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Health Prevention: “It is an investment in our economic development“
MP Rudolf Henke; © private
Prevention is the best medicine, according to the proverb. To internalise this wisdom into as many people as possible is the most important goal of the health prevention. With a view to rising illnesses such as diabetes, mental disorders or adiposity, it is becoming more and more important. In the future it will not only apply to the promotion of primary prevention, but rather embed prevention as a fourth column into the health care system.
Rudolf Henke, MdB (member of the German Bundestag), member of the Board of Directors of the Workers’ group of the CDU/CSU parliamentary group in the German Bundestag, member of the committee on health as well as the committee on education, research and technology assessment, first Chairman of the Marburger Bundesverband (federation), member of the board of the German Medical Association (Bundesärztekammer).
MEDICA.de: Mr. Henke, strengthening prevention has already been on the political agenda in Germany for some time. Recently one gets the sense that this area of the health care system is increasingly being made the center of attention again. Why is that?
Rudolf Henke: I don’t think that prevention has suddenly become important again. The coalition agreement to form the current federal government already determined to establish a national prevention strategy within the legislation. At the beginning of the legislation in terms of health care politics, initially the main focus was on the financial situation of the statutory health insurance, the crisis in the financial industry in terms of general politics and the subsequent economic crisis. At the moment, the legislation attends to the healthcare structure bill. The topic of national prevention strategy is still to come. In a conversation between the German Medical Association with the current German Minister of Economics and Technology and previous Federal Minister of Health Philipp Rösler in August 2010, we agreed to organize a joint working group to define high priority prevention goals and to strengthen physicians in prevention. Now it is getting to be time to substantiate these goals.
MEDICA.de: Prevention should be a natural part of medical education as it is also for instance defined in the Social Security Code. Why does prevention have to be promoted?
Henke: In Germany, preventive measures are strongly influenced by health insurance companies, because they capitalize on paragraph 20 of the SGB V (Social Security Code) to provide prevention benefits. The lawmaker strongly holds off in their design. The new law on realignment of the pharmaceutical market in Germany (“Arzeimittelmarktneuordnungsgesetz”) emphasizes a stronger focus on the additional benefits of pharmaceutical products, so it becomes reimbursable by the health insurance companies. Nothing similar to this has been implemented in prevention yet. The result is that the health insurance companies view themselves as the main players of prevention and try to distinguish themselves from one another by announcing different prevention benefits for the people they insure.
Through these efforts we manage to reach health-conscious people, who improve their life expectancy through prevention benefits and who want to enhance their awareness of life. We are far less able to reach people who don’t live in a health-conscious way. Without question that’s a certain shortfall.
MEDICA.de: The prevention benefits are presumed for physicians, but they are not integrated as a central subject in their university education. This is the case in other countries.
Henke: I have to disagree with you here, since medical studies in Germany for instance include courses in environmental medicine, sports medicine or for example preventative aspects of internal medicine, nutrition or psychiatry. When diseases are being discussed during medical studies, it includes the causes of their development. The training curriculum also incorporates the prevention of disease-causing sources. Physicians are sufficiently sensitized in their education and prevention is among the medical core competencies.
That said, we have one deficiency: when treating already existing symptoms, additional preventive benefits at the doctor’s office are not being reimbursed. That’s a mistake. If you want to reach over 90 percent of the population at the physician’s office on the subject of primary prevention, there needs to be an explanation of benefits that permits talking about a healthier lifestyle without the excuse of an already existing disease symptom. As a physician, I have to talk with the patients about questions of stimulants, sexuality, exercise and the mentally important practice of alternating between stress and relaxation. Oftentimes there is no time left to place these topics with sufficient substance during an accompanying conversation about a cold or a cough.
A physician should conduct a health-focused consultation that particularly addresses exercise and nutrition concerns, smoking and other use of substances, coping with stress and mental stress factors; ©panthermedia.net/Arne Trautmann
MEDICA.de: How can physicians implement these preventative measures in the future?
Henke: I would like to achieve that the physician conducts a health-focused consultation that particularly addresses exercise and nutrition concerns, smoking and other use of substances, coping with stress and mental stress factors. The currently existing restriction of medical prevention to cardiovascular and kidney diseases as well as diabetes mellitus needs to be broken down, because we must not limit preventive check-ups to just these diseases. In the future the exams should increasingly pay attention to target audience and age-oriented factors. Pediatric exams should also pay more attention to identifying possible risk factors to a healthy child development. Topics like diet, exercise, avoidance of mental problems and accident risks should thoroughly be discussed with the parents or guardians.
