Germany: putting economics before ethics
The printed journal includes an image merely for illustration Philip Rösler
Months of political horse trading in Berlin came to an end last week, when German Health Minister Philip Rösler announced a package of reforms to the country’s health insurance system. To deal with a deﬁcit predicted to reach €11 billion by 2011 in the public health insurance fund, the governing centre-right coalition will raise individuals’ contributions to the fund from 14·9% to 15·5% of gross pay. Employers will contribute 7·3% of the total 15·5%, with the insured contributing the rest. Controversially, the 7·3% employer’s contribution will be capped from now on, but Germany’s public health insurance providers will be free to demand unlimited top-up fees from individuals to cover what the health ministry described as inevitable future spending increases. Individuals asked to pay top-up fees greater than 2% of their gross pay might be eligible for government aid, depending on their level of income. The reforms are being touted by Rösler as the path to achieving the perceived economic imperative of decoupling health-care costs from labour costs, and mark a decisive shift away from a system that was lauded for its
guiding ethos of solidarity. Unfortunately, however, it is by no means certain that sacriﬁcing such a cherished principle will bring sustainability to a system in which it is taken as an article of faith that increasing health-care costs are not only unavoidable, but are also necessary for the economic health of the country. Germany now spends more on health care as a proportion of gross domestic product than any country apart from the USA and Switzerland. Any progress towards sustainability will be contingent on the governing coalition—which has suﬀered a series of setbacks in the past month—summoning the political will to tackle those with a vested interest in maintaining such a bloated system. The portents are not good. Recent attempts to put greater price controls on drugs came to nothing in the face of aggressive lobbying from the pharmaceutical industry, while the present reforms represent the opposite of the cost-cutting measures that were promised before the most recent election in September last year. Political will, it seems, is in short supply. ■ The Lancet
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Lighting the way to better health: vitamin D
See Comment page 148 See Articles page 180
For more on Australia’s SunSmart guidelines see http:// www.cancer.org.au/cancersmart lifestyle/SunSmart/ VitaminD.htm For more on vitamin D during pregnancy see Br J Nutr 2010; DOI:10.1017/ S0007114510002436.
The public health message is compellingly simple: avoid the sun to prevent melanoma and other forms of skin cancer. Unfortunately, exposure to sunlight is the mainstay of vitamin D synthesis, and vitamin D deﬁciency causes rickets and osteomalacia, contributes to osteoporosis, and has been associated with many other disorders, including diabetes, cancer, and cardiovascular disease. Ultraviolet B radiation produces 90% of vitamin D in human beings; only a very small proportion can be obtained through diet. However, at high latitudes, levels of sunlight in winter are often so low that vitamin D insuﬃciency is common. Avoidance of the sun’s rays by covering up or use of sunscreen can compound this problem, and is thought to have contributed to a recent increase in metabolic bone disease. Cancer Research UK recognises the need to balance skin cancer prevention with generation of adequate vitamin D, but speciﬁed that “the skin eﬃciently produces vitamin D at levels of sun exposure below those that cause sunburn...when it comes to sun exposure, little and often is best”. Australia’s SunSmart guidelines underwent a revision to reﬂect this balance in 2006–07.
A major concern is that people might seek prolonged sun exposure without protection to boost vitamin D synthesis. Indeed, the American Academy of Dermatology argues that the risks of sun exposure outweigh the beneﬁts, advocating instead for dietary supplementation as a safe source of vitamin D. A report published in the British Journal of Nutrition emphasises that in the UK, a uniﬁed approach to vitamin D supplementation is needed to address deﬁciency in pregnant women and avoid lifethreatening complications for their babies. Despite the simmering debate about sun exposure surrounding vitamin D, the SUNLIGHT consortium’s genome-wide association study, published in The Lancet today, should add to our understanding of the genetic basis of interindividual variability in the synthesis of vitamin D. These ﬁndings could eventually help to identify who is most at risk of vitamin D insuﬃciency and related diseases. Until such potential applications come to the fore, the message about sun exposure has to be sensibly moderate. Enjoy the summer sun, with caution. ■ The Lancet www.thelancet.com Vol 376 July 17, 2010