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Prior to the industrial revolution in the mid-1800 s, the modal lifespan for humans was somewhat less than 75 years. Natural life expectancy was approximately 35 years, with a high child mortality rate strongly contributing to this low figure. At that time, natural life expectancy of someone aged 75 was 6 years, whereas the current life expectancy of, for example, a 75-year-old French woman is 14.5 years. The sharp increase in longevity means an added eight years of life in old age. Nevertheless, the rate of ageing, i.e. the degree of mortality-risk increase related to age, remains astonishingly constant. Preventive strategies that use the absolute risk of age-related diseases for setting treatment goals, in fact treat increasing age. For each population, the risk reaches its peak at a certain age; over a lifetime, the risk of death is always 100%. Under pressure from modern society and medicine, old age is now treated as a disease and medicalised to a great degree. To improve medical management of elderly patients, we will have to accustom ourselves to consider the goals of these actions, to ask ourselves: what is called wisdom?

The practice guideline 'The Prevention Visit' by the Dutch College of General Practitioners utilises a questionnaire and derived risk score related to age, sex, BMI, smoking status and a few more but minor determinants to assess the absolute risk of cardiovascular disease, diabetes and chronic kidney disease. According to this test, all persons over 65 are at risk. The description of the health problem addressed is limited to unfounded speculations on unhealthy lifestyles. Except for smoking cessation and blood pressure reduction, the proposed interventions lack evidence of effectiveness. The undesirable or harmful side effects of advice and treatments, particularly the overtreatment of elderly persons, are not discussed. This prevention visit is therefore an emanation of the culture of fear: health experts exaggerating health problems. In doing so, they transform the basic human fear of ageing and death into seemingly objective 'risks' that need 'treatments'.

Since August 7th, treatment with neuraminidase inhibitors (oseltamivir) in the Netherlands has been limited to those patient groups who are considered at high risk of influenza-related complications. This policy is based on one study which shows only limited evidence of the effectiveness of neuraminidase inhibitors in lowering the number of such complications.

Complaints about the partisan and poor information about mammographic screening go back as far as the introduction of the national screening programme. Research has shown that the great majority of women largely overestimate its advantages and ignore its disadvantages. This article outlines a structured draft of the advantages and disadvantages of breast cancer screening, framed as figures per 10,000 mammographies or 1000 women participating for 25 years with an average of 10 mammographies: 125 women are referred with a false positive diagnosis, 55 cancers are diagnosed during screening, and 21 cancers appear in the intervals between screening. Four women avoid death from breast cancer, 15 women die of breast cancer despite screening, and 51 women receive a diagnosis while screening which does not improve their prognosis, 16-20 of them are treated redundantly. These figures are based on the best evidence available, but are subject to further improvement.

Screening healthy people at low risk of colorectal cancer using faecal occult blood testing (FOBT) is an old method that was proven effective in reducing colorectal cancer mortality in randomised controlled trials published in 1993-1996. Screening reduced colorectal cancer mortality by 1 per 10,000 person-years and increased colonoscopy rates by 50 per 10,000 person-years. Population screening increases the annual cost of the diagnosis and treatment of colorectal cancer by at least 35%. Physicians and other well-informed citizens rarely undergo colorectal cancer screening. In prioritising health care needs, preference should be given to the needs of actual patients, rather than placing demands on healthy individuals.

Due to family planning, Dutch women are increasingly having their first child between 25 and 35 years of age. Compared to 13 other EU countries, Dutch women are having fewer children both earlier and later on in life. From 1970 onwards in the Netherlands, the mean age at first childbirth has increased by 5 years to 29.4 years. The main cause for the rising age at first childbirth is the decrease in the number of young mothers. In 2006, 7% of all childbearing women had their first child after the age of 36; this is just 4.7% higher than in 1970. The percentage of women remaining childless by delaying childbearing too long increased by 0.9%. Considering the social and medical problems in later life, it would not be wise to encourage women to have their babies at a young age, certainly not before the age of 23. Women planning a family should take into account the decline in natural fertility after the age of 35; the future mothers of the Netherlands seem to be planning and deciding wisely.

