40 JAN 1980 .LrUL MEDICINE DREAM, MIRAGE OR NEMESIS? Thomas McKeown BASIL BLACKWELL - OXFORD(© Thomas McKeown 1979 Fs polithed 979 by Bas Blackwell Publier Ltd, Aled St, Onford OX {HID Eng [AL Righe Reserved. No past of this publication may be reproduced, stored in ‘eer sym, or ante, in any frm by ay sen, leon anh thie, phowcopying, receding or there, without the prior permision of Bas Blacewel Pb Lied ‘A sbster version of ht book wa fit published athe 1976 monograph ofthe Rock Caring Sei by the Nofield Provincial Hoya Tra ISBN 0431 tore 0 i ISBN 03: 261 8 i ‘Type by Cotwold Typing La, Gloceter and pine in Geet Bein by Biling nd Som Led, London, Guided and Wore. CONTENTS Preface tothe second edition Throduction 1 Evolution of Health Concepts 2 Inheritance, Environment and Disease 4 Decline of Morality 4 Infectious Diseases 5 Nowinfetve Conditions 6 Health in the Pst 7 Health in che Porure 1 Medical Achievement 9 Now-Pertonl Health Sevices 10 Clinical Services 11 Medial Bd 12 Medical Rereaech 13 Dream, Mirage or Nemesis? 14 Medicine asa nstiution 2» 4s m 2 * uy m1 3 156 176 190Part Two Determinants of HealthDecline of Mortality Aidough he docomenay evidence was very anasto before bits and denths were repiered rationally, thee ir doubt that ‘hg as buen a varesmprovement in heh dng the at ee x ties Dating most of man's exitnce iti probable that considerable proprion of all cldcen ded or were Ml within afew year of et Sch records a ace avaible, token ith een experience in derdoping cout, gge tht although there war considerable vartan fom ime to time and from ple to plac, ot of 10 em Sor lien, on sverge 2-1 ied before he fi biray, ‘eS abour7 before matryIn enol avaned coon Sheds, ote than os pr cet survive vo aul ie The deine of morality, andthe aoe incest expectation off ais = lm between yo and 4 yas in 1709 © 7s Yea for tak and 7 fr females inthe contr (Seen) with he bet ures it aga ate wor the ony indcston of ioprovement in heath Sil lea ae they arin bas for dicosiom of the medical role, and ‘Chapter # examine other indices of medical achievement; the post onemen of death nd tecinent of morbidy rom dnases whi do Ebi Neverlesy il esuggeted tht pity tobe given song mestres which ae sll esl, che prevention of death and ‘rein af fe atere the mos portant achieve’ eis thecefre ‘etl to dtrine the exon fr the decline of mocaliy “The alist national records of births and death ze foe Sweden (179) and France (rom ro) and they leave no dob hat deat ‘ser wc ing from the beginning ofthe nineteenth ear. How foe thre it input nice evidence ht he cecne oqan Strebel, probly nthe fet half the eighth centr, Fike pl gromth of popustion which watevien many comnines Tefre 1800" Atempts hve been shade to atribte tis expansion lngsy to 9 he in innate, brought about by widraval of »° Dacrminants of Health resins on ferily. Thi explanation isnot convincing, since ten fexily be shown the if morality had not deine! he population ‘woud noe have en. Any inctene fom sing bine ia te tightesnthcemiry wold fave bern ofc by he nsequent from the nineteenth century ‘When interpreting the deci of mortality we mst ly to acon sideabic exe on what admitadlyan uncle ote of eres ‘aly, national satis of ext of death. Howeve,n pt ofthe Aficio low) thee ct ae of eonsderale aloe. They aval fist in Englind and Wales (om 1838) In the ya imueditly fer regination the records were incomplete ofr cet reson mtitctory, ft om 18414 pole to cramine he wend Of morality suocated with specie dese, Tht evidence from national sources fon theft hal ofthe intent entry i ot Ivallble ehewhere, 30 in other counties interpretation i val rected the tenth century. Ths ay exp the een ove esimation ofthe contribution of tmmuntzation aod thetpy, sine there measues have hd heir impact mainly, indeed wih one exception {rsecnaton agin sallpox) probably whelly sce 10 Fig 3. shows the death-ate for males and females From 184 to 1971 For the nineteenth century the rates ate fo the ix decades ad foe the twentieth century they ae foe the fist yeae ofeach decade; both were, standatdized in relation to the 1991 population to correct forthe chang ing age structate, since with an aging population the erudedeath-at, underetimate the reduction of mortality which actually occured "Throughout the petiod death-rates were considerably highet for male than for females; they began to Gill n the eighth decade of the nine teenth century and the decline as continued to the present day However, a already noted the examination cannot be resricted 1 the nineteenth and twentieth centuries, since the growth of population (in England and Wales i erebld between 1700 and 1851) indiats chat the decline of the deatherite bogen well before r838. Table 3.1 show the proportion ofthe reduction of mortality which occured in dee petiods 1700 tothe mid ninetenth century (a thed; the second half sacrn Ten monty nd we dh’ pin Sain Daedine of Mortality » g sl ies % i ma oun. Dette (tani 0 1908 poplin gland sad Wale ofthe nineteenth century (a fh); and the ewensith century (neely Taf) Thee figures ae based on the sumption chat the deateece in England and Wales the beginning of the eighteenth contury wat 30. ‘The Swedish death-rate for the period 1751 to 1800 was 274 and the tae for England and Wales i believed to have been st about che sare level o litle higher anu 3.1, Reduction of matali ince t780: Bla and Wales Prange mae f straint 18gh-s4 10 1908 2 =rs Determinants of Health Doubs shout the ely of wate of came of death were unde ted by recent investigation of the sccracy of ertfiaton in the eset dy. Ina lege srs of patents who ded in hospitals davag {ors and 197, clinician aatemostem diagnose were competed Wi the dngnens ade sbiequenly by pontemortem examination. ee once hati chan halt ne in hn ponpetve 68) Wa the lal diagnosis of ewe of denth confme tstgpy. There ‘maining caer were alot equally mpi between those in which thee ‘was only minor diference of opinion and hoe which dsageement veo total ‘That wo sy, she clinical diagnos entered onthe dex Certfeate wa seul rong in about 8 quarter ofthe cus, The Fequent cor in presenedsy crifeaion of ess of dest in spi, of radiological, laboratory and othe supportive evidence, ase doabs bout wineeenh-centiry Rais, and sll more about conclusion cncemingdieacs such ot sallpox and plage inte eighteenth nd tater centuries when cate of death was not certified. “The dificle ar pict serio cates such 8 preumoni ‘where the evidence i prejudiced not only by errs in diagnosis bat ths by changes in diagonte bios and in easication of case of dent Seales fever, for example, war not separated from diphtheria inthe nation clasication in Eaglnd and Wales until :855,n0r typ from yphoid unt 1869, Tei thetfore important to consider some of the main question in rliion tthe infos as whole, ot eta feation to broad cases (ach at acborne of Water- and food-bome tise) eather aT put too mach weight on interpretation ofthe behaviour of any single duewe, Neverels, something can be learned ation of ingle dicate if tee spec festares andthe hin whch te satis likely to fl fom an ex consdeeabe range of e:rot te taken into account In the discussion which follows conditions attfbutble 29 micro organisms are distinguished from conditions whieh are not. The Gstnction cannot be made ill cases. For example inthe early reir tation period cheumatie heart diseate wat not sepaated from other eases ofthe beat, 0 although caused by streptococea infection, {sineluded with non-infective conditions. Nepheis was clasified with 1 Walton HA. and Vickey Ly Itt of Quay. eon ddan: Noel Bovine! Hovpa Tas, 197). 2 ope which spay of sonnfeiv rg, x0 when data fo the Peers clay reve ep sho ken wth conditions etal o micrgensa loop mot cies el rom Tete There arf there conn whichever oy SESE ped in alsin, ream ese of the $e Nchou nyse due syst congest malformatns Sista dttom bela Wih see erestons, the tad dition Cee tea and suri sve condions cn be made wih teovule condense EI SS the proportion ofthe decline of moaltyaodted shire cet e990 m9 Ft Tar Com tot ip; On the supe da te was deen Stomineclve dea bfoe sgh en cau of deh wa ukow, Be oti tal elocion ofthe debate fom he egoning the cents centry fo he present ay oan aecbuable to the dene of he nections In Table 3.2 the reduction of morality sociated with infectious di- caasindvided between tree groupsairborne; water-ind food-borne: fd other, The years 184B-sy have been taken to repent the begin= ting ofthe regitation period because cetfiation of case of death f moi, 1848-34 6397: nd Weler sar 3.3. Redon Engl Condition sible to Taide dees ” [Wacrandfond-bornedimses 5: Other coniors i Toul x Condon not bone to maroon 4 Alder 1 “The cima hs opto of des ond wi peste ESTs en the whe pt OFA 1970 ous! acon te sel eo vey oe blI hve. wie u Determinants of Health wat incomplete daring pare ofthe fist decade after citation, andthe rates for 1848-54 and 1971 were standardized to correspond yvth the age distribution of the 1901 population. Of he fll of morality since the mid ninereenth century, 9 per cent was from sigborne dss, 21 per cent from water- and food-bome diteates, 13 per ent fom fer infections, and the remainder (26 pe cent) om nowinfetive Airborne deus. Table 3.3 shows the contibution made by different sicbome diseases to the total decline of mortality. Rerpirstory tuber culos accounted for +7, pec cent, and more than halo this impeovee ‘ment occured before the end of the nieteenth century, Mortality fom the disease fll continuously, at lest fom the ie when cour of death vas fist egiteted, and by the fh decade it had fllen by about + guaner. ‘aL 53, Stonderdizeddeth-rates (per lin) fiom core ‘diese: England and Wales “fol cee Tubercle epitory) ager a3 ns Beane paeumoniyiuenee 339 BO>8 Bienes eek et a8 Set Feverand diphtheria ris 8 a Soper ae pa ol te infects ofex, pharynx gmx 9g ot Toul oy ws “The next largest contribution was fom bronchitis, pneumonia, (aia ‘Table 5.) inflaenaa(o.9 per cen) le ir unforeontelynecestcy to gr00p these condivons because there is some evidence of tater from One another, For example, both pneumonia and bronchitis death show on increase in years of high influenaa prevalence, and ic acm clea thats ‘number of influenza deaths were ascribed to pneumonia, and, even rote Frequently, 0 bronchiti, Confsion berween bronchitis and ppeoni, at east in old people, suggested by the face thatthe Site rate of met aged 75 and over ateibuted to pneumonia increased bee tseeen 1901 ad 1971, whereas deaths from beonchts decreased. lis Destine of Morality as sh powsle that sone deaths which ecier would have been certied {sold age were transferred to ths categor in whichcase the aumber ‘of deah ro these respratry diteates would have ben lager in 190 {ndthe decline by 3971 corespondingly greater. The rend of mortality vl be examined more closely later, But ece i shoud be noted chat ‘Bere evidence thet the cedacton of the death~rate from pneumonia, ‘ronchiy and intloenan began before theend ofthe aizeteenth centary. Diphtheria and salt fever were asocited with 62 percent ofthe fal of moraty and theeefifhe ofthe decline ocumed before 290% The dtaer can be separated after 1855; the deth~ate from scarlet Soret fl rapidly in the second balf of de nineteenth century, whereas tha from diphtheria increated slightly. Sine 190s hoh have declined, td thee have been few deaths Fim cither disease in England and Wales since 1932 ‘Whooping cough conteibuted 2.6 pe cent to the reduction of mor- tly. The deccate wae relatively small n the