- Email: [email protected]
Population ageing and health
Population ageing and health As researchers, journal editors, and representatives of non-governmental organisations, we are writing to express our concern about the way in which the health implications of population ageing are misrepresented in the media, in policy debates, and sometimes in academic research. Ageing is most often framed in negative terms, questioning whether health services, welfare provision, and economic growth are sustainable. We argue that, instead of being portrayed as a problem, increased human longevity should be a cause for celebration. Moreover, population ageing provides opportunities to rethink health policy for the benefit of all—old and young. Depictions of older people remain stereotyped and generalised, distorting public opinion and skewing policy debates. For example, the use of economic dependency ratios, one of the commonest measures of ageing, assumes that anyone aged 65 years or older is unproductive. Similarly, the use of disability-adjusted life years to capture the health of a population explicitly views older people as a social and economic burden. Yet many older people continue to make substantial social, economic, and cultural contributions, which can be enhanced by measures that improve their health and functional status. Obviously we recognise that the ideals of active ageing might not be achievable for every older person, particularly if they have complex comorbidity or severe cognitive impairments. The economic and noneconomic costs of care provision for these people are undeniable and will rise as the numbers surviving to very old ages increase. Yet their experiences cannot be extrapolated to older people in general; the effects of population ageing on health spending are not as inelastic as is often claimed. This is particularly true in low-income and middle-income countries, where the www.thelancet.com Vol 379 April 7, 2012
relation between health needs and spending is, at best, tenuous. In all countries, demographic effects are strongly mediated by a wide range of unrelated effects, many of which depend on political decisions. Health spending and health-service use are more closely associated with how close one is to death than with chronological age. Indeed, it is often the case that less is spent on older people than on younger people with similar conditions. The key issue in determining the relation between population ageing and health spending is the health and functional status of older people. The association between chronological age and health status is much more variable than is often realised, particularly for those at relatively younger ages (60s and 70s). Newly available data from WHO1 show substantial differences in the health and functional status of older populations in different developing countries. There are also substantial differences in health status within the UK and other developed countries. We still do not understand fully these complex variations in health and functional status. Nevertheless, there is clear evidence that they can be affected substantially by relatively cheap and simple interventions such as the effective management of hypertension, diabetes, and hypercholesterolaemia, and the promotion of healthy lifestyles, in particular regular physical activity.2 Yet in most countries these interventions are not available to large sections of adult populations. The failure of national governments and international agencies to prioritise these cheap and effective treatments represents a missed opportunity to reduce mortality, illness, and disability on an unprecedented scale. Although the non-communicable disease (NCD) agenda has gathered some momentum in recent years, international health spending in lowincome and middle-income countries remains heavily focused on infectious diseases and mother and child health. Yet now that NCDs are on the policy
agenda, there are worrying signs of discrimination against older people. Background documents from the UN High-Level Meeting in September, 2010, describe the deaths of people younger than 60 or 70 years as “premature mortality”,3 implying that deaths of people at older ages should receive a lower priority. If we do not challenge existing policy paradigms and the social attitudes that underpin them, population ageing might indeed lead to a crisis in the provision of health and welfare services. Instead, we should see it as a welcome opportunity to challenge outdated public perceptions, political priorities, and policy models. This challenge will include reorientating health and welfare models to deliver more efficient, equitable, and sustainable interventions. It might also include the diversion of resources from consumer spending, which in many countries has risen spectacularly over the past 30 years, towards meeting the needs of vulnerable people, whatever their age. This is an overtly political challenge; responding positively to it will benefit people of all ages in all societies.
Corbis
Correspondence
Published Online April 4, 2012 DOI:10.1016/ S01406736(12)60519-4 See Editorial page 1274
Participation by LF does not necessarily represent the views of the National Institute on Aging, the National Institutes of Health, or the US Department of Health & Human Services. We declare that we have no conflicts of interest.
