Robert Beaglehole

Alcohol consumption and risk of coronary heart disease.

OBJECTIVE--To investigate the hypothesis that the apparent protective effect of habitual alcohol consumption on coronary heart disease is due to drinkers at high risk of coronary heart disease becoming non-drinkers. DESIGN--Case-control population based study. Data were obtained from interviews with patients with non-fatal myocardial infarction and their controls and with the next of kin of those who had died of coronary heart disease and their controls. SETTING--Auckland, New Zealand. SUBJECTS--Two groups of cases were studied. The first comprised 227 men and 72 women with non-fatal myocardial infarction identified from a population based surveillance programme for coronary heart disease; controls were 525 men and 341 women randomly selected from the same population group and matched for age and sex. The second group comprised 128 men and 30 women who had died of coronary heart disease and had been identified from the surveillance programme; controls were a sample of the previous control group and comprised 330 men and 214 women matched for age and sex. All participants were aged 25-64 years and without diagnosed coronary heart disease. MAIN OUTCOME MEASURES--Regular alcohol consumption; high density lipoprotein cholesterol and low density lipoprotein concentrations. RESULTS--Men with myocardial infarction and men who had died of coronary heart disease were more likely to have been never drinkers (had never drunk more than once a month) than controls (18% v 12% and 23% v 13% respectively). After possible confounding factors had been controlled for, people in all categories of drinking (up to more than 56 drinks per week) had at least a 40% reduction in risk of fatal and non-fatal coronary heart disease compared with never drinkers. Former drinkers also had a lower risk of non-fatal myocardial infarction than never drinkers (relative risks 0.41 and 0.10 in men and women respectively) but a similar risk of death from coronary heart disease. The reduction in risk was consistently greater in women than in men in all drinking categories but there was no clear dose-response effect in either sex. CONCLUSIONS--The results support the hypothesis that light and moderate alcohol consumption reduces the risk of coronary heart disease. This protective effect in this population was not due to the misclassification of former drinkers with a high risk of coronary heart disease as non-drinkers.

The changing global context of public health

Future health prospects depend increasingly on globalisation processes and on the impact of global environmental change. Economic globalisation--entailng deregulated trade and investment--is a mixed blessing for health. Economic growth and the dissemination of technologies have widely enhanced life expectancy. However, aspects of globalisation are jeopardising health by eroding social and environmental conditions, exacerbating the rich-poor gap, and disseminating consumerism. Global environmental changes reflect the growth of populations and the intensity of economic activity. These changes include altered composition of the atmosphere, land degradation, depletion of terrestrial aquifers and ocean fisheries, and loss of biodiversity. This weakening of life-supporting systems poses health risks. Contemporary public health must therefore encompass the interrelated tasks of reducing social and health inequalities and achieving health-sustaining environments.

Sex differences in case fatality before and after admission to hospital after acute cardiac events: analysis of community based coronary heart disease register.

Abstract Objective: To determine whether the reported higher case fatality in hospital after an acute cardiac event in women can be explained by sex differences in mortality before admission and in baseline risk factors. Design: Analyses of data from a community based coronary heart disease register. Setting: Auckland region, New Zealand. Subjects: 5106 patients aged 25–64 years with an acute cardiac event leading to coronary death or definite myocardial infarction within 28 days of onset, occurring between 1986 and 1992. Main outcome measures: Case fatality before admission, 28 day case fatality for patients in hospital, and total case fatality after an acute cardiac event Results: Despite a more unfavourable risk profile women tended to have lower case fatality before admission than men (crude odds ratio 0.88; 95% confidence interval 0.77 to 1.02). Adjustment for age, living arrangements, smoking, medical history, and treatment increased the effect of sex (0.72; 0.60 to 0.86). After admission to hospital, women had a higher case fatality than men (1.76; 1.43 to 2.17), but after adjustment for confounders this was reduced to 1.18 (0.89 to 1.58). Total case fatality 28 days after an acute cardiac event showed no significant difference between men and women (0.85; 0.70 to 1.02). Conclusions: The higher case fatality after an acute cardiac event in women admitted to hospital is largely explained by differences in living status, history, and medical treatment and is balanced by a lower case fatality before admission. Key messages Data from a community based coronary heart disease register were used to examine sex differences in case fatality before and after admission Women had a higher case fatality after admission but a lower case fatality before admission Total case fatality 28 days after an acute cardiac event showed no significant difference between men and women The higher case fatality after an acute cardiac event in women admitted to hospital is largely explained by confounding

Public health at the crossroads: which way forward?

Public health represents societys organised and publicly supported efforts to improve the health status of the entire population; its focus is on the reduction of health inequalities by optimising the underlying determinants of health and preventing disease. But public health is under threat and needs to be strengthened so that it is at the centre of human endeavour--locally, nationally, and worldwide.

International trends in coronary heart disease mortality and incidence rates.

1350-6277 iCl 1999 Lippincott Williams & Wilkins Introduction Cardiovascular disease (CVD) is the leading cause of death world-wide, responsible for approximately 15 million (29%) of the estimated 52 million deaths in 1996 [1]. CVD epidemics began in many developed countries in the early decades of this century [2] and despite reaching a peak in some countries in the 1960s and 1970s, CVD remains the leading cause of death in developed countries and Eastern European countries in transition. Furthermore, the CVD epidemic is advancing in developing countries. Most CVD deaths now occur in the poorer regions of the world, which are still experiencing a major burden of communicable diseases, the so-called double burden of disease. CVD accounts for about 25% of all deaths in developing countries (10 out of 40 million). Coronary heart disease (CHD) is the main form of CVD world-wide, responsible for about 7 million deaths with over half of these occurring in developing countries [1].

Comparison of case fatality in smokers and non-smokers after acute cardiac event.

Although smoking is a major modifiable risk factor for acute myocardial infarction, it has also been associated with an up to twofold lower risk of dying in hospital after an acute myocardial infarction.1 2 We analysed data from a community based register of coronary heart disease to determine whether differences in case fatality (the proportion of those dying) between smokers and non-smokers are restricted to patients who have been admitted to hospital and to evaluate possible explanations for this smokers paradox.nnAll deaths related to coronary causes and all admitted patients aged 25–64 who met predefined criteria for myocardial infarction or coronary death were identified in Auckland, New Zealand, between 1986 and 1992 as part of the World Health Organisation MONICA (monitoring trends and determinants in cardiovascular disease) project. Study criteria, and methods of case finding and …

Reinvigorating public health

n In the Public Health Quintet published in The Lancet, it was pointed out that although the scope of modern public health is broad and inclusive, breadth is missing from much of the practice. It is faced with new and even more difficult challenges brought on by the increasing globalization of the determinants of health. In view of such, this article suggests an approach to address the issue of reinvigorating public health. It is noted that to achieve the goal of reinvigoration, an increase in commitments from the public health workforce to a broader view of public health and to values of equity and ecological sustainability is required. The public health practice needs to focus on overall improvement in population health through the reduction of the readily preventable burden of disease, whether communicable or noncommunicable, especially among disadvantaged groups. Social and economic deprivation should be reduced by focusing on its underlying structural determinants. Moreover, there should be strong political and professional leadership at the global level to increase the value of researches on priority issues, including poor health as a determinant of poverty. Overall, if the reinvigoration of public health gathers pace, the ultimate goal for public health practitioners will be achieved.n