299 e-Letters

  • A chicken and egg conundrum

    This paper is a welcome addition to attempts to explain the effects of the increased deaths in 2015 and beyond. Based on a 25-year career in NHS analysis and demand forecasting may I point out that these recurring periods of higher deaths and medical admissions are always accompanied by higher delayed discharges. Observations such as the association between delayed discharges and deaths/medical admissions have, unfortunately, never been published, however, the curious association between increased deaths and medical admissions has been published. Rather than cite over 100 studies the reader is advised to go to a list of publications at http://www.hcaf.biz/2010/Publications_Full.pdf where multiple aspects of cause and effect and possible causes have been explored.

    Time lags are evident, with unexplained increased deaths always lagging unexplained increased emergency admissions, and lags between males and females evident in very small area geographies. Admissions for particular diagnoses rise while others fall during these curious events. Casemix severity may well be affected.

    While it is clear that austerity has only exacerbated the impact of the current event on delayed discharges, as noted by the authors, I would be reluctant to say which trends are cause and effect, and which trends arise from association rather than causation.

    The clear message is that far more research is required by both...

    Show More
  • Do cardiometabolic, behavioural and socioeconomic factors explain the ‘healthy migrant effect’ in the UK? Linked mortality follow-up of South Asians compared with white Europeans in the Newcastle Heart Project

    We thank Timaeus and Scott for drawing readers' attention to our interpretation(1) of their data which differs from their own(2) (rapid response 28/7/2017). We are glad to explain our thinking especially as the issues go beyond their data and to the concepts and the UK quantitative evidence. We agree that in their paper after adjustment for three socio-economic and an area of residence variables the mortality rate ratios are lower in South Asian groups than in the White group.(2) The explanation for our different interpretation is that we placed emphasis on their model adjusting mortality for age, sex and period while they emphasised the results of models further adjusting for socio-economic status and residence.(2)

    Generally the ‘healthy migrant effect’ is considered as unexpected and hence a paradox because immigrant populations sometimes have better health, most usually mortality, despite their socio-economic and other disadvantages.(3, 4) It is not generally understood as an effect that arises after adjustments for socio-economic and other related factors. In Timaeus and Scott’s model 1 the rate ratios for Indian, Pakistani and Bangladeshi populations born abroad and participating in the Longitudinal Study in England and Wales are shown in their table 5 and were 0.91, 0.95 and 1.01 with the 95% confidence intervals all including the reference value of 1. In model 1, the point estimates of the rate ratios for the same ethnic groups born in the UK were simil...

    Show More
  • Effects of inflicted or accidental pediatric head trauma on later criminality.

    To the Editor:
    Jackson et al (1) demonstrate that head injuries sustained from 0 to 7 years predict higher rates of arrest and conduct problems in young adults. We would like to highlight however, that their findings suggest that head injury of a certain type is specifically linked to juvenile offence.
    A careful examination of their work reveals a trend towards very early occurrence of head trauma that results in serious brain damage. The severity and age distribution of their dataset do not match those reported on overall (i.e. accidental and not accidental) pediatric head trauma. The British national enquiry (2) on overall pediatric head injury reports that 19% of injured children were younger than a year and that 21% of them had a Glasgow score below 15. Conversely, Jackson et al (1) show that 31% of head traumas occurred in the first year of life and that 38% of them resulted in loss of consciousness. An abundance of literature shows that, compared to children with accidental head trauma, abused children are more often < 1 year of age and hospitalized longer (3). Serious pediatric head injury in very young children is caused by inflicted trauma in a substantial number of cases. Brain hemorrhages are also markedly more common in abusive head injuries; this complication has been reported in 8-10% of children in the accident group (4), meanwhile Jackson et al (1) report the same in 18% of their subjects. Taken together, these data point at a large number...

    Show More
  • Absolute Risk Difference is what matters

    This paper makes a number of claims about health in the North relative to the South of England using comparisons of relatively low death rates. When the denominator in such calculations is a very low rate of death, the size of the difference can appear large. However, if we compare the absolute risk of dying, it is relatively close in the North and South and if we were to divide the rate of survival in the South by the rate of survival in the North each year, we would have a very small comparative statistic.

    Abstracts and conclusions can easily be taken out of context and authors of papers like this one should be careful to present appropriate information. For example, the conclusion "...1.2 million northern excess deaths under age 75 over five decades.." implies very high potential death rates, a million! But this figure is presented with no population and reflects experience over 50 years. If we divide by 50, we get 24,000 deaths a year. A further weakness is that no measure of population is provided to put this total number of deaths in context. Using a plausible estimate of 20 million, for example, implies excess deaths at a rate of about 1.2 per 1,000 people. I wonder how many residents of the North are planning to migrate South today to reduce their risk of an early death by just over 1 in 1,000. Yes we should be concerned about all differences in health across regions and social groups but by inflating them with misleading divisions of one small num...