*Peter Lloyd-Sherlock, Martin McKee, Shah Ebrahim, Mark Gorman, Sally Greengross, Martin Prince, Rachel Pruchno, Gloria Gutman, Tom Kirkwood, Desmond O’Neill, Luigi Ferrucci, Stephen B Kritchevsky, Bruno Vellas [email protected] School of Development Studies, University of East Anglia, Norwich NR4 7TJ, UK (PL-S); European Centre on Health of Societies in Transition, London School of Hygiene & Tropical Medicine, London, UK (MM); South Asia Network for Chronic Disease, Public Health Foundation of India, New Delhi, India (SE); London School of Hygiene & Tropical Medicine, London, UK (SE); HelpAge International, London, UK (MG); International Longevity Centre UK, London, UK (SG); Institute of Psychiatry, Kings College, London, UK (MP); New Jersey Institute of Successful Aging, Stratford, NJ, USA (RP); International Network for Prevention of Elder Abuse, Vancouver, BC, Canada (GG); Newcastle University, Newcastle, UK (TK);
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1295
Correspondence
European Union Geriatric Medicine Society, Brussels, Belgium (DO’N); National Institute on Aging, Bethesda, MD, USA (LF); Sticht Center on Aging, Winston-Salem, NC, USA (SBK); and International Association of Gerontology and Geriatrics, Liege, Belgium (BV) 1
2
3
WHO. WHO Study on global AGEing and adult health (SAGE). http://www.who.int/ healthinfo/systems/sage/en/index.html (accessed March 20, 2012). Lim S, Gaziano T, Gakidou E, et al. Prevention of cardiovascular disease in high-risk individuals in low and middle income countries: health effects and costs. Lancet 2007; 370: 2054–62. WHO. Accelerating the MDGs by addressing NCDs: MDG side-event on non-communicable diseases (New York, 20 September 2010). http://www.who.int/nmh/events/2010/ discussion_paper_20100920.pdf (accessed March 20, 2012).
Effect of populationbased screening on breast cancer mortality See Perspectives page 1289
For Carestream see http:// carestream.com/PublicContent. aspx?langType= 1036&id=453003 For Mammography Education Inc see http://www. mammographyed.com/
1296
The Correspondence “Effect of population-based screening on breast cancer mortality”1 is signed by 41 health professionals involved in breast cancer screening, who declare that they have no conflicts of interest. Yet they are subject to at least a confirmation bias: they focus on information favouring their views and do not take into consideration scientific contributions with a high level of evidence that challenge the validity of their conviction.2 More specifically, author Lázló Tabár is Chief Medical Advisor and a member of the Medical Advisory Board of the company U-Systems Inc (“the innovative leader in automated breast ultrasound”), and serves as a member of the Scientific and Medical Advisory Board at the company Three Palm Software LLC (“provider of...software products for medical imaging and information”).3 Tabár is also co-owner of a patent on WorkstationOne, a “user interface and workflow for mammography viewing”,4 teaches mammogram reading on behalf of the company Carestream (“provider of...medical imaging systems and healthcare IT solutions”), and is Chief
Executive Officer of Mammography Education Inc, which specialises in mammography lecture education. Internet portal Manta estimates an annual revenue for Mammography Education Inc of US$1·0–2·5 million.5 There is no harm in doing such activities if they are reported. However, undisclosed potential conflicts of interest discredit the scientific value of publications. Additionally, knowledge of the potential conflicts of interest of the signatories of the letter supporting breast-cancer screening programmes might help women to make an informed choice about whether or not to participate in systematic mammography screening. We declare that we have no conflicts of interest.
Catherine Riva, Jérôme Biollaz, Philippe Foucras, *Bernard Junod, Philippe Nicot, Jean-Pierre Spinosa
“the wider scientific community” to claim that “there seems to be an active anti-screening campaign orchestrated in part by members of the Nordic Cochrane Centre”, before stating that they “remain convinced” that women’s lives and health are saved, is an inadequate response to the concerns about lack of efficacy and harm that arise from the scientific evidence. The only orchestration of opinion seems to be from Julietta Patnick, the Director of NHS Cancer Screening Programmes. Her boss, the UK’s National Cancer Director, has listened and recognised that there is a case to answer.3 Why doesn’t she? I declare that I have no conflicts of interest.
