Success has many fathers, failure remains an orphan

Was the sharp upturn of life expectancy in the Netherlands partly due to increased health care funding for the elderly? I argue that there is nothing unusual to the increasing life expectancy since the beginning of the twenty-first century, and that there is no observable relationship with changed health care funding whatsoever. What was highly unusual was the rather dramatic lagging of Dutch life expectancy between 1980 and 2000. The reasons of this failure remain clouded in mystery

Degenerative Disease in an Aging Population Models and Conjectures

This PhD thesis is rootcd in a mnltidisciplinary project, ca lied Technology Assessment lvlethods (TAM). The (ambitious) aim of the TAM project was to develop a comprehcllsive method of evalnating medical tcchnology in the perspective of multiple risk factors, multiple diseascs and multiple causes of death (Bonneux & Bai'endregt, 1991). Thc project was an attempt to bettel' llllderstand the dynamics of populatioll health status, in particnlar in relation to medical intervclltions, but it was "lso lllotivated by thc rapidly rising health care costs of the past decades, whieh fueled the feal' that ever expanding casts might become economically unsllstainahle in the future (van der Maas & Habbema, 1986). The TAM project would provide a better lUlderstanding of the consequcllces for beth casts and popt!lation hcalth status of a \\Vide array of preventivc aud therapeutic health care interventions, and through that offer the tools for policy makers to huy the better investments in health with a sustaillahle health carc budget. Two factors arc commanly held responsible for the increase in health care costs: aging and health care technology

Adult obesity and the burden of disability throughout life

OBJECTIVE: To analyze the prevalence of disability throughout life and life expectancy free of disability, associated with obesity at ages 30 to 49 years. RESEARCH METHODS AND PROCEDURES: We used 46 and 20 years of mortality follow-up, respectively, for 3521 Original and 3013 Offspring Framingham Heart Study participants 30 to 49 years and classified as normal weight, overweight, or obese at baseline. Disability measures were available between 36 and 46 years of follow-up for 1352 Original participants and at 20 years of follow-up for 2268 Offspring participants. We measured the odds of disability in the Original cohort after 46 years follow-up, and we estimated life expectancy with and without disability from age 50. Two disability measures were used, one representing limitations with mobility only and the second representing limitations with activities of daily living (ADL). RESULTS: Obesity at ages 30 to 49 years was associated with a 2.01-fold increase in the odds of ADL limitations 46 years later. Nonsmoking adults who were obese between 30 and 49 years lived 5.70 (95% confidence interval, 4.11 to 7.35) (men) and 5.02 (95% confidence interval, 3.36 to 6.61) (women) fewer years free of ADL limitations from age 50 than their normal-weight counterparts. There was no significant difference in the total number of years lived with disability throughout life between those obese or normal weight, due to both higher disability prevalence and higher mortality in the obese population. DISCUSSION: Obesity in adulthood is associated with an increased risk of disability throughout life and a reduction in the length of time spent free of disability, but no substantial change in the length of time spent with disability

From evidence based bioethics to evidence based social policies

In this issue, Norwegian authors demonstrate that causes of early expulsion out the workforce are rooted in childhood. They reconstruct individual biographies in administrative databases linked by an unique national identification number, looking forward 15 years in early adulthood and looking back 20 years till birth with close to negligible loss to follow up. Evidence based bioethics suggest that it is better to live in a country that allows reconstructing biographies in administrative databases then in countries that forbid access by restrictive legislation based on privacy considerations. The benefits of gained knowledge from existing and accessible information are tangible, particularly for the weak and the poor, while the harms of theoretical privacy invasion have not yet materialised. The study shows once again that disadvantage runs in families. Low parental education, parental disability and unstable marital unions predict early disability pensions and premature expulsion out gainful employment. The effect of low parental education is mediated by low education of the index person. However, in a feast of descriptive studies of socio-economic causes of ill health we still face a famine of evaluative intervention studies. An evidence based social policy should be based on effective interventions that are able to break the vicious circles of disability handed down from generation to generation

Irreversible Effects of Ivermectin on Adult Parasites in Onchocerciasis Patients in the Onchocerciasis Control Programme in West Africa

Ivermectin is an effective drug for the treatment of human onchocerciasis, a disease caused by the parasitic filarial nematode Onchocerca volvulus. When humans are treated, the microfilariae normally found in the skin are rapidly and very nearly completely eliminated. Nonetheless, after a delay, microfilariae gradually reappear in the skin. This study is concerned with the causes of this delay. Hypotheses are tested by comparing the results of model calculations with skin microfilaria counts collected from 114 patients during a trial of five annual treatments in the focus area of Asubende, Ghana. The results obtained strongly suggest that annual treatment with ivermectin causes an irreversible decline in microfilariae production of ∼30%/treatment. This result has important implications for public health strategies designed to eliminate onchocerciasis as a significant health hazar

On the IMF's Revised Classification of Exchange Rate Arrangements

This study compares the health care costs of The Netherlands with the United States and Sweden and estimates the impact of demographic change on costs. Total health care costs were allocated to disease, age, sex and specific subsectors. For The Netherlands 75% of the costs in 1988 were assigned to specific diseases. Costs of mental disorders and other chronic non-fatal diseases dominate, followed by cardiovascular diseases. The effect of age is strong from age 70 years onwards. The effect of sex, adjusting for age, is small, except for elderly women, who are more expensive. Both total and disease-specific costs are similar in The Netherlands and Sweden, but differ from those in the US. The available data suggest that the differences in medical practice and health care systems may explain a substantial part of the divergent results; demographic or epidemiologic aspects seem less important. Ageing induces, in the Dutch case, a modest 0.7% annual increase in costs. The contribution of other forces in the increase of costs is probably more important. A structural upward pressure on costs also prevails in The Netherlan

Higher education delays and shortens cognitive impairment. A multistate life table analysis of the US Health and Retirement Study

Improved health may extend or shorten the duration of cognitive impairment by postponing incidence or death. We assess the duration of cognitive impairment in the US Health and Retirement Study (1992–2004) by self reported BMI, smoking and levels of education in men and women and three ethnic groups. We define multistate life tables by the transition rates to cognitive impairment, recovery and death and estimate Cox proportional hazard ratios for the studied determinants. 95% confidence intervals are obtained by bootstrapping. 55 year old white men and women expect to live 25.4 and 30.0 years, of which 1.7 [95% confidence intervals 1.5; 1.9] years and 2.7 [2.4; 2.9] years with cognitive impairment. Both black men and women live 3.7 [2.9; 4.5] years longer with cognitive impairment than whites, Hispanic men and women 3.2 [1.9; 4.6] and 5.8 [4.2; 7.5] years. BMI makes no difference. Smoking decreases the duration of cognitive impairment with 0.8 [0.4; 1.3] years by high mortality. Highly educated men and women live longer, but 1.6 years [1.1; 2.2] and 1.9 years [1.6; 2.6] shorter with cognitive impairment than lowly educated men and women. The effect of education is more pronounced among ethnic minorities. Higher life expectancy goes together with a longer period of cognitive impairment, but not for higher levels of education: that extends life in good cognitive health but shortens the period of cognitive impairment. The increased duration of cognitive impairment in minority ethnic groups needs further study, also in Europe