France caught cold by heatwave.

773Bulletin of the World Health Organization 2003, 81 (10) France caught cold by heatwave “Heatwaves are slow and invisible killers that are easy to ignore until it’s too late,” says Eric Klinenberg, a sociologist at New York University. Nowhere has that been more evident than in France this summer. An estimated 11 435 people, most of them elderly, died when record- breaking heat affected France during the first two weeks of August. The death toll made headlines around the world. As the temperatures cooled and makeshift morgues — refrigerated lorries and a food storage warehouse — emptied, officials scrambled to determine why so many deaths occurred and how to avert a similar catastrophe in the future. France is no stranger to extreme summer weather. Twenty years ago, for example, a heatwave provoked 4700 deaths. But current health minister, Jean-François Mattei, told a radio audience last month that the country had learnt little from that event. After the 1983 heatwave, “we never calculated, evaluated or quantified [the deaths] on a national level,” he said. “Therefore, it’s true that we were not prepared for this one.” This year, the timing of the heatwave was important. Temperatures began to climb on 1 August. Four days later, the average daytime high across France reached 37 °C, then stubbornly hovered between 36 °C and 37 °C for more than a week. According to meteorologists, 15% of France’s cities recorded temperatures above 40 °C during that time. Paris sweltered under its hottest daytime highs and nighttime lows in the 130 years that records have been kept. Meanwhile, millions of French men and women, ranging from doctors to apartment building concierges, were on summer holiday — many having left elderly relatives and neighbours behind. Concerns that people were succumbing to the heat surfaced in the media on 10 August. However, government officials, who have been criticized for their reluctance to cut short their own holidays to deal with the crisis, waited until 13 August — the day that temperatures began to fall — to launch an emergency response. It included calling hospital staff back to work and reopening hospital wards that had been closed for the August vacation season. But by then, it was too late. So far, a parliamentary investigation has been launched and two official reports have examined the disaster. A preliminary analysis by the Institute of Health Surveillance, which placed the provisional death toll at 11 435, estimated that 80% of the people who died were 75 years or older. The report found a high proportion of deaths in retirement homes, and regional differences in mortality. Compared to Toulouse or Marseilles, for example, which both had a 45% increase in mortality, Paris and Lyon had bigger increases during the heatwave: 221% and 185%, respectively. The report also noted that signs of the pending crisis were apparent as early as 5 August in the form of increased activity of emergency rooms and paramedics. Those points were echoed in a ministry of health report that dissected the response of the public health system and found a “lack of anticipation, organization and coordination.” Compartmentalization and poor communication between the various health care sectors prevented the early recognition of the scale of the problem. In addition, the response was “strongly aggravated” by the seasonal reduction of doctors, nurses and in-service hospital beds. “The crisis has been a great revealer of pre-existing problems in the health care system,” wrote the authors of the report. They proposed several ways to improve emergency response. Among them: developing an early-warning system based on the activity of emergency services; creating a programme to identify vulnerable elderly people in the community and check on them during extreme weather; and equipping retirement homes with at least one air-conditioned room as well as identifying air-conditioned facilities within neighbourhoods that people could visit for temporary relief from the heat. How many of the proposed remedies will become realities, and when, is unclear. Mattei has long planned to overhaul the public health care system, and it seems unlikely he can ignore the faults that became evident in August. Spurred by the ministry report, he announced US$ 748 million in extra funding for hospital emergency services. In the wake of the crisis, when it was suggested that the French give up News An elderly woman drinks after she was brought by firefighters to the Saint Antoine hospital in Paris, Monday, 11 August 2003. Ke ys to ne News 774 Bulletin of the World Health Organization 2003, 81 (10) one of their eleven national holidays to finance a public health programme for the elderly, they seemed willing. This idea is being reconsidered. It remains to be seen whether or not the other European countries that also sweated out record heat this summer will follow up like France. The United Kingdom has acknowledged 907 more deaths during the hottest week in August compared with a 5-year average for the same period. Portugal says the number of death certificates issued from the end of July to 12 August increased by 545 compared to the last two weeks of July. The Italian Health Ministry has reported 4175 more deaths from mid- July to mid-August this year compared with last. And with an official tally still pending, Spanish officials claim 112 heat-wave-related deaths, but estimates from the press run as high as 6000. The dissimilarities in the number of deaths, both outside France and within its borders, may reflect social and cultural differences as well. For example, mortality during the heatwave was comparatively low in Toulouse. Fati Nourhashémi, a doctor with geriatric services at the University Hospital in Toulouse, points out that 10% of people older than 75 years living in the area live with their families compared to 3% elsewhere in France. Undoubtedly, the heatwave has been a wake-up call to the vulnerability of elderly people in a country where 10% of the population will be 75 years or older by 2020. “It sounded an alarm,” says Nourhashémi. “While the population will probably age better and better, vulnerable elderly people will exist. So whether it’s heat or cold or an