the original DiMasi estimate.[6] While this may seem (perhaps implausibly) low it certainly suggests we need to take industry sponsored research that affects health policy with a healthy dose of skepticism.

— Sam Watson, University of Warwick


  1. DiMasi JA, Hansen RW, Grabowski HG. The price of innovation: new estimates of drug development costs. J Health Econ. 2003; 22(2): 151-85.
  2. Light DW & Warburton RN. Extraordinary claims require extraordinary evidence. J Health Econ. 2005; 24(5): 1030-3.
  3. Light DW & Warburton RN. Setting the record straight in the reply by DiMasi, Hansen and Grabowski. J Health Econ. 2005; 24(5): 1045-8.
  4. Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical research. A systematic reviewJAMA. 2003; 289(4): 454-65.
  5. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic reviewBMJ. 2003; 326: 1167.
  6. Light DW & Warburton R. Demythologizing the high costs of pharmaceutical research. BioSocieties. 2011; 6: 34-50.

Should Researchers Double as Policy Activists?

The UK, from whence this News Blog emanates, is preparing for a general election – one that is exercising psephologists because, like other European countries, the UK is experiencing a fracturing of the vote, with smaller parties encroaching on “traditional” major parties. This News Blog will stand on the sidelines. We cannot be silent on how to reach objectives, of course, and will continue to report on the relevant evidence. However, the political implications will not be discussed. This is not because the CLAHRC WM Director is apolitical. On the contrary, he is a member of a political party for which he has canvassed in years gone by. Instead, the CLARHC WM Director’s ordinance is based on the ideas that firstly, politics should be kept out of the day job (unless politics is the day job), and secondly, it is quite possible to separate the political persona from the work persona, as the Director had to do in his civil service days.

But, what about policy rather than politics? Here we deal with rather more specific issues: caps on carbon emissions, badger culling, promoting contraception in African countries. What should scientists do in these cases? Should they be dispassionate collectors of evidence, or should they double as both evidence collectors and activists for the relevant causes? Climate change scientists could lobby for more stringent controls on emissions; those who show that badger culling has minimised effects on TB control [1] could join protests; and those who find that lack of contraception is the cause of unwanted pregnancy could agitate against puritanical governments, such as that in Uganda.

The issue of scientists as “activists” was discussed at the ‘Global Symposium on Health Systems Research’ conference, Cape Town, in October 2014. The majority – in fact all – who commented supported the idea of scientists as activists. But there was little critical reflection on the potential dangers of activism and how they might be avoided. The CLAHRC WM Director is circumspect when it comes to this idea of scientist activism.

First, scientists have no particular expertise when it comes to the values on which policy may turn. Nobel prize winners sometimes succumb to the temptation to appoint themselves as an oracle, and soon become a public nuisance, as pointed out by Paul Nurse, himself a laureate. Scientific evidence is about how to reach an objective, but which objectives to pursue – that is a question of preferences/values which lie in the realm of philosophy or religion rather than science. Churchill seems to have spotted this distinction when he said “scientists should be on tap, but not on top.”[2]

Second, a reason for scientist activism is the passion scientists have for the cause. But this is precisely where the danger lies. The CLAHRC WM Director is no climate change denier, but he is worried by the frequent gerrymandering of scientific results in this field, where some seem to think the end justifies the means. Activism has the power to corrupt.[3]

There is a counter-argument to the Director’s detached position. This argument holds that scientific results are inevitably socially constructed, and so, rather than pretend that science is neutral/objective, it is better to declare one’s allegiance and let the reader judge. This is not the place for a comprehensive demolition of this kind of constructivist argument – the writer is an unreformed child of the Enlightenment, holding that we should strive to be objective in the collection and analysis of evidence, and hence that we should adhere to scientific rules whose purpose is the avoidance of error.

The CLAHRC WM Director does not go so far as to say that a scientist should not express an opinion. The moral insights of scientists may be no better than those of the population as a whole, but there is no reason to think they are any worse. The crucial point for scientists is to separate their lives as dispassionate empiricists from their lives as advocates. They should be crystal clear, both in their own minds and in their pronouncements, when they have toggled from scientist to citizen advocate. And, of course, there are times when a decision really does turn only on the science – where values don’t enter the equation because nearly everyone has the same preferences. So, in the case of Thabo Mbeki’s failure to accept that HIV is the cause of AIDS, it was quite right for Jimmy Volmink, and other courageous South African scientists, to “speak truth unto power.”

