Jan Mos RIVM 22-4-2010


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Rijksinstituut Volksgezondheid en Milieu en de Volksgezondheid toekomst Verkenningen

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  • How is the relationship between the government and our institute? Minister of Health in The Hague (here at the left), has the political responsibility. He takes the strategic decisions. Our institute (here on the right located in Bilthoven) performs state of the art research and provides knowledge for policy support underpinning these strategic decisions. There is a clear separation between research and policy support which is done at RIVM and political decisions making at the Ministry.
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  • Two other societal problems/ These pictures show the problems of modern societies. Particulate matter, fine dust or air pollution is a major source of morbidity. It kills people and increases the burden of disease. But do we really change our behaviour? The more we live down-town the more 4-wheel cars are popular. However, at the same time society forces the politicians to investigate the health effects of power lines on health. The question is how to handle public concern and how to stimulate people to take their own responsibility regarding the climate change.
  • An example of modern society, using air-conditioning. Scanning patterns is for example needed for Legionella outbreaks. In Amsterdam we had last summer such an outbreak. In this outbreak Google earth pictures were used to locate cooling water equipment on top of buildings. By carefully searching for patterns the source of infection has been traced. All infected people had walked past this building!
  • It’s clear that there are a lot of detrimental trends and that behaviour plays a crucial role! Trends in Spain? Information regarding these aspects? Any strategy to change these bad trends?
  • Most important is that we are able to transform information info meaningful information or in other words wisdom. Here you see geographic information about rubella vaccination rate. Blue areas show low vaccination rate. They coincide with what we call the Bible belt (strict protestants). This group of people refuses vaccination for religious reasons. On the right hand side you see cases of confirmed rubella virus infections. It is clear that the outbreak is related to a low vaccination-rate area. We need this background to evaluate outbreaks. As soon as there are increasing infection rates outside the known danger areas the alarm bell should ring.
  • In order to answer the societal questions we need to assess the risks and to communicate about these risks. The slide is not useful for public information, because many fail to understand logarithmic scales. But you can easily see that the risk of premature death from power lines is much lower than the risk of smoking or accidents at home. Unfortunately knowing the risks doesn’t always change the behavious.
  • It is not possible to do everything. Therefore it is extremely important to set priorities. Question if what do we take into account and how do we weight all the aspects. How do we assess the economic burden of a disease? Do we take into account the risk perception of the general public? In The Netherlands people are concerned about the mast for mobile telephones. Some people are convinced that it will cause cancer, or at least head ache. The Dutch government decided to start a huge investigation.
  • Politicians have to decide how to spend their limited budgets. First they need to know to impact of the different subjects. Second question is how much it will cost in order to reduce the burden. This slide illustrates the use of DALY’s. Daily adjusted life years. Health impact effects are compared for different sources.
  • In order to solve all the problems we need power… is the reply of the regional health centers Is the reply of the Nat Institute? This has to do with formal power. Even in a small country like the netherlands we have many debats concerning regional and national power. There are many examples where we are asked to give an expert opinion on scientific issues. Therefore we need good scientific knowledge that covers the areas needed to take sound decisions. Even if we do not have all of the evidence that should be available for decisions, we must have such strong positions that our advice to professionals, politicians and citizens does make a difference. Authority does not come without scientific knowledge and we need authority because we often lack formal power. Nevertheless authority can be quite powerful.
  • However there is a need for better preparedness and outbreakmanegement In order to control Communicable diseases our minister has decided that it makes no sense to divide risk assessment and risk management. So, regarding the control of Comm Dis our institute is responsible for both aspects, although the minster of health has the final political responsibility. This is definitely not the case of air quality. Essential is that people need a mental map to imagine how their work fits into a bigger concept.
  • We need to understand the real word, how things work. In order to do so we need to construct a model of that complex reality. Our minister wants to lower the burden of diabetes mellitus. What kind of measurements could he take and how will that affect the health system. In order to predict these changes of policy you need to use a model.
  • I see a gradual but steady change in Public Health: we used to focus on sources and effects, like communicable diseases, air pollution and radiation. But now we have grown from relatively simple risk assessment to risk-benefit analysis of systems. So we need to have system knowledge in order to support effective interventions. However, the closer you get to the interventions, the more you need to communicate. What I see as the challenge for NPHI is to interconnect all expertise for the benefit of the public. I see this as one of my special responsibilities.