nineteenth century and sectunted for only about a quarter of the fall Berween 1848-54 and Iprt Neverthelee mortality frm the dsese has decned almost tivo ance about 1870, and there are now few deaths in England and Wales (26 in 2972, of which 22 wee in children unde 1 yz. Measles was astocated with 2.1 percent of the fal f the death-rate Daring the nineteenth and early twentieth centuries eildhood mortal iy from meases was elaively high, bute ell apd fom abot the Sie ofthe Fist World War, Nevertheless mcsles remains an impo tant disease; in 197%, 135,000 cates were nied aad there were 28 deat ‘Smallpox contributed 1.6 per cent to the reduction of the deathe re and almost all of thir maprovement occutred before 1got. Since toot 1pi0 there have been few deaths Gon: smallpox in the British es. Tescoms unnecessary to coment in deal on the retaining infecsions (efear, pharynx, and larynx), which accounted for only ou percent ofthe fal of mortality. There ae also some airboone diseases which taused few dethe and have been clvifed uader och conditions Wats end fodrbone discus, Waer- and food-borne diseases (Table 34) were asoeated with about 2 fifth of the fll of the deathrate Aewecn 1843-4 and 1974; neatly half ofthe impeoreren occurred Ielore 190836 Determinants of Heth TABLE 34, Stondndizeddeath-raser (per milion) [rom wate and fod.bore dest: Englond and Wales eae rts “fete as Giolern diathows dytentery tgs “ulereons (aomsespietsey) 73 Typhoid yet ° Teal 3 3s It ses desirable to group together the diaerhoeal diseases. Inthe ‘twentieth century they comprised essentially darchoea, dysentery, and ‘enteriss busin he petiod 1848-54 there were slo considerable amber ‘of death atibuted to cholera which are included under che ame heade ing. These diseases wece reonsible for about a tenth of the fll in mortality before 1971; a thied of the decline cccusred before 190% DDeatht associated with non-respiratory tuberculosis in 1848s st those shovin inthe Rega General's clavfication at ecroful, tlt meseteri, and hydeocephalus. Deaths atibuted to hydeocephalsin- clude some due tothe congenial and other forms ofthe disease; how ‘ever, in the nineteenth century matt death were andoubtedly from tuberculous meningitis, and ance the diferent types were not thea separated in national satis, itaems right to clas them with other forms of non-repiratory tuberculosis. This overstatement of none piratory tuberculosis death i ofet bythe inevitable ominion of deaths ‘dueto renal and bone and joint raberclons From so0r the clasfiation ‘wat reaonably comprehensive, and there itl dificalty in folowing the trend of morality from that time. The dieae was responsible fet 446 pet cent af the eduction ofthe death-ate between 1848-54 2nd {97H and about a quarter ofthe improvement occurred before 1901, Since syphus was not distinguished feom typhoid fever before 1865, they are considered together in Table 34. [is unforeanate that ths igs necessary, since typhus i not spread by water and food and should be inladed undee ‘othe conition. The balance of deaths doe to typhus and typhoid before 1869 is uncertain, but from chat time st Teast the leer greatly outnumbered the former, The deth-ate fom typhus fl spi in the lar decade ofthe nineteenth century and thee have been fow deaths dating the twentieth, Together thee dteuss Deetine of Morality ” ‘were associated with 6 perce of the reduction of moealityberween tH4best and 1971, of which 84 per cent occurred before 1901 Te should be noted thatthe tate of decline of morality before the taxn ofthe century wat much greater forthe enteric dienes, spread tainly by water, than for the diarrhoeal dseasesspreadmainly by fod. Other dass de to mire-orgenions, There remains miscellaneous up of conditions of infective origin, which are not spread may Uyair, water, or food, o° for which certification of cane of death was smaiictory (inte eae of ‘convulsions and tething). Ditess of this css were responsible for 12.6 per cene of the All of mortality between 1848-54 and 2972 and about a third ofthis decrease oecutted efor tor. "Table 3. thows the contribution made by dlfren conditions; the lage (8 pr cen) wat ron ‘convulions and tething’. Alkhough thee terns were long regarded as unsatisfactory, they were sill employed in igor when 20 958 deaths were ateibuted to ther. By 1941 the tema rane 35, Standardized dethetes (per ils) for ther dvaes bale to miconarganet: England aad Wales econ fran Conbions,tething Sree Mpc, pcos Perper eve Ose ects oa tecthing was o longer accepted hough it wasstll edn asecation tnt eonvubions. The use of ‘convulsion also diainished; only 9 deaths were certified in r961 and none im 1971. This decrease was pre- sumably du mainly co tanler of deaths to other and mre accepable tauses 3 well as tothe general decline of the underyng infetions. Mot of thee deaths were infective. They were abocited particu lary with digases af childhood (ooping cough, meals, ots media eins, paeomonia, gao-enterii, te), and in ths analy atten= Gens been esriced a deaths under s year inthe Reyistear-General’s” Deteninants of Hel reports Although it is not posible to identify the cases of death ine cluded under convulsions and teething, iis probable that most of ther ‘were aicbare infections, ‘The othe dsese specified in Table .s contebuted hte tothe de line of mortalicy: syphilis, 03 per cents appendicitis and peritonitis (04 per cent; and puerperal fever, a4 percent. Except inthe cate af appenilcs there are no special diicules in identifying these conde tions inthe Registas-Generalsclarfcation, Syphilis is taken to jncide the principle maifesationsof the disease: general patlyisof the isa, locomotor ataxia, and ancuryam. Until fost the fequency of deat from cardiovascular syphilis was slightly undecstated, because the clase fication did not separate thore due to syphilitic valvlar ease, Unt 1931 the number of dente sttibuted to puesperal fever wat abo low because infective deste associated with abortion were not Kentied Tie canons under his heading (Table 3.6) ae « eteropencos Coleco, having in commen ony tatty we ot due ttc. Sees or, here they er that they rannobe ee ‘ronal satis ogee thes cones wee settee pet cene of the decline of mortality since 1848-3 and a tenth of at ican eccred belo too | emp ub of exniolgy and detonate tobe intact) sre than a ih of the deaf ener ed thd over were abcd oth ot From 911 ete of ek Simined, dats jeourly beng nae o more scp fatty both nets or example pagum) and none se den) Ths eaegory of deal combed pr cet Ses, ; “Theeading‘pematriy,immatury, nd other de ofits sent! ba pr cn ofthe ecg, uote coves Ege tuner of very diffe conden singe nena ens Ince te cision wat expand ed ose deals wee tee Eeed we neremtsacory coaporen Howeres te dststs tov be mucin the since and ery toe eae 20 Secesatycocombin pematrty whose diese of nny Del oh csnreed telnet eer, int oie Decline of Morty » Tams 16, Studded death-tes (pr willie) fom conditions et atibable co icrocrganion: England ind Wales ‘Brame ren Googe ef stat eines Prmatriy, matty, other doses of ancy mam ga Citberseale doce oS Gcrdovneslae dene sip Gp increne oes Bn aimee Gir dienes ofdigeniverynem 706s 38, Oiierdimaesofneroursynen re) ts Nephe asa fee Pegoney an cali \Cedadlog st) ce Visesce poe on Fg Oldage rare) Ober dieses tes am Tol Bot Ate 336 fill fin nl gor. This agely account for the delay inh more tli Dice arse wit ample poliomyelitis was not specified inthe 1904 and 1921 casi tons, and war probably grouped with ‘caer of the cord’ which ‘other dese of the nervous system. For ex= therefore include 2 few infective deaths. However, te evr is small, for poiomyeliis was nor chen of Inter 2 com ae of death Penland ot ape ingot ad or, bt haben ld fee ge although ome ter ar bleed el vine fen This may be real of mule ron shown pastel rom ‘on “ies exmple, which coud be extended, are curate of the le oferminaogy and cen which ri with condtons Eratcbuabl to mcg There afte ily. a he {a ofthe nections the divion according fo mode of teivion wil lise interpeaon of res forth dene. No rch 3p Froth pouble nthe oe of moeincve ei of death Foe Epc mrty bas ices doing th ey thie enviar celtfderdfom hg cacercaned by oking,” Determinants of Heath andithas masked fll of monty fom some oer ence, brought about by cheap and, so dou, ober nfoeces The pcre io complain audiovaulat diene wheres nein a den rom yor incon ave cared a retacon fom os oem Te un ene ven prea ah sted Deca fs nse nthe gurney of ever 1 ld be noted ht Tedocion of oralty was Tower for tales than fo aes a. per ent and 3.6 pos nn rete the went century). ThA ary to ings ingle deaths fom lang etter and cardiovascular dlarse, without ihe illin ale moreytom nomcnctons de weuld bave ee mach hig Tis mes thatthe dane of move for mae omumokes ha bee comely greser than the gues ugg “Wich the probable exceptions of nfincide and mavation cued below) the il ef mortality before egitration of ean of dst in the prod Eons eget to geot seo ental eto a teduton of ert om infections dae. Ar psinnay fonts prctadon ofthe eon fort reducon ti desrbl to consider he nue af the dene hich delied. For the preegitaton prod Ere ar no reine data concerning individ ese, 0 one mk Sea lnely on ar expen rom 136 theinfectons which ddined were mainly of wo ype sisbome, and water and foad-brse. Moray Fom rome sibore Uneccon paniclytberslon, fl om the ime of egeton ‘but the decline from water~ and food-borne diseases was delayed until the at decade ofthe nineteenth cemay isi probable hat here war a sbramtal odoin of moray fem siden infections inthe pre egiaacon prod The nanbe of dex From wberulns el rapidly fom 1838s the dese was anocted vith eal bal ofthe decent ofthe dente dang dhe econd al ‘he nncteenth cenury. Morality fromdberelsswrconnderble Sn the seventeenth and ighcenth cei the fe ‘Kclning athe time oftepaton suggests hat fe may ave fl Destine of Moraty a Another store infection frm which deaths mt have deed before 88 lips In 834 he death fe the dese at only 63 (petit ec oh ate for epatory ber Ccisandconiderbly lower thnthe rates from whorpng cough nd tees (able 3). We en be les conden abou te ten of mee tity fom othe sbore nets. Diptera ox cone with teal fore and thee no reable information sono dst fom. See sch whooping cog ssn eonhi, pon, md infec ence concerning wate and fod-torne es alo aking Moxaly wn no fling inthe decades fer regen, a id nok NGint dene ane seve ware improvement in ater and eae Sica, in England ond Wakes mn te seventh dome, Undeed te Shun of apelin and the eapié mone fom cimty to tons mat have ince expose to infections sped by water ad food ind the appearance of he, poly forthe tine, nets that gin adione dtr. Ful wemustcoutder tae pone sipicnc ofthe etor-borne dias (pager, pun and salar) sprexd by oh gs and mos si hs ees te ail eign ae pon Fe almos disappeared crn he Drs er ater eo at altho ae vere codec ocalnaly trough sport no extension of the doe crcued ow deta were tbuted to phar fr 163, rien wa ings om ph nd althoogh hee may have Teemsom indigenous css of mala, nos deat Rarer fom inetion sequied everest ged Bf the steno psd co ic by hovin, lgue wa the nat important ofthe vce bore ue i eltionf the deine SEmoraby and growth of goplaon im xcs cemriee However, Sethe dace tually dinppented afer 16, anmot have ben ecined wih he decrease of Get fom 17. “yp was not fecal fom baboneplags ol about che aiddleof te incest centary and wa proba cespnsble for funy ofthe ens anibted to tat arse. Mlvia cold not be ‘eel vclbly fom many thr ever before th te