The increasing prevalence rates of overweight and obesity in prosperous areas of the world are causing concern everywhere. Evidence is now available on the excess mortality caused by overweight and obesity. However, in all populations, including that in Asia, the body mass index (BMI) associated with the lowest mortality is in the category 'overweight' (BMI: 25.0-29.9 kg/m2). Cardiovascular mortality has increased, but is balanced by subtle decreases in other causes of death. Even in the category 'mild obesity' (BMI: 30.0-34.9 kg/m2), evidence of increased total mortality is hard to substantiate. Smaller samples from Dutch prospective studies confirm these findings. The epidemiology of overweight and obesity has been changing. BMI is only a rough calculation of adiposity and its relevance may be worse in tall and well-nourished populations. The major cause of obesity-related mortality, cardiovascular diseases, has decreased considerably, partly due to successful cardiovascular risk management. Mortality is lower in 'overweight' than in 'normal weight' BMI's. Overweight and mild obesity are a totally different story to smoking. Smoking is fatal and saves health care costs by killing. Obesity is now a largely non-fatal condition that successfully avoids premature death by effective risk management but with increased health care costs.

Environmental exposure to man-made electromagnetic fields has been steadily increasing as the growing demand for electricity and advancing technology have created many artificial sources. Over the course of the past decade, numerous sources of electromagnetic fields have become the focus of health scares, most recently mobile phones and their base stations. The predictable reaction to these health scares has been 'more research'. This comment argues that studies of the possible hazards of low-level electromagnetic fields waste scarce financial resources. Many studies have convincingly excluded detectable tangible health hazards. Bayesian logic predicts that the likelihood of false-positive results will be great in studies lacking a prior hypothesis and using non-specific health states as outcomes. The health hazards due to the maintenance of environmental scares by false-positive studies have been neglected. The nocebo hypothesis states that expectations of sickness cause sickness in the expectant individual. Maintaining anxiety by fostering doubts in gullible populations about the quality ofthe environment they live in may cause serious mental illness. Anxiety caused by health scares is an increasing public health problem, which should be addressed in its own right.

In the treatment of confirmed influenza, neuraminidase inhibitors yield only a limited reduction in the duration of disease and are neither efficacious nor cost-effective. Neuraminidase inhibitors would be cost-effective if a deadly influenza virus that is highly sensitive to oseltamivir causes a pandemic soon. If not, then the money invested in establishing a store of oseltamivir is wasted and lost to the health-care sector.

Since the early 1990s, screening with prostate-specific antigen (PSA) testing has increased the incidence of prostate cancer. Any decrease in mortality will not be seen for at least a decade, due to the long natural history of prostate cancer. Death due to prostate cancer is rare, while the prevalence oflocalised tumours is high. The prognosis of these early-detected localised tumours is uncertain, because most patients will die from other causes. Complications of prostate-cancer therapy are common, with high rates of impotence, incontinence and gastrointestinal problems after prostatectomy or radiotherapy. Randomised trials of prostate-cancer screening, notably the 'European randomised screening for prostate cancer' (ERSPC) trial, began with the consent of ethical committees. There is a real uncertainty regarding the benefits of prostate-cancer screening. However, it is clear that these benefits are limited, because prostate-cancer death is rare before the age of 75 years. There is no real uncertainty about the harms of prostate-cancer screening. High prevalence and high rates of treatment complications deduct many disease- and disability-free years from the eligible population (men aged 55-74 years). Therefore, there has been no real uncertainty over the balance of harms and benefits in prostate-cancer screening trials. Days may be added to old age, at the cost of months of disease- and disability-free living. It is not in the best interest of eligible men to participate in these trials. Randomised trials evaluating prostate-cancer screening violate in principle and practice the Helsinki Declaration of the rights of human subjects in medical research.

