In search of a contemporary theory for understanding mortality change

Urbanization and systolic/diastolic blood pressure from a gender perspective: Separating longitudinal from cross-sectional association

There has been a generally negative view of the impact of urbanization on a rising burden of non-communicable diseases including cardiovascular disease. However, the evidence on the relationship between urbanization and cardiovascular health has remained inconclusive. A comprehensive picture of the relationship is lacking, given an implicit assumption that the longitudinal association between changes in cardiovascular health and an increasingly urbanized environment is similar between less and more urbanized communities, men and women. We used the longitudinal data on adults (18-64 years) from the China Health and Nutrition Survey (1991-2015) and employed within-between random-effects models to disaggregates the longitudinal and cross-sectional associations between urbanization and systolic/diastolic blood pressure (SBP/DBP) and examined heterogeneities in the longitudinal association by average urbanization level and gender. We found that the positive longitudinal association of urbanization with SBP/DBP was stronger in less urbanized than more urbanized communities. The cross-sectional association between urbanization and SBP was negative and significant, although the cross-sectional association between urbanization and DBP was of no statistical significance. Moreover, the positive longitudinal association between urbanization and DBP was stronger among men than women, although the gender heterogeneity in the longitudinal association of urbanization with SBP was not significant.

A spatio-temporal analysis of cause-specific mortality in São Paulo State, Brazil

Abstract Using five cause-specific mortality data sourced by the Brazilian Ministry of Health, and over 17 years period, we applied Bayesian spatio-temporal models on 644 municipalities of the state of São Paulo, using logistic model to the binary outcome that specifies whether or not the death was from a specific cause. We modeled the temporal mortality effects using B-splines, while the spatial components were considered through Gaussian and Markov random field, and inference was based on Markov chain Monte Carlo simulation. The results demonstrate consistent downward trend in mortality from infectious and parasitic diseases and external causes, while those from neoplasms and respiratory are rising. Cardiovascular is the only cause-specific death that is kept constant in time. All the causes of death considered show heterogeneous spatial and temporal variations among the municipalities, which sometimes change considerably within successive years. Mortality from infectious diseases clustered around the Northwestern municipalities in 2000, but changes to the Southeastern part in 2016, a similar development as external death causes. The study identifies areas with increased and decreased odds mortality and could be useful in disease monitoring, especially if we consider small spatial units.

Child Mortality and Socioeconomic Status: An Examination of Differentials by Migration Status in South Africa

This study examines child mortality and socioeconomic status among migrants and nonmigrants. It also examines child mortality by migration status in all quintiles of socioeconomic status, comparing immigrants to the native-born and internal migrants to nonmigrants. The results show that among migrants, child mortality decreased faster as socioeconomic status increased than among nonmigrants. The results also show a crossover in the likelihood of child mortality by immigration status as socioeconomic status increased. In the poorest socioeconomic quintiles immigrants had a greater likelihood of child mortality than the native-born while in the wealthiest quintiles child mortality was greater among the native-born.

The rate of country-level improvements of the infant mortality rate is mainly determined by previous history

BACKGROUND

Studies of country-level determinants of health have produced conflicting results even when the analyses have been restricted to high-income counties. Yet, most of these studies have not taken historical, country-specific developments into account. Thus, it is appropriate to separate the influence of current exposures from historical aspects.

METHODS

Determinants of the infant mortality rate (IMR) were studied in 28 OECD countries over the period 1990-2012. Twelve determinants were selected. They refer to the level of general resources, resources that specifically address child health and characteristics that affect knowledge dissemination, including level of trust, and a health related behaviour: the rate of female smoking.

RESULTS

Bivariate analyses with the IMR in year 2000 as outcome and the 12 determinants produced six statistically significant models. In multivariate analyses, the rate of decrease in the IMR was investigated as outcome and a history variable (IMR in 1990) was included in the models. The history variable alone explained 95% of the variation. None of the multivariate models, with the 12 determinants included, explained significantly more variation.

CONCLUSION

Taking into account the historical development of the IMR will critically affect correlations between country-level determinants and the IMR.

