- Email: [email protected]
COUNTING THE DEAD IS NOT ENOUGH
308 DEBATE ON THE BLACK REPORT
SIR,-I should like to make the following points in connection with your Commentary from Westminster (July 18) on the Black report. In the Registrar General’s social classification of the population, social class III, in the middle of the scale, is the largest (it accounts for half the population) while social classes I and V, at the extremes, are the smallest. If "excess deaths" (and therefore, by implication, potentially preventable deaths) are identified as those which occur in a social class because its death rate is higher than that of social class I, then the largest number of excess deaths is in social class III
(table I). TABLE I-OCCUPIED AND RETIRED MEN AND WOMEN, AGED ENGLAND AND WALES,
members of social classes IV and V for whom there can be no reasonable prospect of substantially reducing their risk of death Such compensation could be in the form either of special health and social services provision, or it could be financial. The report’s major recommendation is that income should be redistributed, through taxation, away from families with no young children to families with young children, who would receive 1800 million in child benefits. The scientific (as distinct from the political) case against this is not that the nation has not got the money (as the Secretary of State suggests in his foreword to the report), for it is a redistribution, but that the evidence for the effectiveness of the proposal is not available, as the Secretary of State also recognises. The report itself emphasises the need for more research to explain the reasons for inequalities in health and makes firm proposals for intervention studies which could be evaluated. current
15-64,
1971
Area Headquarters, Avon Area Health Authority,
A. H. SNAITH
Bristol BS1 2EE
COUNTING THE DEAD IS NOT ENOUGH
Source: Office of
Population Censuses and Surveys. Occupational mortality: supplement 1970-72, table A, appendix 2, p 211. *Rounded
to nearest
Decennial
1000.
TABLE 11-CERVIC.’Al, CYTOLOGY SC:REENINC:
.Source: Sibery et al.’I tSource: Cardiff Cervical Cvtology Study-’
In a specific preventive programme the outcome will be influenced by a number of factors, such as response. There is a national screening programme for cervical cancer. Table n gives figures for the potential success of this programme calculated (for purposes of illustration) from published figuresl,2 from different studies for the number of women in each social class, their positive rates for the smear test, and their response rates for the programme. Special measures to ensure 100% response in this programme, if successful, would yield from social class III an additional 159 positive smears, from social class IV an additional 93, and from social class V an additional 68, per 100 000 women screened. The composition of each social class is not fixed and there are problems of definition. In the past half-century the numbers of deaths in social classes I and II have increased and the numbers in IV and V have declined. The reason for this is that the first two social classes have grown while the lowest two have shrunk. I suggest that the right strategy for the public health is to direct preventive programmes with the objective of maximising benefit; to rely on the country’s economy (not the health and personal social services) to reduce the number of deaths in social classes IV and V (as it has for the whole population over the years3,4), and to compensate Burslem RW, Wakefield J Cause of high risk of cervical cancer in socially unclassified women. Br J Cancer 1978; 38: 166-68. 2. The Cardiff Cervical Cytology Study J Epidem Comm Health 1980; 34: 9-13. 3. McKeown T. The role of medicine London Nuffield Provincial Hospitals Trust, 1976. 4. Cochrane AL, St. Leger AS, Moore F. Health service "input" and mortality "output" in developed countries. J Epidem Comm Health 1978; 32: 200-05. 1.
Sibery K,
SIR,-While I applaud the sentiment in the title of your July 18 editorial I am critical of its contents. You argue for the extension and strengthening of the national studies of morbidity statistics from general practice on the grounds that this will enable us to "incorporate true morbidity data into planning". But these statistics suffer from a disadvantage similar to those of hospital activities which, as you point out, tell us much about what goes on in hospital but nothing about the needs of the community. In the same way data from general practice studies illuminate activities in the surgery but reveal nothing of the iceberg of ill-health that never reaches there. Moreover, the general practice studies do not have the advantage of being based on a proper sample: they relate only to volunteer practices. While underplaying the disadvantages of data from general practice you emphasise those of morbidity studies of the general population, pointing out that perceptions change over time (a comment which also applies to data from general practice) and describing the U.S. National Health Interview Survey as "messy" data. In short you seem to regard non-random data from doctors as "hard" while stating that data from random samples of people or patients are "soft". But, as Illsleyl has pointed out, "rather than measuring something less than ’objective’ clinical assessments, selfreports may be measuring something more". At the same time, self ratings of health correlate well with physicians’ ratings,2and when information from medical records and from maternity patients is compared there is reasonably good agreement over many things and over some points most of the discrepancies arise from errors or omissions in the medical notes.33 You would have done better to argue for the extension of health data collected in the General Household Survey which you fail to mention although this has been obtaining information about health from random samples of the population over the past ten years. Institute for Social Studies
London NW3 2SB
in
Medical Care,
ANN CARTWRIGHT
DETECTION BIAS IN ENDOMETRIAL CANCER
SIR,-Dr Horwitz and his colleagues (July 11, p. 66) present data but misleading conclusions on the effect of asymptomatic endometrial cancers on detection bias in case-control
interesting studies.
They argue that the alleged association between exogenous oestrogens and endometrial cancer arises because R. Professional or public health?: Sociology in health and medicine. London Nuffield Provincial Hospitals Trust, 1980. 2. Ferraro KF. Self-ratings of health among the old and the old-old. J Health Soc Behavi. 1980; 21: 377-83. 3. Cartwright A, Smith C. Some comparisons of data from medical records and from interviews from women who had recently had a live birth or still birth. J Biosoc Sc 1979; 11: 49-64. 1.