Susan Bewley [email protected] Women’s Health Academic Centre, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, UK 1
[email protected] Rümikerstrasse 112, Winterthur, Switzerland (CR); Division of Clinical Pharmacology, CHUV, Lausanne, Switzerland (JB); 7 rue du 13e de ligne, Nevers, France (PF); FORMINDEP, 59134 Fournes en Weppes, France (BJ); 75 Av Léon Blum, Panazol, France (PN); and Rue des Terreaux 2, Lausanne, Switzerland (J-PS) 1
2
3
4
5
Bock K, Borisch B, Cawson J, et al. Effect of population-based screening on breast cancer mortality. Lancet 2011; 378: 1775–76. Zahl PH, Gøtzsche PC, Maehlen J. Natural history of breast cancers detected in the Swedish mammography programme: a cohort study. Lancet Oncol 2011; 12: 1118–24. Anon. Company overview of U-Systems, Inc. Bloomberg Businessweek Dec 16, 2011. http:// investing.businessweek.com/research/stocks/ private/person.asp?personId=46676456&priv capId=35880&previousCapId=101546&previo usTitle=Siemens%20Venture%20Capital%20 GmbH (accessed Dec 16, 2011). Patexia. User interface and viewing workflow for mammography workstation. http://www. patexia.com/us-patents/20090185732 (accessed Dec 16, 2011). Manta. Mammography Education Inc. http:// www.manta.com/c/mm48zgy/mammographyeducation-inc (accessed Dec 16, 2011).
The letter signed by 41 people “charged with provision and implementation of breast screening in many different countries”,1 who fail to recognise or declare a single conflict of interest between them, amply shows why an independent review is required.2 Merely lining up beside
2
3
Bock K, Borisch B, Cawson J, et al. Effect of population-based screening on breast cancer mortality. Lancet 2011; 378: 1775–76. Bewley S. The NHS breast screening programme needs independent review. BMJ 2011; 343: d6894. Richards M. An independent review is under way. BMJ 2011; 343: d6843.
I was astonished to see the declaration at the foot of the letter from Karin Bock and colleagues,1 stating that the signatories have no conflicts of interest. How can this be the case for health professionals such as Julietta Patnick, for example? She, like others, is paid for running, recruiting, and promoting a public health screening programme. The UK programme requires an uptake of 70% to make it viable: incentive enough, I imagine, to persuade, coerce, and sell to potential participants. This necessity to make the programme work has resulted in promotional activities. Citizens are invited to attend by means of persuasive literature,2 inadequate to enable informed consent, as is required by the UK General Medical Council.3 Robust public challenges to the unethical nature of this have been made,4 as have promises (not www.thelancet.com Vol 379 April 7, 2012
relation between health needs and spending is, at best, tenuous. In all countries, demographic effects are strongly mediated by a wide range of unrelated effects, many of which depend on political decisions. Health spending and health-service use are more closely associated with how close one is to death than with chronological age. Indeed, it is often the case that less is spent on older people than on younger people with similar conditions. The key issue in determining the relation between population ageing and health spending is the health and functional status of older people. The association between chronological age and health status is much more variable than is often realised, particularly for those at relatively younger ages (60s and 70s). Newly available data from WHO1 show substantial differences in the health and functional status of older populations in different developing countries. There are also substantial differences in health status within the UK and other developed countries. We still do not understand fully these complex variations in health and functional status. Nevertheless, there is clear evidence that they can be affected substantially by relatively cheap and simple interventions such as the effective management of hypertension, diabetes, and hypercholesterolaemia, and the promotion of healthy lifestyles, in particular regular physical activity.2 Yet in most countries these interventions are not available to large sections of adult populations. The failure of national governments and international agencies to prioritise these cheap and effective treatments represents a missed opportunity to reduce mortality, illness, and disability on an unprecedented scale. Although the non-communicable disease (NCD) agenda has gathered some momentum in recent years, international health spending in lowincome and middle-income countries remains heavily focused on infectious diseases and mother and child health. Yet now that NCDs are on the policy
agenda, there are worrying signs of discrimination against older people. Background documents from the UN High-Level Meeting in September, 2010, describe the deaths of people younger than 60 or 70 years as “premature mortality”,3 implying that deaths of people at older ages should receive a lower priority. If we do not challenge existing policy paradigms and the social attitudes that underpin them, population ageing might indeed lead to a crisis in the provision of health and welfare services. Instead, we should see it as a welcome opportunity to challenge outdated public perceptions, political priorities, and policy models. This challenge will include reorientating health and welfare models to deliver more efficient, equitable, and sustainable interventions. It might also include the diversion of resources from consumer spending, which in many countries has risen spectacularly over the past 30 years, towards meeting the needs of vulnerable people, whatever their age. This is an overtly political challenge; responding positively to it will benefit people of all ages in all societies.