Primary health care research in Bolivia: systematic review and analysis

Bolivia is currently undergoing a series of healthcare reforms centred around the Unified Family, Community and Intercultural Health System (SAFCI), established in 2008 and Law 475 for Provision of Comprehensive Health Services enacted in 2014 as a first step towards universal health coverage. The SAFCI model aims to establish an intercultural, intersectoral and integrated primary health care (PHC) system, but there has not been a comprehensive analysis of effective strategies towards such an end. In this systematic review, we analyse research into developing PHC in Bolivia utilizing MEDLINE, the Virtual Health Library and grey literature from Pan American Health Organization/World Health Organization's internal database. We find that although progress has been made towards implementation of a healthcare system incorporating principles of PHC, further refining the system and targeting improvements effectively will require increased research and evaluation. Particularly in the 7 years since establishment of SAFCI, there has been a dearth of PHC research that makes evaluation of such key national policies impossible. The quantity and quality of PHC research must be improved, especially quasi-experimental studies with adequate control groups. The infrastructure for such studies must be strengthened through improved financing mechanisms, expanded institutional capacity and setting national research priorities. Important for future progress are improved tracking of health indicators, which in Bolivia are often out-of-date or incomplete, and prioritization of focused national research priorities on relevant policy issues. This study aims to serve as an aid towards PHC development efforts at the national level, as well as provide lessons for countries globally attempting to build effective health systems accommodating of a multi-national population in the midst of development.

Can mothers recognize neonatal illness correctly? Comparison of maternal report and assessment by community health workers in rural Bangladesh

OBJECTIVES

To validate maternal recognition of neonatal illnesses at home compared to assessment by community health workers (CHWs) during routine household surveillance for neonatal illness in rural Bangladesh.

METHODS

Surveillance in the intervention arm of two cluster-randomized, controlled trials of newborn interventions conducted in Sylhet and Mirzapur districts of Bangladesh. CHWs promoted birth and newborn care preparedness during two prenatal visits, including recognition of neonatal illnesses. CHWs assessed 8472 neonates on post-natal days 0, 3, and 6 between 2004 and 2005 in Sylhet, and 7587 neonates on post-natal days 0, 2, 5, and 8 between 2004 and 2006 in Mirzapur. In both sites, CHW identified neonates with very severe disease (VSD), using clinical algorithms that included ascertainment of illness history reported by mother and observation of clinical signs of illness. We calculated sensitivity, specificity, positive predictive value and negative predictive value of maternal report of any illness sign compared to CHWs' assessments and classification of VSD. Analysis was restricted to mothers whose neonates were assessed by CHWs at home during the routine visit schedule.

RESULTS

Maternal report of any signs had sensitivity of 24% and 20% and positive predictive value of 45% and 54% in Sylhet and Mirzapur, respectively.

CONCLUSIONS

Maternal recognition of neonatal illnesses at home was poor in two rural areas in Bangladesh. Interventions need to be designed to improve maternal recognition, and routine post-natal assessment by CHWs at home may be an essential component of community-based newborn care to improve care-seeking for newborn illness.

Economic development as a determinant of injury mortality - a longitudinal approach

Cross-sectional studies have produced clear inverted U-shaped curves between injury mortality and economic development; yet, this does not mean that single countries will necessarily follow similar curves as they grow richer over time. This study was conducted to examine whether previous cross-sectional findings can be verified using a longitudinal approach. Data for both injury mortality and gross domestic product (GDP) per capita were obtained from an official health database for the member countries of the Organization for Economic Cooperation and Development (OECD) for the period of 1960-1999. Regression models were then used to examine the longitudinal relationship between these two variables. Substantial improvements in injury mortality were observed in all income categories in the selected countries. For higher and middle high-income countries, injury mortality rates (all causes) increased until 1972, peaking in 1972 and then declining. For industrialized countries with relatively low GDP, injury mortality rates increased until 1977 and then declined. Using cubic regression lines for injury mortality rates, for all income categories, injury mortality rates increased up to a GDP per capita of USD 3,000-USD 4,000, then decreased significantly. The rising trends of suicide and homicide rates were observed until countries attained a GDP per capita of around USD 13,000-USD 14,000 for all income categories. It is noteworthy that compared to the intentional injury categories, mortality due to road traffic accidents and injuries from falls declined earlier on in the economic development process. Longitudinal analysis among high-income countries confirms earlier cross-sectional findings; that is, most injury categories seem to follow inverted U-shaped trend lines, with declining trends after peaking at various stages of temporal and economical development. A comparison between time and economy suggests that differences in peaking time between countries for the same injury category is partly a reflection of temporal differences in economic development.

