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A Ripe Old Age

Ageing populations and critically low birth rates require solutions that will come only through partnerships between policymakers and pharma

Be careful what you wish for, you may receive it. This quotation is known to us all, although its origins are probably less well known. It appears as the first line of a classic American horror story, The Monkey's Paw. The appendage in question granted three wishes to its owner, usually with less than pleasant consequences.

A central theme is maximising longevity and a fear of death, which may seem to be stating the obvious, but the one killer we all still have to fear is old age. Whatever interventions we take, whatever lifestyle changes we make and despite incremental advances in healthcare, we still have to die of something.

Slowly but surely, we have begun making inroads into even this most venerable of conditions, as European life expectancies have crept up to levels that could not have been imagined a few decades ago. A good thing? Undoubtedly. However, as the story warns us, our desires may have unexpected consequences.

In fact, our success in extending life expectancy has created a situation where the ability of Europe to sustain its industry, medical and social infrastructure is under desperate and increasing pressure. The scale of the problem is not yet quantified, but it already casts a sombre shadow. The solution to this problem is also unclear, as European and national policymakers are only now realising the scope and scale of the challenge society will face. To date, the predictable knee-jerk reaction has been to look - as usual - at ways to cut drug expenditure.

What has brought us to this unfortunate juncture? Well, as Europe's population has been revelling in these improvements in life expectancy, they have been neglecting something rather important - procreation. The reasons for this are complex. Worried by insecurities in the workplace, concerned with getting on the property ladder and living in the parental home for longer, many Europeans have allowed their optimum child bearing years to pass. Almost insidiously, birth rates have dropped to critical levels.

Today, no country in Europe has a birth rate sufficient to maintain its current population. Only France, with a total fertility rate of 2.01, comes close to it: this compares to a worldwide rate of 2.59. To put this into perspective, were Germany to continue at its current fertility rate, the total population would drop to half its current level by 2050. Other countries face even more dramatic falls, with Spain, Italy, Russia and Ukraine all in the lowest 10 per cent of world fertility rates.

In the simplest terms, the consequences of this incongruence seem clear: greater demand on healthcare facilities coupled with a shrinking tax base to fund it has an inevitable outcome - a rationing of resources. However, the consequences are potentially wider and more serious. Other components of the social model dependent on the next generation paying for the current one, such as state pensions, will suffer in the same way, and other social services may also need to be rationed. Industries, including pharma, will compete with each other in Europe for a shrinking pool of talent to maintain their competitive edge.

The way forward
What can be done to reverse the downward spiral? There are two distinct steps required: firstly, to identify the factors which underpin the problem and take steps to resolve them; secondly, to put policies in place which will buy breathing space for the restorative actions to take effect and stabilise the current crisis.

This is a somewhat simplistic analysis; the underlying causes of the problem are complex, and require thorough deconstruction to get the policy angles right. What is clear, however, is that couples are delaying the age at which they start their families - the average age of first birth is now nearly 30. Unfortunately, by this age, female fertility is already declining, reducing the chances of being able to start a family, never mind have a second or third child.

Sadly, such is the underpinning of economies in the post-industrial world. Women in particular now face a tough choice between motherhood and a career. This is further compounded by the demand for secondary and tertiary levels of education, which is raising the age at which we enter the workforce.

Increasing housing costs act as a further driver to delay starting a family. Yet governments cannot simply restructure their economic policies overnight to accommodate the incentives required to allow for a balanced choice between career and parenthood. The reality is more complex, but the basics remain robust. Countries such as France, with one of the higher birth rates in Europe, offer substantial fiscal advantages to couples choosing to have three or more children. However, these measures are not enough and total fertility rates are still not at sustainable levels.

Hand-wringing aside, what is to be done? Fertility rates need to rise immediately, and current demands on healthcare and social services need to fall immediately. Calling a halt to both requires a two-stage solution: one, to stop the downward spiral and another to put in place long-term sustainable measures to ensure that these problems do not arise again. Empirically, the solutions are very simple, mainly because the options are extremely limited.

Call to action
Coming over the hill, cast in the unfamiliar role of white knight riding to the rescue, are the massed ranks of the pharmaceutical companies. It is so long since they found themselves in the role, no-one recognises them as such, yet the industry actually possesses much of the knowledge and the tools to help fix these problems. The challenge is to communicate the role it can play, and eliminate the inherent suspicions that it currently arouses in policymakers.

How can our heroes help save the day? The first hurdle is slowing the decline in birth rates. The reproductive clock may always tick louder with age, but we are no longer solely reliant on Mother Nature.

