Archive for August, 2013

by David Stuckler and Martin McKee

An early warning sign of a society in distress is when public health statistics begin to deteriorate. In 1981, the US economist Nick Eberstadt was one of the first to warn that the USSR was in deep trouble, based on evidence of rising infant mortality.

Lately several such warnings have been lighting up in the UK. One is a significant increase in suicide rates, numbering 1,000 additional suicides over and above historical trends between 2008 and 2011. 

The charity Mind reported a 50% increase in distress calls in 2012, alongside a significant rise in new cases of depression.  Another is a worrisome increase in age-standardised death rates, concentrated in those older than 85 years of age, reversing a past decline (see figure 1). Had deaths rates in persons over-85 remained at 2011, there would have been about 2,200 fewer deaths in men and 6,150 fewer deaths in women.


Figure 1. Trends in age-standardised death rates in persons ages 85+ per 1,000 population, 2011 and 2012
Why did mortality rates increase in persons over 85 in 2012? Is this a result of an unusually bad flu season? An increase in hospital-borne infections? A result of suicides and other external causes? Or something else?

One possibility is that this rise is a statistical artefact. People aged over 85 are at the highest risk of dying, and so even a large rise in the number of deaths may have occurred by chance alone. However, the UK Office for National Statistics has concluded that the increase is a statistically significant departure from past trends.

Another possibility is that British emigrants returned from crisis-stricken countries, such as Greece, Spain, and Portugal, so artificially swelling the numerator. Yet it seems implausible that sufficiently large numbers of people could have returned and died in such a short period so as to drive the mortality increase.

Taking it as given that the rise is significant and has its roots in domestic causes, to understand whether these deaths could have been avoided, it is necessary to first evaluate the immediate causes of the increase in deaths.

Using the data from the Office for National Statistics annual mortality reports for 2011 and 2012, we decomposed the changes in mortality numbers by specific causes of death for men and women. Figure 2 shows the contribution of 17 International Classification of Disease (ICD) categories to the overall all-cause mortality increase. As shown in the figure, the greatest cause of rising deaths was from “mental and behavioural disorders” (ICD F01-F99) attributable for 34% of the rise in women and 21% in men.On closer inspection, we found this specifically pertained to two sub-categories, “vascular and unspecified dementia” (ICD codes F01 and F03).


Figure 2. Decomposition of the causes of the increase in mortality numbers, 2011-2012

The next largest cause of death was from circulatory diseases, accounting for an additional 22% of the rise in women and 20% in men. Within this cluster of causes of death, the rise was mostly classified as ‘other heart diseases’ and ischaemic heart disease.

Using data on cause of death, we were able to rule out several possibilities. It has been speculated that influenza and pneumonia contributed to the observed rise. However, on closer inspection, these combined categories contributed to only 5.8% and 3.5% of the increase in mortality numbers in men and women, respectively. Deaths from infectious diseases declined, further ruling out the possibility of hospital-borne infections. Additionally we found that external causes of death, including traffic accidents and suicides, were relatively small contributors to the observed mortality changes.

What do these data imply for healthcare professionals, and policymakers? While it is too early to draw strong conclusions, it is clear that there is a need for close monitoring of the health of older people. There appears to be no one specific cause of death or disease outbreak that is responsible for the rise in mortality.

However, as a caveat, it is difficult to ascertain precisely the immediate cause of death in older people, when they may have multiple and interacting co-morbidities. Further analysis should evaluate these mortality patterns by geographical area, particularly with a view to understanding whether the mortality increase was disproportionate in more deprived communities and those hit most by budget cuts.

As with all public health data, these trends cannot be fully understood independently of current social and economic circumstances. One pressing concern is that older people are bearing the brunt of recession and budget cuts. Compared to 2009, 14% more people over 65 were declared bankrupt in 2012, whereas in every other age-group the rate of bankruptcies declined in this same period. 

This hardship exacerbates an already bad situation. British pensioners have the fourth greatest risk of poverty in Europe, behind Bulgaria, Cyprus, and Spain.  The Coalition government’s deep cuts to housing support and winter allowances may further place older persons in harm’s way. We know that older people’s confidence and engagement with life are important determinants whether they will age successfully. 

