Varför satsar vi inte mer på hälsofrämjande och preventiva insatser när vi vet att mycket av den sjukdom som uppstår kan undvikas? Dr. Anna Erat, University of St Gallen, talare vid World Economic Forum, ger i veckans blogg såväl argument som förslag på hur vi kan gå från en reaktiv hälso- och sjukvård till mer hållbar hälsa.
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Prevention and Longevity – Breaking the Mold and Setting the Stage for Evidence Based Practice
Dr. Anna Erat MD/PhD, University of St Gallen, speaker at the World Economic Forum
Preventive and longevity medicine seems to be the buzz-words of the year, following a long time-period of reactive medicine and of the SARS-CoV-2 virus causing havoc all around the world. Albeit the COVID-19 pandemic being a great catalyst in moving our society towards healthcare from a purely reactive sickcare system, some experts still speak against preventive health examinations and longevity medicine.
1. Why is There Still Resistance Against Preventive and Longevity Medicine?
It seems counter-intuitive not to advocate for prevention and solely treat a disease that could have been avoided. After all, approximately 80-90 % of all healthcare costs are allocated to chronic illnesses, many that could have been prevented. Indeed, the WHO estimates that 30-50 % of cancers could be avoided through lifestyle changes and through the abolishing of environmental culprits such as polluted air, poor hygiene, and dirty water.
Arguments against yearly preventive health examinations, or check-ups all together, are the supposed lack of benefits and the high costs associated with them, costing insurers and patients more than $5 billion annually in the U.S. In fact, the famous 2012 meta-analysis by the Cochrane Collaboration, which included 14 independent studies, found that annual check-ups don’t save people’s lives or overall healthcare costs[1]. Furthermore, the study argues that check-ups may lead to lost productivity as healthy adults take time off from work to visit their doctors.
In order to address this critique, the definition and understanding of a preventive health examination must be clearified. To do so, three fundamental questions must be asked:
- WHY: Why do people do check-ups and what motivates them to visit their doctor? Is the aim of check-ups simply to avoid illness and diagnose disease early, or is the aim also to improve health, mental well-being, and performance?
- HOW: What defines a check-up and how should it be conducted? Are all check-ups equal in quality?
- WHEN: When and at what age do people go for a check-up and how often? Is a yearly health screening truly necessary for everyone or do we need to embrace precision and personalized medicine to individualize the frequency?[2]
2. Moving From Purely Reactive Sickcare to a more Encompassing Healthcare
The answer to the first question “why” is simple. Many people do not seek preventive medicine diagnostics and advice solely to allow early diagnosis and treatment of a sickness. People are increasingly paying attention to improving their physical and mental well-being as well as performance, and they use check-ups to optimize health, track training progress, allow healthy aging, and as motivational tools to avoid burn-out or depression (and as a consequence to improve well-being, creativity, productivity and to avoid sick-days).
Already since the early 1990’s several geroscientists – like Dr. Eric Verdin of the Buck Institute for Research on Aging – started asking themselves how their longevity research in C. elegans (a free-living transparent nematode about 1 mm)could be translated into healthcare, and they started shifting from insects to studying epigenetic regulation of aging in humans. Soon a growing body of research could show that for instance inflammation is a central driver of many chronic diseases of aging and that these mechanisms can strongly be influenced by lifestyle factors such as nutrition, fasting, sleep and exercise. In our increasingly health literate society, people are today finally well aware of this mechanism and seek healthcare expertise, coaching and further services to empower themselves to take control of their health optimization.
Furthermore, many patients with chronic conditions such as arterial hypertension, dyslipidemia or cancer survivors seek regular check-ups to avoid disease progression or complications as part of secondary prevention. Hence, the benefits of check-ups should be reevaluated, as most studies like the Cochrane study only assess the benefit of primary prevention of an annual check-up.
While addressing the question of “how”, it becomes clear that all check-ups aren’t equal, as the quality, design and standards of check-ups vary (similar to the outcome between various centers that conduct hip-replacements or coronary angioplasty). Hence, proper standards and new models of preventive medicine – including digital and telemedicine – are urgently called for.
Finally, the question of “when” is also of essence. In the U.S., annual check-ups are frequently requested by employers or health plan providers and insurance companies. Yet, most check-ups are certainly not required annually, but rather less regularly. Furthermore, at young age most screenings and examinations can be avoided altogether, depending on the risk factors and genetic pre-dispositions. PAP-smears, however, are hardly controversial even in very young women. Similarly, it is difficult to imagine that any healthcare worker would oppose young women to be informed about the potential benefit of HPV vaccinations to avoid cervical cancers while doing a check-up at their gynecologist’s office. Equally, the evidence that the general population can avoid colon cancer by removing intestinal polyps as of the age of 45-50 years is overwhelming. In addition, athletes have to be screened for heart conditions much more regularly than the general population among others.[3] And finally, we are not all the same! Factors such as gender, living conditions and genetic background may heavily influence the time-point of potential disease-outbreak and manifestation. In the age of precision and personalized medicine, these factors can hardly be ignored when avoiding illness, optimizing personalized therapies, avoiding unnecessary complications when using the “one fits all model”, and while ultimately saving costs for the entire health system and society. The question here is not “if” but “when”.
3. Setting the Stage for a Healthy and Empowered Society
Altogether, the science as well as practice of preventive medicine and healthy longevity are not going to replace sickcare, but instead they will add an essential new dimension and culture. The cost-saving for a healthcare system is immense, even if only a fraction of chronic diseases can be avoided through apt preventive strategy and measures. A top-down approach where the individual is obliged to wait until injury or disease-outbreak to see a doctor is outdated. Healthcare is not only about putting out a fire and treating disease. Indeed, preventive and longevity medicine encompass much more than simply screening for disease, disorder, and disability. Preventive medicine and longevity entail coaching, digital health solutions as well as genetic medicine, and they promote health literacy. They allow healthcare systems to empower groups and individuals alike to take charge of their own health, resilience, and well-being.
Dr. Anna Erat MD/PhD
Parallel to finishing her PhD in epidemiology and health systems management at the University of Basel, Anna also studied medicine and conducted research at Harvard and University of Zurich medical schools. Before her role as a medical director in Klinik Hirslanden and her current role as managing director of the Longevity Center in Switzerland, she attended executive courses at Harvard Business School and finished the International Directors Program at INSEAD. Apart from mentoring at the ETH and being faculty in the University of St. Gallen Executive School, she gives talks on sustainable health, preventive medicine and longevity for the UN and the World Economic Forum among others.
[1] Krogsbøll LT, Jørgensen KJ, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database of Syste- matic Reviews 2019, Issue 1. Art. No.: CD009009. DOI: 10.1002/14651858. CD009009.pub3
[2] Source: Erat A. Sinn und Unsinn – der Checkup. Der Informierte @arzt» 2020, 11. DOI: 11.23785/ARZT.2020.11.001
[3] Erat A. Pre-participation Evaluation for Screening of Health Risks in Leisure and Young Competitive Athletes. Swiss Sports & Exercise Medicine 2019, 67 (3), 6–11.