THREE DECADES OF HEALTH PROMOTION IN HUNGARY IN THE LIGHT OF GLOBAL CHALLENGES AND POLITICAL CHANGES

Magyarország a rendszerváltást megelőző években az egészségfejlesztés úttörői közé tartozott, ezt a szerepét azonban fokozatosan elvesztette. E folyamatot elemzők még nem vizsgálták, ezért tartottam indokoltnak, hogy a jogszabályok, dokumentumok és a szakirodalom, továbbá az egészségfejlesztés kilenc, egykor fontos szereplőjével készített interjú alapján próbáljam feltárni az egészségfejlesztés peremre szorulásának okait. Kiinduló hipotézisem az volt, hogy az egészségfejlesztés megítélése, s ennek megfelelően gyakorlata a vizsgált időszak nagy részében nem felelt meg a globális kihívásoknak, legfeljebb csupán rövid periódusokban (1986–1989, 2001–2003) közelített a nemzetközi elvárásokhoz. A kuratív medicina politikai lobbiereje mindig erősebb volt, mint az egészségfejlesztőké, ezért kormány- és miniszteri egészségügyi programokban rendre az ellátás fejlesztése, reformja állt a középpontban. Az irodalmi áttekintés és az interjúk igazolták feltételezésemet. Beigazolódott, hogy – néhány kivételtől eltekintve – Magyarországon még az egészségfejlesztés esetében sem fér bele a politikai kultúrába a kontinuitás, ezért az ilyen stratégiákat és projekteket a miniszter- és kormányváltások általában megsínylették. A civil világ fejletlen, működése költségvetési juttatásoktól függ. Az orvosvezetők által uralt egészségügyi kormányzatok társadalompolitikai érzékenysége többnyire csekély, s makrogazdasági és szociális ismereteik is szerények. Közel 30 évvel a népegészségügyben fordulatot jelentő Ottawai Karta megalkotása után úgy tűnik, a magyar egészségpolitika nem tudta valóra váltani esélyeit az egészségfejlesztésben. Pedig 1987 és 2002 között öt egészségfejlesztési stratégia készült el, közülük három jutott el a kormány jóváhagyásáig, de a pénzügyi források megteremtése ezen időszakokban sem sikerült. Még a 2003-ban parlamenti szentesítést nyert hosszú távú program végrehajtásában is jórészt magára maradt a szaktárca, s nem tudta hadra fogni a minisztériumok, önkormányzatok, önkéntes csoportok és vállalkozások sokaságát – az egészség érdekében. Az értekezés fő tanulsága, hogy az Ottawai Karta máig érvényes stratégiai pilléreket jelöl ki hazánk számára is, az Észak – Karéliai Projekt módszerei, akciói pedig a siker esélyével megvalósítható egészségfejlesztés irányaira adnak mintát Magyarországnak. Ennek követéséhez azonban az elkötelezettség mellett növekvő gazdaság és politikai stabilitás is szükséges. Hungary belonged to the pioneers of health promotion before the change of the political system but has lost this role gradually. This process has not been investigated so far, therefore it was reasonable to explore the causes of marginalization of health promotion by analyzing legislation, documents and public health publications as well as interviews with 9 former key advocates and actors of health promotion. It was my opening hypothesis that the domestic assessment and practice of health promotion did not match to global challenges, at most it converged to international expectations in short periods (1986-1989, 2001-2003). The political lobbying force of curative medicine was always stronger than of public health including health promotion, so thus government and ministerial programs consecutively focused on the development and the reform of the health system. The review of literature and the interviews confirmed the initial presumptions. It proved true with some exceptions, that in Hungary the political culture was not in favour of continuity even in case of health promotion, that is why changes in governments or in the person of health ministers led to damages or cut of public health programs started by predecessors. Civic sector is underdeveloped and dependent on state budget. Health governance dominated by medical influence, has low social sensitivity and weak knowledge on macroeconomics. Almost 30 years after the Ottawa Charter (which brought a revolutionary change in public health thinking) it seemed that the Hungarian health policy could not live with the chances in health promotion created by early start and commitments of then leadership. Between 1987 and 2002 five public health or health promotion strategies were elaborated, 3 of them enjoyed government approval, but funding and implementation remained unsatisfactory. Although the public health program of 2003 (The Decade of Health) had been adopted by a convincing majority of the parliament, the health ministry was left alone. Alliance for health was not created by other ministries, local governments, NGOs and businesses in most parts of the implementation process. The lesson of the dissertation that the strategic pillars of the Ottawa Charter as well as the successful methods and actions of the North Karelia project still provide with a good direction and pattern for public health development in Hungary if commitments, political stability and economic environment are associated

