Editorials represent the opinions of the authors and not

necessarily those of the BMJ or BMA EDITORIALS

For the full versions of these articles see bmj.com

Reducing the harms of alcohol in the UK

Successful policies have worked elsewhere, so delays in implementing
them are costing lives
Alcohol causes major health problems—the Cabinet drivers. Some of these specific measures have knock-
Office reported up to 150 000 hospital admissions on effects; French campaigns to enforce drink driv-
and 15 000-22 000 deaths overall in 2003.1 Between ing laws reduced wine consumption in restaurants by
1991 and 2005, deaths directly attributed to alcohol around 15%,7 and a combination of lower alcohol lim-
almost doubled.2 More people are dying from alcohol its for drivers and vigorous enforcement in Australia
related causes than from breast cancer, cervical can- showed wider health benefits.8
cer, and infection with methicillin resistant Staphylococ- Modelling of these measures by WHO has shown
cus aureus combined. Furthermore, the recent report that increasing the price of alcohol is the most effec-
from the World Cancer Research fund confirmed that tive and cost effective measure.9 Like any commodity
claudia bentley

even drinking alcohol within so called “safe limits” the purchase of alcohol is price sensitive. Increasing
increases the risk of cancer of the breast and upper prices has the biggest effect on the heaviest consum-
gastrointestinal tract.3 ers and on young people, who spend a relatively high
The cultural and sociological factors that determine proportion of their income on alcohol.7 Between 1980
our patterns of drinking may date back thousands of and 2003 the price of alcohol increased 24% more
ALTERED STATES, p 1302
HISTORY, p 1310 years.4 As such, the Licensing Act 2005 was always than prices generally, but disposable income increased
unlikely to transform the culture of feast drinking by 91%, making alcohol 54% more affordable in 2003
Ian Gilmore president of the Royal to that of a Mediterranean society. Similarly, other than in 1980.10 Models from the UK treasury show
college of Physicians,
[email protected] options to reduce harm favoured by government and that up to 50% more tax on spirits would increase
Nick Sheron hepatologist, the alcohol industry—education and public informa- government income even though cross border smug-
Medical School, Southampton tion—don’t seem to change drinking behaviour or to gling would probably increase, and taxation could be
university Hospital, Southampton
SO16 6yd reduce alcohol related harm.5 6 So, can we justify try- increased even more for wine and beer before income
ing tougher measures to reduce alcohol related harm— to the treasury would be reduced.11 To suggest, as pro-
Competing interests: iG is a particularly to health—and is there any evidence to ducers and retailers do, that increasing the price of
member of the alcohol Research show they would work? alcohol would not reduce alcohol related harm goes
and education council and
chairman of the alcohol Health The turning point in a similar debate over tobacco against the evidence and the fundamental principles of
alliance uK. nS is a trustee of control was the effect of passive smoking, yet damage marketing—product, price, promotion, and place.
alcohol concern, the drinkaware to third parties from exposure to alcohol misuse is far Early detection and intervention are almost as effec-
trust, and honorary secretary of
the alcohol Health alliance uK. greater. Drinking alcohol is a factor in more than half tive at reducing harm to health but require specific
Provenance and peer review: of violent crimes and a third of domestic violence. funding.9 The Department of Health in England has
commissioned; not externally peer Between 780 000 and 1.3 million children are affected funded a large ongoing study of early detection and
reviewed.
by their parents’ use of alcohol—30-60% of child pro- brief intervention in three settings—primary care,
BMJ 2007;335:1271-2 tection cases and 23% of calls to the National Society emergency departments, and prisons. If this confirms
doi:10.1136/bmj.39426.523715.80 for the Prevention of Cruelty to Children about child the results of previous studies,12 early intervention
abuse or child neglect involved drunken adults.1 This should be implemented more widely and funded
seems justification enough for society to debate what properly. Banning advertising of alcohol and reduc-
reasonable and evidence based means could reduce ing its availability are also effective, although less so
the harm caused by alcohol. than increasing taxation and early intervention, as has
Evidence on alcohol policy has been expertly been the case with smoking.13
reviewed for the Academy of Medical Sciences,7 Perhaps the most striking and convincing recent
the European Commission,8 and the World Health evidence that reducing harmful drinking saves lives
Organization (WHO).9 The findings were similar in comes from Russia. After Mikhail Gorbachev intro-
each case—effective measures included increasing duced his polices on alcohol control, deaths (half of
prices, controlling alcohol advertising, increasing which were caused by accidents, violence, and poi-
the minimum age for buying alcohol, and restricting soning) dropped dramatically, and 1.2 million lives
opportunities to buy alcohol. Others were specific were saved.14 How many more lives will be damaged
measures to reduce drink driving, including lowering by alcohol in the UK before our governments decide
maximum blood alcohol concentrations to 0.5 g/l and to tackle the problem with measures that are likely
increasing enforcement with random breath testing of to work?