epidemiological problem, it’s up to us to anticipate their needs.” O Charlene Crabbe, Paris Drug prices may be too high despite WTO deal A landmark deal that waives international trade rules may work if implemented in good faith, experts say. Poor countries with no manufacturing capability of their own will be allowed to import cheap copies of patented essential drugs under a complex procedure. Campaigners for access to medicines including aid organizations, Oxfam and Médecins sans Frontières, welcomed the fact that the agreement reached by 146 member states of the World Trade Organization (WTO) on 30 August applies to all medicines. But they warned that the new procedure could be time-consuming and bureaucratic, and that the drugs may still be too expensive for some countries. The UN Secretary-General Kofi Annan, issued a statement to the WTO meeting in Cancun, Mexico, days after the deal was clinched in Geneva, saying there was a “moral imperative” for each WTO member state to implement the agreement without delay. Dr Jonathan Quick, Director of Essential Drugs and Medicines at the World Health Organization in Geneva, said the deal solved only part of the problem to getting affordable drugs, for example to AIDS/HIV patients in the poorest African countries. There were other outstanding issues, such as distribution and a lack of qualified staff. “Now we have the deal,” he said, “it’s the starting point we have, and we’re looking ahead. The point is to implement it, monitor it, see if it works and adjust it if it doesn’t.” Campaigners fear that poor countries in Africa, Asia and Latin America, which were supposed to benefit from the deal, may face unnecessary red tape and have to waste precious time to fulfil requirements, such as proving they have no manufacturing capability of their own. Generic drug companies too fear they may be slowed down by red tape which could be a disincentive to take on such orders. Campaigners criticize the agreement, saying it is unrealistic to require manufacturers to declare they are producing drugs for “humanitarian” not “business” reasons, but hope this will be treated as a formality. Other rules threaten to push up the costs of producing copies of patented drugs, as companies have to invest in research to copy the patent before they can go into production. Campaigners fear that rules requiring companies to make their packaging distinctive so that the copies can not be mistaken for the originals and be diverted to developed countries could increase costs too. These special measures to ensure such drugs are not diverted were included on the insistence of the United States, so as not to undermine the pharmaceuticals market or remove the incentive for the industry to invest in research on new drugs. Once importing countries and generics manufacturers have cleared all of these hurdles, prices could be prohibitively high for some of the world’s poorest countries. Jonathan Berger of the AIDS law project at the University of Witwatersrand in Johannesburg, South Africa, summed up the view of many campaigners: “It is way too much red tape, and that it is not a feasible solution. Having said that, it can be used, and the onus is on developing countries with manufacturing capacity to make sure that the appropriate legal framework is in place. That way they can act as quickly as possible to satisfy the needs of countries with no manufacturing capacity.” MSF also urged countries to make the most of trade “flexibilities” allowed by the agreement. Small African countries, for example, can group together and place a joint order with a generic drugs company to make this a viable business proposition. Jonathan Quick said that WHO would do its best to help countries overcome any difficulties with the procedure: “We know there are some administrative issues that have to be dealt with, but we are prepared to work with countries to deal with those.” India and South Africa are among the countries expected to issue compulsory licences to export copies of patented drugs. Brazil, which also has a pharmaceuticals manufacturing capability, has said it is unlikely to export cheap copies of patented drugs under this system, as its drugs industry is heavily subsidized by the government to tackle public health crises at home. Brazil may, however, use the WTO deal to force European and US drug companies to lower their prices for patented drugs. Other countries may also prefer patented drugs, which have been tried and tested, too. “The agreement gives countries an extra negotiating strength they didn’t have before,” said an EU diplomat. Exemptions agreed under the deal on pharmaceutical patent protection for least-developed countries are valid until 2016. While 23 developed countries have said they would not make use of the system, 11 less wealthy 775Bulletin of the World Health Organization 2003, 81 (10) News Doctor prescribing medication in Mongolia W HO /S .G ra ng er nations, including Israel, Mexico and Turkey, said they would, but only in emergencies. The deal agreed by the Trade- Related Aspects of Intellectual Property (TRIPS) council of the WTO, covers all patented products or products made using patented processes in the pharmaceutical sector, including active ingredients and diagnostic kits. Under the agreement, the government of a least-developed country may ask another country such as India or South Africa with a generic drugs industry to issue a “compulsory licence” to produce a particular medicine or pharmaceutical product. The country with the generic drugs industry notifies the TRIPS council as to which product it intends to export and to which country and in what quantity. It must specify the type of packaging to ensure these copies of patented products are easily identifiable. After the TRIPS council has received this information, some WTO member states may ask questions and may even object under the terms of the TRIPS agreement. Once the manufacturer gets the go- ahead, it can start to produce cheaper copies of the patented products and drugs, and export them to the country or group of countries that requested them. Dr Quick said it would be at least a year before needy people in a poor country that uses the system finally receive such drugs. O Fiona Fleck, Geneva