Interplay of politics and law to promote health: improving economic equality and health: the case of postwar Japan

The health situation in Japan after World War II was extremely poor. However, in less than 35 years the country's life expectancy was the highest in the world. Japan's continuing health gains are linked to policies established at the end of World War II by the Allied occupation force that established a democratic government. The Confucian principles that existed in Japan long before the occupation but were preempted during the war years were reestablished after the war, facilitating subsequent health improvements. Japan's good health status today is not primarily the result of individual health behaviors or the country's health care system; rather, it is the result of the continuing economic equality that is the legacy of dismantling the prewar hierarchy.

Inequalities in mortality during and after restructuring of the New Zealand economy: repeated cohort studies

OBJECTIVES

To determine whether disparities between income and mortality changed during a period of major structural and macroeconomic reform and to estimate the changing contribution of different diseases to these disparities.

DESIGN

Repeated cohort studies.

DATA SOURCES

1981, 1986, 1991, 1996, and 2001 censuses linked to mortality data. Population Total New Zealand population, ages 1-74 years.

METHODS

Mortality rates standardised for age and ethnicity were calculated for each census cohort by level of household income. Standardised rate differences and rate ratios, and slope and relative indices of inequality (SII and RII), were calculated to measure disparities on both absolute and relative scales.

RESULTS

All cause mortality rates declined over the 25 year study period in all groups stratified by sex, age, and income, except for 25-44 year olds of both sexes on low incomes among whom there was little change. In all age groups pooled, relative inequalities increased from 1981-4 to 1996-9 (RIIs increased from 1.85 (95% confidence interval 1.67 to 2.04) to 2.54 (2.29 to 2.82) for males and from 1.54 (1.35 to 1.76) to 2.12 (1.88 to 2.39) for females), then stabilised in 2001-4 (RIIs of 2.60 (2.34 to 2.89) and 2.18 (1.93 to 2.45), respectively). Absolute inequalities were stable over time, with a possible fall from 1996-9 to 2001-4. Cardiovascular disease was the major contributor to the observed disparities between income and mortality but decreased in importance from 45% in 1981-4 to 33% in 2001-4 for males and from 50% to 29% for females. The corresponding contribution of cancer increased from 16% to 22% for males and from 12% to 25% for females.

CONCLUSIONS

During and after restructuring of the economy disparities in mortality between income groups in New Zealand increased in relative terms (but not in absolute terms), but it is difficult to confidently draw a causal link with structural reforms. The contribution of different causes of death to this inequality changed over time, indicating a need to re-prioritise health policy accordingly.

Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015

BACKGROUND

Global efforts have increased the accuracy and timeliness of estimates of under-5 mortality; however, these estimates fail to use all data available, do not use transparent and reproducible methods, do not distinguish predictions from measurements, and provide no indication of uncertainty around point estimates. We aimed to develop new reproducible methods and reanalyse existing data to elucidate detailed time trends.

METHODS

We merged available databases, added to them when possible, and then applied Loess regression to estimate past trends and forecast to 2015 for 172 countries. We developed uncertainty estimates based on different model specifications and estimated levels and trends in neonatal, post-neonatal, and childhood mortality.

FINDINGS

Global under-5 mortality has fallen from 110 (109-110) per 1000 in 1980 to 72 (70-74) per 1000 in 2005. Child deaths worldwide have decreased from 13.5 (13.4-13.6) million in 1980 to an estimated 9.7 (9.5-10.0) million in 2005. Global under-5 mortality is expected to decline by 27% from 1990 to 2015, substantially less than the target of Millennium Development Goal 4 (MDG4) of a 67% decrease. Several regions in Latin America, north Africa, the Middle East, Europe, and southeast Asia have had consistent annual rates of decline in excess of 4% over 35 years. Global progress on MDG4 is dominated by slow reductions in sub-Saharan Africa, which also has the slowest rates of decline in fertility.