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 EDITORIALS

1 Prime Minister’s Strategy Unit. Alcohol misuse. Interim analytical report. 9 Chisholm D, Rehm J, Van OM, Monteiro M. Reducing the global burden
London: Prime Minister’s Strategy Unit, 2003. www.cabinetoffice.gov. of hazardous alcohol use: a comparative cost-effectiveness analysis. J
uk/strategy/work_areas/alcohol_misuse/interim.aspx. Stud Alcohol 2004;65:782-93.
2 National Statistics. News release. Alcohol-related death rates 10 Institute of Alcohol Studies. Alcohol, price, legal availability and
almost double since 1991. 2006. www.statistics.gov.uk/pdfdir/ expenditure. 2007. IAS factsheet. www.ias.org.uk/resources/
aldeaths1106.pdf. factsheets/price_availability.pdf.
3 World Cancer Research Fund. Food, nutrition, physical activity and the 11 Huang CD. Econometric models of alcohol demand in the
prevention of cancer: a global perspective. London: WCRF, 2007. United Kingdom. Government Economic Service Working Paper
4 Engs RC. Do traditional western European drinking practices have 2003;140:1-51.
origins in antiquity? Addiction Res 1995;2:227-39. 12 Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B.
5 Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et Reduction of alcohol consumption by brief alcohol intervention in
al. Alcohol: no ordinary commodity—research and public policy. Oxford: primary care: systematic review and meta-analysis. Arch Intern Med
Oxford University Press, 2003. 2005;165:986-95.
6 National Institute for Health and Clinical Excellence. School-based 13 The Impact of Alcohol Advertising. ELSA project report on the
interventions on alcohol. 2007. www.nice.org.uk/nicemedia/pdf/ evidence to strengthen regulation to protect young people.
AlcoholSchoolsDraftScope.pdf. Peter Anderson on behalf of the National Federation for Alcohol
7 Academy of Medical Sciences. Calling time. The nation’s drinking as a Prevention, the Netherlands, and the ELSA project 2005-2007.
major health issue. London: AMS, 2004. www.acmedsci.ac.uk/index. http://www.stap.nl/elsa/elsa_project.
8 Anderson P, Baumberg B. Alcohol in Europe: a public health perspective. 14 Nemtsov AV. Alcohol-related human losses in Russia in the 1980s and
EU Health and Consumer Protection Directorate General. 2007. 1990s. Addiction 2002;97:1413-25.