  • We have become more explicit about our customers. We are a Public Institute, at least financially, but our societal contribution goes further: professionals and the public are our customers.
  • 24-04-10
  • 24-04-10
  • Jan Mos RIVM 22-4-2010

    1. 1. Nederland gezond en wel <ul><li>Gezond blijven </li></ul><ul><li>Voorkomen is beter dan genezen? </li></ul><ul><li>Rollen en taken RIVM </li></ul>
    2. 2.
    3. 3. Three themes <ul><li>1. Role of RIVM in the public domain </li></ul><ul><li>2. What is needed? </li></ul><ul><li>3. VTV: what do we (think) we know? </li></ul><ul><li>Discussion and clarification when needed! </li></ul>
    4. 4. What may citizens expect from their government? What is the responsibility of the federal government? What is the role of state and local authorities?
    5. 5. Government responsible for public health
    6. 6. Government responsible for safe environment
    7. 7. Public health is inherently political … <ul><li>Politics is the process by which groups of people make decisions. </li></ul><ul><li>It is the authoritative allocation of values. </li></ul><ul><li>Although the term is generally applied to behavior within governments , politics is observed in all human group interactions, including corporate , academic , and religious institutions. </li></ul><ul><ul><li>www.en.wikipedia.org/wiki/Politics </li></ul></ul>
    8. 8. Public health is inherently political <ul><li>Within a governmental framework </li></ul><ul><li>Involves complex tradeoffs—one value weighed against another </li></ul><ul><li>May need to act before all desirable information is known </li></ul><ul><li>Frequently need to involve the public — actions, or at least agreement </li></ul>
    9. 9. But Public Health Institutes must be non-partisan… <ul><li>Decisions based on science, not ideology, financial interests, or ‘self-interest’ </li></ul><ul><li>Complex tradeoffs — decision making transparent, quantitative modeling </li></ul><ul><ul><li>Decision analysis should identify and quantify areas of uncertainty </li></ul></ul><ul><ul><li>Public communication, engagement </li></ul></ul>
    10. 10. Political responsibility Research & policy support The ministries have political responsibilities RIVM: independent scientific responsibility (air quality) Risk-assessment (RIVM, ECDC) Risk-management (Government, EU, RIVM ) Clear separation of responsibilities
    11. 11. Summarizing <ul><li>Separation of responsibilities </li></ul><ul><li>But the same goal </li></ul><ul><li>With different roles and interests </li></ul>
    12. 12. Role of RIVM in the public domain <ul><li>The aim of the RIVM is to improve public health and safeguard a healthy environment. </li></ul><ul><li>This is achieved by: </li></ul><ul><li>Research & knowledge integration </li></ul><ul><li>Policy support </li></ul><ul><li>National / federal coordination functions </li></ul><ul><li>Specific intervention programs (NIP, screening) </li></ul><ul><li>Effective communication on health (care) and environment </li></ul>RIVM serves the public authorities, the professional and the public
    13. 13. Three themes <ul><li>1. Role of RIVM in the public domain </li></ul><ul><li>2. What is needed? </li></ul><ul><li>3. VTV: what do we (think) we know? </li></ul><ul><li>discussion </li></ul>
    14. 14. National Public Health Institute scientific role <ul><li>Selection of important public health question </li></ul><ul><li>Define appropriate scientific approach </li></ul><ul><ul><li>Frequently multi-disciplinary </li></ul></ul><ul><li>Obtain needed data </li></ul><ul><li>Participate in decision making, regulations </li></ul><ul><li>Implement, with partners, programs </li></ul><ul><li>Continue monitoring to evaluate impact </li></ul>
    15. 15. Public Health Questions: Emerging Infections (Zoonoses)
    16. 16. Public Health Questions: Problems in the air? particulate matter electromagnetic fields public threat?