INTERPRETATION

Globally, we are not doing a better job of reducing child mortality now than we were three decades ago. Further improvements in the quality and timeliness of child-mortality measurements should be possible by more fully using existing datasets and applying standard analytical strategies.

Impact of economic crisis on cause-specific mortality in South Korea

BACKGROUND

Economic changes can be powerful determinants of health. In the late 1990s, South Korea experienced a steep economic decline. This study examines whether the massive economic changes affected trends in all-cause and cause-specific mortality in South Korea.

METHOD

Mid-year population estimates of 5 year age groups (denominators) and death certificate data (numerators) from the National Statistical Office of Korea were used to compute cause-specific age-standardized mortality rates before and after the economic crisis.

RESULTS

All-cause mortality continued to decrease in both sexes and all age groups during the crisis. Cerebrovascular accidents, stomach cancer, and liver disease contributed most to this decline. A remarkable decrease in transport accident mortality rates was also observed. The most salient increase in mortality was suicidal death. Mortality from homicide, pneumonia, and alcohol dependence increased during the economic crisis, but these accounted for a small proportion of total mortality.

CONCLUSIONS

Short-term mortality effects of the South Korean economic crisis were relatively small. It appears that any short-term effects of the economic decline were overwhelmed by the momentum of large declines in causes of death such as stroke, stomach cancer, and liver disease, which are probably related to exposures with much longer aetiological periods. However, this study focused on rather immediate mortality effects and follow-up studies are needed to elucidate any longer-term health effects of the South Korean economic crisis.

Economic stability and health status: evidence from East Asia before and after the 1990s economic crisis

The East Asian economies of Indonesia, Malaysia and Thailand suffered declines in their economic growth rates in 1997. The Indonesian and Thai government followed the World Bank prescription for adjustment, which included a cut-back in government spending at a time when there were significant job losses. Malaysia chose its own path to adjustment. Evidence presented in this paper shows that although the declines were short-lived that there was an impact on the health status measured by mortality rates for the populations of Indonesia and Thailand. There was little apparent impact on the health status of Malaysians. The lessons for other developing economies include the importance of social safety nets and the maintenance of government expenditure in minimising the impact of economic shocks on health.

Los Años de la Crisis: An examination of change in differential infant mortality risk within Mexico

The main aim of the present analysis is to test the possibility that the period of economic hardship characterizing Mexico over the decade 1986-1996 has negatively influenced infant health outcomes. Data on births from two installments of the Encuesta Nacional de la Dinámica Demográfica, a nationally representative demographic survey, are used to determine whether a reduction in mortality differentials has paralleled the overall drop in the national infant mortality rate. The findings indicate that the decrease observed in the overall infant mortality rate has been matched by decreases in several disparities at the same time that it has been marred by increases in others. The data support the possibility that where you live has become an increasingly salient factor in determining the odds of infant mortality. High parity, low education and unemployment status have also become more salient factors in predicting post neonatal infant mortality risk in the more recent period as compared to the earlier period. As Mexico's infant mortality rate begins to stabilize in the near future, this research highlights the need to re-focus our research efforts on the causes and consequences of differential mortality trends.

A mortalidade por doenças infecciosas no início e no final do século XX no Município de São Paulo