nineteenth entry ann te cry Regia-Genel reports presume ‘Stud under ae such ar iermiten fever. In vw of he lack of ce onan et ny el pro cng pole Mhatibere were pienso typhus prolly aeing the oot a imervas ding he pe-egistton prod and that morality declinede Dermat of Heath ntl he ese vial peated in he at nineteenth century ‘sunlit malin watever portant case of death Being linac conditions ar not reilly sited othe pura ice nee fur of not les thn 23°C i eeguied bone te seal eye of Pl edu agar (he ease of malignant saben maa ean be complied nthe mosquito an 15°C neded free pti Inthe asesment vectors dearer are sighed ach fe ig- nica place inthe history of mori thn he one they occupy developing counties cody, The cesson cen The developing cou ey er ar pc whe inate onion el many peraites and anil vector pricy fie, euitog, and sai ih the ele hat iene sich a dyer, malar, yellow fret and ichinommininareendeni over lage arene Dinter region conditions were snl for most deus spread by te tal eso ner Shanty nde he ath bis olserestion that England (ike ment of were Earope) hs the worst weather and the best climate in the world. fe Nox-unrective conpitions) Table 5.1 megened thst in the psi fom 48-54 to 1901, now infective eondons were sucked with # per cot ofthe decline ‘moval Mos of hi redacon wa in to case of ental pe sed the ise, either of which provides convincing evidence of 2 deci The em od age war wed in espe of both nections and tonvinfetive condo nd the fc ttm this period there wat onset nee of ent xtfed bronchi patamonn aed infos, an ‘ter eardoraclr dene, suggests Ua the apparent Sli old age’ deat reed msn froma ear ote cope The ater dees compre singe and bearogencou pro of com ditions, many of which were natin ced for example haemorchage, morteton, and nity). Moreover, redaction of deaths wat mainly in evo categories. Oa contd of ‘tha and Siar oflangs te" Many ofthe dent ntbuted tothe ease wee probly amnetd with epustorinfecdons and he apparent deine teeween 184-54 and 1901 tay lave been due many oases to other extegories (ch a1 bonchit, preumons, and infuens) m2 ‘ul of improved cerifcation, The other ca of deaths which fall ‘manly ar bit, atopy snd ween death, cose uno ity 6 Deslse of Ms The fst wo of thee terms are quite unetsactory and the reduction of deaths was no doubt due largely to improvement in diagnosis and {laifcation. Although alent deaths ace shown separately in the Registac-General’ceports, those clailied a sadder deaths may have included a considerable number caused by violence. Aboot a quarter of these deaths ore in the fst year of Li, so that sore may have been ue oinfinticide, Others, no daubt,weeesinile vo thse which would be described today a cot deaths, which means tha ihe cause of death was unknown, ‘Against ths background it seems ccaronable to conclude tht the ARegitrar-Gencal’s statistics provide no convincing evidence of re- nation of deaths from non-infective exes betwen “448-54 snd 190, tnd the etimate of # pe cent (Table 3) i probaly dae mainly to ‘rots ineatfietion and casiliction. old scot allow thatthe fall of mortality before egistzaton almost eniely with infectious dsates However, there are fro non-infetive eases of death infanticide and starvation) which ‘may have been important, although this cannot he coafiemed. fons atonal aii Ina survey ofthe history of infanticide) Langer coeluded that i was paced ona substantial sale in both aie and moder Ses? In Lic cghteench and ninetenth centuries, the poor, ely able to sp porte family they lead had evaded cesponnbliy By pig of Farther aon’ Theme condasion war reached By many conte pory water, among them Dick who beeved hat infant ws favly lee prevleat in Eaghnd than on the tank: of the Ganges Langer quoted Ryan who examined the medical epee ofthe problem of nfande: "We cannot ignore the fc thatthe cme of ‘inicio well that of criminal abortion, wideprendandon the crete Although he fequency of infnide cane be einated, therercems no cazon to dsent eon Lange's ew thie was common tel the lee quarter ofthe nineteenth entry, when 1 began to be Tedaced bycngent relations by gown pliner in mater fd ld ae, ad nally and mos five, by the pend of eo “AEs ab imposible tata the equeny of death om Gee asst ont dat fom nfcios dre which ee rom poor tution Aiough experience developing counts ods) sggess 7 Hise of hod rr Lange W, nf: Bove vey (U0, 884“ Determinant of Hed that che later wa ch more comin than he formes it sem robe 2 dt inte eighteenth and ences eer deh sx gta os ingot, a Gan el fod defy. In the is all year ofregitation of case of death, 167 des were sttibuted to starvation, However, an analysis of 6) deaths by Tart showed thatthe daifetion was unsatitictory (Bey inl 13 pre tons who were ad o have died fom thee of cold), In spite ofthe lack of atniel evidence, Ubelieve chat death From infanticide was probably common, and death from starvation not u- common, in the eighteenth and nineteenth centuries. I this is tue, smortaliy fom thee causes may have declined before regiteaton of ‘aus of death in 1838, and cereainly did so after that time, Although this tend cannot be confemed from national statics, i is quite por sible tar there were the only non-infectve causes of death soca With asigifiean reduction of morality before the twentith century. a Infectious Diseases "have concluded that the il of morality sac heen ofthe seven testh century was dae predominantly to 2 reuron of eat rom infections decase. However on nfcive casero death were snc Zed with about squares of the decree of desi this enter. To ndestand dhe iaunces which ave brought about the modem ime ovement in eal ti therefore ncerary to ene thereon for the decline ofthe infections and of cern nonnfesive condom. ‘These ate the subjects whch wl be ducused i this hope and dhe one tha flows “This bring co an moran question in the itor ofthe pase three entre It wil be sagged (Chapt: 6 tat the predominance tes lo theft aici revoltonto,e00 yeatago When en began to aggregate in popoluios of comiderble Tee Why then dd the nfecons dine Rom aboot the time of he tren apical and ina sevoltions whch edt the aggre= ion of il larger and more desl packed polation? The answer {Se parndoe mst be ought the race of miroocpanisns| funder hich ey spread andthe pote ofthe human host, inherited or acquired. However fo an understanding ofthe infos its vsatsctory snc ety an genta i They ing ge which naan adapt ach other by nat seeton, The EU Thabo ui nt erie 2 Sct cere Grape: isan expreion ofan interaction tween «pute Strand an 2 poreaar ho. For example» meses rs whi ‘Hes on dren ina developed cout ate rately benign, may fave devastating efecs when encountered By» population forthe fist time, When asesing the major influences on te infects i wil therfore be necesry to dings Berween the following {o Inveacnn between ongnison ad hore When expoed to 4““6 Devries of Heath ecvoraimsovera prod of time the oss gain hough mtr ‘leon sa site rtune which gently decried Ted tion wo thse etance Emma may to be aque oy trasmision om the mother erin pose tes poate These typeof mmisiy, inked and oe sent due cet mn rrvenon oe foe evnentl ) tennizaion ad thrpy mmanity may ao el fom se cesfilinmiution, andthe outcome of a erablhed infection sto be modied by terepy. 1) Maes of pra. Pet ace very diferent for dient mero xpi a hey of ome by peveing contac wih orgs sdetmied gly bythe wy Eitan Ina devel oped county revel efoto he end of cokes by pre fkatonof tr te mor ico connor by Spe oi ing anda pr tngoble i ‘ssbeeenfeson ich te conn colby fevening epee to the virus, x : (2) The nun ofthe ho, The rss of an encounter wih 2 seto-ngan se iBerord aot aly byte inked ot soqed immunity of shh bu alo by hs gene dente of health erin peel, wl be sugned by Seon “Thien pos a for annals of eps for he decline of infection Geis opt he backround ef nue ‘ining ofthe tncracton betwen el ow te mse Comite pouty athe dined sbsaniiy tos ange tte charter ofthe dene nen independent ofboth ede ‘stron and denise nvitonmeealfecaingnotona ine rovonens sin liv irmntaton and they at we met {Ser de cotibuton of pece medal ments ogee on the sigelicnce of setucton of export nein mt tot nesting othe meer sf seed of wir-oguis: And a cine of the fnperce oa ere food rapes eos ‘por of te ampcaion between naleston nd ito, “Was the decine of the infections during the pas few centres sociated wwth a change in che character ofthe dats, that with modification Infectious Dieses " cf the ration beeen the micro-organisms and their hoi? Sach a Sarge noeinepenent of te etenment ner is determined tnegay ty an coal eatonhpo te snout bower, ets kind which mast have occorred continiuly dating mans wi “has been suggested that a change of his yf was important, and ven hati asthe main reat forthe decline of mocay and im prorementinbeals,Greensood, fr example emphasized the impor dence of the “eve-arying sate of the imnvobgileonstation of the herd and in as presen adres to he mein Assocation af tnmunclgits Magill wot: Ir wos see: wo bea more logical tonclaion the during seen yet, qute regu of ov therapeutic forts sate of lative equilriom os elie oalf between che tleobesand he “everrarying sat ofthe immu nologiecomsituion efthe her" rave equ shih wl omic, perp, jase Sslong sits not disturbed, unduly, by blogic event" According to til imerpreton the end of marily fom infeious di Sr event independent of bsh medial nrvention ad he vast nomi nd soil development ofthe past dee entre. “The rounds on which twas posblet echo radical conchion arcimporant Mail sed bes on theineitvenes td dangers af vaccination aga sabi, the detne of ekeeons Jong before tfecivewenimens te brio of dipthess n the inet cen tary fi ncened in prevalence aod snagnaey inthe me of the tenury and decined before the inrodoecon of toe), and che fapdredveton of peurnonia deatherats in New York Sate bel Shem drops were Known, flowed bya azz of the decline Fomabout he inte when antibiotics wereintodaced Moreover, these cramps could be extended the cholera vaccie eqied uni teeaiy Sy ineratonal guns aon les he tvction of moral ffom aiphhesin the ipso id not everywhere coincide withthe inrodution ofmmaniaon: and act foe haus wanbl i tery which appear to have been independent of medial and other infuence ‘Nevecces, akhoogh specie meres had ie fect onthe tend ef many infetons, he qusion concen te dpieance of changes +. Gren M, ‘ght death ty, pat, pet Gre’ of the ap Sel Sy 99958) Mag TP "The fmanelog and be el ps Cs6 Devrinant of Beth inthe characte ofthe detest complex.f wl therefor be desable Serie hip fh ge dh Si noe sate ofthe immunologie constaton ofthe hed, ded “TaGiimunolgil cotton of «gence nlunced gay by the monalyexpeseneofthoe whch precede i Ths ma tt clay art the pat when the major of e-hor people Sed ftom infetios dine without reproducing. Under sch condos there wa igo tua lection respec immunity incon, ‘The propos thatthe dine of moray reed from «change in theimmmoloiel conto ofthe popula cere ipl that Shee was heey moral tan ear prod wh ed othe tha indians who were glnealy lew ssepl. According to th imerpretatin, he banal and prolonged dele of inetd vet da ret, notes inprovemen sce the eighteenth centr bat tehigh mertaty which mot have pede Atbough hei siboe incon, nde ttn fein a ~—rtrté“‘ town, with uncon living and weking conditions, i ust five deursated Hence we can iy confident hat redaction of xpos t infection, through beter hygiene, ses delayed une the {Bron hough thee may well have bee sme mprovenient a8 4 secondary contequence of the declining