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Chronic diseases in the year 2005

In 1988, a Dutch committee was appointed to study possible developments in chronic diseases. Diabetes mellitus, chronic non-specific lung disease, and rheumatoid arthritis were the chronic conditions selected for this study on public health policies because of their high morbidity toll. This book reports the Committee's conclusions on rheumatoid arthritis. The first part of the book is concerned with a description of the current dimension of the problem. The prevalence, incidence, and mortality of rheumatoid arthritis in the Netherlands were calculated from previous studies, despite some reservations on their accuracy-expressed also by the authors. Indeed, one of the epidemiological sources on the general population did not consider laboratory and radiographic data for the diagnosis ofrheumatoid arthritis. Another study involving general practitioners considered rheumatoid arthritis together with ankylosing spondylitis. A summary of the clinical features ofthe disease and its treatment is included for the general readership. Another chapter is concemed with patients' quality of life and the problem of drug consumption, which is examined in a qualitative and quantitative way. The health professionals involved in the care of the rheumatoid patient, including general practitioners, physiotherapists, nurses, health visitors, home helpers, social workers, alternative medical therapists, medical specialists, and ergotherapists, are examined and their rate of utilisation by the patients is carefully calculated. In the second part of the book, a scenario of the possible future developments is sketched. It is based on the written response to a number of questions by a group of 35 experts that included not only rheumatologists, but also general practitioners, nurses, ergotherapists, surgeons, researchers, and representatives of social groups. In the third and last part of the book, four possible future scenarios based on the foundation study and the expert's opinions are described and discussed. This exercise is certainly interesting, but it is based mostly on soft data, such as the epidemiological considerations comprised in the first part. The four scenarios consider different combinations of demographic changes and rate of diagnosis of rheumatoid arthritis. The important message is that the absolute number ofrheumatoid patients is predicted to increase by 21% in 2005 compared with 1990. Approximately 8-5% of this figure will be attributable to population growth and 12.5% to population aging. An additional increase of about 20% in the number of known rheumatoid arthritis patients will derive from better diagnostic practices, especially by general practitioners. As several data reported by the authors suggest that only 50% of the patients with rheumatoid arthritis are currently being recognised, there is much room for improvement. These calculations, however, do not consider the secular trend in the incidence of rheumatoid arthritis that is declining according to several studies performed in the United Kingdom and USA. Because ofthe large number ofvariables considered and the uncertainty of previous data, it is dangerous to predict the future, even in the field of rheumatoid arthritis. This has been the general rule since the times of the Delphi oracle and of the sybil of Cuma; nevertheless, the authors have been brave enough to tackle this subject. The book is not structured in a traditional way, but reports stepwise the committee's considerations. Therefore it is not always easy to find single pieces of information; the absence of an analytic index, although understandable in this type of report, is a further complication. It is a pity that nearly half of the 256 references are in Dutch and difficult to find for the foreign reader. The readership of this book is represented primarily by rheumatologists involved in epidemiological research, or who are simply concerned with the possible developments in the care of rheumatoid arthritis. It may also be of interest for anyone involved in decisions regarding health policy issues in rheumatic diseases. The book could stimulate similar studies in other countries and should be recommended reading for politicians involved in public health.