A melhora das condições de vida do homem durante o século XX contribuiu para transformações da estrutura demográfica e para mudanças dos padrões de morbi-mortalidade. Com o objetivo de discutir essas mudanças, pretende-se comparar os dados de mortalidade do Município de São Paulo em 1901, 1960 e 2000. As causas de morte foram obtidas das seguintes fontes: Anuários Estatísticos da FSEADE, para 1901; Anuário de 1961 do Departamento de Estatística do Estado e CD-ROM de Mortalidade do Ministério da Saúde, para o ano de 2000. Os demais dados - de população, de nascidos vivos, coeficientes de mortalidade geral e infantil - foram obtidos do CD-ROM "500 anos de Divisão territorial e 100 anos de Estatísticas Demográficas Municipais" da FSEADE. Do início até o final do século XX, a população do Município de São Paulo aumentou 36 vezes, o número de nascimentos quase 24 e o número de óbitos 13,6 vezes. No entanto, as taxas de mortalidade diminuíram, a mortalidade geral foi 2,6 vezes menor no ano 2000 e a mortalidade infantil 11,3 vezes menor. A proporção de óbitos por doenças infecciosas declina de 45,7% do total de óbitos em 1901 para 9,7% em 2000. Em 1901, entre as 10 principais causas de morte no Município, 5 eram doenças infecciosas, correspondendo a 37% das mortes; em 1960, apareciam nesta lista apenas 3 doenças infecciosas (16,1% dos óbitos), e em 2000 apenas a pneumonia constava entre as principais causas de morte. Doenças como tétano, difteria, coqueluche, sarampo e escarlatina mostraram-se controladas no final do período. No entanto, a pneumonia, a tuberculose, a septicemia e a aids ainda se situam entre as que merecem especial atenção na área de saúde pública.

Diferenciais intra-urbanos de mortalidade em Belo Horizonte, Minas Gerais, Brasil, 1994: revisitando o debate sobre transições demográfica e epidemiológica

Modelos de transições demográfica e epidemiológica não têm sido debatidos com grande freqüência pela comunidade acadêmica brasileira. Este estudo tem por objetivo rever criticamente os estudos referentes a estes modelos de transição, analisando suas contribuições e limites à investigação em saúde das populações urbanas do Brasil. Dados do Município de Belo Horizonte são usados para ilustrar os aspectos teóricos levantados neste artigo. Um total de 10.558 declarações de óbito do ano de 1994 foram processadas visando à classificação da causa básica do óbito e local de residência - 75 unidades geográficas. As áreas foram classificadas de acordo com a proporção de chefes de domicílio com baixa escolaridade. Estruturas populacionais e taxas de mortalidade ajustadas por sexo e idade das áreas foram comparadas. As taxas de mortalidade indicam que Belo Horizonte está experimentando múltiplos e desiguais processos de transição epidemiológica. Nas áreas mais pobres, as doenças infecciosas dos adultos têm sido substituídas pelos homicídos. Em geral, os achados sugerem que as grandes cidades brasileiras possuem padrões de mortalidade que variam de acordo com os diferenciais sociais e econômicos.

Care seeking in Sri Lanka: one possible explanation for low childhood mortality

This paper examines care-seeking practices of mother caretakers with children less than five years of age in a rural district of Sri Lanka. The study was carried out from June to September 1998, documenting care-seeking practices of mother caretakers in a population of 2248 children in 60 villages. Of the five targeted diseases in the IMCI programme (Integrated Management of Childhood Illnesses) that were the focus of the study, acute respiratory infections (82.0%) and diarrhoea (14.8%) were predominant. Although malnutrition was highly prevalent it was not recognised by mother caretakers as an illness. Findings show that in 65.0% of illness episodes in children the mother caretakers sought outside care and treatment. Caretakers sought treatment from both private and public sectors with the majority seeking care in the private sector. Care seeking of mother caretakers was driven by symptomology. Young children with higher perceived severity and high-risk symptoms were brought to provider care more frequently, although a large percentage of episodes with low-risk symptoms were also brought for outside care. Care seeking was similar across socio-economic groups. The study points out that high care seeking of mother caretakers in Sri Lanka, particularly for illnesses with acute high-risk symptoms and signs, is a plausible explanation for the low level of childhood mortality despite the prevalence of a high rate of malnutrition.

Exposure, resistance, and recovery: a three-dimensional framework for the study of mortality from infectious disease

It has been suggested by several scholars that debates surrounding the study of mortality could benefit from a framework that integrates social and economic factors with the biological mechanisms of illness and death (Johannson and Mosk, Popul. Stud. 41 (1987) 207-236; Mosley, International Population Conference, Vol. 2, Florence, IUSSP, Liege, 1985. pp. 189-203; Mosley and Chen, in W. H. Mosley, L. C. Chen (Eds.), Child Survival: Strategies for Research, Population Council, New York, 1984, pp. 25-45; Murray and Chen, Soc. Sci. Med. 36(2) (1993) 143-155; Ruzicka, International Population Conference, Vol. 2, Florence, IUSSP, Liege, 1985, pp. 185-187). In this paper, I present a conceptual framework aimed at doing this for infectious disease mortality. The framework is built around three proximate processes: (1) exposure to potentially lethal pathogens, (2) resistance to disease pathogens after exposure, and (3) recovery from disease episodes after contraction. I apply this conceptual framework to morbidity and mortality from cholera across 41 less developed nations.

