Trevor J.B. Dummer

Changing health in China: re-evaluating the epidemiological transition model

Abstract This paper reviews the changing health situation in China, which has shown remarkable improvement in the 50 years since the founding of the People’s Republic of China (PRC) in 1949. At first sight this improving health situation follows the classical epidemiological transition model. Just three decades ago health in China was characterised by high rates of infectious disease and early mortality (diseases of poverty) in a mainly peasant society. More recently infectious disease rates have decreased, with corresponding and extended morbidity and mortality associated with an aging population in a rapidly urbanising society. This process has given rise to new health problems, including chronic and degenerative diseases (diseases of affluence). Nonetheless, while there is some validity in the application of the epidemiological transition concept, further analysis demonstrates that China faces a new epidemiological phase, characterised by increasing life expectancy and diseases of affluence coupled with the emergence and re-emergence of infectious diseases. We demonstrate that China’s state policy plays a major role in defining the parameters of health in a Chinese context. We conclude that, today, China is faced with a new set of health issues, including the impact of smoking, hypertension, the health effects of environmental pollution and the rise of HIV/AIDS; however, state policy remains vital to the health of China’s vast population. The challenge for policy is to maintain health reform whilst tackling the problems associated with rapid urbanisation, widening social and spatial inequalities and the emergence of HIV/AIDS and other infectious diseases.

Health geography: supporting public health policy and planning

Geography and health are intrinsically linked. Where we are born, live, study and work directly influences our health experiences: the air we breathe, the food we eat, the viruses we are exposed to and the health services we can access. The social, built and natural environments affect our health

Hospital accessibility and infant death risk

This study of all 4889 infant deaths within the cohort of all 287 993 births in Cumbria, northwest England (1950–93), found no evidence of an increased risk of infant death with greater travel time to hospitals.

Longevity in the 21st century: a global environmental perspective

One of the great human success stories in the last few decades has been the marked increase in longevity in many, albeit not all, societies across the globe. Lifespans reaching into the 80s, 90s and 100s are becoming increasingly common, and forecasters predict even greater proportionate gains to come during the course of the 21st century. This article summarises the gains that have been, and continue to be, made then examines the extent to which these will continue in the face of climate change that will probably give rise to more frequent environmental disasters and threats in the future, as Malthusian and neo-Malthusian checks on longevity. Older people will themselves be among those groups most vulnerable to environmental disasters, and policies will be required to assist older people in many unstable environments around the globe in order to ensure their survival. Previous work on Asian longevity will be augmented by case studies of Hurricane Katrina and the recent Haiti earthquake in order to assess the validity of these generalisations.

Changing socioeconomic inequality in infant mortality in Cumbria

Aims: To investigate infant deaths in Cumbria, 1950–93, in relation to individual and community level socioeconomic status. Methods: Retrospective birth cohort study of all 283 668 live births and 4889 infant deaths in Cumbria, 1950–93. Community deprivation (Townsend score) and individual social class were used to estimate socioeconomic status. Logistic regression was used to investigate risk of infant death (early neonatal, neonatal, and postneonatal) in relation to social class and Townsend deprivation score, adjusting for year of birth, birth order, multiple births, and stratified by time period, 1950–65, 1966–75, 1976–85, 1986–93. Results: The risk of infant death in all categories was higher in the lower social classes and more deprived communities, although inequality in risk of neonatal death declined after 1975 to such an extent that there was no significant difference in neonatal death rates by socioeconomic status in the most recent time period. By contrast, there was no narrowing in socioeconomic inequality in postneonatal death risk over the study period. Community deprivation was associated with a significant increased risk of postneonatal death after adjusting for individual level socioeconomic status. Conclusions: Postneonatal deaths remain higher in the most deprived communities and in the more disadvantaged social classes. The social, lifestyle, and environmental determinates of adverse health outcomes for children need to be fully understood, and interventions should be designed and targeted at the more socially deprived sectors of our community.

Corrigendum: Rural and Urban Residence During Early Life Is Associated with a Lower Risk of Inflammatory Bowel Disease: A Population-Based Inception and Birth Cohort Study.

Objectives:To determine the association between inflammatory bowel disease (IBD) and rural/urban household at the time of diagnosis, or within the first 5 years (y) of life.Methods:Population-based cohorts of residents of four Canadian provinces were created using health administrative data. Rural/urban status was derived from postal codes based on population density and distance to metropolitan areas. Validated algorithms identified all incident IBD cases from administrative data (Alberta: 1999–2008, Manitoba and Ontario: 1999–2010, and Nova Scotia: 2000–2008). We determined sex-standardized incidence (per 100,000 patient-years) and incident rate ratios (IRR) using Poisson regression. A birth cohort was created of children in whom full administrative data were available from birth (Alberta 1996–2010, Manitoba 1988–2010, and Ontario 1991–2010). IRR was calculated for residents who lived continuously in rural/urban households during each of the first 5 years of life.Results:There were 6,662 rural residents and 38,905 urban residents with IBD. Incidence of IBD per 100,000 was 33.16 (95% CI 27.24–39.08) in urban residents, and 30.72 (95% CI 23.81–37.64) in rural residents (IRR 0.90, 95% CI 0.81–0.99). The protective association was strongest in children <10 years (IRR 0.58, 95% CI 0.43–0.73) and 10–17.9 years (IRR 0.72, 95% CI 0.64–0.81). In the birth cohort, comprising 331 rural and 2,302 urban residents, rurality in the first 1–5 years of life was associated with lower risk of IBD (IRR 0.75–0.78).Conclusions:People living in rural households had lower risk of developing IBD. This association is strongest in young children and adolescents, and in children exposed to the rural environment early in life.

