Since 1972, the number of children being born every year in Germany has been lower than the number of people dying. Demographic change is impacting on our society. A growing number of older and old people means, among other things, that there is an increasing demand for healthcare services. In this interview with Kathrin Nolte, Prof. Klaus Berger, Director of the Institute of Epidemiology and Social Medicine, and his deputy, Prof. André Karch, talk about the challenges this will entail for research and healthcare.
How is demographic change impacting on medical research?
Klaus Berger: The discussion is influenced in particular by the question of which department is looking at demographic change. As an epidemiologist I deal not only with rising life expectancy and changes in the frequency of illnesses, but also with risk factors and consequences for diseases which occur in old age and how these affect patients’ quality of life. Neurodegenerative diseases such as dementia, for example, were extremely rare 100 years ago. Today we describe these cases as epidemics. People experience these diseases more frequently because they live much longer than their parents or grandparents did. And this has consequences for all areas of our healthcare system - from training for medical students and nurses to the choice of areas of medical specialisation.
André Karch: I’d like to mention another aspect: the development which Klaus Berger just talked about has changed the research landscape and funding for research in the past 15 years. Today we have reached a point where providers of funding recognise much more clearly the challenges which the overall disease burden in the population entails. And that is the focus today of numerous research funding lines. New areas of research are being opened up, particularly research into the provision of healthcare.
If demographic change has consequences for all areas of the healthcare system, which diseases and causes of death are attracting more attention from researchers?
Klaus Berger: Above all, it’s the neurodegenerative diseases such as dementia or Parkinson’s disease. In my view, interest in the biological fundamentals of neurodegenerative diseases has increased considerably. Population-based studies are much more detailed than 20 years ago: we do magnetic resonance imaging, we collect blood for genetic analyses and we use examination methods which are clinically established. This means that we can develop biological models for the onset of diseases and better explain their mortality rate. Not only the work involved but also the costs are increasing. Also, there are more big international research alliances carrying out fundamental research, for example in genetics. A lot of it doesn’t make it into practice in hospitals, but it helps to improve our understanding of the mechanisms of diseases.
André Karch: As a result of changes in age groups among patients, the focus on diseases is changing. This includes, unmistakeably, the neurodegenerative diseases. But it affects all areas of medicine, for example infectious diseases too, which is what I deal with, and cancer. The trend today is towards using preventative measures to counteract the disease burden which occurs at the end of a patient’s life. This, for example, has an influence on recommendations for vaccinations against pneumococci and influenza, which is a priority in this age group, especially.
Do you have any other example symbolising this change in thinking?
André Karch: We are also looking at the question of which age groups certain screening methods for cancer are suitable for. In many countries, the mammography screening programme is restricted to the age group 50-69. The medical world is now discussing whether it would make sense to extend the programme to the age of 74, or even 79. There are indications that even at this age people can live noticeably longer as a result of early detection measures.
What preventative measures are necessary for a meaningful response to the effects of demographic change?
André Karch: Older age groups in the population need specific offers. Naturally enough, the preventative measures will change in response to whatever diseases are more in focus as a result of changing age structures. The timescales involved in thinking about prevention are certainly long: the so-called "life course approach" takes up the idea that people need to invest in prevention in childhood, in youth and as adults in order to improve their quality of life in old age.
The impression is that early prevention is decisive for more quality of life in old age. How should any durable provision of health services and care services for the future be designed?
Klaus Berger: Health economists have coined a nice expression: "healthy life expectancy". The aim is to link increased life expectancy with increased healthy life expectancy. The most recent figures for North Rhine-Westphalia show that, in the case of women, healthy life expectancy is increasing half as fast as their life expectancy. For men, the ratio is slightly better. This shows that, just from an economical point of view, more people inescapably fall ill at the end of their life if we don’t manage to harmonise this. It means that we quickly reach a point at which society finds it more difficult to finance a health service.
What do we need to avoid in this development?
Klaus Berger: We mustn’t end up with a privatised healthcare system as in the USA. In such countries, the health service is only completely accessible for rich people. A demographically workable system responds to changes in society and in the range of diseases occurring and makes services available which people need in old age in the field of health and care provisions. But this is a big challenge.