Illsley
SIR,-I should like to make the following points in connection with your Commentary from Westminster (July 18) on the Black report. In the Registrar General’s social classification of the population, social class III, in the middle of the scale, is the largest (it accounts for half the population) while social classes I and V, at the extremes, are the smallest. If "excess deaths" (and therefore, by implication, potentially preventable deaths) are identified as those which occur in a social class because its death rate is higher than that of social class I, then the largest number of excess deaths is in social class III
(table I). TABLE I-OCCUPIED AND RETIRED MEN AND WOMEN, AGED ENGLAND AND WALES,
members of social classes IV and V for whom there can be no reasonable prospect of substantially reducing their risk of death Such compensation could be in the form either of special health and social services provision, or it could be financial. The report’s major recommendation is that income should be redistributed, through taxation, away from families with no young children to families with young children, who would receive 1800 million in child benefits. The scientific (as distinct from the political) case against this is not that the nation has not got the money (as the Secretary of State suggests in his foreword to the report), for it is a redistribution, but that the evidence for the effectiveness of the proposal is not available, as the Secretary of State also recognises. The report itself emphasises the need for more research to explain the reasons for inequalities in health and makes firm proposals for intervention studies which could be evaluated. current
15-64,
1971
Area Headquarters, Avon Area Health Authority,
A. H. SNAITH
Bristol BS1 2EE
COUNTING THE DEAD IS NOT ENOUGH
Source: Office of
Population Censuses and Surveys. Occupational mortality: supplement 1970-72, table A, appendix 2, p 211. *Rounded
to nearest
Decennial
1000.
TABLE 11-CERVIC.’Al, CYTOLOGY SC:REENINC:
.Source: Sibery et al.’I tSource: Cardiff Cervical Cvtology Study-’
In a specific preventive programme the outcome will be influenced by a number of factors, such as response. There is a national screening programme for cervical cancer. Table n gives figures for the potential success of this programme calculated (for purposes of illustration) from published figuresl,2 from different studies for the number of women in each social class, their positive rates for the smear test, and their response rates for the programme. Special measures to ensure 100% response in this programme, if successful, would yield from social class III an additional 159 positive smears, from social class IV an additional 93, and from social class V an additional 68, per 100 000 women screened. The composition of each social class is not fixed and there are problems of definition. In the past half-century the numbers of deaths in social classes I and II have increased and the numbers in IV and V have declined. The reason for this is that the first two social classes have grown while the lowest two have shrunk. I suggest that the right strategy for the public health is to direct preventive programmes with the objective of maximising benefit; to rely on the country’s economy (not the health and personal social services) to reduce the number of deaths in social classes IV and V (as it has for the whole population over the years3,4), and to compensate Burslem RW, Wakefield J Cause of high risk of cervical cancer in socially unclassified women. Br J Cancer 1978; 38: 166-68. 2. The Cardiff Cervical Cytology Study J Epidem Comm Health 1980; 34: 9-13. 3. McKeown T. The role of medicine London Nuffield Provincial Hospitals Trust, 1976. 4. Cochrane AL, St. Leger AS, Moore F. Health service "input" and mortality "output" in developed countries. J Epidem Comm Health 1978; 32: 200-05. 1.
Sibery K,
SIR,-While I applaud the sentiment in the title of your July 18 editorial I am critical of its contents. You argue for the extension and strengthening of the national studies of morbidity statistics from general practice on the grounds that this will enable us to "incorporate true morbidity data into planning". But these statistics suffer from a disadvantage similar to those of hospital activities which, as you point out, tell us much about what goes on in hospital but nothing about the needs of the community. In the same way data from general practice studies illuminate activities in the surgery but reveal nothing of the iceberg of ill-health that never reaches there. Moreover, the general practice studies do not have the advantage of being based on a proper sample: they relate only to volunteer practices. While underplaying the disadvantages of data from general practice you emphasise those of morbidity studies of the general population, pointing out that perceptions change over time (a comment which also applies to data from general practice) and describing the U.S. National Health Interview Survey as "messy" data. In short you seem to regard non-random data from doctors as "hard" while stating that data from random samples of people or patients are "soft". But, as Illsleyl has pointed out, "rather than measuring something less than ’objective’ clinical assessments, selfreports may be measuring something more". At the same time, self ratings of health correlate well with physicians’ ratings,2and when information from medical records and from maternity patients is compared there is reasonably good agreement over many things and over some points most of the discrepancies arise from errors or omissions in the medical notes.33 You would have done better to argue for the extension of health data collected in the General Household Survey which you fail to mention although this has been obtaining information about health from random samples of the population over the past ten years. Institute for Social Studies
London NW3 2SB
in
Medical Care,
ANN CARTWRIGHT
DETECTION BIAS IN ENDOMETRIAL CANCER
SIR,-Dr Horwitz and his colleagues (July 11, p. 66) present data but misleading conclusions on the effect of asymptomatic endometrial cancers on detection bias in case-control
interesting studies.
They argue that the alleged association between exogenous oestrogens and endometrial cancer arises because R. Professional or public health?: Sociology in health and medicine. London Nuffield Provincial Hospitals Trust, 1980. 2. Ferraro KF. Self-ratings of health among the old and the old-old. J Health Soc Behavi. 1980; 21: 377-83. 3. Cartwright A, Smith C. Some comparisons of data from medical records and from interviews from women who had recently had a live birth or still birth. J Biosoc Sc 1979; 11: 49-64. 1.
Illsley