Editor's Choice

Lessons from around the world

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6936 (Published 01 December 2010) Cite this as: BMJ 2010;341:c6936
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

It’s hard to resist the pull of American healthcare. Despite its poor outcomes and high costs, we tend automatically to look to the United States for new ways of delivering care. Flawed though it is, US healthcare fascinates with its flashes of excellence. I doubt this will change soon, but we shouldn’t be blinded—there is much we can learn from elsewhere. The BMJ’s occasional series “Looking to Europe” has so far covered France (BMJ 2008;336:254), Germany (BMJ 2008;337:a1997), Spain (BMJ 2009;338:b1170), the Netherlands (BMJ 2009;339:b3397), and Sweden (BMJ 2009;339:b4566), and a forthcoming article will look at Turkey’s successful healthcare reforms. Now it’s time to look further afield.

Andy Haines has long championed Brazil’s public health successes (BMJ 1993;306:503-6). This week, with Matthew Harris (doi:10.1136/bmj.c4945), he itemises them again—remarkable reductions in infant mortality and hospital admissions for diabetes and stroke, and great leaps in antenatal care and vaccination coverage, exceeding even the ambitions of the Millennium Development Goals. All of this since its Unified Health System was set up in response to the constitution of 1988. The Family Health Programme followed in the 1990s; staffed by doctors, nurses, and community health workers, it is “probably the most impressive example worldwide of a rapidly scaled up, cost effective, comprehensive primary care system.” On Brazil’s behalf they complain that its successes have not had the recognition they deserve.

Haines and Matthews don’t underestimate the challenges ahead. Nor, while celebrating Brazil’s undoubted achievements, do Tom Hennigan (doi:10.1136/bmj.c5453) or Frederico Guanais (doi:10.1136/bmj.c6542). Although health outcomes have improved, large disparities persist, while support for the public system is falling among the emerging middle class. Here too are lessons for the rest of us.

Meanwhile colleagues around the world face difficulties that doctors working in industrialised countries can scarcely imagine. What can we learn from them? Our clinical review this week—on oesophageal cancer—comes from Sweden (doi:10.1136/bmj.c6280). But it is accompanied by a commentary on managing this condition in a resource poor setting, Malawi (doi:10.1136/bmj.c6723). Alexander Thumbs and Eric Borstein describe the suffering of patients who present late and must travel long distances for rudimentary investigation and without hope of a cure. But some are benefiting from self expanding metal stents provided through a charity funded trial. If readers find this sort of commentary interesting and useful, we will commission more of them.

Finally, a reminder that we may also need to unlearn things. Early clamping of the umbilical cord has become established practice. And despite research and editorials saying that it is better to delay clamping, the practice continues. Recently James Neilson made a renewed call for it to stop (BMJ 2010;340:c1720). This week David Hutcheon writes that clamping the functioning umbilical cord before natural vasospasm has done its work is an unproved intervention that may harm the baby (doi:10.1136/bmj.c5447). Unhelpfully, NICE guidelines still advise early cord clamping as part of the active management of the third stage of labour. It would be good to hear why.


Cite this as: BMJ 2010;341:c6936


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