The supposed health risks of passive smoking are leading to increasingly restrictive legislation on smoking. Tobacco smoke is undoubtedly irritating to the eyes, nose and throat of non-smokers, but politicians wanted more spectacular facts. There is some evidence of fatal consequences of passive smoking, particularly increases in lung cancer and heart-disease mortality among non-smokers exposed to tobacco smoke. Most studies compare the non-smoking partners of smokers and non-smokers. The observed relative risks are too small to be ascertained reliably. The more than twentyfold increased risk of lung cancer among smokers and the presence of tobacco-related metabolites in non-smokers' body fluids lend support to the hypothesis that passive smoking causes lung cancer. The less than twofold increased risk of heart disease among smokers and the documented social-risk factors cast doubt on the validity of the increased risk of heart disease in non-smokers, associated with having a smoking partner. The precautionary principle regulates potential environmental health hazards: the suspicion and the hazard must be sufficiently serious to take legislative action. There is ample evidence of tobacco smoke's carcinogenicity and the accumulated knowledge strongly suggests that the legal threshold of an acceptable environmental health risk has been exceeded.

Objective: To quantify the medical consequences of the tobacco use in the Netherlands for the past 50 years and the near future., Design: Theoretical study based on the national death records and published risks by cause of death of tobacco use., Method: Observed lung cancer mortality (1950-1999) was related to birth cohort and age by a statistical model (according to Peto), and then projected into the near future. The smoking intensity was defined as the difference between the expected lung-cancer mortality if no one smoked and the observed lung-cancer mortality. Using this smoking intensity and published risks for other smoking-related causes of death, the model provided estimates of smoking-related mortality by age, sex and cause of death., Results: In 1999, 18% (women) and 32% (men) of all mortality before the age of 70 was attributable to smoking. If no one had smoked, Dutch life expectancy for men and women would have been 3 years and 1 year higher, respectively. Between 1950 and 1999, 13% of all deaths were caused by smoking, the large majority (> 90%) of which occurred among men. Between 2000 and 2015, slightly more deaths are to be attributed to smoking (14%), 62% of which will be among men. In 2015, women will have caught up with men in terms of absolute numbers of lung-cancer mortality., Conclusion: Around one quarter of premature deaths were caused by smoking. In the near future, women of the baby-boom generation will have reached middle age and the highest (relative) smoking-related risks. It is important that clinical practice takes this increased risk of disease into account among middle-aged women who smoke.

The recent Cochrane review on mammographic breast cancer screening disclosed no convincing reduction of breast cancer mortality, together with an increase in the number of aggressive treatments. Given this outcome, there no longer exists solid experimental evidence to support mass screening. In the Netherlands over 800,000 women are invited to participate in this activity yearly. Is this still justifiable? The final answer rests on the conclusions from the analyses carried out from three different perspectives. From the methodological viewpoint, a broad re-analysis is needed which also takes the long-term adverse effects of radiotherapy into account. From the tumourbiological perspective, whether 'early' diagnosis really has potential therapeutic consequences should be explored further. From a societal perspective, more detailed and balanced information is required, since expectations regarding the effect of screening are unrealistic. Given the preliminary outcomes of these analyses, there are now serious reservations as to whether continuation of screening is justified. Women should be informed about this matter promptly.

Guidelines for clinical practice have as their primary aim to improve that practice. However, the increasing flow of medical technology threatens to exhaust the financial reserves. There is now an undeniable conflict between what can be done and what can be paid for. This leads to a conflict between the responsibility of the caregiver for the individual patient and for society. Either available care is denied or health insurance is ruined. This inevitably leads to increasing inequality: only the better off can afford a therapy which is effective but not efficient. The individuals right to health care can never entirely be reconciled with the societal imperative for a more just distribution of financial resources. Guidelines which are a result of a bargain between all stakeholders are therefore more just: they are a compromise between the rights of the individual and those of the society. The legal status of guidelines should be reinforced.

