The World Health Organisation. Interview with the director general. Interview by Fiona Godlee.

Dr Hiroshi Nakajima was elected director general of WHO in 1988. Born in Japan, he trained as a psychiatrist before joining WHO in 1973. He was WHO''s regional director for the Western Pacific from 1979 to 1988. His term of office has been marked by criticism of his management style and allegations of misuse of WHO''s funds. I spoke to him at WHO''s headquarters in Geneva in July. I have presented the interview in the form of questions and answers. It would be misleading, however, not to make clear that in doing so I have transcribed conversation which was at times extremely difficult to follow. I feel that it is important to emphasise this in the context of an interview with an international leader, one of whose primary tasks must be to communicate his views on health to people across the world. The interviews gave me first hand experience of the difficulties in communication that staff, diplomats, and others, including Japanese leaders, have consistently commented on since Dr Nakajima took office.     

The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey

Background

Most knowledge of fibromyalgia comes from the clinical setting, where healthcare-seeking behavior and selection issues influence study results. The characteristics of fibromyalgia in the general population have not been studied in detail.

Methods

We developed and tested surrogate study specific criteria for fibromyalgia in rheumatology practices using variables from the US National Health Interview Survey (NHIS) and the modification (for surveys) of the 2010 American College of Rheumatology (ACR) preliminary fibromyalgia criteria. The surrogate criteria were applied to the 2012 NHIS and identified persons who satisfied criteria from symptom data. The NHIS weighted sample of 8446 persons represents 225.7 million US adults.

Results

Fibromyalgia was identified in 1.75% (95% CI 1.42, 2.07), or 3.94 million persons. However, 73% of identified cases self-reported a physician’s diagnosis other than fibromyalgia. Identified cases had high levels of self-reported pain, non-pain symptoms, comorbidity, psychological distress, medical costs, Social Security and work disability. Caseness was associated with gender, education, ethnicity, citizenship and unhealthy behaviors. Demographics, behaviors, and comorbidity were predictive of case status. Examination of the surrogate polysymptomatic distress scale (PSD) of the 2010 ACR criteria found fibromyalgia symptoms extending through the full length of the scale.

Conclusions

Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. The association of fibromyalgia-like symptoms over the full length of the PSD scale with physiological as well as mental stressors suggests PSD may be a universal response variable rather than one restricted to fibromyalgia.     

Health, justice, and the environment

In this article, we argue that the scope of bioethical debate concerning justice in health should expand beyond the topic of access to health care and cover such issues as occupational hazards, safe housing, air pollution, water quality, food and drug safety, pest control, public health, childhood nutrition, disaster preparedness, literacy, and many other environmental factors that can cause differences in health. Since society does not have sufficient resources to address all of these environmental factors at one time, it is important to set priorities for bioethical theorizing and policy formation. Two considerations should be used to set these priorities: (1) the impact of the environmental factor on health inequality, and (2) the practicality of addressing the factor.     

Hepatitis C virus screening trends: A 2016 update of the National Health Interview Survey

Background50% of liver cancer is caused by hepatitis C virus (HCV). Baby boomers are at increased risk and are recommended for one-time HCV screening. However, <13% of baby boomers were screened in 2015.Materials and methodsWe are updating a previous study using 2013–2015 NHIS data to examine HCV screening prevalence by birth cohort, with 2016 data. We used logistic regression to evaluate whether HCV screening prevalence changed over time, stratified by birth cohort.Results and discussionThe sample consisted of 132,742 participants from 2013–2016. Screening increased in baby boomers from 11.9 to 14.1%. Odds of HCV screening for baby boomers was significantly associated with age, gender, race/ethnicity, and other variables and increased significantly with each subsequent year (aOR = 1.21, aOR = 1.33, aOR = 1.42, consecutively). While HCV screening is increasing over time, there is still room for improvement and future interventions should focus on increasing HCV screening among groups demonstrating significantly lower screening prevalence.     

Trends in the association of obesity and self-reported overall health in 30 years of the Integrated Health Interview Series

This research examines trends in the relationship between obesity based on self-report height and weight and self-perceived health over a 30-year period. Importantly, this period included the articulation of comprehensive public health campaigns on excess weight and thus provides opportunities for assessment of the efficacy of the campaign, as well as the broader psycho-social impact of excess weight. Using novel data from the Integrated Health Interview Series, odds ratios for the association between obesity and self-perceived health were estimated for repeated cross-sectional samples that are nationally representative of noninstitutionalized American adults aged 18-85 and older spanning 1976-2006. Our findings show that (i) there are weak associations between obesity and self-perceived poor health; (ii) these associations are particularly small among men, often to the point of being nonexistent; and (iii) weak relationships for both men and women have remained virtually unchanged over the past 30 years. Several reasons why the public health campaign around excess weight has had limited traction are discussed including the collective problem of excess weight in America and how this undermines current approaches in public health efforts addressing excess weight.     