An analysis of health levels and various indicators of urban environments for Healthy Cities projects

STUDY OBJECTIVES

(1) To identify and to categorise the various city indicators that are related to health levels; (2) to demonstrate the extent of the influence on health of these categorised health determinants; and (3) to demonstrate both the interactive associations among the health determinants and the magnitude of influence of each health determinant on the people's health.

DESIGN

By using city statistics of study areas, the health index and health determinant indices were formulated. The extent of influence of health determinants on the health index was examined by regression analysis; the interrelations between the health determinants and the health index were examined by correlation analysis.

SETTING

All the administrative units in Japan with populations more than 100 000 were selected as study areas to analyse the relation of health and health determinants.

MAIN RESULTS

The nine health determinant indices used-healthcare resources, preventive health activities, environmental quality, housing, urban clutter, local economy, employment, income, and education-explained 51.6% of the variances of the health index as a whole in the cities studies. The health determinant indices showed interrelations with each other, in addition to individual health determinant indices having a high correlation with the health level index of the population.

CONCLUSIONS

Both individually and collectively the health determinants are closely related to the health status of a population and individual determinants interact with each other. Simultaneous analysis of the interrelations among health determinants and health status would contribute to widen integration oriented perspective in policy interventions based on collaboration between different sectors of society.

The relationship between social stratification and all-cause mortality among children in the United States: 1968-1992

BACKGROUND

US childhood poverty rates have increased for most of the past 2 decades. Although overall mortality among children has apparently fallen during this interval, these aggregate mortality rates may hide a disproportionate burden imposed on the least advantaged. This study assessed the impact of social stratification on long-term US childhood mortality rates and examined the temporal relationship between mortality attributable to social stratification and childhood poverty rates.

METHODS

Using US childhood mortality data obtained from the Compressed Mortality File (National Center for Health Statistics) and a county-level measure of social stratification (residential telephone availability), I evaluated the impact of social stratification on long-term trends (1968-1992) in age-adjusted mortality and compared the resulting attributable proportions to trends in childhood poverty rates.

RESULTS

Between 1968 and 1987 the proportion of US childhood deaths attributable to social stratification decreased from.22 to.17. Subsequently, it increased to.24 in 1992, despite continuous declines in overall childhood mortality rates. These proportions correlated strongly with earlier childhood poverty rates, taking into account an apparent 9-year lag. Among black children comparable trends were not observed, although throughout this time period their mortality rates were far higher than among the rest of the population and declined more slowly.

CONCLUSIONS

Despite declining childhood mortality rates between 1968 and 1992, children living in the least advantaged counties continued to die at higher rates than those living in the most advantaged counties. This differential worsened considerably after 1987, and by 1992 had a substantive impact on US life expectancy at birth, resulting in perhaps the most significant (in terms of years of life lost) reversal in the health of the US public in the 20th century.

Attaining health for all through community partnerships: principles of the census-based, impact-oriented (CBIO) approach to primary health care developed in Bolivia, South America

This article describes a flexible primary health care methodology which was developed by Andean Rural Health Care and its colleagues in Bolivia, South America. This methodology, the census-based, impact-oriented (CBIO) approach to primary health care, involves determining local health priorities as defined both by locally acquired epidemiologic information and by the local people themselves. The CBIO approach to primary health care is now functioning successfully at seven program sites in Bolivia, which together serve 75,000 people in urban and rural communities in three distinct cultural and ecological regions of the country. High levels of coverage of basic health services can be achieved through a system of 'epidemographic' surveillance of all families and through home delivery, when needed, of priority services to those at risk. When the services provided are based on local health priorities, when they are provided in a technically effective manner, and when the community has a strong partnership in planning, implementation and evaluation, then the CBIO approach to primary health care will lead to measurable health improvements as defined by changes in population-based rates of mortality and illness in the community. On the basis of our experience, we believe that the CBIO approach offers great potential for strengthening the effectiveness of local health programs in impoverished communities around the world in a way which fosters community ownership and, hence, long-term sustainability.