prevalence of dis at an tater pate “Theva lide dobcabout the charac ofthehypenic mest Inthe nineteeth cetey there wereno large improvemensin working 2 living contony ad the msin advances were prion of Seatce and sewage daporal, From about 1gc0 thee mess were rol extended by fod hygiene, fttng mom etic the guy SF Beare tt dine was aot ple to pee ie mk frisevorgnns, andthe rapid ll of deat from garcons, Which comebuced substnly to the dedi of nfne morality, wat Unetoe invodeton af sealnton, boing anda tampore of {nik Encconmenal meses hve of cue been extended the presen onary, by iproverents in working and living contin Coking the lat 0 indude advances (uh an conuel of atmospheric elt ith Pot ” pallotion) inthe community atlargesswellasin domestic circumstances, “The conclusions conctsning the influence of Smmuniation and therapy om the infections may be summaries follows, Except in the ate of vaccination agains malpox (soca with 1.6 per exe of the ‘eduction of the death-ate in England an Wales from 1848-34 t0 tort), itis unlikely that pertonal medial cre had asgniicane effect we ihonalty fone infectious dicnes bie the ewentith cen $Beween 1900 nd 1935 there was contibuson in some discates an tenin in teeatinent of diphtheria: sargeey ix appendicitis, peritonitis, fond eat infections; salvatean in ayphilisyineavenous therapy in die- ‘hoeal dieses; pasve immunization aguest tetanus; and improved ‘bseric eat in prevention of puerperal fever Butevenfthese measures ‘vere responsible forthe whole decline of woraity from these condi tons afte goo, hich cleat chey were net, they would acount for tol «small pat ofthe decease of deaths waich occurred before 1938 From that time the fst powerful cemotlerapeutic agents, sulphon- fides and, later, antibiotic, came into se, and they were sup~ plemented by improved vaccines. Howeve, they were certsnly not $e only casas fo the continued fl of meray. conclude that m= rmunizaton and treatment coneibued lie to the reduction of deaths from infectious dieses before 1935, and over the whole petiod since cause of death ws fest epistered they eee auch less important than other influences. Tn the light of these conclusions eoncermng the twentieth century, ‘ais mone enlikely that personal medial ete hada significant effect on the eend-of mortality in the cighteenth and eatlynineeenth centuries, “The other reson for the modern transformation of health was the change in eproductive behaviour which edto the decline ofthe breh= {ate The significance ofthis change can tardy be exaggerated. in England and Wales, for example, ithe bieh-ate bad contiaued ats tater level, the population today would be about 140 eather than 50 tilion. The effects on health and velfre can be imagined. While, ‘hetefoe, the inal progzee was duc 10 her influences, the change 5 reproductive practices which cerrited numbers was the essential ‘omlenyent without which the advance, ice those associated wih the fire agricultural revolution, wold soon have been reversed, Moreover the restraint on eprodsetionarobably had det effect con morality. If infinscade had the sigafiance which has been sag gested, the vital elimination of ths inspomant ese of death was doe iy to avoidance of unwanted pregnancies, Indeed, a1 noteda Deserminats of Health previously, itis quite possble that this bchavioural change made the Targes contsbution tothe decline of nan-infectve aust of death Te would be unwise to atempt to expres numerically the contribu tion that diferen influences have made to the fll of mortality, There are t00 many unknowns. We do aot know the eases of death inthe eighteenth and early nineteenth ceneute, 20 conclusions for that time can only be informed guesses. Since repittration of cause of death, the Registrar-Generl's clasificaton har included some illdefined and heterogeneous categories (ich at prematurity immaturity, other die cases of infancy’ and ‘old age) whore composition t far Fim dear ‘And itis not posible to extimate with any precion the contibution ‘which therapestic and other advances have made tothe decline of the multiple noninfective eases of death which together were aociated with shout 2 quarter ofthe reduction of mortality inthis century. ‘With due regard fr these and other grounds for rerervtion, {believe itis posible to draw a few general conclusions concerning the main influences on health during the past three cents. 1. Improvement in nutrition vss the care and, over the whole peried since about 1700, the mor important influence 2. Hygienic measures were responsible for atleast ith of the eduction of the death-rate between the mid nineteenth eentry and today. Tit isthe proportion ofthe decline which was associated with water and 4. With the exception of vaccination against smallpox, whose conse isvion was smal the influence of immunizason sad Geapy on the decate was delayed ul the west cetay, ad ad le fet on national morality uends Before the introduction of slghonamides in son, Since hate it as not been he only of, pobubiy, the most Important induence, 4. The change in reproductive prac iat was wry significant, since tensed thatthe in health brought about by other mests was not reversed by ring umber Eve group together the advance in nutton and hyena en vironmental tates, the influences ceponsible for the decline of ‘morality andincrened expectation of ie were eqvizoamena have ral and thaapeatie They beeme effective fom te eighteen, ‘ittenth and ereneth entries respectively ond sh onde teat aio tha of thei eftivene sich ld to the decline ofthe a Health in the Futue “Theappeisa ofinencsoneshin ep ree cena song dhatee owe the improwement not to wet hapens when we sel Botrothe cae do mors ln become se emai wel pot ene spesic mensch vacant and mention Bites we cjoysbigactandrd of mttonandiven eae ieenvuonmuat la lest one porate pert, reproduin, We dis behave more spony Towerc its une ta tee inane wl have the ue el sve importance inthe tela ndsisied anes the dele of theintecns has ben flowed by a change inthe charac of heath prolens;and even a developing coun pole dat he inf Shs a len mode! by rane edu on ie ad tconaogy in gence is ecfore worth eramiing th at ‘bevel eblevswhichare becoming pedeminane athe infections decline From the dicution ofthe determinants of heakn (Chapter 2) it is evi= dent that there are only two ways in which disease occurs. fe results cither from erors in gnete programming 2 feciztion, or from the fact that the embry, foets of live-boen individual, correctly progra~ ned, isexposed ro a envionment for which th genes are not adapted, Haemophilia and Turners syndrome ate exampls ofthe first mechan- ims most congenital malformations andthe costmon types of physical tind mental lines sppeae tobe examples of the second, Ifa proposition in thi form (everything i Ace i mot A sem sl evident, its implications for our understanding of dsete origin are not. Inthe fret place, che environment (sing the erm in eefrence to all, non-ereditary influeoces) for which dhe genes are adapted isnot chatto Daterinans of Hel ‘of the presene day, but the one in which our ancestor evolved daring the husdseds of thowrand of year ofthe nomadic period. The equire- _ments for health ofthe digestive, cardiovaclat and reproductive sys. tems ace thetefore likely to be that the demands on them should not difer greatly from those made during man's evoltion. When con- fronted with the uncetsntes of evidence relating dit, exercie and reproductive experince to diseases of thee systems, i is instuctive to ask ourselves in what ways present-day practices have departed fom those of czy man, For example, one can see why nutetonise ell that we may eat what we lke so long as we don like much patio Jae saturated fats, sugar in its various forms, some animal proteins, coffe, alohal, refined foods and unteined foods which have been rade palatable by additives These retritons ate severe, but under- indale, when we realize that thee aim isto bring us nearer to the dietary regime of our ancestce who were hungry most ofthe time "There ia farther consideration, namely, that vast changes from the condivons under which man evolved were astociazed with the rane inions from nomadic to agricultral to industrial way of lif. At the tsk of some oversimplifeation, it might be sid shat both the nomad and the agricultral periods were characterized by the multiple efecs ‘of poverty whose influence in health was aggravated by lck of owe ledge; but the Laer period difered from the calierin the predominance offnfectiou dizer. Induscaizaton, with the sdvances in agriculeue tnd inerewed knowledge of disease origins and mechanisms, brought {clic rom many ofthe problems associated with poverty; bu by po viding an exces of resources over needs, jt opened the way tothe ees of fluence “However, except in elation to some infections, to which (because of high morality earl in life) adaptation occurs within afew generations, the pace of human evoltin i slow, snd man bas not adapted genetic= ally tothe changes ofthe las few dhousand, and particularly the lst few hundeed, yea. 1s unlikely that he wil adapt quickly in fue, since the effectvenes of natural rlecton is greatly redaced in petiod ‘of low ferry and low morelty when most live-born individeals {epreduce The solution of common diteate problems wil not, the ote occur naturally a it did during man's evolution, by elimination ‘of deleterious genes, I ial the mote important that we should under. stand, and 10 far a posible control, environmental determinants of dicate ‘Against this background, the residual dese problems canbe divided Heath the Faw » broadly into four ses, disinguishabe according to the feasibility and teas oftheir control 1 shall refer to chem a: celgtively intractable; preventable, associated. with poverty; preventable, associated with Sfluences and potentially preventable, not known to be related to “The diseases inthis cas compris the following: 0 Gmc sa Theyinduethe re sge-gn ode and te et hemes abet ot of wch elite a torn, Gee et tie, foun inl SECT ean af vein sd ened al be a ae no common dice 0) oer das denned t frzator Tee a peg come oe ey nieve Se scared th dh decree ye sd he (Dieses in tc heron ines ie pra Mos yp ot nerdy and congeners ef Sea dee, blk meee nd ama gives no fon EOE at soch condone cine eevee eee tenes which lxdeshem pee ey erty HET etch ely to eam idend, east nthe ft Korte ce ao though the dices inthis ca have is eomman thei elie intacly. een cnidesing the apponch 1 them we should rh ercen bnoaies psn st ih feed onde) cp) salve arene ne ie Tn be exe fhe est we elton such anecepaln Dower dese ad mena Seoul probly be age tthe beeauon would PR eidoy or deiconepon or Uh But geneially de ren th cdr may coms tthe em of «long 20d cen PRP ou bese co sgpr a he w u e ae ng motiy ot cen sniy would make desl o SIE Binh hho who woold be aiei | i li fe Determinant of Heth In designating thet dieaes at elaively intractable, Tams notsuggest- ing that they offer no scope for prevention or treatment: The With- drawal of thalidomide, the prevention of Rhesus haemolytic diver, tnd the treatment of phenylketonara ate notable examples, quite dif- ferent in kind, of seasures which have been roceefl in the handling ‘of problems inthis cls, Neverthle, I believe that mos of them will prove tobe relatively intractable, and that even inthe tied group (@) bove solutions wil not often aves inthe case ofthe malformations ‘caused by thalidomide or rubella) from ecognition of sdverse environ imental influences, The significance ofthis