However, both salutogenic factors are under threat, the first because of the sustained attacks on them by some politicians and sections of the media who seek to exploit generational divisions as a pretext for further cuts in the welfare state,  and the second by cuts in local government budgets, such as libraries, day, and sports centres, that reduce older people’s opportunities to meet with others.

There are signs that mortality trends could become worse in 2013. The most recent data indicate that this elevated death rates has not only continued into 2013, but now also appears to include persons between ages 65 and 85.  A July 2013 ONS report states that “Cumulated 2013 deaths to the beginning of July are 5.6 % higher than the average for the same weeks over 2008-2012. Up to age 65, deaths counts in 2013 are similar to those in 2012; and below those for the previous two years. Over 65, deaths in 2013 have been substantially higher than those for 2012 over the year so far. For those over 85, overall deaths in 2012 were very substantially higher than over the previous two years; and deaths in 2013 look on track to be similarly high.”

Unfortunately, detailed cause of death data for 2013 will not be publicly available until the end of the year. It reminds us of the lack of priority that politicians place on public health data, compared with rapidly available stock market and economic data. At least for now, these worrisome trends call for further monitor and close investigation.

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by Professor John Ashton, President of the Faculty of Public Health

What is the best way to advocate and improve public health policy? Quietly and diplomatically, or through loud and public protest? Or is there room for both approaches?

These are some of the questions that are part of the discussion that led to the Faculty of Public Health’s (FPH) recent decision to withdraw from the government’s Responsibility Deals, a group drawn from industry, local authorities and the public health community.

The aim of the responsibility deal was to provide a quicker means of improving public health policy than bringing new legislation before parliament. The logic was that a ‘carrot not stick’ approach would lead to faster progress than forcing companies to meet new legal requirements. Participating organisations signed up to pledges on public health issues such as physical activity, taking a billion units of alcohol out of circulation or reducing calories in food.

FPH had representatives on the alcohol, food, physical activity and health at work networks until July 2013. We owe a debt of thanks to those FPH representatives who gave up their time to challenge decision-making and question the logic of the direction public health policy was taking. We can be sure that their input has helped mitigate some of the worst excesses of a commercial need to put the value of shares ahead of public health.

FPH’s decision to join the responsibility deal was controversial and much debated throughout the past two years. There are many people within the public health community who disagreed with our participation. Others felt it was better to be at the table, than to leave the debate unchallenged by public health expertise.

Given how public health policy has developed in recent years, the available options for effective advocacy have sometimes seemed like the moment in the film Argo when CIA officer Jack O’ Donnell has to admit that the ludicrous-sounding plan to rescue American hostages in Tehran, by pretending they are the crew of a sci-fi fantasy movie, is the ‘best bad idea’ he has.

Unlike the fictional and public world of a Hollywood film, much of public health advocacy goes on in a less public fashion. It has become clear that government public health policy has fallen victim to a concerted and shameful campaign of lobbying by sections of the tobacco and drinks industry who are putting profits before health and public safety.

The balance of gains and losses of participating in the responsibility deals shifted recently when the Government made it clear that a minimum unit price for alcohol and standardised packs for cigarettes would not be introduced.

In light of this, we withdrew from all of the Responsibility Deal groups. Using legislation to bring in measures like minimum unit pricing would have been quicker than a ‘softly softly’ approach. There is also no way of knowing if the responsibility deals have been truly effective because it is unlikely the key pledges will be evaluated.

For example, there is no case for saying that the Billion Unit Pledge for alcohol is a success because any gains from people drinking lower alcohol beer have been cancelled out by the increase in people drinking wine and spirits. On these two measures alone, the Responsibility Deals have not achieved their original purpose.

FPH has worked with governments of all political persuasions since it was first founded over 40 years ago. We want to continue to work with Government to improve people’s health. We know that the best way to improve everyone’s health is by working in partnership and we remain committed to doing so. However, we, like other NGOs with limited resources for the important work we do, need to make sure we use our influence and expertise in the most effective way possible. We look forward to continuing our advocacy work and will keep you updated on how it progresses.

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