Combating poverty: the charade of development aid

Scrap development aid as we know it and give the money to independent
pro-poor aid organisations
Poverty is acknowledged to be the biggest risk for ill repayments, leaving only $14 for direct aid.
health worldwide. The World Health Organization Easterly contends that the entire aid set-up is fatally
estimates that about 1.2 billion people live in extreme flawed, as donors largely lack evidence based knowledge
poverty, without decent shelter, clean water, adequate of the situation on the ground in poor countries, or of
sanitation, or sufficient food.1 The response of the rich how to make aid effective. The crux of the problem,
nations to global poverty has been to wave the magic he argues, is that “The status quo—large international
wand of development aid, also known as “official devel- bureaucracies giving aid to large national government
opment assistance,” which distinguishes it from ad hoc bureaucracies—is not getting money to the poor.” Conse-
assistance for emergencies such as natural disasters. quently, the poor are not getting the vaccines, the antibi-
Development aid is meant to help eradicate poverty otics, the bed nets, the doctors, or the nurses they need to
through the stimulation of economic growth. improve their health. Tumwine observed in a recent BMJ
A total of $2.3 trillion (£1.1 trillion; €1.6 trillion) editorial that “expenditure on health has not improved
has been spent on development aid over the past five substantially in poor countries, and hospital wards in
Dan J Ncayiyana emeritus vice decades, and it has been the subject of vigorous debate these countries are best described as pathetic.”5
chancellor and professor, among development economists. Three books have
durban institute of technology, emerged on the subject in the past two years—The Self interest rules
durban 4000, South africa
[email protected]
Bottom Billion by Paul Collier, The White Man’s Burden Some critical observations on development aid merit
Competing interests: none declared. by William Easterly, and The End of Poverty by Jeffrey attention. Although aid is often equated with charity, in
Provenance and peer review: Sacks.2-4 While each takes a different view of devel- reality it is more about the political and economic self
commissioned; not externally peer opment aid, all share former US Treasury Secretary interest of the giver, with much of it being tied to the
reviewed.
Paul O’Neal’s sigh of exasperation that, “We’ve spent purchase of goods (including military ware) and serv-
BMJ 2007;335:1272-3 trillions of dollars on these problems and we have ices from the donor country.6 Development aid buys
doi: 10.1136/bmj.39420.432951.80 damn near nothing to show for it.” Development aid influence, with French and British aid largely going to
has done next to nothing to help grow national econo- their former colonies, and that of the US to Israel and
mies or to lift people out of extreme poverty. Egypt. Development aid has not lived up to its promise
Collier blames the poverty stricken countries of the of unleashing economic growth and, ironically, coun-
bottom billion of the world’s six billion population tries that have registered the most robust growth in
themselves for “falling behind and often falling apart, recent years—such as India, China, and Botswana—
[who] co-exist with the twenty-first century, but [whose] were recipients of the least aid, and vice versa.
reality is the fourteenth century: civil war, plague and So, what should be done about development aid?
ignorance.” He believes that for aid to be effective, Firstly, we must scrap the idea that development aid—as
these situations will need to be dealt with through presently structured—is the best way to eradicate poverty.
national political reform, or even external interven- Development is a long term process that may not benefit
tion. Sachs disagrees and argues that the amount of the poor for generations. Poverty remains an enduring
money given in development aid is too small to have feature of life in India, China, and Botswana despite
an effect. In 2002, development aid amounted to $30 spectacular growth rates. Development is best achieved
for each sub-Saharan African; $18 of this sum was through national initiatives and good governance,
spent on donor country consultants, food aid, and debt coupled with equitable international trade arrangements

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 EDITORIALS

(something the wealthy nations refuse to do at the World not indentured to political patronage.7 Oxfam has a
Trade Organization). deep understanding of the complexities underpinning
The needs of the poor are immediate and cry out for poverty, and it works for and with the poor to provide
direct and urgent intervention now. International aid them with relief aid and to empower them to help
genuinely earmarked for eradicating poverty must be themselves. Above all, Oxfam is able to “speak truth
taken out of the hands of the politicians and bureau- to power” in its advocacy for the poor.
cracies of both donor countries and recipient countries. Rich countries may still wish to coddle dictators and
Such funds should be controlled by independent and other regimes—malevolent or otherwise—with hand-
accountable agencies, which have knowledge of the outs intended to influence solidarity or security; just
existing needs and have direct access to those in need. don’t call it development aid.
Aid must be contingent upon the accountability of those 1 WHO. Health and development: poverty and health. www.who.
int/hdp/poverty/en/.
who administer it, feedback from those who benefit from 2 Collier P. The bottom billion. New York: Oxford University Press, 2007.
it, and measurable or otherwise verifiable outcomes. 3 Easterly W. The white man’s burden. Oxford: Oxford University
Press, 2006.
Oxfam International—aa confederation of 13 organi- 4 Sachs J. The end of poverty. London: Penguin Books, 2005.
sations working together with over 3000 partners in 5 Tumwine J. Equitable access to health care. BMJ 2007;335:833-4.
6 Nelson EAS. Development aid: the way forward. BMJ 1994;481-2.
more than 100 countries to find lasting solutions to 7 Oxfam International. United for a more equitable world. www.
poverty and injustice—is a good example of an agency oxfam.org.