conchsion for research will be considered in Chapter 12. (2ReVENTADL®, associatao wit rovenTY Tes broadly tae to sty that in che pat the predominant heath probe lems-the infections ere attadated with poverty, for it was the removal of inflences such at malnution, defecive hygiene and bad Tiving and working conditions that ed to thee decline. However, many people in advanced counties are now largely protected fiom these Fisks, but fice others related to an exces rater than a deficiency of fesources, Ie might therefore be ssid thatthe residual problems are chiefly those asocinted with afleence, and that 2 disusion of helth In the forere shoud be focused exclusively on them. While secognzing thatthe division between the wanstonat and ry ~Lhave merely separated india periods sin sense quite abi the problems ofthe pat three centuries ftom those ofthe present and foreseeable futute =I hin it not posible to overlook the continuing impoctance of il-heakth derived from povery. In 2 lage pat ofthe ‘world tis stil predominant, and even inthe developed countccs there ze people whote health needs owe mote to poverty han to afluence. It Bahereloxe accesary to ases che scope for farther advances through a envio ‘wider application of the traditional measures: nu tl, bebavioual and therapeutic. tefl Bai for this assessment is a comp «erent populations and of different sections of the same popelation, ‘Table 71 pies the life expectation at bith for childeen born around toro, Tie difecence between the continents with the highest estimate (Garope, 71) and the lowes (fica, 43) was nearly tieey years Even ‘ewer figures have been cecarded for single counties such as Sweden (G2. for males and 77.7 for females in 1971-2). Hest the Batre 5 rancx pt Lif eet at birth deren continents. Rise e ein & Das (erodng USSE)_ 55 Europe exuding USSR) 71 Oceanis a uss = Word sel 5 Wa et Sa Amal rep PH WHO, Gees, However, when compating developed and developing countries we ast remember that mor of the late rein eopieal and subtropical eas where there are special direst pecblems not seen or racely seen intemperate zones Hence itcannot be id thatthe differences are due ‘wholly to poverty, for although health in Bangladesh or ora! India {Could be brought much nearer to thai Scandinavia if resources Cnlimited, is unlikely that i could be ase tothe same level “This eervation docs not are incon parsons between technologic= slly advanced counties in temperate pars of the world. Fig. 7. shows the trend of infant mortality (deaths ofive-born chien i the Sst tof if) in se countries between 1950 and 1975. At the begining, [SF this period dhe highest ate (in Japan) was chee ms the lowes (it Sweden) tthe end oft the higher in Scodand) was still nearly owice that ofthe lowes agin in Sweden) "A good deal ean alo be learned fron: sogial class differences within the same county. In Britain the population is divided for saistial purpose into five else identified according tothe occupation of the Ipoaieboer. Fig. 7.2 shows mortality ie 1670-2 for sill-bcths, nfs under # year, culdren aged 1-14 and adults aged 15-64, The fist cwo ste expressed a death-rates (per thoata} tou bits and per thousand live-birth espectvely) andthe last wo standardied morality ratios (GMS) Inall four groupe there isa seibng increase in mortality from the wealth cise (0) 0 the poorest (Vi The clas ferences are greater in retion to infective and parasitic genes and diets ofthe respiratory sytem, bat ate alo quite marked for malignant neoplasms, diseases of the nervous system and seas organs, divats of the dgenive system, dscases of the genito-urnary fyitem, and accident, poisonings and v lence ‘Some ofthe vavntion in deati-rnes between countries and between social clas can be accounted for in her ways; for exaiple, by deaths% Determinant of Heath , Death unde yee my Tae per TO He ir ne ‘| Tioga) 0 | 0 | bo al co sal 0 7 lo xl ho eS 9 \ cu 7. Init snr in lected count, 1950497, Source! Proton nd death reing hi, HMSO, Londo, 197, eal in te Bae ss Sinden etn 19 io 1 vor v oT vor v Social ass u ‘Social class Coen ys) yA Se) § w goo EB i a vot v or vo v soe seta reune 73. Moralty by ocd sad age Source: Otaptnl meta, 197-78, HMSO, Lodo, 1978 98 fiom tropical diseases in developing coustses and, less certainly, by Afecences in behavious between the cages. (There is some evidence that smoking is now more commom among the poor than among the wel-to-do, and this would increase mortality ffom malignant neo- plasms and some other auss of death, both infective and non-infee- five) However think there litle dog tha the dferences in heath experience are atributable manly to the director indirect effects of poverty, and would be largely eliminated if ie were possible to rie thelower standard ofliving and medica cate tote level ofthe highest. “There ae two lines of evidence which led eo the conclusion that dis tare is now often associated with affzence, Ones the observation chat fectainaypes of behaviout characerie of 25 affluent socety~ over tating, physical nae, smoking, ete may cus sickness o deth;, the other 5 the finding tat some specie diseases such a cithoss of the liver and cancer ofthe lang are atribuable mainly <0 ilzences of this kind.6 Determinants of Health Although about two-thirds of the people inthe world ae sil under sone forthe tne in htey ee me cous whe he ‘opportunity to veret is no longer confine’ #9 small mince. In Englnd and Wales young and insldleaged men are now on average aout 4b heavier han those of the sme age and height nthe 19.30%, and American men ate even heavier Life imirarice ata provide nupresive evidence ofthe effects of obeaty. Men who ate more than 35 per een above the average for thet age and height have a desterate Se gh ae wt 5 per ene The enced a i cm several uses, patiulelyichaiie her di ‘he dsr eboney Coie eho and sees Teas also been shown tha mortality from coronary artery dteste increas with phys inactivity. Thi elatonship war fat demon strated by comparison of deathrate in 3 wide ange of occupations listed in atonal sais; i has ben conirmed by examination of ‘experience of the disease among workers in eupations which difer in ther physical demands: bus drives and eohductors: government clecks and postmen: longshore wien inactive and es active groups Although the mechenism by which physical asvity protect fom ‘coronary artery dseuse i ol uncles, eh baie finding tl notin oube. “The association between ciethois of the iver and consumption of alcohol seven mote svking, but is well own and need not be vcused a eng The imporane of inne reed aflrnc nd the diesi insome eset of establhing unequivocsby their relationship to dear, de wel lente by th prevent ate cf ede incon I tis From conclsive to saggestive. “The link between smoking and cancer ofthe lng ithe most con= ining since i¢ meets epideailogical requirements which might be regacded as analogous to Koch's postulate in the ease of the infections 1. There i an epidemic ofthe dee. 2. A plauable agent (moking) is acted withthe deat. 3. The use ofthe agent has increased and the increae isin the expected temporal relation to the epidemic ofthe deae(n both sex). g.Semol ofthe gt fs lord mori fm he dee Cn te respect of cancer ofthe intestine it hasbeen suggested tha che feequent occurence in advinced counties ofa condition which is are inraralcommurities of developing countries may be duet the change Heath the Fate & in dc, parila refinement of food and temoval of fibre, fis ‘xlanston i corectiisndentandale ha two ofthe four fines of rlene sted above canot be mt. The sefnemeat of food began Jong befor ese of death wan epered (a Eigie Grand, ten Inve ex Bato refered tothe seperation of he bran fim the four he milf the old miter; hence thee ae no record ofthe onset of the tpidere of the dues or of incresed consumption of the pombe tau agen refined fo. Inthe bres canes variation in fregzeey i diferent sections ofthe poplston, pasclynelation oft, is very suggeive Stenvironmental ioe; but agin and for obvious ree, the ‘fidence dfn, Large changes epocaton perp the most {Frfoond ie human history, wee anced with te wasn fom igh eo low birhrats in the past century. They have modified the gest i progancy, the terval between pogances the age ats. Fagnncy andthe ctl numer of pregnancies, 5 well ascited Frases fc as nteroure,concepuon, nd breast-feeding teem. aie posible dat one ot ore of tev changes fas been associated Sita cree in pevlence of beat canes, but fo the ends wee ora ee dest inal cds : Fonly there a report ofan intereing tempt oct persona tehavious more general fo phys! vats BelocandBrelow asesed fhe eer on heakh of falling sven rulo which would have de- lighted Montaigne, an erly advocate ofsel-dcpine nd mode Mom (0) don't sncke cscs () sleep for seven hous) et ieakéer (2) keep weight down) dink moderately (f)exeteie aay) don't et bees meal “These were almost too good tobe te; vr is aot ofen so Iandsrely rewarded and indeed isnot any wo Bebe ha seven Tur of tee and aking bres at quvdent sheath practices ot song and winning constant weigh. However, vas cone “Tied that eth and longevity increased wi he nner of ees {Bled Fo peopl aged ver 75 following ll the rls, eat was thd tobeas god sor thee aed s5-4q who fllowed ls than hee; SUM expen at age as was 11 ye loager fr people following ‘Ee or seven rls tan for thoe flowing ls than for. +. Bel, N. B. and Blow, Ly ‘Relitonip of physi re wand nathan srive Mee (192) 429 “SEC NB Retort of hth pce aol moray san 30970 6788 Deterninaus of Health ‘here remain a number of duees which donot cleat int any of the preceding cases. In prince they ae preventable fo there 20 ‘ean to elev they are deternined reversibly a frlination or that, cheenitonmentlnGuences which other se prenatal, However, ey hve ot raped amporcen im ono of for ae thy known to have atten ffom changes ascited with auenee ‘They cea eteogencousgroup They inde rome scat rem infection sucha the common cl, fen and vie pesiont, well a gastco-ntnial daar doe to virsen More tena, uggs thas many peychisre condos are inthe ame eas. A fe" of them have responded to advances inthe andod of Wing and ted caleare for example terary spi ones requan ease ofadnsion to ment hosp and probably, dsnes asocated with oie azads td muitinal defences There ate some siking deren tm bor pial adniion cso hizphreniy for example Between nave {orn and ‘new” Aualans (hoe who have recerly emigted fom maybe ated to poet. And there ee emake in dae experience which maybe afleaed by lucne: the wide difene inthe incidence of peptic lea coun- thes of wesemn Eoope, andthe change inthe mllemale rai of deaths de to pefration rom peptic ulcer in New York iy during ths century Eom one to ene to aboot twenty to one), Wik mck execpions which re aot eal interpreted, there evidence thar lie common fons of ners, pychose an paychoromai il roses ace det asocted with eer poverty or sues. Folly, anumer of phycal dieses example, mfp sles, sheutatid ant, sont ces of renal diene and a nocey of tances) mat be put inthis betcogenous cam often Bene nt tnough i known about chet orig to eeble us to jdge the mature of the sign infence in hi actly. In the preceding discussion diseases were divided broadly into wo categories according to the possibilty oftheir prevention by contol Health nthe Fate %» of enviconmental(non-genetie) infuencs, Those inthe fst category ‘ovsidred tobe elatvely intractable, on the grounds that chey te due abnormalities of genes or chromosomes o,f they are not, that the inluences which lad to dkem