The dishes follow one another. Fish, no wine, but for dessert, a generous panacotta with red fruits. “Why not, if we don’t snack between meals,” smiles epidemiologist Antoine Flahault, between bites. Consulted like an oracle during the health crisis, the specialist came, for lunch, to present his new book to us, Tell me ! – Better health at any age (Robert Laffont, March 2024).
Inside these 300 pages dedicated to prevention, a few surprises: the scientist, for ten years at the head of the Institute of Global Health in Geneva, one of the health watchdogs in Europe, refuses to preach abstinence and elimination of risks. A “utopia”, he writes. Far from the constraints of the genre, he prefers to recall the medical consensus and present alternatives, not without greed, to unhealthy habits, from lifestyle to diet.
Because he is convinced: to be heard, you must avoid injunctions. And above all, that science infuses minds and culture. Thus Antoine Flahault constructed his work as a succession of life scenes, seasoned with literary references, from La Peau de Chagrin by Balzac to Doctor Knock by Jules Romans. At the table, he shares a dream: that tomorrow, more than yesterday or today, popular authors and screenwriters will take advantage of their success to make good practices “cool”. Interview.
L’Express: We often complain in France about the weakness of the prevention policy, and at the same time, a recent study published in The Lancet Regional Health Europe has once again shown our good results in terms of health: we have overall fewer cardiovascular pathologies and fewer cancers than our neighbors. How do you explain this paradox? Prevention isn’t so useful after all?
Antoine Flahault: Certain indicators are above all a reflection of the performance of the health system, the level of income and the cultural habits of different countries, rather than public prevention policies. Take the obesity rate, which is a significant risk factor for cardiovascular disease and cancer. France ranks rather well on this criterion due to our eating habits: we eat three meals a day at the table and we snack relatively little, while the Anglo-Saxons eat more often throughout the day. In Australia, for example, telling a child that you don’t snack between meals when he says he is hungry is almost considered abuse! This is one example among others, but it can partly explain our results on these pathologies.
Furthermore, widespread access to quality medicine thanks to Social Security contributes to bringing the population to a very high age, even though a significant portion suffers from chronic illnesses or disabilities. But this does not tell us much about the extent and effectiveness of the prevention policies implemented. From this point of view, healthy life expectancy at age 65 is a much better indicator of the quality of a country’s prevention: whether at this age you can keep your population healthy for a long time, efforts have been made for prevention. However, it is clear that, on this indicator, France is in a very average position.
What are the models to follow?
The Japanese are on the top step of the podium in disability-free life expectancy, with a ten-year difference with the French at the age of 65. It is enormous !
What are their secrets ?
First, they do more physical activity. They were the ones who invented the pedometer: the Japanese word for this device means “10,000 step counter”. This public health message has been very well promoted, a bit like the “five fruits and vegetables” in France. Since then there has been some controversy around the figure of 10,000, but it now seems well demonstrated that walking more than 4,500 steps is already very good, and that the benefit increases to around 7,500 to 10,000 not per day.
The Japanese also have a tradition of fighting against social isolation which seems quite interesting to me. They organize themselves around “moai”, small mutual aid groups around common interests. A Japanese person may belong to six or seven different “moai” – college friends, shooting star hunters, former colleagues, etc. They meet regularly and support each other. This was particularly useful during Covid: when a person was isolated, they could count on others for their shopping. We see that even retirees continue to have an active social life, including centenarians, which is very important for their mental health, to limit cognitive decline.
Finally, the Japanese also benefit from good eating habits, with a diet consisting of a lot of fish and poultry but little red meat, unlike the French. They still consume too much salt, but little sugar. And they have good results when it comes to alcohol and more recently tobacco.
How did they do it?
When it comes to alcohol, the explanation is more to be found in genetics. The Japanese carry a liver enzyme that prevents them from drinking heavily, as they feel the effects of alcohol after just one or two drinks. Concerning smoking, the local industry, very powerful and linked to the State, decided to promote tobacco heated without combustion (like Iqos, Editor’s note) and the consumption of classic cigarettes fell by 50%.
