The Individual's Chances
The risks to the individualor at any rate their order of magnitudeof suffering an accident as a schoolboy cyclist or an elderly pedestrian, of developing leukaemia for a radiologist, of producing malformation from rubella or breast cancer from chronic mastitis, can be estimated only if the experience of whole populations of individuals is known and the relevant averages can thus be calculated. Figure 3 uses the method of the life-table, an easy and rather neglected technique, to give a rough idea of the 'risks' the average male in England and Wales now runs during his middle age, and it complements the picture of Figure 1 a and b. It is in the light of something like a one-in-eight chance of suffering from coronary heart disease, one-in-ten from peptic ulcer, that the use of such terms as 'epidemic' have their warrant. About 33% of men reaching 35 years now die before they reach 65 years, compared with just over 20% of women. This approach is likely to become increasingly useful as forward-looking 'prospective' studies are initiated, for example, to try to learn something about the differences made to middle-age mortality by different ways of living.
The middle-aged man's risks today, England and Wales. Rough estimates1,2,914
The study of community health serviceshow they are working, what needs they are serving and how well, what they ought to be doingis a slowly developing branch of social medicine little speeded by the war-time successes in rather different fields. Table 2A gives a few examples of simple analyses, using epidemiological methods, and the kind of questions (rather than answers) that emerge.
Why has the introduction of the National Health Service, in which for the first time every child has, or can have, a general practitioner, made so little difference to the school health service ( Table 2A )? What are the appropriate roles of school doctor and GP today? How much 'family medicine' can the general practitioner do if the children are treated elsewhere?
Is there enough 'serious' medicine to maintain keen clinical interest in general practice; how is the work divided between 'serious' and other problems ( Table 2B )?
Since most attendances at these large and representative industrial medical officers' clinics ( Table 2C ) seem to be for 'industrial' reasons, who, it may be asked, does the industrial medicine in the great majority of factories and other work places where there is little or no industrial health service? What are the different elements in industrial medicine (carried out on the shop floor as well as in the clinic), and what is their relative importance, so that priorities for early advance can be planned?
The diabetes figures ( Table 2D ) show that social classes I and II did much better with the introduction of insulin than classes IV and V (this is seen throughout 'young' diabetes). How are the benefits of anti-coagulants being distributed today or of the new cardiac surgery? Differences are, I fancy, more likely to be regional and local than related to 'social class'. And tonsillectomy? Is Glover's fantastic tale[20] still true today? Do children in Leeds, Leicester and Exeter still run three times the risk of losing their tonsils as do the children of Manchester, Bradford and Gloucester? (And do these differences affect the children who most need to have their tonsils removed?) In how many other examples of medical, obstetric or dental care would such community comparisons stimulate fresh clinical thinking?
Housing policy, pursuing the figures in Table 1 , evidently does not mean in the comparatively prosperous city of Aberdeen, little affected by bombing, that young people of any social class are finding it at all easy to start a home of their own (Figure 4 ). Half of all families in 1951 were sharing dwellings. These housing figures are an illustration of the value of trying to base 'operational research' about social services on populations: the idea of the human needs the services are and should be meeting at once becomes important. (Not that the assessment of 'needs' is at all easy: so often 'demand' is revealed? Createdby supply. However, in the health servicesschool, maternity and child welfare, appointed factory doctorwhich were established to meet needs that certainly have since changed and may have lessened, a re-assessment of the present situation is urgent. My private notion is that the Central Health Services Council might be armed with a research secretariat; otherwise I see no prospect of having enough 'operational research' carried out.)
Proportion of families living in shared houses or flats, Aberdeen, 195121
Int J Epidemiol. 2007;36(6):1165-1172. © 2007 Oxford University Press
Copyright 2007 International Epidemiological Association. Published by Oxford University Press. All rights reserved.
Read in opening a discussion at the Section of Preventive Medicine and Infectious Diseases at the Annual Meeting of the British Medical Association, Glasgow, 1954, and since expanded. First published BMJ 1955;2:395-401. Reprinted with permission.
Cite this: Uses of Epidemiology - Medscape - Dec 01, 2007.
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