    17. 17. Public Health Questions: Legionella (environment) Legionella in cooling-towers
    18. 18. Public Health Questions: Behaviour, trends and concerns for the future physical inactivity excessive alcohol use severe obesity Overweight smoking stable stable Stable bad stable good bad bad bad bad bad bad stable good good youth Females Males Trend
    19. 19. National Public Health Institute scientific role <ul><li>Selection of important public health question </li></ul><ul><li>Define appropriate scientific approach </li></ul><ul><ul><li>Frequently multi-disciplinary </li></ul></ul><ul><li>Obtain needed data </li></ul><ul><li>Participate in decision making, regulations </li></ul><ul><li>Implement, with partners, programs </li></ul><ul><li>Continue monitoring to evaluate impact </li></ul>
    20. 20. Transform information into wisdom (science)
    21. 21. Understand risk assessment and communication Risk on premature death power lines benzene disasters legionella noise passive smoking airpollution Radon traffic accidents alcohol accidents at home fat food lack of physical activity obesity mobile phone base station smoking 10 -2 10 -10 10 -9 10 -8 10 -7 10 -6 10 -5 10 -4 10 -3
    22. 22. Priority setting: use transparent criteria <ul><li>Burden of disease and Cost of illness </li></ul><ul><li>Include Trends </li></ul><ul><li>Evaluate effectiveness and efficiency of preventive measures </li></ul>
    23. 23. DALYs in the Netherlands, 1980 - 2020 0 5000 10000 15000 20000 25000 1980 2000 2010 1980 2000 2020 1980 2000 2020 1980 2000 2020 1980 2000 2020 PM10 long- term Noise Radon UV Traffic accidents DALYs per million people
    24. 24. Relative burden: 7 infectious diseases in Europe
    25. 25. What is needed? <ul><li>Good scientific background, credibility </li></ul><ul><li>Priority setting requires integrated knowledge based on </li></ul><ul><li>Biomedical & health science </li></ul><ul><li>Health systems effects </li></ul><ul><li>Effective interventions </li></ul><ul><li>Thrive for a strong position to advice: </li></ul><ul><li>Professionals, Politicians, Citizens </li></ul><ul><li>Consumer behavior experience </li></ul><ul><li>Risk communication </li></ul><ul><li>Effective interventions </li></ul><ul><li>No formal power – authority needed (central vs local) </li></ul>
    26. 26. What are the consequences for RIVM? <ul><li>The Dutch government has redefined its role in public health </li></ul><ul><li>Our Institute is under reconstruction (mainly research)! </li></ul><ul><li>Additional tasks: </li></ul><ul><li>better preparedness for outbreak / risk management </li></ul><ul><li>Prevention and intervention programs (based on burden of dis) </li></ul><ul><li>Protect and promote health (alcohol, overweight, etc) </li></ul><ul><li>This requires to unify many different tasks of our institute </li></ul><ul><li>You need mental maps </li></ul>
    27. 27. Conceptual model for the Dutch PHSF
    28. 28. Develop models to get grip on reality
    29. 29. Need to develop knowledge-model ‘ Sources’ ‘ Effects’ ‘ Systems’ ‘ Intervention laboratory and field research, modeling desk research and (inter)national networks Chain Communication
    30. 30. NIPH owner Customers Sister institutes Research centers citizens professionals Budget-holder Need to develop stake-holder model
    31. 31. Three themes <ul><li>1. Role of RIVM in the public domain </li></ul><ul><li>2. What is needed? </li></ul><ul><li>3. VTV: what do we (think) we know? </li></ul><ul><li>discussion </li></ul>
    32. 32. Public health reporting in the Netherlands <ul><li>Public Health Status and Forecast 2010 </li></ul><ul><li>Fons van der Lucht & Johan Polder </li></ul>Datum invullen 25 maart 2010 Titel van de presentatieVan gezond naar beter – VTV 2010
    33. 33. General purpose of public health reporting <ul><li>to provide an overview and analysis of the available data and information in the field of public health, on a regular basis </li></ul><ul><li>with explicit identification of any gaps in the information supply </li></ul><ul><li>for the: </li></ul><ul><ul><li>evaluation of current health policy </li></ul></ul><ul><ul><li>preparation of new health policy </li></ul></ul>