Developing and Validating a Tablet Version of an Illness Explanatory Model Interview for a Public Health Survey in Pune,India

Background

Mobile electronic devices are replacing paper-based instruments and questionnaires for epidemiological and public health research. The elimination of a data-entry step after an interview is a notable advantage over paper, saving investigator time, decreasing the time lags in managing and analyzing data, and potentially improving the data quality by removing the error-prone data-entry step. Research has not yet provided adequate evidence, however, to substantiate the claim of fewer errors for computerized interviews.

Methodology

We developed an Android-based illness explanatory interview for influenza vaccine acceptance and tested the instrument in a field study in Pune, India, for feasibility and acceptability. Error rates for tablet and paper were compared with reference to the voice recording of the interview as gold standard to assess discrepancies. We also examined the preference of interviewers for the classical paper-based or the electronic version of the interview and compared the costs of research with both data collection devices.

Results

In 95 interviews with household respondents, total error rates with paper and tablet devices were nearly the same (2.01% and 1.99% respectively). Most interviewers indicated no preference for a particular device; but those with a preference opted for tablets. The initial investment in tablet-based interviews was higher compared to paper, while the recurring costs per interview were lower with the use of tablets.

Conclusion

An Android-based tablet version of a complex interview was developed and successfully validated. Advantages were not compromised by increased errors, and field research assistants with a preference preferred the Android device. Use of tablets may be more costly than paper for small samples and less costly for large studies.     

Sustainability,Health, and the Human Population

A sustainable human population (e.g., range, density, and total numbers) is essential to health and in management. The notion of sustainability applies to all species and ecosystems and to the biosphere. Sustainability involves the health not only of individual humans, but also of ecosystems and other species. Thus, sustainability of the human population is important because of the wealth of factors involved: both the elements of systems it affects and those that contribute to its size. In this article, I address the sustainability of the human population on the basis of the argument that other species serve as examples of sustainability at the species level—an example of an application of systemic management that simultaneously accounts for complexity and achieves measurable health for individuals, species, and ecosystems. I conclude that the human population is two to four orders of magnitude larger than is optimally sustainable when compared with the populations of other mammalian species of similar body size and that this is a significant contributor to health problems for our species, other species, and ecosystems—a systemic pathology.     

Association between random glucose and all-cause mortality: findings from the mortality follow-up of the German National Health Interview and Examination Survey 1998

Background

Random glucose is widely measured in epidemiological studies and in the clinical setting when standardized fasting protocols and oral glucose tolerance testing or HbA_1c measuring are not feasible. The relationship between random glucose and all-cause mortality has hardly been studied so far and was examined in the present study.

Methods

We ascertained mortality status among 5955 persons aged 18–79?years and free of known diabetes when participating in the German National Health Interview and Examination Survey 1998 (mean observation time 11.7?years, 458 deaths). Cox regression was applied to analyze the association of random serum glucose with all-cause mortality taken potential confounders into account. Relative mortality risks were estimated as hazard ratios (HRs) with 95% confidence intervals (CIs) modeling random glucose as categorical or continuous variable.

Results

Compared to random glucose levels of 4.3 -?<?5.3?mmol/L, HRs (95% CIs) were 1.94 (0.85–4.45) for levels <?4.3?mmol/L and 1.16 (0.89–1.50), 1.20 (0.91–1.58), 1.42 (0.88–2.29), 2.02 (1.26–3.25) and 4.71 (2.20–10.10) for levels 5.3 -?<?5.8, 5.8 -?<?6.8, 6.8 -?<?7.8, 7.8 -?<?11.1 and?≥?11.1?mmol/L, adjusted for age, sex, lifestyle, anthropometry and chronic diseases. An additional adjustment for fasting time or HbA_1c yielded similar estimates. Modeling continuous random glucose by restricted cubic spline functions revealed comparable findings.

Conclusions

In the present epidemiological study drawn from the general population, random glucose showed a significant association with all-cause mortality, independent of main potential confounders. Thus, random glucose measures are highly relevant to health risk assessment among people without known diabetes when fasting glucose or HbA_1c are difficult to obtain.