Assisted conception has been around for a long time. The latest assisted reproduction techniques (ART) are able to overcome many of the issues around getting pregnant faced by older couples. While not a panacea, it actually offers an effective and economically viable route to improving pregnancy rates. Unfortunately, it suffers from a disproportionately bad press, positioned as anything from a `lifestyle' treatment akin to cosmetic surgery, to a potential source of eugenics. Equally, it is perceived as expensive, unreliable and riddled with questionable practices.

The science is sound, however, and alternative approaches to improving pregnancy rates are practically non-existent. Those countries which have embraced widespread access to fertility treatment, such as Belgium and Denmark (where around 1 in 20 children are conceived by ART), have seen demonstrable benefits to their total fertility rates at a cost in line with other incentives. With economies of scale this could be improved further.

The challenge lies in getting policymakers to see this approach as offering a return on investment. Dougie Gibb, associate marketing director at Organon International, is familiar with the political inertia: There is a consensus that we do face a fertility crisis, but no consensus on solutions: we see no co-ordinated approach across Europe. Belgium is raising access to treatment from three cycles to six; meanwhile, the UK is looking to cut funding across the board. Policies driven by results and best practice, rather than short-term financial constraints, would surely be preferable.

If not quite 'problem solved', at least the industry has made a valuable contribution. It has also found time to address our other issues. The biggest of these is keeping the workforce healthy and contributing to the economy for longer, as well as reducing their demands on existing health services. To do that, we need to delay the range of chronic illnesses which currently atrophy the work pool.

Delaying tactics
Cardiovascular disease (CVD), obesity, diabetes, musculoskeletal conditions such as rheumatoid arthritis and osteoporosis, and neurological disorders all whittle away at workforce numbers. Effective public health programmes could delay, or prevent, the consequences of many of these conditions, and European countries now strive to meet targets to reduce known risk factors of CVD.

A fully-funded and wide-ranging prevention programme covering other major disease areas would make major improvements in health outcomes. However, the investment in establishing early control of diabetes, or providing sufficient access to bone densitometry scanners is not so widespread, primarily due to the perceived costs of so doing. The return on investment, and indeed the cost of not intervening, is seen as somehow beyond their purview.

To an extent, this approach is understandable. Forced to work within the narrow constraints of health budgets, and charged with delivering maximum impact for minimum expenditure, policymakers rarely look at the wider returns. Indeed, why should they? Most departmental budgets are clearly defined, so there is no fiscal incentive to benefit other ministries.

This seems to be an impasse, but to continue this way is a clear lose:lose scenario for both protagonists. Companies are being forced to do business with a customer with decreasing resources and more mouths to feed.

The dynamic between national governments and the industry has to change. As complex as the situation appears, whatever drivers and influencers have created this crisis, the solutions are simple: people need to work longer, and birth rates have to increase. The former change will probably be permanent, at least for the foreseeable future; the latter almost certainly requires long-term social change.

In the short term, the only real solution is intervention: disease prevention programmes, including effective drugs, and an uplift in access to fertility treatments coupled with career flexibility to remove disincentives to having families.

Such interventions will come at a price, but at the same time they have a value. Society is now at a stage where it is necessary to assess the impact of healthcare spending across a wider sphere. Yet, we still see a focus on narrow cost-containment measures, such as how to cut drug spending. No-one will argue that expenditure should not be kept in check, but cost-cutting should no longer be seen as a surrogate for value.

To achieve the change in mindset among both policymakers and manufacturers requires a realisation that the role of healthcare has changed. It is no longer just about preventing illness; it has become a primary factor in maintaining the broader functions of the economy and society. Both sides need to move out of the narrow silo of healthcare, and develop broader, more holistic policies.

Such a change will not be easy, but it is a necessity. A first step should be for the industry to lead the way in creating workplaces that fit the ideals of health promotion and the particular needs of older workers. It will provide the industry with a toehold on the moral high ground. This should be matched by recognition from governments that industry - not just pharma, but also health insurers, financial services and social service providers - has a pivotal role to play in providing solutions.

There is a pressing need for constructive debate to crystallise the nature and scope of the challenges that demographic change is creating. Only then can roles and responsibilities be properly assigned, allowing each partner to bring their particular talents to bear.

Getting a win:win outcome requires the formation of partnerships between industry and governments. Such partnerships have never been fully productive for the pharma industry in the past. This time the rules have changed.

The debate is broadening beyond the existing boundaries into less entrenched positions, and this, combined with the pressing necessity for solutions, will finally create a lasting symbiosis. Only then, perhaps, we can all live happily ever after.

The Author
Colin Mackay is the director of the healthcare and pharmaceutical practice of Weber Shandwick Worldwide (www.webershandwick.com)

8th March 2007

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