Web 3.0 and medicine

Make way for the semantic web
This time last Christmas, medical blogs and RSS feeds tains that access to a global “web of data”—what weaves
were the hot technology topics, and we were debating the entire web together into a coherent whole—should
the merits of newer models of scholarly publishing in help to solve humankind’s most complex problems.4
web 2.0, such as open access and medical wikis.1 Can To understand why we need web 3.0, let’s exam-
web 3.0 be here already? ine the current state of the web. Currently, access to
Recently, a neurologist devised an apt medical meta- endless reams of unorganised information in web 2.0
tiM beRneRS-lee bycaRina GenOVeSe/Getty

phor for web 3.0. He suggested that, “The development shifts the online habits of doctors to searching, not find-
of the graphical web from its early days in 1995 to the ing. Consequently, medical librarians believe that it is
social web of late 2007 is comparable to the developing necessary to build better mechanisms for information
brain.” He went on to say that, “Whereas web 1.0 and 2.0 retrieval.5 6 As a colleague said to me recently, “we
were embryonic, formative technologies, web 3.0 prom- need find engines, not search engines.”
ises to be a more mature web where better ‘pathways’
for information retrieval will be created, and a greater The problem with search results
capacity for cognitive processing of information will be In medicine, finding the best evidence has become
built.” (Personal communication, A Wong, 2007.) increasingly difficult, even for librarians. Despite its con-
So what is web 3.0, and why is it called the semantic stant accessibility, Google’s search results are emblematic
Dean Giustini ubc biomedical
branch librarian, diamond web (table)? Although both terms are used interchange- of an approaching crisis with information overload, and
Healthcare centre and Vancouver ably, they convey slightly different, if complementary, this is duplicated by Yahoo and other search engines.
Hospital, bc, canada V5z 1M9 views of the new web. The web 3.0 label is often used Consequently, medical librarians are leading doc-
[email protected]
Competing interests: none
as a marketing ploy for “the next big thing.” An impor- tors back to trusted sources, such as PubMed, Clinical
declared. tant feature of web 3.0 is that it enables computers to
Provenance and peer review: talk to each other so that they can perform the tasks At a glance: Comparison of the features of web 2.0 and 3.0
commissioned; not externally necessary for us to do our work. However, a primary
peer reviewed. Web 2.0 Web 3.0
feature of web 3.0 is that it uses metadata—data about “The document web” “The data web”
BMJ 2007;335:1273-4 data. This will transform the web into a giant database, Abundance of information Control of information
doi: 10.1136/bmj.39428.494236.be and organise it along the lines of PubMed, or one of Controversial No less controversial
our trusted medical library catalogues.2 “The social web” “The intelligent web”
Somehow, the term semantic web has escaped the The second decade, 2000-9 The third decade, 2010-20
reproach of web 3.0, perhaps because it was coined Google as catalyst Semantic web companies as
by the respected web expert Sir Tim Berners-Lee in catalyst
his landmark paper in Scientific American.3 His ideas Wisdom of the crowds Wisdom of the expert
continue to have tremendous salience. Berners-Lee’s Mashups, fragmentation integration,
view is that we need to use semantic annotation to new tools

express the meaning latent in web documents, by Search, search, search Why search, when you can find?

drawing out inferences in documents deep within the Google’s Pagerank algorithm Ontologies, semantic systems

web. As a pioneer in search technology, and director of Lawless, anarchic Standards, protocols, rules

the World Wide Web Consortium, Berners-Lee main- Print and digital Digital above all else

