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“Doctors should also use their expertise for the common good”
Sep. 2020Kids and teens
Susanne Stronski Huwiler, a paediatrician and Co-Head of the Public Health Service of the City of Bern, explains in an interview why adolescents respond better to specific prevention messages than to abstract concepts. And why paediatricians and general practitioners need to get more involved in public health policy.
Ms Stronski, adolescents consume fewer recreational drugs today than they did 20 years ago, but their screen time has increased. How unhealthy is that?
We’ve known since Paracelsus’s time that nothing is intrinsically healthy or unhealthy. It’s the dose that makes the poison. The main problem with digital media is that excessive consumption leaves too little time for other things, such as learning or physical exercise outdoors. In addition, the sleep-wake rhythm – that is in any case shifted in adolescents – is destabilised even further by the blue light emitted by the screens. A monotonous diet and a lack of exercise as a result of lack of sleep are some of the main reasons why nearly a quarter of today’s adolescents are overweight or even obese. It also strikes me that adolescents seem increasingly to be losing their awareness of the here and now. They may be sitting in a bus, but their minds are somewhere completely different.
In a recently published article (*) you call for prevention to be aligned with the developmental tasks that adolescents need to cope with as they transition from childhood to adulthood. What exactly do you mean?
Adolescence is a time of rapid physical development processes. Sexual drive develops. Suddenly the most urgent questions are “Who am I?” and “Where do I belong in the world?”. A fundamental reorganisation of the brain takes place. Unused synapses are removed, the proportion of grey matter decreases, and in exchange the proportion of white matter in the brain grows. Thought processes become faster, but not all at the same time. The first things to reach maturity are the structures in the reward system. The areas in the prefrontal cortex, where functions such as impulse control are situated, are the last to mature. This kind of information should be taken into account when developing prevention measures.
How, specifically?
The adolescent brain is considerably more susceptible than the adult brain to substance dependency – in particular nicotine dependency. Prevention messages need to focus on less abstract and more specific content and not just warn adolescents about smoker’s leg and lung cancer – these are risks that they won’t be exposed to until much later in life. What we need to tell adolescents about is things that affect them directly.
In your article you bemoan the fact that the prevention potential of health reporting in Switzerland is not being exploited to the full.
We’re on the right path with our health system, but we don’t actually know very much about how it works. That’s true of adult medicine and even more so of medicine for children and adolescents. Compared with other countries, Switzerland is a veritable desert in terms of health data. We need data to steer the system. Data are available in Switzerland, but they are mostly lying unused in hundreds of different medical practices.
Does the Swiss health system cater well for adolescents?
This country basically has a system that provides a very good service on a global scale. For example, the termination rate for teenage pregnancies is one of the lowest in the world at 3 in 1,000 young women. The very well designed HIV education campaigns certainly played a part in this. Yet I still feel there is room for improvement. There is no central medical resource in Switzerland that specifically addresses the needs of adolescents – a field known as adolescent medicine.
What aspects should adolescent medicine focus on?
Compared with pensioners, adolescents naturally belong to the healthy part of the population. Yet there are still some health problems specific to adolescents. This is the age at which many psychiatric disorders, for example, become evident for the first time – and are frequently not diagnosed until much later. Adolescence is a difficult time for many people with chronic disorders because their condition often becomes harder to treat in this phase. This is partly because the balance that they had found is in many cases derailed by the physical development they are going through and needs to be reattained and managed – which is the case with diabetes, for example. But also because adolescents break rules and want to cross boundaries. A young patient with asthma may think it’s more important to go out with his colleagues than to strictly follow the instructions given by his parents or doctor. This is understandable to a certain extent because that adolescent is also trying to gain independence.
Why do you want GPs and paediatricians to get more involved on a political level?
From a doctor’s point of view there are so many things that are not really negotiable. But if we don’t speak up, nothing will change. I was in the USA for a long time, where it is more normal for doctors to input their expertise into health policy discussions too.
Can you give us a specific example?
The American Academy of Pediatrics published a paper years ago that clearly opposed the installation of soft drink vending machines in schools. The facts were quite clear and showed that the absence of these machines led to a relevant decline in overweight students. But in Switzerland nobody had the courage to say the same thing for a long time.
Warum möchten Sie, dass sich auch Haus- und Kinderärzte vermehrt auf politischer Ebene einbringen?
Aus der Sicht von Medizinern gibt es so viele Sachen, die eigentlich nicht verhandelbar sind. Aber wenn wir unsere Meinung nicht laut kundtun, ändert sich nichts. Ich war längere Zeit in den USA, wo es selbstverständlicher ist, dass die Ärzteschaft ihr Fachwissen auch in gesundheitspolitische Diskussionen einbringt. Dieses gesellschaftliche Engagement fehlt mir in der Schweiz ein Stück weit. Klar sollten sich Ärzte in erster Linie um das individuelle Wohl ihrer Patientinnen und Patienten kümmern, aber darüber hinaus sollten sie sich nicht scheuen, mit ihrer Expertise auch zum Allgemeinwohl beizutragen.
Können Sie ein konkretes Beispiel nennen?
Die US-amerikanische Fachgesellschaft für Pädiatrie hat schon vor Jahren eine Stellungnahme veröffentlicht, in der sie sich klar gegen das Aufstellen von Süssgetränk-Automaten in Schulgebäuden geäussert hat. Die Faktenlage zeigt eindeutig, dass das Fehlen solcher Automaten zu einem relevanten Rückgang von Übergewichtigen führt. Doch hier in der Schweiz traute man sich lange nicht, das so zu sagen. Deswegen haben wir damals im schulärztlichen Dienst von Zürich jahrelang für die Verbannung der Süssgetränkeautomaten aus den Schulgebäuden kämpfen müssen.
Bei der Diskussion um das neue Tabakproduktegesetz (TPG) bringen sich die Kinderärzte doch ein?
Ja, das neue TPG ist ein wichtiger Schritt in die richtige Richtung. Leider sind im Gesetz immer noch nur partielle Werbeeinschränkungen vorgesehen. So wird das Ziel, Kinder und Jugendliche umfassend vor dem Einstieg in den Tabakkonsum zu schützen, noch nicht erreicht. Ich hoffe, dass die Erfahrungen mit der Initiative «Kinder ohne Tabak» viele Kolleginnen und Kollegen motiviert, sich künftig vermehrt für strukturelle Veränderungen und eine gesundheitsförderliche Umgebung einzusetzen. Denn aufgrund ihrer Erfahrung und ihrer Glaubwürdigkeit sind Ärzte bestens für ein anwaltschaftliches Engagement zugunsten einer positiven Entwicklung von Jugendlichen geeignet.
Zum Schluss noch eine Frage zu einem anderen Thema: zum neuen Coronavirus. Welche Auswirkungen hatte der Lockdown auf die Gesundheit der Jugendlichen?
Zu einer gesunden Entwicklung gehört, dass Jugendliche eigene Lebenswelten ausserhalb der Familie erschaffen. Stattdessen wurden sie im Lockdown auf die Ursprungsfamilie zurückgeworfen. Zudem konnten einige Jugendliche mit psychiatrischen Symptomen ihren Arzt oder Psychologen nicht mehr sehen. Bewegungsmangel zusammen mit falscher Ernährung, eventuell noch kombiniert mit Schlafmangel durch exzessiven Gebrauch von sozialen Medien können zu Übergewicht führen. Allerdings können wir zum Ausmass noch keine Aussage machen, ebenso fehlen Zahlen zu den psychischen Erkrankungen.