Public health nihilism vs pragmatism: history, politics, and the control of tuberculosis

Tuberculosis (TB) began to decline in the Western world in the mid- to late 1800s. In the United States, the disease receded until the mid-1980s, when that trend was reversed. Although the TB epidemic in the United States subsided in response to public health interventions, it sparked a controversy regarding the relative value of targeted public health measures vs broad social reform. That controversy, which echoed earlier debates calling for structural reform over public health programs, was further strengthened by the historical and demographic studies of Thomas McKeown. His influential thesis maintains that clinical and primary prevention efforts had little effect on TB mortality. In this paper, the historical literature is used to examine whether public health had a significant impact on the decline of TB mortality rates in several countries. Specifically, the paper describes the arguments for and data affirming the efficacy of 2 major public health interventions over time: segregation of those infected with pulmonary TB and eradication of bovine TB. This review finds support for the hypothesis that public health measures, along with other factors, led to falling rates of TB mortality beginning in the late 19th century.

Income inequality and population health

A number of studies have suggested that inequalities in the distribution of income may be an important cause of variations in the average level of population health among rich industrial nations. However, what is missing from the debate so far is any systematic review of evidence about the relationship between different measures of income distribution and indicators of population health. This paper aims to bridge that gap. First, it summarizes the recent English language literature on this topic and illustrates the methodological problems that weaken the inferences that can be derived from it. Secondly, it presents new empirical estimates of the relationship between different measures of income distribution, infant mortality and life expectancy based on the most authoritative data published to date. In contrast to most earlier studies, we find very little support for the view that income inequality is associated with variations in average levels of national health in rich industrial countries. Some possible explanations for these differences are outlined.

[Gastroenteritis and acute respiratory infections among children up to 5 years old in an area of Southeastern Brazil, 1986-1987, II--Diarrhea]

INTRODUCTION

The decrease morbi-mortality gastroenteritis in is related to the factor responsible largely for the fall in infant mortality and mortality from communicable diseases in developing countries. Nevertheless, diarrhea is still a considerable public health problem in these countries, especially among children under 5 years old.

OBJECTIVES

To describe some aspects of the of gastroenteritis epidemiology among children up to 5 years old, resident in areas of S. Paulo county.

MATERIAL AND METHOD

A probabilistic sample of children up to 5 years old was studied (n = 468). The epidemiological survey was undertaken in five areas S. Paulo county (Brazil) from March 1986 to May 1987. Data were obtained through household interviews once a month over a year.

RESULTS

During the follow-up 139 diarrhea episodes were registered, with a mean duration of 5.5 days. Twenty percent of the diarrhea events were followed by at least one other case in the household. The incidence of gastroenteritis was 2.78 episodes per 100 children/month. The highest incidence affected the children of up to 2 years of age. In 46.1% of the gastroenteritis episodes medical assistance was not sought, the children were treated by their mothers or not at all: 51.8% of the diarrhea events were attended to by the primary health care service, and only 2.1% were attended to by a hospital. No child died as a consequence of diarrhea. Of the therapeutical interventions used the most frequent were oral rehydration (25.2%) and oral rehydration with antibiotics (11.5%). Various socio-economic and personal background factors such as living conditions, water supply, sewarage, coverage; family income per capita and prior history of frequent gastroenteritis were associated with a higher incidence of gastroenteritis.

DISCUSSION

The results seen to reflect the tendency of morbi-mortality by gastroenteritis to decrease in S. Paulo county during the 1980's when hospital treatment of diarrhea presented a considerable reduction. This tendency must be observed closely, because it will influence the changes to be mode in the kind of demand for medical care.

The impact of the economic crisis and the US embargo on health in Cuba

OBJECTIVES

This paper examines the combined effects of a severe economic decline since 1989 and a tightening of the US embargo in 1992 on health and health care in Cuba.