— Richard Lilford, CLAHRC WM Director


  1. Jenkins HE, Woodroffe R, Donnelly CA. The Duration of the Effects of Repeated Widespread Badger Culling on Cattle Tuberculosis Following the Cessation of Culling. PLoS ONE. 2010. 5(2): e9090.
  2. Quoted in: Churchill RS. Twenty-One Years. London: Weidenfeld & Nicolson. 1965. p.127.
  3. Lomborg B. The Skeptical Environmentalist: Measuring the Real State of the World. Cambridge: Cambridge University Press. 2001.

Je suis Raif: bloggers, freedom of speech, doctors and torture

Recent events have drawn attention to three related issues of interest to this part-time blogger with an interest in health care. One shows the high value that Western democracies place on freedom of speech. Another illustrates a contrasting value system and, in a curious way, highlights the complicity of doctors in torture. Could these events on the world’s stage have any resonance within the microcosm of the NHS?

The attack on the French satirical magazine Charlie Hebdo provoked a robust defence of freedom of speech from nations across the world. Even the Saudi Arabian ambassador took part in a solidarity march in France. Which is ironic – back in Saudi Arabia, Raif Badawi faces 50 lashes a week for 20 weeks outside of al-Jafali mosque in Jeddah. His crime was to write a blog criticising religious authorities in Saudi Arabia. The right to criticise is not universally valued and speaking out can be construed as disloyalty.

Fortunately, the latest instalment of his sentence has been postponed because the prison doctor decided that his wounds had not sufficiently healed.[1] Medical intervention has gained Raif Badawi a week’s respite, but it also raises the question of medical complicity in torture. Interestingly this phenomenon is not confined to Saudi Arabia. Medical complicity in legally sanctioned torture has also occurred in Western democracies. How can this happen?

Over a decade ago in the BMJ I predicted that doctors in Guantanamo Bay risked becoming accessories to torture.[2] Three doctors responded to my letter, vying each other in outrage at my suggestion. Anyone with the tiniest knowledge of social psychology would have made the same prediction. Individuals’ behaviour is constrained by the norms of the organisation. In his famous 1971 Stanford Prison Experiment,[3] Zimbardo demonstrated that given the power over others, some individuals will behave sadistically, while others feel unable to intervene. This was of course exactly what happened in Guantanamo.[4] It had previously happened in Abu Ghraib. It will happen again in similar circumstances unless specific measures are put in place to create an organisational culture where this is unacceptable. This means leadership, clear standards of behaviour, external oversight, and open reporting of lapses in standards of behaviour.

Are there any lessons for health services? Freedom of speech is important. The NHS does not flog whistle-blowers in public places, but they often suffer punishment.[5] [6] Organisational culture shapes behaviour, even among health professionals. Without leadership, transparency and external oversight, any organisation risks slipping into poor practice. Cartoonists, bloggers and whistle-blowers may make us feel uncomfortable. But this is all the more reason not to silence them.

— Tom Marshall, Deputy Director CLAHRC WM, Prevention and Detection of Diseases


  1. Tran M. Saudi blogger Raif Badawi’s case referred to supreme court, says his wife. The Guardian. 2015-01-16. [Online].
  2. Marshall T. Doctors in Guantanamo Bay are at risk of being accessories to torture. BMJ. 2002. 324: 235.
  3. Haney C, Banks C, Zimbardo P. A Study of Prisoners and Guards in a Simulated Prison. Washington, D.C.: Office of Naval Research. 1973.
  4. Nye J. U.S. military doctors broke oath to design new torture techniques to be used at Guantanamo Bay. Daily Mail. 2013-11-04. [Online].
  5. Public Concern at Work. Whistleblowing the inside story – Main report. 2013. [Online].
  6. BBC News. Worcestershire hospitals ban paramedic Stuart Gardner. BBC News. 2015-01-16. [Online].

Speaking Truth Unto Power*

* The original quote, “Speak truth to power”, is thought to have been coined by Bayard Rustin in 1942 and referred to the role of religious groups.[1]

Science plays an increasing role in modern society, identifying problems and then developing and testing solutions – climate change being a prime example. Individual scientists often make discoveries, but professional/scientific societies are arguably more persuasive in influencing practice and policy.[2] The Nigerian Academy of Sciences orchestrated the country’s successful programme to contain the Ebola outbreak according to Andrew Green, writing in the Lancet.[3] He gives further examples of successful policy interventions prompted by African Academies. The CLAHRC WM Director was reminded of the iconic advice, often attributed to Germaine Greer, “Don’t complain, organise.”