The tobacco community is very hesitant about heated tobacco, and I will obviously not promote it to non-smokers. On the other hand, with a team from the Institute of Global Health in Geneva, we have clearly shown the interest of these alternative products in reducing the risk among smokers. It’s the same thing with “snus”, this chewing tobacco very popular in the Nordic countries. The European Union continues to prohibit them, even though they have largely contributed to the virtual disappearance of cigarettes in Sweden.
Finally, even without medical revolution nor major technological innovation, we could already live in France much longer in good health…
Of course ! Several recent articles have shown that the possible gains could reach an additional twenty years for some. With many benefits to boot. Economic, first of all: certainly the increase in life expectancy leads to paying pensions for longer, but this additional expense would be largely offset by the savings made on the health system by older people in good health for longer. Caregivers, often women, would be less mobilized and could work more or keep their jobs. Healthy older people consume more, go to restaurants, go out, etc. With lower care needs, prevention helps to facilitate the management of caregiver shortages. Not to mention the benefit for climate change of favoring walking and cycling, or even reducing your consumption of red meat!
What would be the priorities for France?
We have significant room for improvement when it comes to promoting physical activity. I’m not talking about sport, but about physical activity and the fight against a sedentary lifestyle in general: walking, having standing meetings, having sit-stand desks, etc. Same thing for tobacco and of course also alcohol. Sweden and Italy have consumption almost 40% lower than that of the French. This shows our margins for progress.
How did these countries get there?
The Swedes have “deprivatized” the sale of alcohol, that is to say, alcoholic drinks are available only in state stores, which are not interested in sales, have restricted opening hours and do not advertise. It was very effective, but I’m not sure it can be transposed to us. The Italian model seems more interesting to me. This country is both a major producer and exporter of wine – it regularly competes for first place on the podium with France.
But the Italians have been more successful in promoting non-alcoholic drinks. Here, the party is always associated with alcohol, whereas this link has been broken in Italy, particularly among young people. This is good for the manufacturers themselves, because these products are taxed less even though they are almost as expensive as alcoholic beverages, and it is also good for public health.
So prevention is not always synonymous with injunctions and deprivations?
Sometimes we have to be directive, due to lack of time – with pregnant women, we can’t really take the time to convince them, we have to change our behavior as soon as the pregnancy is known. But otherwise, yes, we obtain much better results by making people want it. I cite in my book this famous Swedish example, where the steps of a subway staircase were transformed into a piano. Users quickly abandoned the neighboring escalator. It’s still much more fun than saying “for your health, take the stairs!”.
You know, my secret dream would be that Netflix would help us live longer in good health. Slipping public health messages into series would certainly be very effective. Like in my novel, where I feature in my novel a character of a pregnant woman who discusses her pregnancy with two friends at a café, a father who fights so that his daughter does not make headers in football… For now , in American series, it’s quite the opposite: the heroines always find themselves at one time or another with a glass of red wine in hand. This is not really the right message! Perhaps tomorrow, the screenwriters will have “public health” advisors in the same way that they already have advisors on respect for minorities! We know that this works: in Brazil, a large part of the decline in the birth rate has been attributed to telenovelas, where female models of success were often associated with a reduced number of children.
What about testing policies?
In matters of prevention, as in all things in medicine, we must rely on science. For my part, I often refer to the work of the US preventive service task force, which establishes consensus based on a very comprehensive analysis of the literature. For prostate cancer screening, they are clearly against after age 70, and highlight a lack of evidence of a benefit before this age. For breast cancer screening, they advise waiting until menopause, because before then the risks of false positives are too high – except of course in the case of genetic abnormalities.
Regarding drug consumption, you defend a position that is still quite controversial for the moment: total liberalization. For what reasons ?
Indeed, I think that all drugs, including cocaine and heroin, should be legalized and regulated as we do for alcohol and tobacco. We can clearly see that prohibition leads to the emergence of trafficking and mafias. More than half of those imprisoned today are for drug-related crimes. The war against these substances is a gigantic failure. It would probably be much more effective to allocate the resources mobilized in this fight to a real prevention policy regarding all problematic drug use!
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