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EDITORIALS

Glossary iteration of its predecessor, and web 3.0 should be no

Data mining—a process of knowledge discovery or retrieval of
exception. In medicine, we should focus on the abil-
hidden information from data banks and clusters of databases ity to locate trusted clinical information, while creating
Mashup—a web application or site that mixes content from the means to produce new knowledge. Information
multiple sources retrieval in web 3.0 should be based less on keywords
Medical wiki—a website or similar online resource that than on intelligent ontological frameworks, such as
allows users to add and edit medical information collectively the National Library of Medicine’s Unified Medical
RSS (really simple syndication)—a format for sharing Language System, Medline’s trusted MeSH vocabulary,
content between different websites or some other tool.
Semantic web—a project that intends to create a universal The National Library of Medicine is working on auto-
medium for information exchange from 2008 and beyond mated indexing, which may be part of the solution for
by putting documents with computer processable meaning searching the biomedical web.10 Finally, as we move
(semantics) on the world wide web further into the digital age, our trusted print libraries
Social tagging—the application of freely chosen labels, or must continue to be well funded and should not be
tags, to web documents, web pages, and photo sharing
forgotten in the midst of the intelligent web.
sites, such as www.flickr.com
The question of whether http://del.icio.us and www.
Web 3.0—a term used to describe the evolution of the web,
and our responses to it, in finding and organising new connotea.org—two popular social tagging sites—will be
information useful in web 3.0 remains doubtful.11 Social tagging or
“indexing” has limitations because of poor controls of
Evidence, and the Cochrane Library, and even taking synonyms, homonyms, spelling conventions, and other
them to their library bookshelves instead. Unless better linguistic variations. Think about the myriad ways we
channels of information are created in web 3.0, we can describe a heart attack; these variations have enormous
expect the information glut to continue. implications for searching and require control to optimise
Web 3.0 is likely to have a big effect on medicine retrieval.
in 2008. In bioinformatics, it will become more com- A smarter medical web is coming. Its two most excit-
mon to process ever larger amounts of data. In fact, ing features will be the better organisation of documents
experts in bioinformatics already search for data from and a deeper use of the knowledge base in medicine. In
disparate systems, and they have started to build rich terms of searching, the semantic web should resemble a
semantic relations into information tools for knowledge library catalogue, where documents are described and
discovery. Finally, greater capacity for creating knowl- given meaningful access points for easy retrieval. How-
edge in medicine will be possible if we have the will ever, in getting to web 3.0, let’s aim for something better
to publish clinical data openly and transparently, and than the current web, not the incoherent mess of web 2.0.
subject it to scrutiny.7 Logically, web 3.0 should bring order to the 21st century
Developing a more personalised healthcare system web in the same way that Dr John Shaw Billings’s Index
will be an important challenge for doctors in web 3.0. Medicus brought order to medical research back in the
In an era of greater personalisation, treating patients’ 19th century.12 As a medical librarian, I sincerely hope
health problems according to their genetic profiles will that web 3.0 will return us to some of the time honoured
depend on using the latest information technologies.8 principles of my profession.
Even the treatment of new diseases and warning systems 1 Giustini D. How web 2.0 is changing medicine. BMJ 2006;333:1283-4.
for natural disasters will benefit from the merging of 2 Cho A, Giustini D. The semantic web as a large searchable
catalogue: a librarian’s perspective. Semantic Report. 2007. www.
epidemiological datasets with virtual, three dimensional semanticreport.com/index.php?option=com_content&task=vie
tools like Google Earth. Making the search for health w&id=52&Itemid=79.
3 Berners-Lee T, Hendler J, Lassila O. The semantic web. a new form
information efficient and responsive to patients’ needs of web content that is meaningful to computers will unleash a
will also help reduce the costs of medical treatment. revolution of new possibilities. Sci Am 2001 www.sciam.com/article.
cfm?articleID=00048144-10D2-1C70-84A9809EC588EF21.
4 World Wide Web Consortium. Semantic Web Health Care and Life
Knowledge creation Sciences Interest Group. 2007. www.w3.org/2001/sw/hcls/.
Social software enthusiasts may well find that the new 5 Robu I, Robu V, Thirion B. An introduction to the semantic web for health
web will be fertile ground for the creation of knowl- sciences librarians. J Med Libr Assoc 2006;94:198-205.
6 Lorence DP, Spink A. Semantics and the medical web: a review of the
edge. Although already popular, wikis may well serve barriers and breakthroughs in effective healthcare query. Health Info
as platforms for the exploration of web 3.0. One inno- Libr J 2004;21:109-16.
vative wiki—Wikiproteins—is already using semantic 7 Willinsky J, Murray S, Kendall C, Palepu A. Doing medical journals
differently: open medicine, open access and academic freedom. Can J
technologies. In contrast to other wikis, Wikiproteins Commun 2007. http://pkp.sfu.ca/node/776.
imports data mined from several of the world’s lead- 8 Cho A, Giustini D. Back to the future: viewing health librarianship
through the semantic lens of web 3.0. Canadian Health Libraries
ing biomedical databases, such as PubMed, UniProt,
association (in press).
and the National Library of Medicine. Its integrated 9 Mesko B. Web 3.0 and medicine. ScienceRoll blog. 2007. http://
entries are a useful combination of genetic informa- scienceroll.com/2007/04/06/web-30-and-medicine/.
10 Aronson AR, Bodenreider O, Chang HF. The NLM indexing initiative.
tion and scientific literature. Notably, the confluence Proc AMIA Symp 2007:17-21.
of databases in Wikiproteins yields more than two mil- 11 Kamel Boulos MN,Wheeler S. The emerging web 2.0 social software:
lion factual associations for data mining and over five an enabling suite of sociable technologies in health and health care
education. Health Info Libr J 2007;24:2-23.
billion associated pairs.9 12 Lyndenberg HM. John Shaw Billings: creator of the National Medical
Each new version of the web should be a better Library, and its catalogue. Chicago: American Library Association, 1924.

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