    Show More
  • Evidence for a healthy migrant effect on mortality in England and Wales

    Hayes et al. [1] repeatedly cite a 2013 article by Scott and Timæus [2], also published in this journal, as having ‘not found a healthy migrant effect in South Asians’ and as providing ‘little evidence of a South Asian mortality advantage’. This contradicts our own interpretation of the results that we presented in that paper. We concluded that ‘Immigrants are selected for good health’. Moreover, with specific reference to South Asians, we stated that: ‘adjusted for SES and residence, … Indian, Pakistani, [and] Bangladeshi … immigrants all had lower mortality than UK-born Whites who were living in similar circumstances to them … This suggests that immigrants from the Indian subcontinent … are … selected for health’.

    We think it regrettable that Hayes et al. do not indicate to readers of their paper that their interpretation of the results in our paper is almost diametrically opposed to our own. Moreover, they provide no explanation whatsoever of why they came to the view that we had misinterpreted our results.

    Our study investigated all-cause mortality at ages 1−79 in 1991−2005 by self-reported ethnicity and country of birth. The data were from the Office for National Statistics Longitudinal Study of England and Wales for the cohort aged 0−64 in 1991. Poisson regression was used to adjust the estimates for metropolitan residence and three indicators of socioeconomic status. In the fully-adjusted model, but not the model that adjusted only for age, sex and per...

    Show More
  • Local versus Nationwide

    This is an excellent article which serves to highlight the value of Public Health work in economic terms. The findings need to be taken into account as future health and social care systems evolve. For example, in the UK, Sustainability & Transformation Plans (STPs) will only truly be sustainable if they get past paying lip service to Public Health programmes and actually invest in their implementation.

    One aspect of the paper that is less helpful, however, is the distinction between 'local' and 'national' Public Health programmes. Such a distinction is arguably unclear and invalid given the fact that many national programmes require effective local implementation in order to be effective. This local implementation includes local investment, local co-design of delivery and local promotion and engagement of stakeholders and residents. In the UK, this work is undertaken by Public Health teams in local authorities in partnership with Clinical Commissioning Groups, Primary Care teams, Pharmacists and the Voluntary Sector. Effective local implementation also relies to some degree on co-design with residents.

    To take an example from the list of 'National' interventions, family planning programmes in the UK are usually funded from the local Public Health budget and implemented according to a local strategy. For example, in some areas universal provision is supplemented by outreach services aimed at offering vulnerable women...

    Show More
  • Misleading representation of SCHER Report
    John F Beal

    Sirs, Peckham et al's selective reporting of the findings of the SCHER report (2011) risks giving readers of your journal a highly misleading interpretation of data on the fluoride intake of children in areas supplied with water containing 1 mg/l of fluoride.

    Careful analysis of the full detail of the SCHER report (2011) shows that 6 to 12 year olds will not exceed the recommended upper limit (UL) of 2.5 mg per...

    Show More
  • Hepatitis C elimination by 2030 is feasible in developed countries but challenging in resource poor developing countries
    Gee Yen Shin

    The World Health Organisation's setting of global viral hepatitis elimination targets, focused on hepatitis B & C, is most welcome1. In their commentary article, Hellard, Sacks-Davis & Doyle describe strategies by which hepatitis C elimination by 2030 can be achieved by a combination of direct acting antiviral drugs against hepatitis C, opioid substitution therapy and needle and syringe programmes...

    Show More
  • A missed opportunity? Fluoridation and hypothyroidism - correlation or causation.
    Douglas W Cross

    The analysis of data on the prevalence of hypothyroidism in areas with different concentrations of fluoride in the public drinking water supplies, by workers at the University of Kent,[1] is interesting but by no means conclusive. The authors rightly emphasise that their findings do not prove that fluoridation causes people to develop the condition,but only that there is a clear correlation. In fact this study raises m...

    Show More
  • SEP, Increased Incidence of Brain Cancer, and Potential Role of Mobile Phone Usage.
    Sarah J Scott

    In relation to the reported findings in this study of a correlation between higher socioeconomic position and incidence of brain tumour, specifically giloma and acoustic neuroma, among a cohort of Swedish-born residents, the authors postulate 'completeness of cancer registration' and 'detection bias' as a potential explanation.

    This seems unlikely, especially given the progressive nature of brain tumour pathology...

    Show More