    34. 34. Public health reporting by cVTV/RIVM <ul><li>PHSF report: every four year (2010) </li></ul><ul><li>Thematic reports </li></ul><ul><li>Websites (regular updates): </li></ul><ul><li>Public health Compass </li></ul><ul><li>Public health Atlas </li></ul><ul><li>Costs of illness </li></ul><ul><li>Euphix.org </li></ul>
    35. 35. Conceptual model for the Dutch PHSF
    36. 36. PHSF in The policy cycle (Anderson and Hussey) Preparation (agendasetting) Implementation (programme implementation) Evaluation Development (policy formulation)
    37. 37. Preparation (agendasetting) Implementation (programme implementation) Evaluation Development (policy formulation) Min. Health: Policy-document (2006/2007) Municipalities: Policy-documents (2008/2009) RIVM: PHSF-report (2010) Healthcare-inspectorate (2009)
    38. 38. From healthy to better <ul><li>Public health status and forecast 2010 </li></ul><ul><li>(The fifth PHSF) </li></ul><ul><li>Fons van der Lucht & Johan Polder </li></ul><ul><li>Issued and offered march 25, 2010 </li></ul>Datum invullen 25 maart 2010 Titel van de presentatieVan gezond naar beter – VTV 2010
    39. 39. Life expectancy increases <ul><li>Life expectancy 2008 </li></ul><ul><li>Man: 78,3 </li></ul><ul><li>Women: 82,3 </li></ul><ul><li>Dutch Women not in top of Europe </li></ul><ul><li>Sharp increase in last 4 years </li></ul><ul><li>2 Years </li></ul><ul><li>Continuation of increase 2050: 6 years more </li></ul>
    40. 40. Nadenken over consequenties….
    41. 41. Large differences in life expectancy within the Netherlands <ul><li>Lower life expectancy in big cities (e.g. Amsterdam, Rotterdam) </li></ul><ul><li>Lower life expectancy in ‘rural’ deprived areas (Limburg, Twente, Groningen, Betuwe) </li></ul>
    42. 42. Persistent and large health inequalities (healthy)Life expectancy by level of education) <ul><li>Gap in Life expectancy </li></ul><ul><ul><li>7.3 years men </li></ul></ul><ul><ul><li>6.4 years women </li></ul></ul><ul><li>Life expectancy without limitations: </li></ul><ul><ul><li>14 years </li></ul></ul><ul><li>Trends in the gap </li></ul><ul><li>constant/slight increase </li></ul>
    43. 43. More disease, but more health More years, with more chronic diseases But also in good health (trend will continue)
    44. 44. Most prevalent diseases <ul><li>Top 5 of diseases: each disease more dan 600.000 cases </li></ul><ul><li>(based on health care registrations) </li></ul><ul><li>Diabetes </li></ul><ul><li>Arthrosis </li></ul><ul><li>Coronary Heart diseases </li></ul><ul><li>Complaints of neck and shoulder </li></ul><ul><li>Hearing loss </li></ul>
    45. 45. Why are there more diagnoses? <ul><li>Medical factors </li></ul><ul><ul><li>Increasing Knowledge: Prevention and early detection and treatment </li></ul></ul><ul><ul><ul><li>(early detection: cancer and DM; better treatment cataract) </li></ul></ul></ul><ul><ul><li>Successes in health care attribute to the increasing number of diagnosis </li></ul></ul><ul><li>Social factors </li></ul><ul><ul><li>less acceptance of inconvenience or discomforts </li></ul></ul><ul><ul><li>Less tolerance for variance in behaviour and health </li></ul></ul><ul><ul><li>Extension of the health concept </li></ul></ul><ul><ul><li>Medicalisation of daily complaints </li></ul></ul><ul><ul><li>Higher demands of our knowledge based economy </li></ul></ul>
    46. 46. … and why is doesn’t have to mean less health <ul><li>Health is more than the absence of disease </li></ul><ul><ul><li>'feel good' </li></ul></ul><ul><ul><li>'do the things </li></ul></ul><ul><ul><ul><li>you want to do' </li></ul></ul></ul>
    47. 47. Less smokers, but still 27% smokes
    48. 48. Overweight stabilizes at high level
    49. 49. Priority setting: Tackling the biggest problems? <ul><li>Smoking causes the highest burden of disease </li></ul><ul><li>However : </li></ul><ul><li>Many determinants of health still unknown </li></ul><ul><li>Lifestyle behaviour is clustering and has a common cause </li></ul><ul><li>Living healthy is not easy </li></ul><ul><ul><li>( what’s healthy, personal differences, environmental influences) </li></ul></ul><ul><li>The social and physical environment as a starting point? </li></ul>
    50. 50.