Corbis
Correspondence
Published Online April 4, 2012 DOI:10.1016/ S01406736(12)60519-4 See Editorial page 1274
Participation by LF does not necessarily represent the views of the National Institute on Aging, the National Institutes of Health, or the US Department of Health & Human Services. We declare that we have no conflicts of interest.
*Peter Lloyd-Sherlock, Martin McKee, Shah Ebrahim, Mark Gorman, Sally Greengross, Martin Prince, Rachel Pruchno, Gloria Gutman, Tom Kirkwood, Desmond O’Neill, Luigi Ferrucci, Stephen B Kritchevsky, Bruno Vellas [email protected] School of Development Studies, University of East Anglia, Norwich NR4 7TJ, UK (PL-S); European Centre on Health of Societies in Transition, London School of Hygiene & Tropical Medicine, London, UK (MM); South Asia Network for Chronic Disease, Public Health Foundation of India, New Delhi, India (SE); London School of Hygiene & Tropical Medicine, London, UK (SE); HelpAge International, London, UK (MG); International Longevity Centre UK, London, UK (SG); Institute of Psychiatry, Kings College, London, UK (MP); New Jersey Institute of Successful Aging, Stratford, NJ, USA (RP); International Network for Prevention of Elder Abuse, Vancouver, BC, Canada (GG); Newcastle University, Newcastle, UK (TK);
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1295
Correspondence
European Union Geriatric Medicine Society, Brussels, Belgium (DO’N); National Institute on Aging, Bethesda, MD, USA (LF); Sticht Center on Aging, Winston-Salem, NC, USA (SBK); and International Association of Gerontology and Geriatrics, Liege, Belgium (BV) 1
2
3
WHO. WHO Study on global AGEing and adult health (SAGE). http://www.who.int/ healthinfo/systems/sage/en/index.html (accessed March 20, 2012). Lim S, Gaziano T, Gakidou E, et al. Prevention of cardiovascular disease in high-risk individuals in low and middle income countries: health effects and costs. Lancet 2007; 370: 2054–62. WHO. Accelerating the MDGs by addressing NCDs: MDG side-event on non-communicable diseases (New York, 20 September 2010). http://www.who.int/nmh/events/2010/ discussion_paper_20100920.pdf (accessed March 20, 2012).
Effect of populationbased screening on breast cancer mortality See Perspectives page 1289
For Carestream see http:// carestream.com/PublicContent. aspx?langType= 1036&id=453003 For Mammography Education Inc see http://www. mammographyed.com/
1296
The Correspondence “Effect of population-based screening on breast cancer mortality”1 is signed by 41 health professionals involved in breast cancer screening, who declare that they have no conflicts of interest. Yet they are subject to at least a confirmation bias: they focus on information favouring their views and do not take into consideration scientific contributions with a high level of evidence that challenge the validity of their conviction.2 More specifically, author Lázló Tabár is Chief Medical Advisor and a member of the Medical Advisory Board of the company U-Systems Inc (“the innovative leader in automated breast ultrasound”), and serves as a member of the Scientific and Medical Advisory Board at the company Three Palm Software LLC (“provider of...software products for medical imaging and information”).3 Tabár is also co-owner of a patent on WorkstationOne, a “user interface and workflow for mammography viewing”,4 teaches mammogram reading on behalf of the company Carestream (“provider of...medical imaging systems and healthcare IT solutions”), and is Chief
Executive Officer of Mammography Education Inc, which specialises in mammography lecture education. Internet portal Manta estimates an annual revenue for Mammography Education Inc of US$1·0–2·5 million.5 There is no harm in doing such activities if they are reported. However, undisclosed potential conflicts of interest discredit the scientific value of publications. Additionally, knowledge of the potential conflicts of interest of the signatories of the letter supporting breast-cancer screening programmes might help women to make an informed choice about whether or not to participate in systematic mammography screening. We declare that we have no conflicts of interest.