METHODS

Data from surveillance systems for nutrition, reportable diseases, and hospital diagnoses were reviewed. These sources were supplemented with utilization data from the national health system and interviews with health leaders.

RESULTS

Changes in Cuba include declining nutritional levels, rising rates of infectious diseases and violent death, and a deteriorating public health infrastructure. But despite these threats, mortality levels for children and women remain low. Instead, much of the health impact of the economic decline of Cuba has fallen on adult men and the elderly.

CONCLUSIONS

To be consistent with international humanitarian law, embargoes must not impede access to essential humanitarian goods. Yet this embargo has raised the cost of medical supplies and food Rationing, universal access to primary health services, a highly educated population, and preferential access to scarce goods for women and children help protect most Cubans from what otherwise might have been a health disaster.

Explaining rising mortality among men in eastern Europe

Since the mid-1960s, rates of premature mortality have increased among men in all Eastern European countries, giving rise to an East-West health divide. The paper examines the existing data concerning the possible role of levels of smoking, fats consumption and/or environmental factors in explaining this phenomenon. An overview is offered of the key ways in which social experience in Eastern Europe has diverged from that in the West and it is argued that such an overview is pre-requisite for understanding the deteriorating health of men in the East. The importance of the 'incongruity' between aspirations and the means of achieving them is highlighted, as is the centrality of family-based coping strategies. It is argued that the devaluing of the public sphere and valorization of the private domain contribute to the greater health vulnerability of men under in Eastern Europe. The importance of the private sphere is reflected in the fact that the rise of premature male mortality has been overwhelmingly concentrated in the non-married population in the East European countries for which data is currently available.

Infant mortality and mother's education in Ondo State, Nigeria

A bivariate analysis of infant mortality in the 1986/87 Ondo State Demographic and Health Survey data indicates that children of secondary school graduates experienced a higher rate of infant mortality than children of less educated mothers. Although this pattern has also been shown in a few other Demographic and Health Surveys, this paper explores the Ondo State data to explain why infant mortality showed such a counterintuitive pattern in relation to maternal education. This search for an explanation of the pattern started with an examination of the data for errors and then proceeded to examine the importance of some intermediate mechanisms that had been suggested for the education-child survival relationship. The results suggested that data errors, use of health services and quality of maternal care were not enough to explain the relationship. Rather, results of a logistic regression analysis showed that breastfeeding duration and maternal age at childbirth were statistically the most significant variables for predicting infant survival in Ondo State. The inverse relationship between mother's education and infant mortality rates that was not shown by bivariate analysis came out clearly only after controlling for the effect of breastfeeding duration. The linkage between these findings and broader social and economic realities of Nigeria was provided through reviews of available information. The conclusion from the study was that, although breastfeeding and maternal age showed up as the most statistically significant variables, they apparently are just the variables that effectively captured the effects of the harsh economic conditions, especially among secondary school graduates, that prevent most young mothers from translating their child-rearing ideals into reality.

Widening inequality of health in northern England, 1981-91

OBJECTIVE

To identify relative and absolute changes in mortality in the Northern region of England between 1981 and 1991.

DESIGN

1981 and 1991 census data were used to rank 678 wards on an index of material deprivation composed of four variables (unemployment, car ownership, housing tenure, household overcrowding). Standardised mortality ratios (all causes) were calculated for various periods between 1981 and 1991 and for different age categories.

SETTING

Counties of Cleveland, Cumbria, Durham, Northumberland, and Tyne and Wear.

RESULTS

During 1981-91 mortality differentials widened between the most affluent and deprived fifths of wards in all age categories under 75 years. The decline in the relative position of the poorest areas was particularly great, and there was no narrowing of inequalities across the remainder of the socioeconomic spectrum. In absolute terms, there were improvements in mortality in all age categories in the most affluent areas. In the poorest areas improvements in the 55-64 age group were balanced by increased mortality among men aged 15-44, a slight rise among women aged 65-74, and static rates among men aged 45-54.

CONCLUSIONS

These results re-emphasise the case for linking mortality patterns with material conditions rather than individual behaviour.