    51. 51. Opportunities of prevention <ul><li>Health protection and disease control (vaccination, screening) have produced a lot of health gain in the past </li></ul><ul><ul><li>Maintainance </li></ul></ul><ul><ul><li>Expansion </li></ul></ul><ul><li>Health promotion (focused on lifestyle changes) is less succesfull </li></ul><ul><ul><li>Normative aspects (freedom of choice versus lifestylepolicy) </li></ul></ul><ul><ul><li>Lacking knowledge (effectiviness of interventions is largely unknown) </li></ul></ul><ul><ul><li>Institutional aspects (Unclear responsibilities, too many parties) </li></ul></ul><ul><ul><li>NB. Still opportunities when we deal with these problems </li></ul></ul>
    52. 52. The future of healthcare <ul><li>Large increase in health care costs: </li></ul><ul><ul><li>Demographic developments </li></ul></ul><ul><ul><li>Medical technology </li></ul></ul><ul><ul><li>Less possibilities for laboursaving innovations </li></ul></ul><ul><ul><li>Many employees needed in the health care sector </li></ul></ul><ul><li>More health ≠ less health care </li></ul><ul><li>More health = more participation </li></ul>
    53. 53. <ul><li>30% van de economische groei door betere voeding en gezondheid </li></ul>30% van de economische groei door betere voeding en gezondheid
    54. 54. Investing in health is necessary <ul><li>Health is wealth </li></ul><ul><ul><li>Health is highly appreciated </li></ul></ul><ul><ul><li>Health is a source of human capital (education and employment) </li></ul></ul><ul><ul><li>Health is a important condition for societal participation (Quality of the society) </li></ul></ul>
    55. 55. Investing in health is necessary <ul><li>To get back in the top of Europe </li></ul><ul><li>Prevalence of diseases is increasing, limitations stabilize </li></ul><ul><li>Lifestyle is still a threat </li></ul><ul><li>Persisting health inequalities </li></ul><ul><li>And </li></ul><ul><li>Everybody is needed on the labour market </li></ul><ul><li>Or in volunteer work or informal care </li></ul><ul><li>Health contributes to welfare and societal well-being </li></ul>
    56. 56. A future for prevention <ul><li>Long term: </li></ul><ul><li>– concerted action, clear targets and a framework for assessment and appraisal: </li></ul><ul><li>normative debate, investing in knowledge, and organisation of the public health field </li></ul><ul><li>Short term: </li></ul><ul><ul><li>Investment on effectiveness </li></ul></ul><ul><ul><li>Priorities </li></ul></ul><ul><ul><ul><li>Limitations </li></ul></ul></ul><ul><ul><ul><li>Health inequalities </li></ul></ul></ul><ul><ul><ul><li>Broadening the lifestyle perspective (societal problem in stead of an individual) </li></ul></ul></ul>
    57. 57. Gezondheidsbevordering moet anders <ul><li>Bij gezondheidsbevordering verder kijken dan gedrag </li></ul><ul><li>Aandacht voor fysieke én sociale omgeving </li></ul><ul><li>Aandachtspunten voor de korte en lange termijn. </li></ul>
    58. 58. Toekomst van preventie: Lange termijn <ul><li>Maatschappelijk actieprogramma </li></ul><ul><li>Heldere doelen op elk niveau </li></ul><ul><li>Afweging in samenhang </li></ul>
    59. 59. Toekomst van preventie: korte termijn <ul><li>Gericht op de algemene bevolking (universele preventie) </li></ul><ul><li>Gericht op hoogrisicogroepen (selectieve preventie) </li></ul><ul><li>Gericht op individuen met een verhoogd risico (geïndiceerde preventie) </li></ul><ul><li>Gericht op het voorkomen van complicaties (zorggerelateerde preventie) </li></ul>
    60. 60. Een zorgvolle toekomst <ul><li>Is de zorg een koekoeksjong… </li></ul><ul><li>of… </li></ul><ul><li>een kip met gouden eieren? </li></ul>