Catherine Riva, Jérôme Biollaz, Philippe Foucras, *Bernard Junod, Philippe Nicot, Jean-Pierre Spinosa
“the wider scientific community” to claim that “there seems to be an active anti-screening campaign orchestrated in part by members of the Nordic Cochrane Centre”, before stating that they “remain convinced” that women’s lives and health are saved, is an inadequate response to the concerns about lack of efficacy and harm that arise from the scientific evidence. The only orchestration of opinion seems to be from Julietta Patnick, the Director of NHS Cancer Screening Programmes. Her boss, the UK’s National Cancer Director, has listened and recognised that there is a case to answer.3 Why doesn’t she? I declare that I have no conflicts of interest.
Susan Bewley [email protected] Women’s Health Academic Centre, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, UK 1
[email protected] Rümikerstrasse 112, Winterthur, Switzerland (CR); Division of Clinical Pharmacology, CHUV, Lausanne, Switzerland (JB); 7 rue du 13e de ligne, Nevers, France (PF); FORMINDEP, 59134 Fournes en Weppes, France (BJ); 75 Av Léon Blum, Panazol, France (PN); and Rue des Terreaux 2, Lausanne, Switzerland (J-PS) 1
2
3
4
5
Bock K, Borisch B, Cawson J, et al. Effect of population-based screening on breast cancer mortality. Lancet 2011; 378: 1775–76. Zahl PH, Gøtzsche PC, Maehlen J. Natural history of breast cancers detected in the Swedish mammography programme: a cohort study. Lancet Oncol 2011; 12: 1118–24. Anon. Company overview of U-Systems, Inc. Bloomberg Businessweek Dec 16, 2011. http:// investing.businessweek.com/research/stocks/ private/person.asp?personId=46676456&priv capId=35880&previousCapId=101546&previo usTitle=Siemens%20Venture%20Capital%20 GmbH (accessed Dec 16, 2011). Patexia. User interface and viewing workflow for mammography workstation. http://www. patexia.com/us-patents/20090185732 (accessed Dec 16, 2011). Manta. Mammography Education Inc. http:// www.manta.com/c/mm48zgy/mammographyeducation-inc (accessed Dec 16, 2011).
The letter signed by 41 people “charged with provision and implementation of breast screening in many different countries”,1 who fail to recognise or declare a single conflict of interest between them, amply shows why an independent review is required.2 Merely lining up beside
2
3
Bock K, Borisch B, Cawson J, et al. Effect of population-based screening on breast cancer mortality. Lancet 2011; 378: 1775–76. Bewley S. The NHS breast screening programme needs independent review. BMJ 2011; 343: d6894. Richards M. An independent review is under way. BMJ 2011; 343: d6843.
I was astonished to see the declaration at the foot of the letter from Karin Bock and colleagues,1 stating that the signatories have no conflicts of interest. How can this be the case for health professionals such as Julietta Patnick, for example? She, like others, is paid for running, recruiting, and promoting a public health screening programme. The UK programme requires an uptake of 70% to make it viable: incentive enough, I imagine, to persuade, coerce, and sell to potential participants. This necessity to make the programme work has resulted in promotional activities. Citizens are invited to attend by means of persuasive literature,2 inadequate to enable informed consent, as is required by the UK General Medical Council.3 Robust public challenges to the unethical nature of this have been made,4 as have promises (not www.thelancet.com Vol 379 April 7, 2012