MEDICA.de: With the implementation of the new strategy comes a simultaneous rise in costs for health care. Who will assume the new benefits and measures for prevention?
Henke: If you just think in short periods of time, it might come to a price increase. However, if you look over a long period of time, the implementation of the prevention strategy is an investment in avoiding otherwise necessary medical costs. Today for the most part we pay for treatments whose causes originated 25 years ago.
At this year’s Congress for Internal Medicine, Professor Lehnert pointed out the plasticity that our genetic code possesses and what epigenetic influences are of importance. During the pregnancy stage in early childhood, when we are in a particularly forming biographical phases, we can already be reached with preventive interventions. One needs to pay attention to corresponding findings. The belief in a fixed genome that determines a specific course of health apparently is not correct. This knowledge fundamentally changes medical understanding and has impacts on the chances of influence that we have. If we wait until a disease has already occurred and only then try to adopt therapeutic measures that are available, it will be difficult.
One example: if diabetes mellitus is genetically fixed, a person will inevitably fall ill from it. However, diabetes mellitus type 2, which today can also occur in 12-year olds, has to do with the metabolic syndrome. This syndrome already leads to limitations in pancreatic reserves before the physician can verify sugar in urine. This means: even before the phase of malfunctioning glucose tolerance, the capacity and reserve of the pancreas is limited. If the physician is able to intervene at this point in time, there is a chance to delay this form of diabetes for years. In this case one would have succeeded to help a person lead his/her life more health-consciously and remain productive for much longer. Many lifestyle diseases don’t befall a person like a law of nature, but are rather the cause of a certain way of living. This knowledge has to be purposefully propagated by already approaching children, parents and relatives in nursery schools, at school and in family centers. Needless to say, this cannot be an exclusive endeavor by the public health service.
MEDICA.de: How can prevention actually be measured? How can it be guaranteed that this strategy is also purposefully put into action?
Henke: Generally I think that we have to say goodbye to looking at health outcomes research as an activity that can primarily be performed at university hospitals or at a few major research institutions. Also for preventative reasons, an opportunity should be provided to utilize routine data from health care, as it for instance accumulates at the statutory health insurance. Then we probably have significantly better opportunities to make statements on the effectiveness of preventative measures. The health research program of the German Federal Government plans to create a population cohort from where such studies could be started. It is advisable to implement this very meticulously and scientifically-based.
Prevention takes place in medical patient counseling; © panthermedia.net/ Wavebreakmedia ltd
MEDICA.de: In closing, what do you wish for prevention in Germany?
Henke: I wish for the possibilities of prevention in terms of health promotion to be recognized as an opportunity to contribute to economic strength. It is an investment in our economic development. After all, it is not great for any person to be unable to work, to be sick and in need of treatment. At the same time it also keeps him from contributing to the economic income. And so the health question also turns into an economic one on whether we add more weight to prevention in society. I also have a feeling that in the discussion that is going on everywhere about skilled labor, we should also see an opportunity to make it possible for people to remain active in their jobs up to a ripe-old age. In French companies there frequently is the chance to exercise during your lunch hour and to go jogging. This has not made its way into German company culture yet. If we manage to convince physicians to develop patient counseling in this direction, Germany then could close the gap to those countries where life expectancy is even higher than here.
MEDICA.de: The medical profession increasingly develops into that of a “health promoter“. What does this mean for this profession?
Henke: Physicians should help sick people as best as they can. It is even more ideal to help these patients to avoid diseases. There are already a few examples where this change in roles has already taken place to a great extent. By now, in dentistry we have a changeover to successful prevention that works with individual and group prophylaxis. This way, in Germany we can utilize prevention to change the epidemiology. However, you must not pit one against the other.
MEDICA.de: How do you rate German prevention strategies in an international comparison?
Henke: Some time ago I visited Japan and Taiwan and found confirmation that the life expectancy of people in these countries is higher than in our country. Apparently, this has little to do with genetic predisposition. When people of Japanese or other East Asian descent grow accustomed to a Western diet and way of living, they also soon suffer from the same health issues as the Western world. It appears to be related to diet and I believe that in this aspect we can learn from other countries in an international comparison.
Germany can also learn more when it comes to smoking prevention. There are still too many people here and particularly also politicians who perceive it as a restriction on their freedom if they are no longer permitted to pollute somebody’s air with a load of smoke. However, a liberal handling in my eyes includes that my rights stop where I start to harm somebody else. As a consequence of improved tobacco controls we also notice that tobacco consumption among 12 – 18-year olds is decreasing.
The interview was conducted by Diana Posth and translated by Elena O’Meara