ate ikely to be inaccessible because they are prenatal. Mort of thete conditions are present ac bith, although some are not ecopnized until ltr (extain ese of congenital, heat disease) and others ae not manifested unt late life. Diseases of this type can be though of atthe price tobe pid forthe advantages which acceue Erin the intiate exchange of genes at fertilization and longed petiod of intra-uterine fe, The selution of soch problems ‘depends on the prevention of thee conception or birth, or on eincal, intervention a in the treatment of cardise malformations o, in late life, an aehtichi. By definitional thor diseases are dve to 2os-natal influences, al- though the feebty of thee prevention on che bass of present know- Tedge varies enormotaly. The predominant cuses of ichalth in she past infectious disease, were determined by conditions ceated by the Fist agricultural zevoltion, the aggregation of populations and xsoci- ated poverty, and the modem improvement in health was brought thout by thei removal ot medifirtion. ‘Ona worldview it might be si thatthe majo influences on heath are unchanged. In many counties in Asn, Aiea and Latin Americs the infections areal predominant; malautition remains the most serious cause of dtete, hypienic conditions ae usualy primitive and population growth isnot ecively controled, Even among the ad= ‘anced countries conditions ae nt uniformly good, for there ace con- siderable difecences in health indices between countees and between population groupe within the same countay. Hence for the world asa ttle the order of Importance ofthe chet in luencs is probably the same a in the patt- national, environment, behavioural and cline fail Howevee, some of the variation in developed counties, for crample in perinatal morality, is ow considerably affected by di fencer n standards. of medical cre “The balance between disease asociated with poverty and chose associated with fluence it changing, and thereare grounds for chinking that in some advanced counuies the later ae already predominant They ate determined by gesional behaviour in which the changes ate comparatively receot: for example, refined fonds became widely aval= tle from the esly nineteenth century Sedenay living dats from the introdvetion of mechanized transport, psreully the autombile: andDetects of Heath ing on a significant wale has occurred only im recent 0 ee ‘Alhough the tive importance of behaviour infec camo be einated acer ts porble ose the fc of te of them, namely king Take 7 shows or oer (35 cia ‘tes daly aad ove and nonsmokers of vat ag, the nen cxpecition of ie which ocutel beeen 138-544 197. Proms {pas henner satan wm swt al oe chan bal hat ‘tame 7.2. Increase ie expect of if of mle inthe period * ted on mney ep Ba dasa oka md nonsmker 08 (eu fies aia Eglaed nd When nS and 1972 for non-tmsokert. Tis el an be ntepreted to mean that inthe past, ‘century the improvement in expectation of life of mature males from al ‘ous has ben reduced by at lest half by smoking alone The fact that So large a reduction has been du to single practice sugges that in ‘advanced countries bebivioural influences are now more important than others and see the changes in behaviour ace character ofan fluent society, it scems permissible co conclude that dienes avociated ‘with afuence are now predominant. The order of importance of the influences on health has altered to this extent, that personal behaviour is nov relatively more Significant than food deficiency and environ- A nena hee 8 Medical Achievement In Part One I conclded that the contbution of clinical medicine to the prevention of death and increase in expectation of life in the past ‘hice eentuces was smaller than that of other inflanees. Thi isn of {ouse the only index of medical seevenent; doctors ae aso con= ‘emed largely with posponenent of deth (om specific ees) and treatment of otLital esses, 34 wel as ith the cae of patients for ‘whom ite can be done by active interveion. However, while recog zing that all dete contibutions ae iexportan, I hink iis desirable to put them into perspective, and this canbe done by considering the Fellowing question. ‘Ler us suppose that a patent i asked to choose besween two poss- bilities fora newborn child: that it shosld have the benefit of the increas in expectation oflifesince the beg.ming ofthe eighteenth cen tary ffom about yo yeas to over 79) sith the asociated reduction of ‘otbidiey fom the cteats that hive decied, but he denied all other ‘medical treatment or that should have mach treatment, but cetonn to the former high risk of death in ee if, with about 30 per cent of surviving te maturity. The choice here isbesween the benefits that have fesutedffom the decline of mortality and all others not reflected in this index. No wellinformed person would doubt that the parent Should choose the former, This way of loking st things may seen: highly theoreti, but it hata considerable bearing om health policy deesions, particularly in developing couuries where 2 choice hat to be made eeween investment in preventive and cherapeutic mear “However, an apprisal of all aspects of medical achievement is needed 4s background foe dacusion ofthe med eal ole, and [shall consider jt in elation to: prevention of death; postponement of deaths and treatment of non-fa dseses, oo Daterinants of Health Although the contsbution of medicine under thi heading has aredy been examined (Chapters 4 and 3), we mu lok st t more closely in the period when clinial procedares became effective. This is desirable not only to put che cecord straight, but aio if we are to wse medical, achievement ia dhe past a8 4 guide to its posnbiitesn the futur. For this purpose dhe lac thicty yene ace in some rexpects more instructive than the previous dheee hundred, ‘Mortality from tuberculosis fell harply from the te when it was fist, recorded, so that large part ofthe decline occurred before the intro- duction of efesve treatment in 1947 (Fig. 8.1). However, a graph on i= _— \ se a a oon 8.1, Respiratory bec mean aa eats (Gandacins to 991 poplin) aglnd and Wal this cle conceals the large contribution made by chemotherapy inthe Inter stages, so we need to examine the death-ate more closely immedi ately before and after steptomyein came into use. Since experience of the diese varies by age and Sex, deathrates since 1p2t are shown, separately for male and females in thee age groups: under 15; 15-44: and 45 and over (Figs 8.2 and 83). Straight lines have been fied t0 Medical Achievement % 2s Mate \saniover estat (er ion) so \ \ Oars Bs ee Ie Eo rncunt 82. Rspratty tees: sl dents of ales ‘Eglnd sod Was, the ates forthe yeats 1921 to 1946, and extrapolated to 197, allowing forthe slight increae berween 1946 and 1947 “On the shumption tat vithoutetreptomyan the decline of morality swould have continued atabout the sam ates between rgat and 3048, tatimates have been sade ofthe contributor of treatment. The zeus se given in Table 8.1, for the sexe combined. Chemotherapy reduced the namber of deaths in dhe period since it as introduced (1998-71) by 31 per cent forthe whole period since cause of death wat fist recorded (1848-72 the reduction was 3.2 per ent. ‘BCG vacenation was ued fromabout theme time a streptomycin and ie is checefore dieu o separate the efcts ofthe to measures, Inthe examination ofthe trend of mortality "Table 8.1) c was atenned thatthe benefit wat due wholly to chemotherapy. That hi assumption {sot unreasonable i suggested by the expeence of the Netherlands,* Determinants of Heath 100 Death gr miion room 8. Resprtoty ebeeulois annal dete of eae Englund and Wl. ARLE Bt, Euinatd muir of deaths fom respirator bec prevented by ase of cenotherapy: Bagland and Weles. Etinmted by emapolsion* 273727. 437265, Aeteal Ghar taste Dents prevented noms 986 Proporton fds prventel "81% 33th Tore whi hasmever had antionsl BCG programme, but nevertheless ad the lower death rm respitory tuberculosis for any European country in 19579 and 1967-9 Fg 64) “The history of taberuls sts, perhaps beer than that of ny cotter infection, 2 general point about the contibution of therpy Medal Ackivenest 9s Deas fm Tate “per oo Dos» ww DDesme iced ind & WHE fetes Iseden le I oo Proce iui fun i a art oon 64 Tete: death pe 00,08). Sources: Wal Best Sits Reo, 33 048970: ‘Word Heath Satie Au, (570 [Bective clinical intervention came late n the history of the diease, dnd over the whole petiod oft decline te effect was smal in elation {o that of other influence, But although the problems presented by tuberculosis in the sid ewenteth centr? were smaller than those in| the ely nineteenth, it wae atl common and often aa disease with igh evelof sociated morbidity. In ovoofitsforms,tuberculousmen= Inglis and snary tuberclos twas ivareby fatal, The challenge* Deterinante of Healt to medical science and practice wat to increate the rate of decline ‘of mortality, and, if posible, finaly remove the threat of the disease which had been 2 leading cause of infectious death for neatly two Centuries, In this it was outstandingly succesful, and it would be ‘Unreasonable to ndereimate thie achievement sto ovedlook the fact, that it was preceded, nd probably necessary preceded, by mode tation of the conditions ~ low resistance from malnutrition and heavy cago fomoverowng which meee ori Both clinical trials and clini experience lave no doubt sbout the value of antibiotics in treatment of bacterial pneumonia. Unfortunately in national sate cannot be separated from viral and other forms ‘and indeed, until quite recently, peumoni (all caus) Svas not cistinguihed fm other respiratory infections. Tn the nineteenth cenry it was grouped with bronchitis and infu- enna, and Fig 8 shows the trend of morealt feom the three dsesses, Tt increased inthe law years ofthe century, but declined fly rapidly 2000 wa a oun 8, Beach, acumen on infaea: dearten (Gandadied to 190% fopatcon) ghnd and Wale, Metcl Achivenent ” fom about 1900. Is hac sorprising dat ther sno visible change in the slope ofthe curve after the introdution of chemotherapy ince the diagram is based mainly on conditions in which antibiotics are not eflecve or England and Wales its pouible vo sxamine the death-rate fom ‘pneumonia (all avs from 2931, and Fig. 6 and 8.7 show the rates or males and females respectively i tree ape groups. Mortality fell dating the whole period snd at ages O-r4and 45-64 the rate of decline Maes Death ition) iia? Suphoanie anti ng and Ws increaed afer the wseofulphonamider and anibotcs; chee was ite Aiference in the tus age group. In he sme period deaths from pneumonia tse sharply fr Boh tenes at ages over 6, bt ere ize Freation is even more difical since che many decent causes of death Prsaded under this heading in old people make the diagnosis wholly tnreible "Tha dats cat no doubt on the effesvenes of antibiotics inthe tccutment of bacterial paeumenia. Whatthey do show is that mortality fom ecrpinatory diseases certified initially under “bronchi, influenzaDeterminant of Heath Subpbonarider Antibie oun. Preamonia: metn soul Jatt of Tense Englund and We and pneumonia, and later under pneumonia, wa filing from about the beginning ofthe centary, and that is continued decline alter 1995 was not due manly to chemotherapy. Motley from diphtbesain England and Wales bas fallen ely con tiavounly since che Ite nineteenth century (Fig. 8.8), when treatment by antioxin wat introduced. The rte increased sligly a the begin- ring of he Ist ar, bu fll api fom about the time when national programme of immunization began. Diptera is now a rare disease, tnd many doctors isned since the Second World Wat have never sen fesIn the nix yoas from 1965 to 1970, there were only nine deaths From diphtheria in England and Wales. itis tempting to attbute the decline of diphtheia deaths between 1895 and 1933 to trestment by anton, andthe rapid fll since 1940 toimmunization, Nothing in the evidence isseriosly inconsistent with this interpretation, and if morality from the other common infections dad incensed o remained constant in the same period it could posibly be accepted unneiervedly. But the fact that, without prophylaxis or treatment, dieses such 28 whooping cough and meals also caused far fewer death, euggests that other influences ray aio have been at Medical Achivvemast = oT ot i = iat oom t sect io ae : ar Ew i x) To) RD THO so HO Ta 19 T ver ncune 88, Diphtheria: death ates of ehilten unde "nglnd and Wale : ‘workin diphtheria, With ue regard fords eservaton i sems prob= ble thas immunization had moze effec on the control ofthis disease than of anyother, with the exceptions of poliomyelitis and, posi, Smallpox. This conclusion i supported by the hgh lye] of immunity hich follows the use of a good antigen. Evidence for England and “Wales in 1g61-p indicated thatthe re ofan attack of diphtheria was aboot six times greater and the isk of fil atak ten tes greater, in those not immunized than im those irsmunied Fig, 9 shows the tend of mortality from smallpox in England and ‘Wales since cause of death wa fist epistersd. Unfortunately, there ae to reliable data forthe eighteenth and eather centuries, but the London Bil of Mortality sugges tht epidemics of the deste cased roany deaths, partially among children. 