— Richard Lilford, CLAHRC WM Director


  1. Green J. The Origin of the Phrase “Speaking Truth to Power”. [Online].
  2. Wilson B, Thornton JG, Hewison J, Lilford RJ, Watt I, Braunholtz D, Robinson M. The Leeds University Maternity Audit Project. Int J Qual Health Care. 2002; 14(3): 175-81.
  3. Green A. African science academy initiative reflects on progress. Lancet. 2014; 384: 1836.

Exercise and Health

Readers of the News Blog will have seen previous articles on exercise and health.[1] [2] It is more dangerous to have diabetes or to smoke than to be a coach potato, but there are many more coach potatoes than people living with diabetes or smokers, so overall, more people lose their lives from inactivity than from either the diabetes or the tobacco. It also turns out that the marginal gains of more exercise decrease as total exercise increases. Totally sedentary people (about 25% of the US population) have by far the highest risk. This is the basis for an interesting review and editorial in the Annals of Internal Medicine, advocating policy focusing on the totally sedentary,[3] [4] as well as a news article in the BMJ.[5]

— Richard Lilford, CLAHRC WM Director


  1. Lilford R. Anti-obesity interventions. Dec 12 2014. [Online].
  2. Lilford R. Two provocative papers on diet and health. Dec 12 2014. [Online].
  3. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. Sedentary time and its association with risk for disease incidence, mortality and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med. 2015;162; 123-32.
  4. Lynch BM, Owen N. Too much sitting and chronic disease risk: steps to move the science forward. Ann Intern Med. 2015;162: 146-7
  5. Mayor S. Prolonged sitting increases risk of serious illness and death regardless of exercise, study finds. BMJ. 2015; 350: h306.

Feeling Young is Good News if You Are Feeling Old!

People who feel older than their chronological age have a considerably higher chance of dying within ten years than age-matched counterparts who feel younger, according to a recent prospective population-based study.[1] This is despite the authors controlling for baseline medical conditions and excluding deaths in the first year to mitigate reverse causality. This is yet another study relating general attitude to health.

— Richard Lilford, CLAHRC WM Director


  1. Rippon I, & Steptoe A. Feeling Old vs Being Old: Associations Between Self-perceived Age and Mortality. JAMA Intern Med. 2014. [ePub].

Evaluating Service Interventions

CLAHRCs were invented to align research practice with service change. As a result of such alignment, here in the West Midlands we have been able to evaluate service interventions with the scope and timescale of the service imperative, including:

  • Peer support for mothers at high social risk to see whether there is an improvement in mother/child bonding – individual person RCT.[1]
  • Rearranging mental health services to reduce delay in treatment for schizophrenia in adolescents – multi-centre before and after study.[2]
  • Case-finding for cardiovascular risk in Primary Care to assess uptake of services – cluster step-wedge RCT.[3]
  • Educational intervention to improve attitudes to mental health in schools – cluster parallel RCT.[4]

A brilliant example of an evaluation driven by service change is the Oregon Health Insurance experiment. Expansion of medical coverage was implemented by lottery, inadvertently generating an RCT. This was used to evaluate the effects of improving access to health care. The political and logistical issues behind the trial are discussed by Allen et al.[5] and the result will be summarised in a forthcoming blog.

— Richard Lilford, CLAHRC WM Director


  1. Kenyon S, Jolly K, Hemming K, Ingram L, Gale N, Dann S-A, Chambers J, MacArthur C. Evaluation of Lay Support in Pregnant women with Social risk (ELSIPS): a randomised controlled trial. BMC Pregnancy Childbirth. 2012; 12: 11.
  2. Birchwood M, Bryan S, Jones-Morris N, Kaambwa B, Lester H, Richards J, Rogers H, Sirvastava N, Tzemou E. EDEN: Evaluating the development and impact of Early Intervention Services (EISs) in the West Midlands. NIHR Service Delivery & Organisation. HS&DR 08/1304/042. 2007.
  3. Marshall T, Caley M, Hemming K, Gill P, Gale N, Kolly K. Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedge cluster RCT. BMC Public Health. 2012; 12: 908.
  4. Chisholm KE, Patterson P, Torgerson C, Turner E, Birchwood M. A randomised controlled feasibility trial for an educational school-based mental health intervention: study protocol. BMC Psychiatry. 2012; 12: 23.
  5. Allen H, Baicker K, Finkelstein A, Taubman S, Wright BJ, Oregon Health Study Group. What the Oregon health study can tell us about expanding Medicaid. Health Aff. 2010; 29(8): 1498-1506.