Relationship between drinking water and toenail arsenic concentrations among a cohort of Nova Scotians.

Consumption of arsenic-contaminated drinking water is associated with increased cancer risk. The relationship between arsenic body burden, such as concentrations in human toenails, and arsenic in drinking water is not fully understood. We evaluated the relationship between arsenic concentrations in drinking water and toenail clippings among a cohort of Nova Scotians. A total of 960 men and women aged 35 to 69 years provided home drinking water and toenail clipping samples. Information on water source and treatment use and covariables was collected through questionnaires. Arsenic concentrations in drinking water and toenail clippings and anthropometric indices were measured. Private drilled water wells had higher arsenic concentrations compared with other dug wells and municipal drinking water sources (P<0.001). Among participants with drinking water arsenic levels ≥1 μg/l, there was a significant relationship between drinking water and toenail arsenic concentrations (r=0.46, P<0.0001). Given similar levels of arsenic exposure from drinking water, obese individuals had significantly lower concentrations of arsenic in toenails compared with those with a normal weight. Private drilled water wells were an important source of arsenic exposure in the study population. Body weight modifies the relationship between drinking water arsenic exposure and toenail arsenic concentrations.

Rationale, design, and methods for Canadian alliance for healthy hearts and minds cohort study (CAHHM) - a Pan Canadian cohort study

BackgroundThe Canadian Alliance for Healthy Hearts and Minds (CAHHM) is a pan-Canadian, prospective, multi-ethnic cohort study being conducted in Canada. The overarching objective of the CAHHM is to understand the association of socio-environmental and contextual factors (such as societal structure, activity, nutrition, social and tobacco environments, and access to health services) with cardiovascular risk factors, subclinical vascular disease, and cardiovascular and other chronic disease outcomes.Methods/DesignParticipants between 35 and 69 years of age are being recruited from existing cohorts and a new First Nations Cohort to undergo a detailed assessment of health behaviours (including diet and physical activity), cognitive function, assessment of their local home and workplace environments, and their health services access and utilization. Physical measures including weight, height, waist/hip circumference, body fat percentage, and blood pressure are collected. In addition, eligible participants undergo magnetic resonance imaging (MRI) of the brain, heart, carotid artery and abdomen to detect early subclinical vascular disease and ectopic fat deposition.DiscussionCAHHM is a prospective cohort study designed to investigate the impact of community level factors, individual health behaviours, and access to health services, on cognitive function, subclinical vascular disease, fat distribution, and the development of chronic diseases among adults living in Canada.

Association between Diet Quality and Adiposity in the Atlantic PATH Cohort

The aim of this study was to examine diet quality among participants in the Atlantic Partnership for Tomorrow’s Health (PATH) cohort and to assess the association with adiposity. Data were collected from participants (n = 23,768) aged 35–69 years that were residents of the Atlantic Canadian provinces. Both measured and self-reported data were used to examine adiposity (including body mass index (BMI), abdominal obesity, waist-to-hip ratio and fat mass) and food frequency questionnaires were used to assess diet quality. Overall, diet quality was statistically different among provinces. Of concern, participants across all the provinces reported consuming only 1–2 servings of vegetables and 1–2 servings fruit per day. However, participants also reported some healthy dietary choices such as consuming more servings of whole grains than refined grains, and eating at fast food restaurants ≤1 per month. Significant differences in BMI, body weight, percentage body fat, and fat mass index were also observed among provinces. Adiposity measures were positively associated with consumption of meat/poultry, fish, snack food, sweeteners, diet soft drinks, and frequenting fast food restaurants, and inversely associated with consumption of whole grains and green tea. Although all four provinces are in the Atlantic region, diet quality vary greatly among provinces and are associated with adiposity.

The Canadian Partnership for Tomorrow Project: a pan-Canadian platform for research on chronic disease prevention

BACKGROUND: Understanding the complex interaction of risk factors that increase the likelihood of developing common diseases is challenging. The Canadian Partnership for Tomorrow Project (CPTP) is a prospective cohort study created as a population-health research platform for assessing the effect of genetics, behaviour, family health history and environment (among other factors) on chronic diseases. METHODS: Volunteer participants were recruited from the general Canadian population for a confederation of 5 regional cohorts. Participants were enrolled in the study and core information obtained using 2 approaches: attendance at a study assessment centre for all study measures (questionnaire, venous blood sample and physical measurements) or completion of the core questionnaire (online or paper), with later collection of other study measures where possible. Physical measurements included height, weight, percentage body fat and blood pressure. Participants consented to passive follow-up through linkage with administrative health databases and active follow-up through recontact. All participant data across the 5 regional cohorts were harmonized. RESULTS: A total of 307 017 participants aged 30–74 from 8 provinces were recruited. More than half provided a venous blood sample and/or other biological sample, and 33% completed physical measurements. A total of 709 harmonized variables were created; almost 25% are available for all participants and 60% for at least 220 000 participants. INTERPRETATION: Primary recruitment for the CPTP is complete, and data and biosamples are available to Canadian and international researchers through a data-access process. The CPTP will support research into how modifiable risk factors, genetics and the environment interact to affect the development of cancer and other chronic diseases, ultimately contributing evidence to reduce the global burden of chronic disease.