1796 onesith ofall deaths inVAI | Death (pt ition) & a rooms 89, Solpox: death te: England and Wales, al London were scribed to smallpox. Morley declined sapily fom te nineteenth century and since about 1910 thece have been rla- tively few death in the Brith les. ‘Vaccination was used fr in 1798, made compulocy in 1852, and enforced rigorouly between 1872 and 1887, when the aceeptancee for children war about go per cent, But parents increasingly took a= vantage of the concientious objection clause, and in 1948, when com pulion cessed, ln than go percent of infants were vaccinated. In 1971 {e war decided that vaccination should no longer be recommended 25 ine procedce in erly daildhood. Ttiemot easy to aes accurately the contribution that vaccination has made to the decine of mortality fom smallpox. Creighton, che his torianof infectious disease, considered itwieles; but is view sgenerlly regarded as perverse and inconsistent with the evidence, fa the ight Medial Ackioenett wer of present knowledge of the high degree of protection afforded by ‘aecination fora muted period st seems resonable to believe thatthe procedure was very effective nthe ate nineteenth century when a high Proportion of eileen were immunized, ad still more nthe meanares Free more reeendly to prevent the spread ofthe disease by identification tne vaccination of people exposed to smal pox. Peomyelis appears to ave heen ace dee bef teh uy, btn inet ha ace ines inary SER Th numberof people in ete but wih few or no cial ‘Gunoions exceeds grey (6) about f00 to one) the umber feted by par ‘Beca a the ling dsabives which are common in patients «0 Ly ise it ern ner 5: Engen vd Weroa Detominonts of Health who survive, chee is some tendency to overenimate the importance ‘of poliomyeltein elation to other infections In 1947, when the high- fst deatherate was recorded in England and Wales, there were 33 deaths petmlion children under 1, compared with from whooping cough ind 6 from meaies. In 171-80, before dhe decline in morelity began, fhe at coo dates weve responnible for r4t5 and 1038 deaths (pet sillion under 15) sespecively ‘Since the number of death fom poliomyelitis is small, he reduction in mortality made litle contuibution to the decline of the overall eath-ate However, che dialing elec are so serious thatthe trend ‘of noifiatons i move important than in other infections. This showrn in Fig. 8.10 for England and Wales Theratfellsharply Gor 1946 when immunization was introduced, and by 1964-5 there svete fee cases This strongly ggests that immtiztion was respan- ‘lef the reduction of notifestonsand prevention of diabiltiesand deaths. Moreover, laboratory evidence indicates that it gives a high degece of immunity, a4 measired by the tee of erulating antibodies. Results of clini wale are ako impressive. Fly, poliomyelitis has been almost climinated from counties which have had immunization programmes, whecea it ill common in counties which have not fore the First World War the annual death-ate from tetas in England and Wales vat 7 per millon of population. The rate has fallen alive continuoualy since that time (Fig. 8.11) and is mow well below 0.5 per milion asive immunization, in which tetanus anstoxin is given atthe ie of injury, has been used extensively since the Fest World War. How= fever, it has certain dadvantages, and dusing the Second World War fn was replaced by active immunization by tetanes toxoid Passive immunization is believed to have had a substantial effet on mortality from tetancs, ad although routine active immunization of cluldcen was intodvced only cecently, large numbers of aduls have been protected since the Second World War, including all those who served inthe armed forces, But while itis probable that immunization fcncibuted substantially, other explanations (uch asthe disappearance ofthe fore from the roads) mst be found forthe considerable reduce tion of deaths before it wa aed. Te should also be mentioned that rc has been a significant improvement in treatment Medical Achioeent 103 Aa eat pr lin) ol erated TE TBIO HIT TWD NS TNS TST TAS HW TT THD 1S 0 neon 81, Tet mean aes det gland and We “The death-ate rom whooping cough in England and Wales(Fg. 8.12) fas declined since the reventh decade ofthe ninecenth century. The cffectvencs of testmens isi in dou is the contribution of immunization ; i «| \ a A Ta TTT WHO HDT Te Pet reve 812, Whooping cough: dest te of dln under 4 gland 2nd Woes104 Deteincns of Heals ‘As mortality had fallen to ow level before iminuniaton wat inteo- duced, its vase mast be judged i relation to morbidity, of which the evidence sche rend of notations. Thirsource is notoriously sai factory, because feqsently cater are not noted “The fate has declined almost continuovsly since 1950 (Tig. 8.13), although there have been period, by former expesience elativly small, epidemics. Unfortunately for the purpose of interpretation, ‘iminization tends to be intioduced gradlly and it i not easy to be certain when it was et cued extensively. The Annual Report of the (Chief Medical Office suggest thet the procedure may not have been in {general use until t leita few years aftr the ont of the decline of notifications. It as aso been observed that in Germany, where inm~ nization wat not wed nationally, notifications decrated Opinion, including medical opinion, i sll divided over the rls tive advantages and disadvantages of immunization against whooping ‘cough, A deckion is important in practice: bu it isnot eset for this 09 Notions (pe sox a aera wari met Yer oun £11. Whooping cough: pean sl ntion rates ‘of cde der 15: Eland nd We. Medical Achioonart os, analysis, andinconchuding that the matter stil open zeal Hsldane's ematk, that in a tientlie paper one cana most gouge the inelecal honesty ofthe author by the numberof phenomena he oF she eaves ‘unexplained ‘With some variation intimin, che history of meates hasbeen rather similar to that of whooping cough. The dsthese fll continuously fiom about 1915 (Fg. f4)s Westent (cf secondary infections) has been pose since 1995; and morality wasnt low level before immt= ization wat weed, Fig. f.15 shows the trend of notification. The cate decrested fom 90 to 1956, wat more of les constant to 1960, and declined eapidly N\A m0 \ s | oun B24, Mea: dent asf eden andr 15° aglnd and Wels 1 Haddin, BS Seon London: Penton, 988 68106 Determinants of Health Notions ge ton) o Be int net et Messe: mean ann paifaon ‘of citen snr 1}: England wd Wal. fier that time [twas not until mid. 1968 that vaccination was used tationaly and les than a quater of ll children had been protected by the end of 1972! conclade that the contibuson of immunization t0 the reduction of notifications inthe lst decade cannot be decided on this evidence. "There are many other infetionsia which prophylaxis and treatent ace effective, Internationally perhaps the most important are wopical, iseases such as malaria and yellow fever, which realy fll outside the scope this discussion. Althoughsyphilishad declined for other reasons, it was nil important when salvarin became avilable early in this cenvary, and mortality fll to low level before the arenicals were replaced by peniili, Other eceable infectious disease include bac- feral meningitis, sub-acte bacterial endocarditis, typhoid, oxteo-anyel- ‘n,puerperal fever, bacterial infetions ofthe eat, pharynx and lary, Medical Achieve weve wr cellulitis, gonorshoes,carbunce and cysts. Some ofthese condi ‘Ste wually Gulf wniceated; others are important a caues of morbidity father than moctaly “This appeal of ome ofthe st important medical advances envet file doube that tei inapact was ruck smalls than is generally be~ Teved. Theinfeerions were declining longbefore succes intervention sas posible, and sine that time, with some notable exceptions espe ily fn the ease of tuberculors and poliomyclst) immunization and Trclument were les effective thas ther inflances. eis significant that (ue peoceduees which were caeolly astesed by randomized control ‘Gh [lor example BCG vaccination) do nc appeat to have had the Expected cetul, The conlsion which sem sesapable is that dhe ‘ences which deterine man's zesponseoinfectious disease-geneti futetional, envicoamen'al and bebatiouca, 2s well as medical-are Fnftely complex, and we need to be very cautious before assuming thot we fly understand the infections, oc that we have in ovr hands the ceca means of thee contol “The chief requitement for an understanding of health i the past is Explanation of the sge and fll of infectious diseases, Tn elation to the ‘ihre, however, sessment of achievements with non-commonicable dscns i agosbly, more sigaiicant. fs developed countries, they are Show the predominant causes of sckoest anc death, and what hat bee ehiewed in the understanding an contol of sech conditions is there fre valable if incomplete, ndiation offature possibilities, TCnfortunatly its very dificult to ases the achievement Tr the Sin place, because non-comnmunicale dss vary greatly in severity. Gorton ind the extent of azocisted morbidity and disability, morality Spa fr le satfactory index than in the cae ofthe infection, where the outcome is often either death or complete recovery, Secondly, Inany clinial proceduces have never been stisfactrilyevaloted, and ‘face ose ie bed on indirect laboratory esidence or on clinical m= reson. A short assent ofthe medical contribution can therefore ede mote than alist of conditions in which cna intervention enerally believed t be effective. te bi dhoughefal examination of medial advances inthe period agsou7svafiee discussing the management or infectious dieses Thomasro Determinant of Healt ‘concluded thatthe lit of decive new accomplishments is not much Tonger than the contents ofthe Fllowing parse ‘Therchavebeen afew other namo ecology