Recently guidelines for cholesterol lowering therapy by means of 'statines' (HMG-CoA reductase inhibitors) were published by the National Organization of Quality Assurance in Hospitals. The part about primary prevention of cardiovascular disease is based on absolute risks for coronary heart disease as calculated by the Framingham Heart Study risk functions and on a cost-effectiveness analysis. However, the function predicts risk of disease such as silent infarction and angina pectoris. The incidence thus produced is higher than any observed clinical incidence. Absolute risk increases exponentially with age, but remaining life expectancy, and thus benefit, decreases. Therefore, decisions about treatment levels are based on arbitrary assumptions. The function is ultimately only used to advise treatment to the smoker, while the better choice is always to stop smoking. The effectiveness is overestimated by using a long time horizon of treatment of 25 years in the cost-effectiveness analysis. Primary prevention of coronary heart disease according to the new guidelines is still very expensive.

Objective: To estimate the costs of health care in 1994, the development of the costs assigned to specific diseases, and the future costs., Design: Descriptive., Setting: Erasmus University, Department of Public Health, Rotterdam, the Netherlands., Method: For each health care sector, costs were allocated to 62 diagnostic groups, age and sex making maximal use of national registries and other sources with data on health care use in the Netherlands., Results: More than 80% of the 60 billion Dutch guilders that were spent on health care in 1994 could be assigned to specific diseases. Most costs were made for non-fatal diseases like mental deficiency, dementia and musculoskeletal disease. Except for cardiovascular disease, the share of major causes of death in the total costs was not significant. Average costs per inhabitant were low during youth and adulthood but increased exponentially with age from age 50 onwards. Between 1988 en 1994, health care costs experienced an annual growth rate of 5.2%, caused by price and wage increases (one half), ageing (a quarter) and other effects on health care costs such as epidemiological and technological change (a quarter)., Conclusion: The main determinants of health care use in the Netherlands were old age and disabling conditions. Due to ageing and other influences, real health care costs in the years to come will increase by an average annual rate of 2.4%.

Objective: To estimate the numbers of hip fractures among Dutch women caused by senescence in contrast to decreasing postmenopausal bone loss., Design: A Markov chain model in a multi-state life table., Setting: Department of Public Health, Erasmus University of Rotterdam, the Netherlands., Method: Cross-sectional data of prevalences of femoral neck bone mineral density, measured in an epidemiological survey (1993), were related to numbers of hospital admissions for hip fractures among women aged 55 and older, using a (published) relative risk for hip fracture of 2.6 (95% confidence limits: 1.9-3.6) per decrease by I SD of bone mineral density. We varied the prevalences of bone mineral density in the multi state life table and looked at changes in the expected number of fractures., Results: If bone loss were to cease after the age of 55, this would decrease the number of fractures by 39.4% (30.4%-45.2% in sensitivity analysis). If bone loss were delayed by 7.5 years, the number of hip fractures would decrease by 14.8% (10.0%-19.9% after 5 to 10 years' delay). If compliance decreases by age (3% per year), then the number of hip fractures would decrease by 5.6% (3.4%-11.0% after 1%-5% decrease of compliance per year)., Conclusion: Bone loss is only one of the many age related causes of hip fractures. Population based interventions targeting only bone mineral density, while ignoring comorbidity, have only a limited potential for preventing hip fractures.

This study is an essential prerequisite to gain more insight into the complex relationship between public health and the costs of medical care. It offers a first tentative but comprehensive description of the total direct costs generated by all diseases in the Dutch population. We classified estimated direct costs of illness (39.8 thousand million guilders) by type of care, sex, age and 48 diagnostic categories for 1988. In order to estimate the costs of health care in the year 2030, we linked this information with demographic development. We were able to allocate 75% of all costs to diseases. Ranking by major disease categories revealed that mental disorders account for the highest proportion of costs (20%), followed by diseases of the circulatory system (9%), and diseases of the digestive system (8%). Costs of medical care increased significantly with age and were presumably incurred for non fatal ailments. Health care costs for men and women were almost similar. In the year 2030 the costs of dementia and diseases of the circulatory system will increase most. A reliable estimate of the costs should also take epidemiological and economic considerations into account.