Health diplomacy: spotlight on refugees and migrants

Nowadays, refugees and migrants are the focus of intense political debate worldwide. From the public health perspective, population movement, including forced migration, is a complex phenomenon and is a high priority on the political and policy agenda of most WHO Member States. Health diplomacy and the health of refugees and migrants are intrinsically linked. Human mobility is relevant to all countries and creates important challenges in terms of both sustainable development and human rights, to ensure equality and achieve results through the Sustainable Development Goals. This book is part of the WHO Regional Office for Europe’s commitment to work for the health of refugees and migrants. It showcases good practices by which governments, non-state actors and international and nongovernmental organizations attempt to address the complexity of migration, by strengthening health system responsiveness to refugee and migrant health matters, and by coordinating and developing foreign policy solutions to improve health at the global, regional, country and local levels

Pharmacological preconditioning with gemfibrozil preserves cardiac function after heart transplantation

While heart transplantation (HTX) is the definitive therapy of heart failure, donor shortage is emerging. Pharmacological activation of soluble guanylate cyclase (sGC) and increased cGMP-signalling have been reported to have cardioprotective properties. Gemfibrozil has recently been shown to exert sGC activating effects in vitro. We aimed to investigate whether pharmacological preconditioning of donor hearts with gemfibrozil could protect against ischemia/reperfusion injury and preserve myocardial function in a heterotopic rat HTX model. Donor Lewis rats received p.o. gemfibrozil (150 mg/kg body weight) or vehicle for 2 days. The hearts were explanted, stored for 1 h in cold preservation solution, and heterotopically transplanted. 1 h after starting reperfusion, left ventricular (LV) pressure-volume relations and coronary blood flow (CBF) were assessed to evaluate early post-transplant graft function. After 1 h reperfusion, LV contractility, active relaxation and CBF were significantly (p < 0.05) improved in the gemfibrozil pretreated hearts compared to that of controls. Additionally, gemfibrozil treatment reduced nitro-oxidative stress and apoptosis, and improved cGMP-signalling in HTX. Pharmacological preconditioning with gemfibrozil reduces ischemia/reperfusion injury and preserves graft function in a rat HTX model, which could be the consequence of enhanced myocardial cGMP-signalling. Gemfibrozil might represent a useful tool for cardioprotection in the clinical setting of HTX surgery soon

The soluble guanylate cyclase activator cinaciguat prevents cardiac dysfunction in a rat model of type-1 diabetes mellitus

BACKGROUND: Diabetes mellitus (DM) leads to the development of diabetic cardiomyopathy, which is associated with altered nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) signalling. Cardioprotective effects of elevated intracellular cGMP-levels have been described in different heart diseases. In the current study we aimed at investigating the effects of pharmacological activation of sGC in diabetic cardiomyopathy. METHODS: Type-1 DM was induced in rats by streptozotocin. Animals were treated either with the sGC activator cinaciguat (10 mg/kg/day) or with placebo orally for 8 weeks. Left ventricular (LV) pressure-volume (P-V) analysis was used to assess cardiac performance. Additionally, gene expression (qRT-PCR) and protein expression analysis (western blot) were performed. Cardiac structure, markers of fibrotic remodelling and DNA damage were examined by histology, immunohistochemistry and TUNEL assay, respectively. RESULTS: DM was associated with deteriorated cGMP signalling in the myocardium (elevated phosphodiesterase-5 expression, lower cGMP-level and impaired PKG activity). Cardiomyocyte hypertrophy, fibrotic remodelling and DNA fragmentation were present in DM that was associated with impaired LV contractility (preload recruitable stroke work (PRSW): 49.5 +/- 3.3 vs. 83.0 +/- 5.5 mmHg, P < 0.05) and diastolic function (time constant of LV pressure decay (Tau): 17.3 +/- 0.8 vs. 10.3 +/- 0.3 ms, P < 0.05). Cinaciguat treatment effectively prevented DM related molecular, histological alterations and significantly improved systolic (PRSW: 66.8 +/- 3.6 mmHg) and diastolic (Tau: 14.9 +/- 0.6 ms) function. CONCLUSIONS: Cinaciguat prevented structural, molecular alterations and improved cardiac performance of the diabetic heart. Pharmacological activation of sGC might represent a new therapy approach for diabetic cardiomyopathy