improvement. compare indehive efaciveney se 19, but he Bo the have been fo elvely come lesen, Childhood lesen apd cera oid amor i item, For enample cn now be cated by chemotherapy ina banda poperdon of cate, ut dee ate only few thousand of thee per yea inthe coun. Endocineeplacemene chery ha become highly cece and elatvly it~ fxpenine (sentine’ comideing the cow of ering fr enesedendosne ‘Grormale) fora vaiey of dort involving te adrenal pity, parm ‘byte, vary, and thyroid n paral, he bioceml textmen of thyoid {puinconhes improved sake, Hematology bas oered new and ecive feplcemen sextment Fr cetain sna, lminslgieal propyl 20% prevents mow ce of hemolytic dente ofthe newborn. Progees in anes, cle physiology, and earopulmsnarypysilogy har rely advanced fhe field of rer v0 Gat separtve and oer procedures cen now be done nbc formerly wee eciclyimpouile™ “This paragraph provider areatonable summary of decisive advances, some of which were launched before 1950, To them should be added the treatment of malignant hypertension and, in some exes, exentil Ihypertenson, Soccesfal measures also include the treatment of acci- ents, surgical weatment of earde conditions, relief of prostatic ob- struction fenalsansplans ad cre ofa minority of cancers. Treatment ‘of obit conditions may be le-aving, 2 the valuable investigations ‘of mateenal mortality ia Britain have shown. So £00 is intervention in ‘other emergencies (abdominal obstruction, perforated peptic wlet). There are many dherapis (refereed 10 below) which postpone rather than prevent death fom a specifi eats, or provide ref of symptoms without afecting expectation of life, which in many disorders isnot threatened ‘What should be noted about these advances is that they are not re- stited to preventable disorders, suchas accidents, which in an ideal ‘world would not occur, They include conditions casted inthe pre- edi chapters relatively intactable, The prevention ofthesshaerno- iyi disease ia remarkable example of an advance made ponble by 2 combination of genetic and clinical knowledge. The identification nd abortion ofa foetus affected by Down's dea is another solution (Of an apparently intractable peoblem made posible by application of Thomann 'On esence ntehnolgy of dct Dakine, Medical Achinoenen 109 genetic knowledge, Equally impresive ina gute differen way isthe {mmense technical accomplishment hick estes child witha patent ‘ducts arteriosus ot an atial septal defect to 2 lie of noc duration nd quality. Such achievements suggest ht furcher investigation may tnake it possible fo prevent, eliminate or tet succesally some of the ‘mos felt disorders with which medicine is now confronted “The we ofthe decline of mortality the main index of improvement in bealh is sometimes sid overlook the contbution of medica incerventon which postpones death bur does not change its ease Diabetes cited as an example ofa dice in which the extension of life isnot cefected in the trend of mortality, because the same cause often appeats later on a death eect "Fhe inerpretation of death rates is admitedly complex. They are based onthe number dying (the numero) over the roal population (ihe denominator) If deaths fom a dene ae reduced, the death-ate from that disease andthe deathrateFromall eases (sing no other lhanges have occurred) both fill, becaute the nemerator is sales and the denominator larger. Ths tue whether the aut of death is eim= inated (sin typhoid) oe portpaned (sin dabets). Moreover, n both ces the ate ace permanently lowered, ecause the number dying in {year emaine smaller in relation 20 the 2opulation at rk. Hence the postponement and prevention of death fom a specific ease are both reficced in the index. ‘When examining the trend of mortaliy ove 2 considerable peiod itisimportant to standardize forage charges inthe population (an ap= proximation tothe ideal bass far examination, the agespeife mot bly ates). The need for this rocedareitevidene froma comparison of, eath-rates fom dabeter before sri fer insulin. In England and Wales the exude rates were 107 (pet malon) it 1pt1-20 and 125 in 1973, which would seem to imply that mostly increased over this petiod ‘When standardized to the 1973 popolation, che death-eae in 1911-20 was However, standasdiaton doesnot remave all the dificult of nter- pretation. Disbetes apps to be more earamon than inthe pas, bot Fis nor posible to dawocate the efects of improved survival, beter diagnosis and posibly other infuences, Survival of dabei has beenne Determinants of Heath gravely prejudiced by th increased Fequency of smoking during the petiod when effective teatuent (oy invulin and oral diabetic deug) has been availble. And finally, mortality statics are very unreliable, because many diabetics de from arterial degeneration and their deaths are ofien attabuted to diease ofthe kidney, heart and brain, ‘With due regard for these difficulties, wefil evidence ofthe effec of | ‘wcatment cin be obtained ffom examination of age of death of dax bess, Fig 8.26 hours (or England and Wale) the number of sur vivors of colors of 1,000 female expoted to the mortality rates of 2o1i-20 and 1975. The difference in mean age at death at the two pevods was approximately ten yeas 1911090 es — mime erty a ion SS cote er wireenetgeress, Hite toprsee, em pA Ft icone 8.16. Survivors fom aesot f 100 female expoed Thiyto morality fom dubts at ates of 911-30 ah 0 Medical Achievemeat um te may seem surprising that age at death was s late neatly 70 in sgtteao and nearly 80 3973, This explined partly bythe fact shat ven before inauln mont diabesis died relavly late in hife. (The age {death in t911-30, and the extension of i which has resulted from trestment, would of coutte be vary difent if actetion were te pricted to juvenile diabetin) But thelateag of death salso determined by the fact chat deathe of diabetes Gom all cuss other than diabetes, were inevitably exclided from the cohort and those dying feom a Single cause, diabetes or any other, are highly and favourably selected in respect of length of Hf. This is merely mother way of saying that the stk of death fom a single diese alrerdy manifested i often less than the risk of death frou all other cattetaken together. Indeed, it ‘could be sid to many people by way of easurance: you willbe fort tatifyoutivelong enought die from the dase which most you exe. For sessment of the effet of poxponertent of death fom a single sea whovecontebtion tthe total dalseof moray ismall he change in age-specific death~ates and ince in expectation of probably the bet indices. But in assent ofthe concibuion of Tange mater of cates (sin the ese ofthe non-nfctve condiions considered in Chapter 3, both the prevention andthe postponement of death ae reflected fuly accurately inthe rend ofthe agestandard- ined mortality tes, When presenting the rerlte of his experiments on himself »distine guished biologist seemed to say: Take one average human being, for fxample,). BS. Haldane. Adopting the se unconventional xatisieal fpproach, we can state the ration between morbidity and mor~ tality by considsing the experience of one lkeland poet. William, ‘Wordsworth fellowed meet of the rules fo: health now advocated by life stylists. He did not sake or drink; unk some of his bes friend he avoided opium; he lived and worked in the open ar, added leele weight and took an amount of exercie which would fave daunted ‘most joggers. De Quincey eximated that Wordsworth walked between tys000 and 180,000 mules during hir life, and if s> he must have averaged neatly ten miler sda for sixty yeas Predictably, according tothe heath ules, be had long life. Howeverm Determinant of Heat he an his sister bath sured good del fom minor morbidity = Hiithe toodache, bowel ups abd names oter ened ceoetts recorded meso by Dovey inher Jorn sing She yeas in Dove Coup. At focus mental ath tas een 9 ed ite a sn sbmotal eins wiser, but though seeny of he eterence fom te ight uggesive, see imo eM ck Gar was ever consummated, What Wordswors iooy ‘festa tne here ao meer clot reson between morbiiy IAF Taowy The dea sven ote ives fe no aly he esta nh hee gat from day ody. Steen, there bs been luge eden i sickest aid sr eat chat have delved. Th parser ee ofthe [Eilat scpuatoryand venereal nection, Tei conuton fo che Soiidon emily cannot be messed, but publ chat ‘Sages thn that fom non-al eaes, Keseme ite Bk hat Tre Saal eiminaion of chronic repatory tubercles wot the reset angle infloence on declining Sikes es ahs pen conto, however, we are conned wih medic chleveiba ough went of dae a bites that €o ot HIS hs mnemene account mun be ken of both the egueney ‘Bittneu oa conden: the common coda mos people Zp fegunly rheumatoid ach and ei peenia re sch es cee har ie more Sablig for tore who ae ef. Wane noe exceptions there o wholly eetve etme forename nes ich uble mos people rm dy 0 dy. FR Rote sue ropraoryinfcsonn, dig dire, the sel Tee Gecir aioe ttened co su teumati and vey SFist nea, pata he news and peyote, The cee lena daewe. Aste tory of many famous people SEE SEs dues were formerly among the mor common esses Tae Racomfor toy they can be prevented and teste and in Seeeey Sittey of Seen in Bean they accounted for only four pet Tere eens of which people complied mow feguney. Le Seid ee nteeing to have aetna oft iegoency i the ast See RO SS te cde or he our of Lous RIV, Loos hinsel ‘Shred prolyl hs eh and wo dou wou ay fave TSE STR pute, deamauss, one or two misenes and sve een of Fane for s ode des rons yaad de cn be done to elenedscomfr om te comin cna mgt so be id hat any ahough By 80 Medic Achievment us mean all of them, are teansient abd preent ne permanent threat the ‘qualty or duration of life. Neverthels, suck conditions are responsible fhe a great deal of il-health, and heir prevention of teatment i 4 [egitenate goal of medical research and pacice. Indeed, considering SOF frequency of the common cold inthe celestial eounting-house ‘where such impondersbes can be weighed, is elimination might be ‘Considered at important asthe treatment of ene ofthe moce serous but {ene pevalen diseases Happily, only those dipesing of research funds ae fequted to make such value judgement. “These have been advances in ceatment of any uncomforeable and in same eas, disabling conditions, including hernias, piles, varicose ‘eins, Patkingoa's dete pemphigus and uleatve colitis. lshoughh either cheomatoid arthritis nov osteoartsis can be cured, sympto= hae relief can be povided and surgical treatment i sometimes ce- tmarkably seeesf, particulary by eeplacement of the diseased hip, ue ofthe outstanding achievertents of contemporary medicine. The fnsjor paychoses, schizopheeia and matic cepresion, ate still unex plained, but drug checapy has benefted many patients and, by makiog them more manageable, has ceduced the dificlies involved in chit Care, There has Been litle advance inthe treatment of mentally sub- formal patients although they can be astted by educational and tccupasionl opportonises aswell as pesona cae Because the nor-aal dicsce vary greatly in frequency, dartion| andscverity, itis oeay to vammaeize achievements thee extent, eis recognition ofthe dics they presen ater than a ttcsm fof medial research and practice to say that while symptomatic reli ‘an be provided for some, perhaps all patiens, with some notable ex- ‘eptons the undesying conditions eannot at present be cured. This is teuc ofthe relatively benign conditions which rovble most people From Gay to day, and of the les common caues of serious ease and dis- ably.